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January 9, 2006
Raising
the Bar (Coding) on Patient Safety By implementing barcoding technologies, healthcare organizations can pump up their defenses against medication errors. On August 29, 2005, a 21-year-old San Jose, Calif., man died three days after a physician injected him with the wrong medication. The California Department of Health Services reported the patient, who was diagnosed with non-Hodgkin’s lymphoma, was given the wrong chemotherapy drug. A physician wrote an order for the correct chemotherapy drug and was notified that a pharmacist had hand-delivered the drug and that it was ready to be administered, the report found. The physician told investigators that a nurse handed him the prefilled medicated syringe without checking the label and that he also failed to check the label for accuracy before injecting the drug into the patient’s spine. It was discovered soon afterward that the man had been given the wrong medication, and doctors informed him and his family that he would likely die as a result of their error. This error occurred despite the hospital’s policy, which states, “There should be a second licensed person checking the drug before administration,’’ according to the report. The pharmacist who delivered the medication to the wrong hospital unit and subsequently delivered that patient’s prescribed medication to the deceased man’s unit couldn’t explain how the fatal error occurred. The pharmacist also told investigators there is no policy or procedure for the delivery of these drugs, according to the report. Errors are not intended when it comes to medication dosing, but more than 7,000 patients die annually because of improperly transcribed, prescribed, processed, or administered medications. According to a report in the Archives of Internal Medicine, “19% of medication doses are in error, about 7% of which were deemed potentially harmful to the patient.” The categories of medication error most frequently reported are: wrong time, 43%; omission, 30%; incorrect dose, 17%; and unauthorized medication, 4%. Bedside bar coding, while not being billed as a timesaving measure for nursing and clinical staff, enhances patient safety and is a technology that most patients embrace. Planning
for Barcoding Implementation Mark Neuenschwander, president of The Neuenschwander Company, a Bellevue, Wash.-based consulting firm that specializes in pharmacy automation, agrees that the implementation needs to involve an interdisciplinary team that includes pharmacy as well as nursing professionals. “It would also behoove a hospital to involve patient safety people and eventually the marketing department,” he states. “Once implementation is begun, the hospital should make the community aware of the safety measures that are being implemented.” Neuenschwander says the American Society of Hospital Pharmacists conducted a survey that revealed a patient’s greatest fear entering the hospital is receiving the wrong medication. Prior to beginning an upgrade to barcoding technology, a facility must have the infrastructure in place to support the switch. Since nursing and pharmacy professionals will bear the brunt of the change, Neuenschwander says they must be involved in the talks from the beginning. “They have to be comfortable working within the parameters of the new system,” he says. “Pharmacy has to make sure that all of the medications that will make it to bedside have bar codes and that those bar codes contain the information required for the system and those bar codes have to be scannable with the system that’s in place.” Hospitals will try to buy as much medication as possible with bar codes, but, according to Neuenschwander, the number of barcoded meds has been low. “As barcoding regulations go into effect in April 2006, manufacturers will be required to barcode all packages,” he says. “That means every package—from single pills in a blister pack to ampules, vials, syringes, salves, and ointments—will be bar coded. Any medication that touches a container will need the code.” Bulk-packed pills will need to be bar coded at the point of dispensing. Hospitals can choose to do the coding themselves or outsource it to a prepacking house. “Pharmacy has to make sure they not only have bar codes on the medications but that they are all mapped to the correct information so when the system scans any bar code it will accurately tell the caregiver what medication they have in their hand and it will accurately record in the system what medication was given to the patient,” Neuenschwander says. Also, facilities have to decide which type of patient barcoded wrist bands they will use, which way the bar code will be positioned on the wristband, and how the nurses’ bar codes will be applied to their badges. Mike Wisz, principal of Mike Wisz & Associates, agrees that the switch to bar coding impacts all disciplines, from pharmacy and nursing to risk management specialists. “Everyone that is involved in the medication use process needs to be at the table,” he says. “The change to bedside bar coding needs top-down management support in order to be effectively implemented.” Training “There is either instructor-led or computer-based training available,” Wisz notes. “In a pinch, nurses have been trained in as few as 15 minutes—that happens when an untrained nurse floats in unexpectedly.” Galusha says Sacred Heart geared up for barcode training by showing the nurses that the new technology would have only a minimal effect on their routines. Because the facility was a development site for the software, “The system operated in pilot mode until the nurses became comfortable with the technology,” she says. There was plenty of in-house buzz before the technology was introduced. “We had information in staff meetings and blurbs put into the weekly newsletter,” Galusha says. Still, there were hurdles to overcome. Galusha says she knew some nurses would be a bit fearful of the computer system because they had never before used it on a daily basis, but steps were taken to alleviate those concerns. “We offered basic computer and keyboarding skills to the nurses and clinicians before the technology and training were introduced,” Galusha says. In-house nurse “champions” were recruited and given seven days of in-depth training. Once prepared, this core team trained and supported their peers. “Peer-to-peer training is more effective than having an outsider—who works with the technology every day—come in and conduct the training,” Galusha says. “It was really for those in the classes to see they are nurses like me and if they can do it, I can do it.” Each of the four implementation phases involved a two-week training series for staff members of three to four units at a time. Go-live followed immediately after so there was little time for new users to forget what they had learned. Members of the core team were positioned on the units to provide immediate answers to questions the nurses had once they were on their own with bedside barcoding stations. “Another key factor to the success of our rollout was that the nurses didn’t have to wait for support. There was a trained nurse on hand 24/7 for a full week on the units that went live,” says Galusha. Neuenschwander agrees that any rollout should be gradual. “There used to be the idea of the big bang theory when it came to rollout, but we’ve found it’s better to do a floor at a time,” he says. “Getting a really great pilot program with really positive leaders for the technology is also crucial to a successful rollout and acceptance.” Wisz, who says a typical time frame for implementation is four to six months, agrees that the technology should be validated on a pilot nursing unit but is against a gradual rollout process. “One of the primary reasons I don’t recommend a gradual rollout is because you’re then operating a dual process—pre- and post-automation—and it’s confusing,” he explains. “As long as the system’s workflow redesign has been completed, I strongly recommend validating the technology in a test area and rapidly expanding it to the rest of the house after that.” How did Sacred Heart handle the dual process? “To minimize confusion resulting from a dual process, we considered patient transfer patterns between units when assigning units to one of the four implementation phases,” Galusha says. She agrees with Wisz’s estimate of the rollout time, saying that of Sacred Heart’s 623 beds, 500 were up and running in four months. Embracing
the Technology Initially, there is always resistance to any change in the way a nurse, or any professional, does their work. “The nurses become experts at what they do and when it’s changed it makes them feel a bit discombobulated, but with training, support, and a well-thought-out plan, they accept it more quickly,” Galusha says. Neuenschwander says there are five “rights” of medication administration: the right patient, right medication, right dose, right route, at the right time. “Bedside bar coding is a matter of safety and efficiency,” he says. “Two axioms I tell clients is the first thing you have to think about when introducing a system to the nurses is that it should be as safe as—or safer—than the system (paper) you are replacing and it should eventually be as efficient, or more efficient, than the system you are replacing.” With those items taken into consideration, Neuenschwander says the nurses will be more accepting of the technology. “Bedside bar coding is not necessarily a timesaver but it is a much safer system,” he says. In the grand scheme of things, Galusha says once the nurses become proficient on the new equipment, they will find it requires virtually the same amount of time as the old paper methods. One factor is the way the technology is delivered, such as a PDA or computer on wheels (COW). “Each device has its trade-offs,” Neuenschwander says. “PDAs have smaller screens but are more portable. The COWs have larger screens but might be more cumbersome. Whichever system is chosen, it has to enhance the nurse’s job, not make it more frustrating to embrace the technology.” Safety, he says, has to do with making it easier for the caregiver to do right—and harder for them to do wrong. What is the bottom line on selling the nurses on the technology? Galusha says, “Nurses are employees and even though they might fear the change to a new system, as long as they received good education and support, their initial resistance can be overcome and they will step up to the plate.” A nurse’s main objective, Galusha says, is to provide the highest quality of care, and as long as they feel competent with the bar coding, they will embrace it. During the course of a nurse’s career, he or she will have likely been introduced to and learned to work with many advances. Neuenschwander says eventually a nurse will have an epiphanal moment when the system prevents them from making an error and they are turned into believers. “Selling the technology to the nursing staff is selling peace of mind,” Wisz says. “There are many nurses who have gone home and worried if they’d made a mistake or if there was an error they could have prevented. Getting peace of mind will win them over.” Educating
the Patients According to Neuenschwander, the patients feel good about the technology and the time the nurses are spending with them rather than in the paper documentation process. Because patients fear receiving the wrong medication, they see the new technology as a way to feel safer during their hospitalization. “Bedside bar coding offers everyone a safety net,” he says. “Bar coding is the lowest-hanging fruit in the medication use process for error prevention and avoiding adverse drug events.” Sacred Heart used posters in the waiting rooms and patient rooms, television advertisements, and in-room education to introduce patients to the new technology. “We encouraged the nurses to explain what they were doing as they were doing it and the patients were very accepting,” Galusha says. Neuenschwander says it’s common for nurses to say upgrades in technology will cut down on their time spent with patients. “We tell them [nurses] that the reality is they will spend more time with the patients and at their bedside because they won’t be spending their time behind a computer screen at the nurse’s station,” he says. “Additionally, they are truly spending more time at the bedside because they are training the patients on the technology as it’s implemented.” Wisz says patient word of mouth is another best-selling way to talk up the new technology. “We’ve heard of patients telling their friends and family, ‘Hey, they have a computer that makes sure you get the right medication,’” he says. “It makes the patient feel safer and they are very accepting of it.” Bottom
Line “I think it’s important to note that from our experience we have definitely prevented medication errors,” she says. “We can run reports, analyze info, and, if medication was delivered incorrectly, we can track where the error occurred. We continue to have staff report actual errors and those have dropped dramatically, while reporting of near-miss situations has remained relatively constant.” Other success stories include Lancaster (Pa.) General Hospital, which has demonstrated a 54% reduction of medication errors through the use of bedside barcoding technology as measured by direct observational methodology, according to Wisz. In terms of costs, Wicz says a white paper was developed to generalize costs across a number of different approaches or situations for overall implementation of a bedside barcoding system. It showed that for a 500-bed hospital, an overall implementation, including software, hardware, and hospital labor costs, could be as high as $1.9 million. —
Robbi Hess, a journalist for more than 20 years, is a writer/editor
for a weekly newspaper and monthly business magazine in western
New York.
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