Bar-CodingBar-Coding at the Bedside at the Bedside

Presented by:

Diane W. Allen, RN, MS, CNOR

Chief Nursing Officer & VP of Operations

Concord Hospital

Concord, New Hampshire

Our Results . . .

Medication Errors Medication Errors per 100 Adjusted Admissionsper 100 Adjusted Admissions

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

4.0

4.5

'92 '93 '94 '95 '96 '97 '98 '99 '00 '01 '02

80% Reduction in Medication Errors

Med Errors Compared to CMIMed Errors Compared to CMI

0.0

0.5

1.0

1.5

2.0

1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 20020.0

1.0

2.0

3.0

4.0

5.0

CMI MedError

0

5

10

15

20

25

30

1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002

Med Errors/100 Admits % RN Turnover

Med Errors Compared to Med Errors Compared to RN TurnoverRN Turnover

ISMP Survey ResultsISMP Survey ResultsDecember 2000December 2000

65%60%

56% 56%55% 55%54% 53%52% 50% 49%49%46% 46%45%

42%37% 34%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%M

EMBE

R 17

MEM

BER

21

MEM

BER

15

MEM

BER

2

MEM

BER

6

MEM

BER

16

MEM

BER

18

MEM

BER

4

MEM

BER

9

MEM

BER

14

MEM

BER

10

MEM

BER

11

MEM

BER

12

MEM

BER

19

MEM

BER

5

MEM

BER

3

MEM

BER

8

MEM

BER

1

MEM

BER

7

MEM

BER

13

MEM

BER

20

ISMP Survey Results ISMP Survey Results 2003 Compared to 20002003 Compared to 2000

ConcordConcord Hospital - At a GlanceHospital - At a Glance(photo by Rixon Photography)(photo by Rixon Photography)

Concord Hospital - At a GlanceConcord Hospital - At a Glance

295 bed not-for-profit regional medical center

Located in the capital city of Concord, NH

2nd busiest acute care hospital in New Hampshire

Serving approximately 150,000 patients

Regional referral center for:

• Orthopaedic Services

• Cardiac Services

• Women’s Health

• Comprehensive Cancer Services

Clinical Technology Development Clinical Technology Development & Medication Safety & Medication Safety

as Organizational Prioritiesas Organizational Priorities 2001: One of “10 Most Improved”

• HHN “Most Wired” Hospitals & Health Care Systems 2001: VIP Award for Clinical Achievement

• Awarded for reduction of medication errors

• McKesson Corporation 2002: One of 100 “Most Wired”

• HHN “Most Wired” Hospitals & Health Care Systems 2002: Cheers Award for Safe Medication Practice

• Institute for Safe Medication Practices 2003: One of 100 “Most Wired Small & Rural”

• HHN “Most Wired” Hospitals & Health Care Systems

Making Medication Making Medication Administration Safe at Administration Safe at

Concord HospitalConcord Hospital

STAR Pharmacy System

Decentralized Pharmacist Role

Bar-Coding of Medications at Bedside

Medication Administration Process PI

•VHA Collaborative

•ISMP Survey

•IHI Quantum Leaps in Patient Safety

Purchasing &Inventory Unit Dose Prep

PharmacyOrder Entry

1 2 3

MedicationPreparation

MedicationDispensed

RN PreparesTo Administer

MedicationAdministered

To PatientMonitoring &

Follow Up

4 5 6

7 8 9

MEDICATION ADMINISTRATION PROCESSRight Patient, Right Medication, Right Time, Right Dose,

Right Route

MDOrder

Components of Medication Bar-Components of Medication Bar-Coding SystemCoding System

Bar-Code Label affixed to all individual med doses

Online Medication Administration Record as

part of Clinical Documentation System

Laptop computers with bar-code scanners -

”COWS”

Proxim 2mb/sec Wireless Network

Bar-Coding at the Bedside

Bar-Coding at the BedsideBar-Coding at the Bedside

The Nurse

Scans Bar-Code on ID badge to log on and as “signature”

Selects patient online

Selects and reviews medication order online

Scans Bar-Code on medication

Bar-Coding at the Bedside

The Computer

Matches Bar-Code to medication order

Checks 5 rights of medication administration

& notifies nurse of any discrepancies

Documents medication administration

Charges patient for medication

Reminds the nurse of missed and late

medications

The “Final Line of Defense” The “Final Line of Defense” in a Complex Processin a Complex Process

Purchasing &Inventory Unit Dose Prep

PharmacyOrder Entry

1 2 3

MedicationPreparation

MedicationDispensed

RN PreparesTo Administer

MedicationAdministered

To Patient

Monitoring &Follow Up

4 5 6

7 8 9

MDOrder

““Hidden Benefits” of Medication Hidden Benefits” of Medication Bar-CodingBar-Coding

Enhanced Reporting Capabilities• Support PI & education activities

Recruitment & Retention• Appeal of “high tech” environment• Recognition of patient safety/safe work

environment as important retention factors

Implementation ProcessImplementation Process

6-8 month planning process Extensive Staff Involvement & Champions Pilot Unit

• Developed standard procedures

• Implemented Meds & IVPB’s only on first unit

• Resolved “bugs” & “glitches” Intense 24 x 7support by expert resources Timely roll out to other units Formal evaluation at 3-months & 6-months

Early ChallengesEarly Challenges

Redesign of med administration process

Uncovers practice issues• Belief systems & assumptions

• Need to differentiate from “computer” issues

Lack of commercially prepared individual med doses with bar-code labeling

What Have What Have We Done Lately?We Done Lately?

Increased utilization of Bar-Coding

• Decreased work arounds and “shadow system”

• Upgraded scanners to newer more effective technology

• Improved quality of Bar-Coding labels Reinforcement of importance of Bar-Coding Implemented Bar-Coding on Maternity and AM

Admit Unit

What Have What Have We Done Lately?We Done Lately?

Executive Walk Arounds

Blameless Culture and Anonymous reporting• Focus on Near Misses as Opportunities to

prevent errors• Balance with accountability

Birthdate as 2nd identifier for med admin and other key processes

Standardized Abbreviations

Where are We Going?Where are We Going?

Bring med carts closer to patients & Bar-Code

scanning equipment

Educate & involve patients in the process

Implement bar-coding in PACU, Cardiac Cath

Lab & Outpatient Units

Implement hand-held devices for scanning

patient ID bands

Implement CPOE

Why Does Why Does It Really Matter?It Really Matter?

The Victims of a Medication Error

1.) The Patient

2.) The Nurse

Lessons LearnedLessons Learned

Don’t underestimate the magnitude of the

implementation

Recognize that technology solves some

problems but creates others

A strong Pharmacy-Nursing relationship is

essential

Don’t pilot on a specialty unit

Standardization of med times across all units is

essential

Lessons LearnedLessons Learned

EVERYONE needs to understand “The WHY”

Accept you are never done

We are better than we were yesterday but not as good as

we will be tomorrow!