There is ample evidence that barcode technology for medication has had a significant impact on patient safety. But while most U.S. hospitals have adopted barcode medication administration, experts say there's big room for improvement.
According to a recent study conducted at Boston's Brigham and Women's Hospital and published in the New England Journal of Medicine, the use of the bar-code electronic medication administration significantly reduced the rate of errors in order transcription and in medication administration as well as potential adverse drug events.
The study, "Effect of Bar-Code Technology on the Safety of Medication Administration," concluded that while barcoding did not eliminate errors altogether, it remains "an important intervention to improve medication safety."
Mark Neuenschwander, president of the Neuenschwander Company and cofounder of the unSUMMIT for Bedside Barcoding, said that currently more than two-thirds of U.S. hospitals are scanning most patients and medications before administering them.
"And doing a fairly good job," said Neuenschwander. But he contends that there's room for improvement.
"Using technologies with best practices, getting the final third to adopt and getting all to expand their medication coverage," is essential, he said, adding that one noticeable gap is that most BCMA hospitals are not scanning medications in OR or ER.
Since 2012, barcoding has been required for hospitals under Stage 2 meaningful use's core measures.
Teamwork and leadership
The successful implementation of BCMA requires baseline knowledge of barcoding as well as teamwork and leadership, says Jeff Chalmers, assistant director, pharmacy informatics at the Cleveland Clinic.
Chalmers suggested that a good start would be for the barcode team to read the practice resources and guidelines provided by the American Society of Health System Pharmacists with regard to medication barcoding.
"Once you've armed yourself with that information, the creation of a strong multidisciplinary steering committee including pharmacy, nursing and physician leadership to sponsor the program and make key decisions with input from front line staff is an important first step."
From a pharmacy-centric perspective, Chalmers says one of the most important activities to embark on early in the project is to take an inventory of all products in the pharmacy to determine which products are barcoded and which are not.
"Subsequently, the development of operational procedures to get barcodes on all projects is also challenging and important," he said.
Chalmers asserted that the development of a system to screen all incoming products' barcodes to determine if the system can read National Drug Codes before they are dispensed to patients, would allow hospitals to have a sustainable system with as few erroneous alerts directed towards nurses as possible.
Chalmers, a member of the Pharmacy Informatics and Technology section and the Section Advisory Group for Clinical Decision Support and Clinical Information Systems at ASHP, added that it's important that the front line nursing staff also understands how the system works and what the expectations are for using it – as well as an efficient way to report problems they see with the system are all key for making the system work for the staff who relies on it the most, nurses.
Despite the fact that there is currently no solid data on adverse drug events, Chalmers said that it is possible to review, through reporting techniques, "near miss" events, where nurses were warned of a mismatch between the medication and the patient's orders and were able to avoid making a medication error.
"We have the capability to review these near misses and pass along this information to other nurses with regard to mistakes that may be easier to make due to look alike-sound alike medications, or medications with similar packaging," said Chalmers.
Integration is key
Tina M. Suess, RN, manager for medication safety integration, at Lancaster General Hospital in Lancaster, Pa., encourages hospitals to move toward an integrated BCMA platform allowing clinical decision support to be "aligned" and streamlined across all areas of the medication use process.
For example, if the provider overrode an allergy alert during CPOE and the pharmacist overrides it during order verification, why should the nurse need to see an allergy alert at the point of administration?
Suess said it's important to have ownership of the data.
"BCMA systems provide a plethora of information to allow hospitals to improve the medication use process, said Suess. "Hospitals need to define 'who' will own the data and oversee the process for improvements."
She added that many hospitals make the mistake of "decentralizing" the data.
"Although this is better than not looking at the data at all … it doesn't allow a big picture look," Suess said.
Suess offers the following tips to health systems considering BCMA:
- Optimize the relationship between pharmacy and nursing. Nurses use the BCMA technology… but the software is often owned by pharmacy. I would suggest a nurse … who works in the pharmacy as the operational owner to drive adoption and practice and process changes.
- Make sure someone is "looking" at all technology and that alerts are firing at the appropriate "technology" spot in the medication use process
- Go true unit-dose and eliminate manipulation of the dose by the nurse at the bedside. The BCMA system can fire an alert if the nurse scans a 10 mg tablet … for the 5 mg dose. The nurse can "tell" the computer that they broke the tablet … butif the nurse fails to actually break the tablet, the result is a wrong dose error.
- Ensure that pharmacy adopts a "quarantine" environment that ensures product is "mapped" into the system before being dispensed.
- Monitor the human interface with technology. Use direct observation to actually observe how end users are using the technology. Very valuable approach to identifying needed system improvements and to find out "workarounds"
- Invest in the necessary infrastructure for success. Don't introduce an environment in which the BCMA cannot be used. Invest in wireless infrastructure, appropriate number of electrical outlets to charge the workstation on wheels and purchasing enough devices to meet the patient care demands
- Create an environment that allows for timely resolution of identified problems.
Finally, industry insiders note that BCMA is a large undertaking that requires significant pharmacy and nursing resources.
However, according to the Cleveland Clinic's Chalmers, "Given the fact that the administration phase of the medication use cycle is the stage where errors are the most likely to reach the patient, it seems logical that we devote the time and resources here to protect our patients."
