Manic for Medication Safety

Feb. 1, 2007

Bar codes and drug information databases are helping to reduce medication errors

The tragic deaths last September of three premature newborns who were mistakenly given an adult dose of heparin in an Indianapolis hospital did more than just make headlines. It also served as a stark reminder that too few healthcare organizations have in place adequate safeguards that can prevent medication errors.

Bar codes and drug information databases are helping to reduce medication errors

The tragic deaths last September of three premature newborns who were mistakenly given an adult dose of heparin in an Indianapolis hospital did more than just make headlines. It also served as a stark reminder that too few healthcare organizations have in place adequate safeguards that can prevent medication errors.

Those who give more than lip service to issues of patient safety know that they not only have to invest in new technologies, but they also need to regularly review and update their policies and procedures pertaining to the ordering and distribution of medications. While errors can occur at any point along the route, from the physician’s initial order, to the filling of carts in the pharmacy, to the administration of meds by nurses at the bedside, it is at the point of care that clinicians can establish a last line of defense.

Not surprisingly, implementation of bar-code technology at the bedside is proving to be an effective way to reduce most medication errors. “The benefit is that it’s at the end of the pipeline and most likely is going to catch everything coming down that pipeline,” says Jim Douglas, R.N., clinical systems administrator at Northern Michigan Hospital in Petoskey, Mich. Douglas says that in 2006 alone, the hospital reduced medication errors by 5,744 and prevented 400 serious medical errors, including two that would most likely have been fatal. Since beginning the implementation of the Cerner Bridge Medication Administration point-of-care technology in 1998, more than 21,000 medication errors and a total of five fatalities have been avoided.

Bar Coding for Safety
At 243 beds, Northern Michigan Hospital has about 120 physicians with privileges, 450 registered nurses and 15 pharmacists. But as is the case with most hospitals, the hand-off of patient information during a normal shift change can be sketchy at best. To ensure that nurses coming on to the floor are apprised of each patient’s status and any medications already administered, the Joint Commission on Accreditation of Healthcare Organizations mandated hospitals establish standards for effective shift transfer communication.

One of the most serious oversights has always involved the amount of drugs being administered and the time frame during which they should be given, says Douglas. This often involves pain management drugs that can be given near the end of one shift, and then administered again at the beginning of the next shift if the patient is still in pain.

But another common overdose involves insulin. “Forty percent to 60 percent of patients in most hospitals are on insulin, which reflects the diabetes epidemic in this country,” says Douglas. Here again, he says, is where confusion at shift change—a misread order, or a case where “the L.P.N. gave it, but didn’t tell the R.N.”—can have dire consequences. Since the point-of-care bar-code scanning system alerts the nurse as to all previously administered medications based on the five rights (right patient, right medication, right dose, right time and right route), these kinds of overdoses are avoided. In fact, according to Douglas, 176 insulin-related errors, including 69 that were considered serious errors, were prevented in 2006. In addition, from July 2006 to the end of the year, more than 102 sound-alike errors also were avoided.

The move to a point-of-care bar-code solution proved to be a logical next step for this hospital. “We had done everything we could do in a paper world to reduce medication errors,” Douglas says.

At a time when few vendors offered this type of technology, Northern Michigan Hospital purchased the bar-code scanning system from Solana Beach, Calif.-based Bridge Medical Inc., which was subsequently acquired by Kansas City, Mo.-based Cerner Corp. It took about two years before the system was ready to roll out at Northern Michigan Hospital because interfaces had to be written, medications had to be bar coded and nurses had to become familiar with a new way of administering meds. When the system finally went live on Halloween 2001, Douglas says, “Some nurses thought it was a treat, while others thought it was a trick.”

Smoothing Human/Technology Interaction and Integration
Probably the biggest challenge was getting nurses who had never interacted with a computer to start interacting with a computer all the time. “We tried to get them to use the computer to look at the most pertinent information,” says Douglas. After hours of hands-on training and then actual use of the system, the nurses began to see the benefits of bar coding, although some still felt that the scanning process added another step and would take more time. “It took about two years to move from ‘Why would I scan?’ to ‘Why wouldn’t I scan?’” Nurses were told that while scanning might take a little longer at the front end, in the long run it might save time because they wouldn’t be filling out as many occurrence reports for medication errors and caring for overdosed patients.

Systems integration also posed a challenge. Initially the hospital had to write interfaces to the pharmacy’s information system, which emanated from another supplier, but last spring the pharmacy converted over to Cerner’s Millennium PharmNet. Since pharmacists now have access to the wireless, Web-based bedside scanning system from workstations in the pharmacy, they can see exactly what time and what dosage of a medication was given to any patient. Because the data is in real-time, dosing changes can be made before the next scheduled dose is to be administered.

Obviously, this point-of-care solution has dramatically reduced medication errors at Northern Michigan Hospital. But, it also has been a cost-effective solution. Serious medical errors could result in a patient spending one or more additional days in the hospital, which hospital administrators have estimated at about $2,600 per day. Less serious errors can cost about $10 each in labor which, according to Douglas, is based on the time it takes to “package up a wrong dose, take it back to the pharmacy and get the right dose back into the nurse’s hand.” Given the possible expenditures for extra patient days and labor costs, the hospital estimates it will have saved more than $1 million in 2006.

Improving on an Already Good Patient Safety Record
When it comes to getting drugs from the pharmacy to the nurse in the safest and most efficient manner, bar-code technology and automated devices are playing a larger role. Chambersburg Hospital in Chambersburg, Pa. is a not-for-profit, acute care hospital with 247 beds and a medical staff of 169. It also has a staff of eight full-time pharmacists, two full-time pharmacy managers, five full-time pharmacy technicians and six part-time pharmacy technicians.

David Grant, R.Ph, M.B.A., director of pharmacy and respiratory care, says that in February 2005, through a partnership between the pharmacy and information services departments, the hospital implemented an automatic medication storage and retrieval system. It also implemented an oral solid repackaging system from Mountain View, Calif.-based Omnicell Inc. and began the process of implementing an eMAR/BMV (Electronic Medication Administration Record/Bedside Medication Verification) system from Westwood, Mass.-based MEDITECH in April 2006.

The combination of the two systems reduced the time it takes to fill medication carts, reduced dispensing errors and improved overall safety at the bedside. “Our error rates were within industry standards to begin with,” says Grant. “However, our reported error rate in January 2006 was 0.05 percent, with 12 percent of those being dispensing. As of September, our reported error rate was 0.03 percent, with 3 percent of those being dispensing on total monthly doses that average 110,000.” Since the bulk of the eMAR/BMV processes rollout was recently completed, the impact has not been fully realized, he notes.

At the heart of the new pharmacy system is the Omnicell WorkFlowRX, which integrates an automated storage and retrieval carousel (PharmacyCentral) with a tablet/capsule repackaging device (SafetyPak). The automated and password-protected carousel system has 20 levels from which meds can be selected. The repackaging system, which has a footprint of only 25 square feet, can handle up to 500 different tablets or capsules. By integrating these systems with the OmniRx medication dispensing cabinets, the pharmacist is better able to ensure that the right medication will get to the right patient. “Whenever a pharmacist enters an order, it shows up on a picking queue so the technician is directed to the right level,” Grant explains.

A No-Paper Cart Fill
Because the carousel revolves automatically, the drugs come to the technician instead of the technician having to hunt for the drugs. This has made filling carts more accurate and efficient. “Our cart fills used to take 15 to 18 man-hours,” says Grant. Since it used to be a paper-based process, each and every medication had to be picked by hand and placed in the patient carts.

For a while, paper lists were still used. But when everyone felt comfortable with the automated system, the pharmacy went forward with at least a one-day trial and initiated a day with a no-paper cart fill. “We have not looked back since,” says Grant. Because carts are delivered at 3 p.m., the trial cart fill began at noon. In an hour and a half, the job was complete. Grant says that the average time still runs between 90 minutes and two hours. In addition, he says, “Our drug costs per patient day have declined, allowing us to reduce our budget by 7 percent.”

The new system also has allowed the pharmacy to better manage its inventory because it tracks the medications used against the inventory and indicates when supplies are low. “We create a suggested order everyday at noon and it’s automatically uploaded to our wholesaler,” Grant says.

Admittedly, there were some challenges in rolling out this pharmacy system. The biggest headache that affected both the carousel system and, ultimately, the eMAR system, revolved around bar codes. “The FDA rule did not enforce narrow standards for bar codes on pharmaceuticals,” Grant says. Also, the rule fell short in enforcing that each tablet/capsule had to have a bar code from the manufacturer. “We had to find a way to apply our own bar codes efficiently. By using SafetyPak, Chambersburg Hospital has been able to do 85 percent of its own bar coding of oral solids,” Grant says.

e-Prescribing for Safety
Having a patient’s medication history and clinically relevant drug information at your fingertips can dramatically reduce medication errors even before an order is written. For Gregory James, D.O., M.P.H., medical director of Sun Coast Family Care Center in Largo, Fla., a new hand-held solution not only provides him with vital information, but also wireless e-prescribing capabilities.

Developed by Tampa, Fla.-based Gold Standard Inc. and available through Informed Decisions LLC, a subsidiary of Gold Standard, the eMPOWERx uses a pocket PC/PCS phone to provide the clinician with preferred drug lists or formularies; real-time, patient-specific prescription histories; medication alerts for interactions, allergies and other health drug issues; relevant drug information; and, an interaction reporting tool from Clinical Pharmacology, Gold Standard’s electronic drug information and medication management resource. Because it utilizes a secure wireless network, prescriptions can be sent directly from the point-of-care to the pharmacy.

As a Doctor of Osteopathic Medicine, James has the same prescribing rights as any M.D. and eMPOWERx enables him to select the correct drugs for his patients. Getting between 8,000 and 10,000 patient visits per year, Sun Coast Family Care Center is owned and operated by Sun Coast Hospital in Largo, where James also serves as the Family Practice Residency Program Director. The nonprofit, 45-year-old hospital is licensed for 200 beds, and James’ clinic operates primarily as a teaching site for interns and residents. Interestingly, James says about 30 percent to 40 percent of his patients are on Medicaid and between 25 percent and 30 percent are on Medicare.

The fact that so many of these patients are on Medicaid actually became a plus for the successful operation of eMPOWERx in this practice. “Every time a Medicaid patient fills a prescription, their data gets entered into the system,” James says. “As long as they use their Medicaid card when filling a prescription, their medication history can be accessed via eMPOWERx.” This is an added benefit since the system also alerts the doctor when it is time to refill a patient’s prescription. If he orders the refill, that order is automatically sent to the pharmacist, who then contacts the patient.

But the biggest benefit, according to James, is the wealth of drug information he can access prior to entering an order. “I can access eight or nine different formularies, so I can get the patient on the right medication right out of the box.” In addition, because the system reviews therapeutic alternatives for non-preferred drugs, it asks James if he wants to see an equivalent drug in the formulary.

However, choosing the correct drug is more than just matching a specific medication with a patient’s illness. One of the system’s major benefits is its alert system, which red-flags drug-drug or drug-food interactions and allergies, thus reducing the chances for serious or fatal medication errors. To ensure that physicians have the latest data on all available medications, Gold Standard also provides regular updates to PDLs (Preferred Drug Lists). James began using eMPOWERx about two years ago and found it simple to use, saying that it takes only one or two days to get up to speed. Use of the technology also grew among his students. “I gave the residents the option,” he says. “Only two out of 20 opted out.”

However, there is no opting out when it comes to patient safety. Whether it is scanning a bar code on a medication at the bedside, getting the correct drugs from the pharmacy to the nurse, or checking formularies to determine the most appropriate drug prior to ordering, the primary goal is to reduce medication errors and to prevent tragic outcomes that are still too common in institutions charged with the responsibility of saving lives.

Richard R. Rogoski is a free-lance writer and contributing editor to HMT. Contact him at [email protected].

For more information about: Millennium PharmNet from Cerner Corporation,

WorkFlowRX from Omnicell Inc.

eMPOWERx from Gold Standard

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