December 20, 2010
The Benefits of Bar Coding
By Lindsey Getz
For The Record
Vol. 22 No. 23 P. 20
Bar-coding technology adds an extra level of patient safety to the medication administration process.
Using electronic bar coding can reduce medication errors, making the technology increasingly more popular in hospitals and health systems. The technology ultimately adds another level of verification into the “five rights” of medication administration that nurses are already familiar with: being sure the right medication is going to the right patient at the right time and frequency of administration in the right dose through the right route of administration.
Here’s how it works: A provider places an electronic order that passes through the pharmacy system. The pharmacist reviews the order to make sure there are no allergy or drug interactions. Once the pharmacist approves the order and schedules the dose, the information is passed on to the electronic medication administration record (eMAR) and a nurse.
At the patient’s bedside, a nurse retrieves the product and scans its bar code along with the patient’s bracelet. As each medication is scanned, the system tells the nurse that everything is correct or brings up a warning that something is wrong. “We call it a closed-loop system,” explains Anne Bane, RN, MS, director of clinical systems innovations at Brigham and Women’s Hospital in Boston. “The medication order is tracked electronically through all the steps of the medication process: ordering, dispensing, and administration. There are checks and balances at each step to ensure the patient receives the right medication.”
The result is better patient safety. “It’s a huge patient safety initiative,” says Chris Altendorf, administrative director of nursing informatics at Baptist Memorial Health Care Corporation (BMHCC) in Memphis. “It assists in preventing medication errors right at the bedside. The bedside is the last stop before administration and therefore a critical place to prevent errors from occurring. This kind of technology can make an enormous difference with patients.”
“While traditional methods would rely on people and processes, mostly recorded on paper, this technology adds a third dimension to the process by tracking it on the computer,” adds Edna Boone, MA, CPHIMS, senior director of healthcare information systems at HIMSS. “You’re no longer relying on a human being alone to verify a correct medication passed or a near miss. In addition, it’s important to note that bar coding goes beyond bedside administration because it encompasses all of the steps that medication dispensing goes through, including pharmacy receiving and inventory.”
The benefits of improved patient safety have been backed up by a new study funded by the Agency for Healthcare Research and Quality (AHRQ), published in the May 6 issue of The New England Journal of Medicine, which concurs that using bar-code technology with an eMAR substantially reduces transcription and medication administration errors as well as potential drug-related adverse effects. Researchers at Brigham and Women’s Hospital compared 6,723 medication administrations on hospital units before a bar-code eMAR was introduced with 7,318 medication administrations after the introduction.
Having bar-code eMAR technologies in place was associated with error reductions related to the timing of medications, such as giving a medicine at the wrong time, and nontiming medication administration, such as giving a patient the wrong dose. There was a 41% reduction in nontiming administration errors and a 51% reduction in potential drug-related adverse events associated with this type of error. In addition, timing-related errors (a patient was given medication an hour or more off schedule) were reduced by 27%, and no transcription errors or potential drug-related adverse events related to this type of error occurred.
While a computer is incorporated into the process of verifying the five rights, it still requires a nurse and a pharmacist to use their thought processes, says Bane. “The intention is to double-check the thought process, not to replace it,” she explains. “The pharmacist still needs to know the patient’s medical history and review the product. And when the nurse takes the product out of the cabinet, he or she still needs to go through the reasoning process. Implementing this technology doesn’t mean anyone should just rely on what the computer says and not use their critical-thinking skills.”
In fact, nurses may occasionally need to rely on their clinical judgment to override what the computer says. “Any discrepancy will show up on the computer as a warning, but there may be a justified reason for that discrepancy, so the nurse needs to use clinical judgment,” says Penny Scott, RN, CMQ/OE, MSQA, clinical informatics manager at Saint Margaret Mercy in Hammond, Ind. “Perhaps the medication is being given earlier than scheduled because the doctor changed the order or perhaps the doctor just ordered that the patient needs a double dose. It’s not like the computer does all the thinking for you; it’s still necessary to think through the process.”
Scott says there are other circumstances where a nurse would need to use clinical reasoning, such as if a patient’s ID band must be updated because of a room number change or the bar-code label on the medication must be updated due to a change in the pharmaceutical vendor. There are times when the computer will issue a warning and the nurse must figure out why. “Things change frequently in a hospital, and nurses need to be ready to adapt and use their clinical judgment,” Scott notes. “In the end, it’s just an added level of safety for the patient but not a replacement for reasoning.”
While it certainly adds an extra layer of safety, some worry that the technology will also add a lot of extra time to the workday. However, most organizations that have implemented an eMAR indicate that, after an initial learning curve, workflow is not heavily interrupted. Altendorf says it has added some time, but that will diminish over the long term. “Plus, the trade-off is patient safety, and there’s no nurse out there that doesn’t value that,” she adds.
If nurses had poor medication administration processes in the first place, they may not like this technology since it won’t allow them to take shortcuts, says Bane. The technology will support good medication administration habits by adding another level of safety, but it will not fix poor processes. “However, if a good medication dispensing habit is already in place, this technology is only going to add more support,” she notes.
In the long term, it could actually become a time-saver. “Before this system, we used to transcribe all of the medication onto a patient chart,” says Bane. “Now we don’t have to write everything down because it’s recorded on the computer, so once the learning curve is over, it may actually save time. However, saving time really wasn’t the driver for implementing this; it was patient safety. Making nurses more efficient is a secondary benefit that we do appreciate.”
In terms of downsides, Boone says technical issues are often centered on the battery life required to power the devices necessary for bar coding. “Printing issues may also arise, and you can get an unreadable band,” she adds. “But malfunctioning scanners are pretty rare and are routinely tested in the pharmacy for accuracy.”
Bane says more durable scanners are an issue that vendors must address. “These devices are getting usage in some pretty tough environments,” she notes. “It’s not like an office where equipment gets used from 9 AM to 5 PM. Equipment in hospitals is getting used 24/7 and by multiple users. That’s a future issue for vendors to address and also a reason why it’s important to partner with the right vendor.”
Even the best computer systems can go down, making it important to have a downtime plan, says Altendorf. “There is no system in the world where you shouldn’t be prepared for downtime,” she says. “There are a lot of things that can happen to knock out power. You can’t take any clinical system live without the right procedures in place first.”
The VA was one of the first to implement bar-coding technology in its hospitals. Things have come a long way since then, says Chris L. Tucker, RPh, director of the Bar Code Resource Office in the Veterans Health Administration Office of Health Information. When the system was rolled out in 1999, computers were still on dial-up, and most people weren’t even familiar with using Windows. As a result, a lot of the hurdles that needed to be cleared centered on the technology—just learning to use a mouse was an obstacle back then.
Today, even though staff members are more familiar with computer use, technology can still be a potential hurdle. “It’s important to keep in mind that people adapt to technology differently and even if they’re familiar with using the Internet at home, they may not be familiar with it in the workplace,” says Elizabeth Mims, MBA, RN, deputy director of the Bar Code Resource Office. “It’s important that the business processes in place support the activities that follow the policies and procedures and that staff is given the time to adapt to the learning curve.”
In terms of involving staff in the implementation process, the key people to be on board include the doctors, the pharmacists, and the end users, who are the nurses. It’s also important to have IT staff, clinical systems staff, quality assurance, engineering, and maybe even housekeeping involved on a multidisciplinarian team. And the HIM team is also critical, says Altendorf. “I cannot emphasize enough that you need HIM involved in the implementation because all of this information will go into the final medical record,” she says. “If you don’t plan to have the format correct prior to ending up in the medical record, you’re going to have problems.”
Having a team or a staff member in place to handle bar-coding concerns can be effective. The VA created bar-code medication administrative coordinators, the initial go-to people for end users when issues arise. “In addition to that, we also established bar-code multidisciplinary committees that are required to meet monthly and discuss any issues,” says Tucker, adding that it’s important for facilities to understand what their operational baseline is when first implementing a bar-coding system.
“They should engage in a strong study to detect what their error rate is prior to implementation,” he says. “They will see detectability increase, but fewer errors are actually happening. These are averted errors, and they’re being caught. When implementation first occurs, it often leads to the realization of just how many errors were probably happening and not caught prior to the use of a bar-coding system.”
Communication is also a key to successful implementation, adds Tucker. “It’s important that end users can see the decisions being made by management and that end users are part of the entire process, including selection and evaluation of the system that’s being considered,” he says. “You need to actually subject it to usability to determine whether it’s going to work.”
Altendorf says the end users’ participation helped determine the appropriate vendor for BMHCC. “We had it narrowed down to two vendors, both of which had pretty equal stats on patient safety and quality,” she says. “So we ended up picking the system based on what we thought was the most user friendly—the one that end users felt best met their needs. The bottom line is that I can sit in my office and help install or fix IT problems, but I don’t use the system every day. It was critical the end users were involved.”
While bar-coding technology works well in most inpatient departments, there are some settings where it doesn’t make sense, such as in an emergency department. “Medications need to be readily available in emergency situations such as codes and rapid responses when going through the scanning process is going to slow things down a little,” says Scott. “In addition, in these situations the physician is right there ordering the medication on the spot. It’s not the same process as the physician putting the order in and the nurse administering the medication at a later time [as would typically occur in a traditional inpatient setting].”
The operating room is another area where the process of medication dispensing is not conducive to bar coding, adds Altendorf. “Based on what’s occurring with the patient at any given time under anesthesia, medications may need to be changed or given at a moment’s notice,” she says. “The process just doesn’t happen the same way.” However, BMHCC is using bar coding in its outpatient areas, something that many providers have not yet implemented. “We are trying to provide as much quality and safety as we can, wherever we can,” Altendorf says.
Facilities that have a neonatal ICU may also find bar coding to be a challenge, says Boone. “The unit and dose size of medications given in this department are at such small increments that there are often no bar codes at these doses,” she explains. “This requires the pharmacy to produce special bar codes.”
Though it may not work everywhere, when implemented in the right departments, bar coding can boost efficiency and add another layer of patient safety to the medication dispensing process. “Just remember that change takes time,” says Mims. “You need to plan on the time needed to change processes. The technology will only be as reliable as the workflow it’s meant to support.”
— Lindsey Getz is a freelance writer based in Royersford, Pa.
More Than Medicine
Bar-coding technology has other uses in hospitals and healthcare settings beyond medication dispensing. At North Mississippi Medical Clinics, the facility uses bar-code scanners to automatically allocate transcription audio files to patient records. Each physician has his or her own handheld recorder programmed with a personal author ID. After the work type (type of visit) is coded and a doctor sees a patient, the physician scans a bar code on the patient record and then dictates a message. It automatically links that dictation with the intended patient. When it’s time for the next job, the doctor clicks “New Job” on the recorder to start again.
“Before going to the handheld device, the doctor had to use the phone, so this is a huge time-saver,” says Connie Renfroe, RN, clinical automation and efficiency coordinator. “This adds the freedom of mobility. The doctor can walk out of the room and dictate as he or she walks to the next room.”
Workflow is hardly affected by the change, as the medical group’s transcriptionists, who receive the dictations, can still work from home. The biggest hurdle was teaching the physicians the new process.
“When implementing, it’s critical to communicate one on one with the person who will be using this technology,” says Amy Hester, PC support for management information systems with North Mississippi Health Services, the parent organization of North Mississippi Medical Clinics. “Doctors are busy, but you need to make sure they understand the process. We wanted to be there while they were in action, so we worked around each doctor’s schedule so that we could follow them and be available to answer questions, teaching as we went. Doctors typically don’t like change, so you sometimes need to offer a lot of support.”
Safety and privacy are other concerns that can’t be overlooked. At North Mississippi Medical Clinics, it’s a policy that recorders don’t leave the building. Doctors still have the option of using the telephone to call in a dictation if they’re working from home. “The fact that each doctor is assigned his or her own recorder—and they are not meant to share—prevents most safety challenges in the first place,” says Hester. “Plus, there’s a four-digit PIN number that’s needed to listen to the recorder and once a job uploads to the system, it automatically erases it from the recorder. It’s pretty simple.”