Bedside Bar Codes: Protecting Patients and Nurses
Cherie Galusha , RN, MSN ( http://www.shmc.org/),
Mary-Michael Brown , RN, MS
and Jamie Kelly, BA ( http://www.bridgemedical.com/)
Human factors are frequently to blame for medical errors (Kohn, Corrigan, Donaldson, 1999). The incidence of error increases when facilities are understaffed and nurses are forced to manage higher workloads (Whitman, Kim, Davidson, Wolf, Wang, 2002). Tragically, human error in the medication administration process can result in patient injury and death, loss of licensure and livelihood for nurses, and additional financial burden for institutions. Acknowledging the existence of unavoidable human error and providing caregivers with tools to intercept potentially harmful activities at the bedside before patient harm results targets these patient safety concerns.
Bar code point-of-care (BPOC) technology reduces and prevents bedside misadventures. Using a bar code scanner and a computer software application, nurses can verify the five rights of medication administration, access clinical decision information, and gain visibility to real-time medication orders at the point-of-care. With proper instruction and use of BPOC systems, hospitals supply the tools to enact positive safety initiatives for patients and nurses.
Key words: adverse drug events, bar code point-of-care, information technology, medication errors, patient safety
The concern for patient safety continues to pepper news reports, personal conversations, and professional healthcare publications (Goldstein, 2003; Clancy, 2003; Clarke, 2003; LaPoint, Jollis, 2003, Manasse, 2003). Americans now view hospitals as danger zones. This, of course, is not news to nurses who are all too aware of the risks of patient care; especially those inherent in the medication use process. The reality is that errors negatively impact good people and good nurses. This article describes the medication error problem, addresses the depth of technology to prevent errors, considers the utility of bar code technology to reduce and prevent nurse-related errors (medication, blood, specimen collection) and explores the role of the nurse in adapting this technology to clinical practice.
According to the U.S. Pharmacopoeia (2002), primary factors contributing to medication errors are distractions and workload increases, many of which may be a result of today's environment of staff shortages and cost containment. Ironically, medication errors only worsen the cost equation. Hospitals pay for errors in increased lengths of stay, treatment costs and litigation (Bates, Spell, Cullen, Burdick, Laird, Petersen, 1997; Classen, Pestotrik, Evans, Lloyd, Burke, 1997; Weeks, Waldron, Foster, Mills, Stalhandske, 2001; Shannon, Boxold, 2002). Patients pay dearly by experiencing pain, disability, and even loss of life. In many cases, there is a nurse involved who will pay with his or her career through administrative reprimands and license revocation. But even if the nurse escapes allegations of negligence, he or she may despair indefinitely having contributed to a medication-related injury or death.
It is encouraging to witness a growing understanding that medication use in hospitals is a complex process rife with failure points (Kohn, Corrigan, Donaldson, 1999; Schneider, 2002). However, for all of the recognition about systems' errors, hospitals continue to place nurses in the vulnerable position of delivering potentially errant doses day after day with no safety net except constant reminders to "be careful and follow policy." While patient advocacy may be at the core of a nurse's professional commitment, errors continue to reach and harm patients. This paradox may be due, in part, to the fragmented use of information technology in healthcare ( Institute of Medicine , 2001; Kilbridge, 2002; Bates, 2002).
Missing Link at the Point-of-Care
Several technologies to enhance medication safety include unit-dose distribution, pharmacy automation, and the development of computerized prescriber order entry systems (George, Emons, Uchida, Kosecoff, 2002; Bates, 2000). These technological innovations support all phases of the medication use process with one exception-- at the point-of-care where nurses administer medications to patients. As the number and complexity of drug treatments grow, physicians and pharmacists now use electronic reference material to aid them in prescribing and reviewing medication orders. The order entry, transcription and dispensing stages all benefit from technologies designed to detect and prevent errors. Yet, if a nurse prepares to give the wrong medication to a patient, no system is in place to intervene-- making the point of administration the most vulnerable to errors that may harm the patient. This point is underscored by the landmark findings reported in the Adverse Drug Event Prevention Study (Leape, Bates, Cullen, Cooper, Demonaco, Gallivan, et al, 1995).
Leape and his colleagues (1995) studied adverse drug events (ADE) in 11 clinical units at two academic medical centers over a six month period (Leape, Bates, Cullen, Cooper, Demonaco, Gallivan, et al, 1995). These researchers learned that medication errors originate in the different phases of the medication use process in the following proportion: 39 percent during physician ordering, 12 percent during order transcription, 11 percent during medication processing, and 38 percent when a nurse administers a medication. Of interest however, is the interception rate. Over one-half of physician prescription errors and almost one-third of transcription and medication processing errors were intercepted, largely by nurses, before reaching the patient. Regrettably, only two percent of the nurse administration errors were intercepted before reaching the patient.
A recent study emphasizes the extent of medication administration error occurrences (Barker, Flynn, Pepper, Bates, Mikeal, 2002). Barker and his associates observed over 3,200 doses of medications administered in 36 health care facilities in the greater Atlanta and Denver metropolitan areas. These investigators reported that almost one in five medications administered to a patient by a nurse were done so inaccurately. And, up to seven percent of these errors were considered to be potentially harmful by a panel of physicians. The researchers extrapolated that for a typical 300-bed hospital, more than 40 potential and preventable ADEs are committed each day.
Bar code point-of-care protection
Bar code technology is present in many venues, including grocery stores, retail shops, and libraries. (Thompson, 2002). It offers exceptional accuracy and speed when compared with manual entry methods (Yang, Brown, Trohimovich, Dana, Kelly, 2002). Recognizing the considerable risks associated with medication administration, a bar code point-of-care (BPOC) patient safety system has evolved to act as a bedside sentry on the lookout for potential errors and provide a safety net where none previously existed. The initial inspiration of coupling bar codes with medication administration is credited to an Eastern Kansas Veteran's Affairs Medical Center nurse and is now commercially available to safeguard and facilitate medication administration, blood transfusion and laboratory specimen verification (Wiebe, 2002).
Recently, the US Food and Drug Administration proposed national bar code label requirements for human drug products (US Food and Drug Administration, 2003). The proposed rule calls for linear bar codes on drug labels for hospital use. The FDA expects to rule on this proposed use of bar code labels by November 2003 (Kasey, 2003). If accepted, the rule becomes effective three years after the publication of the final rule (FDA, 2003).
BPOC software applications vary in their functionality but the most advanced systems use touch screen and bar code scanning technology to provide up-to-the-minute information on medication orders, patient allergies, administration history, clinical observations, specimen draw lists, transfusion orders and more. A BPOC system uses a laptop or handheld bedside computer to communicate data, real-time, with other hospital information systems, including patient orders and registration systems via a dedicated server. The BPOC server, through interfaces constructed between other information systems (admission-discharge-transfer, pharmacy, billing, electronic-prescriber-order-entry) permits communication between the point-of-care software and the other information systems. For example, as a physician's order is reviewed, verified, and entered into the pharmacy computer system, this transaction is communicated via an interface to the dedicated server. This message is then sent to the bedside software, real time, and alerts the nurse that a new medication or a change in a medication has just occurred. In some systems, as the nurse confirms this order or order change, the new medication is automatically and electronically transcribed to the medication administration schedule.
Each medication must be mapped to a specific barcode in the hospital formulary for recognition by the bar code scanner. Although bar code labeling all medications is desirable, it may not be practical. Hence, some BPOC systems permit the nurse to select, rather than bar code scan, a medication. Systems providing bar code scanning compliance reports offer insight into the number of times a nurse selected a medication and compares this number to the times s/he could have actually scanned the medication.
Results of an Institute for Safe Medication Practices field test indicate that many stand-alone pharmacy information systems fail to detect potentially lethal orders, including doses that exceed safe limits (1999). Therefore, total reliance on a pharmacy information system (PIS) to buffer medication administrations from prescription and transcription errors is ineffective. With mounting demands placed on a decreasing number of hospital pharmacists, whose personal diligence must intercept errors that pass through the PIS system, some mistakes are bound to escape notice. As a result, the minimum standard of practice for medication administration is checking the "five rights" (right drug, patient, dose, time and route).
BPOC technology automates the “five rights” check by prompting the nurse to bar code scan his or her name badge, patient identification wristband to access the patient's medication profile, and medication to verify that the drug, patient, dose, time and route all match. These checks are done at the point-of-care just prior to the actual administration, not at the automated dispensing cabinet, a practice that can easily lead to a bedside error.
While scrupulously validating the “five rights” supplements error avoidance activities, medication mishaps involving allergies and drug effects are not prevented by merely checking the five rights. Advanced BPOC systems incorporate clinically relevant decision support information related to high-risk situations such as look-alike/sound-alike drug names, patient allergies, and clinical guidance regarding the effects and undesirable effects of some medications.
A realistic example of a near-miss averted with a BPOC system is illustrated by this scenario. A nurse accessed a patient's medication orders and noted that the patient was to receive glyburide (Diabeta) 5 mg by mouth every day. As the nurse began to administer this medication, she scanned the medication thought to be glyburide. The BPOC system responded with a "no order in system" alert for glyburide. Upon closer inspection, the nurse realized that she had scanned a package of glipizide (Glucotrol) that the pharmacy had inadvertently dispensed in the place of glyburide. As well as being from the same drug classification, these two generic drugs, which were not considered therapeutic substitutions, have similar sounding names and nearly identical packaging.
Another desirable feature of BPOC is the system's electronic medication administration record (eMAR). The eMAR provides a real-time record that reflects an accurate, contemporary view of the medication administration history, rather than a pharmacy snapshot provided at various intervals throughout the day. All new medication order information entered into the pharmacy system is instantaneously sent to the patient bedside, updating clinicians on adjustments made to a patient's orders and preventing administration of doses after an order is modified or discontinued. Further, the BPOC system provides a printable, legal medication administration record for inclusion in the patient medical record.
Blood Transfusion & Laboratory Specimen Verification
Like medication administration, the transfusion of blood products presents additional bedside risks to patients. The primary reason for an acute hemolytic blood transfusion reaction is administering the properly labeled blood to the wrong patient ( Linden , Wagner, Voytovich, Sheehan, 2000; Myhre, McRuer, 2002). Creators of BPOC systems recognize these risks and provide checks to ensure patients receive the specific unit of blood that was typed and cross-matched for them before transfusion takes place. This BPOC feature can help avoid patient identification errors by positively verifying the patient's bar coded wristband with the patient's identification, blood product, and blood type on the blood component container labeling. The BPOC system prompts the user to electronically record the patient's vital signs at hospital recommended sequences before, during, and following the transfusion. The BPOC system permits documentation of any transfusion reaction episode and provides this report at the bedside on an adhesive label that is easily applied to a transfusion record and placed in the patient's chart.
The use of BPOC in transfusion activities has made it possible to reliably check blood by one nurse, instead of two, meet the American Association of Blood Banks standards for positive patient identification, and safely transfuse blood components while electronically capturing key data, including vital signs and transfusion reactions (Marconi, Langeberg, Sirchia, Sandler, 2000; Sandler, Langeberg, 2002). Similarly, nurses can use BPOC verification to enhance the accuracy of specimen collection. The system can provide a permanent link between the patient and laboratory specimen that eliminates specimen identification errors by positively identifying a patient and linking the patient to active laboratory orders. The system can then generate a bar-coded specimen container label using a small, portable printer, at the bedside, while capturing all necessary documentation of the collection process.
A fully computerized eMAR eliminates illegible notations and can reduce end-of-shift overtime by automating order confirmation and medication documentation. In the traditional updating process, the pharmacy-transcribed order may go unseen until the night shift nurse performs a manual MAR reconciliation. An incorrectly transcribed order could result in several errant administrations prior to being detected by the night nurse. Because BPOC systems are real-time, new orders entered into the pharmacy information system, are posted for confirmation whenever a nurse initiates the computerized medication administration process. Medication documentation occurs only after the nurse confirms the patient has received the medication.
A real-time view of current orders allows a nurse to immediately verify that the pharmacist's order interpretation matches the physician's intended order. The value of real-time reconciliation is illustrated by this example. A patient had a dose appearing on the bedside BPOC screen for dalteparin (Fragmin) 9,000 units subcutaneously twice each day. The nurse selected the order on the screen and received the warning: "Unconfirmed Order Discontinued." The nurse cancelled the transaction, confirmed the discontinued order with the pharmacy and did not give the medication. This real-time reconciliation process not only saves time, but also enhances the medication use process by giving you immediate visibility to current order information.
There are occasions, such as STAT orders, when a medication must be administered prior to the order's entry into the pharmacy system. A well-designed BPOC system allows the nurse to either bar code scan or select the medication on the computer, but it will issue a warning that there is "no order in system". When the order eventually arrives at the pharmacy and is processed, the nurse is able to “link” the order with the “orphan” administration. The BPOC system provides a list of medications that has the same generic name and dosage forms as the order from which the nurse select the appropriate match. The nurse can link any administrations that should be associated with the order. The hardcopy MAR will then show these administrations linked to the appropriate order. While this process is more involved than a standard administration, linking allows for the correct documentation of first doses and STAT orders as well as the safety checks reliant on accurate previous dose data. If however, the associated order has not been linked within 24 hours, the “no order in system” activity is stored as a possible medication error. Conversely, if after receiving a BPOC generated warning, the nurse cancels out of the transaction and does not administer the medication, this activity is recorded as a possible prevented error.
Because the eMAR is a retrospective document, the nurse does not interact with it in the medication administration process. The nurse therefore will need a tool that gives visibility to medication orders and due times without logging into the computer. BPOC systems can generate a worksheet for this purpose. The shift configurable worksheet displays all confirmed medications in a concise, chronological format intended to help the nurse organize workflow. This worksheet is designed as a tool for use when taking change-of-shift report as well as for medication administration. Nurses can use this worksheet throughout their shift to manage medication administration activities and changes. The worksheet displays all active and future orders confirmed in the system but only displays the doses that are required for administration for the designated shift.
Nurses may appreciate the difference that BPOC technology makes in their work as soon as the system is implemented. However, point-of-care protection is not the only benefit. The system collects a wealth of data that can be analyzed in the reports application to yield significant value to process improvement projects. Point-of-care data enables analysis of the incidence and nature of near-miss situations as well as possible errors. A complete archive of administration data is available to supplement inventory, billing, cost containment, quality improvement, formulary management and other macro-institutional initiatives.
The nurse's role in perfecting safety systems
Perhaps the most visible proponent of BPOC system use may be the Veterans Affairs Medical Centers (VAMC). The VAMC hospitals utilize an internally developed (non-commercially available) system called “Bar Code Medication Administration” (BCMA) to aid nurses when administering medications and to reduce medication errors that may reach the patient. The VAMC has published results indicating that BCMA has reduced medication administration errors by up to 86 percent (Johnson, Carlson, Tucker, Willette, 2002). Still, the system continues to evolve as the VAMC hospitals gain insight into their own medication use process.
Researchers recently investigated the VAMC's use of the BCMA system and found that design flaws, training deficiencies and a lack of policy and procedure changes needed to govern the new technology's use, contribute to system side effects that may actually induce potential ADEs (Patterson, Cook, Render, 2002). The authors cite several limitations of the BCMA system which hinders nurses including: (1) confusion caused by automatic removal of some medications, (2) reduced coordination with physicians, (3) nurses dropping activities to reduce workload during busy periods, (4) increasing priority of BCMA system in conflict with patient care needs and (5) difficulty of pharmacy to easily enter tapered doses (Patterson, Cook, Render, 2002). These challenges are not inherent to all BPOC systems. As described in this article, other systems offer order clarification functionality, nursing worksheets, real time electronic MAR access and other features that reduce possible side effects like those found in the VAMC system.
Nurses play the primary role in identifying possible medication-related side-effects, particularly if systems' issues force deviations from common medication administration workflow or established policies. As the end users of these systems, nurses must be empowered and motivated to provide feedback and aggressively seek system improvements that facilitate ease-of-use and further patient safety. As such, nurse participation is essential to the interdisciplinary effort required to successfully implement BPOC technology in a hospital.
Today's hospital environment can test a nurse's fortitude and dedication on a daily basis. Even the most fail-safe technology cannot shelter clinicians completely from the risks associated with long shifts and burdensome patient assignments. However, the implementation of point-of-care patient safety technology offers error protection for the nurse and his or her patients. The data generated by BPOC highlight failure points in processes that jeopardize the safe administration of medications and dispel misconceptions about the role of nursing negligence in ADEs. Ultimately, a BPOC system can offer a safety net as nurses continue to push for changes that reduce clinical vulnerability at the point-of-care.
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Cherie Galusha RN, MS
Ms. Galusha is coordinator of the barcode medication verification (BMV) program at Sacred Heart Medical Center (SHMC) in Spokane , Washington . She earned a baccalaureate degree in Nursing from Southern Adventist University and a Master of Science degree in nursing from the University of Florida . Her expertise is in nursing education, having taught at the associate and baccalaureate level for 17 years, and serving as program chair for six of those years. More recently, she brought those skills to the acute care setting as the bar code medication verification (BMV) system was developed, tested, and implemented. SHMC is a 623-bed facility where the BMV system is used by approximately 1500 caregivers to enhance medication safety for patients.
Mary-Michael Brown RN, MSMs. Brown is a senior clinical consultant with Bridge Medical in Solana Beach , California . She has spent over 20 years in the clinical setting as a critical care nurse, nurse manager, and clinical nurse specialist. She held the CCRN credential from 1982-2001. Ms. Brown earned her baccalaureate degree in nursing from Georgetown University and her master's degree in acute care nursing from Boston College . During a two-year tenure with APACHE Medical Systems, Ms. Brown analyzed critical care data and assisted clients with outcomes management improvement projects. She is currently applying her clinical experience and interest in data by analyzing medication error information using the Bridge suite of patient safety information technology solutions.
Jamie Kelly BA
Jamie Kelly is the director of marketing for Bridge Medical, Inc., a provider of patient safety solutions. Prior to joining Bridge, she served as a marketing manager for Marconi Medical Systems, a manufacturer of diagnostic imaging equipment. She is a recipient of the Hammer Award from former Vice-President Gore's National Partnership for Reinventing Government for her quality management work with the National Resources Conservation Service. She is the editor of the “Point of Care,” a bi-monthly electronic update of news and events related to point-of-care safety subscribed by over 1600 healthcare providers, leaders, researchers and policy makers. Ms. Kelly holds dual degrees in Political Economics and Japanese language form Michigan State University .