Bar-Coding
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
per 100 Adjusted Admissions
4.5
4.0
3.5
80% Reduction in
Medication Errors
3.0
2.5
2.0
1.5
1.0
0.5
0.0
'92 '93 '94 '95 '96 '97 '98 '99 '00 '01 '02
Med Errors Compared to CMI
2.0
5.0
4.0
3.0
1.5
1.0
2.0
1.0
0.0
0.5
0.0
1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002
CMI
MedError
Med Errors Compared to
RN Turnover
30
25
20
15
10
5
0
1992
1993
1994
1995
1996
1997 1998
Med Errors/100 Admits
1999
2000
2001
2002
% RN Turnover
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
MEMBER 20
MEMBER 13
MEMBER 7
37%
MEMBER 1
42%
MEMBER 8
46% 46%45%
MEMBER 3
MEMBER 5
MEMBER 19
50% 49%49%
MEMBER 12
MEMBER 11
MEMBER 10
65%
60%
56% 56% 55% 55%
54% 53% 52%
MEMBER 14
MEMBER 9
MEMBER 4
MEMBER 18
MEMBER 16
MEMBER 6
MEMBER 2
MEMBER 15
MEMBER 21
MEMBER 17
ISMP Survey Results
December 2000
34%
ISMP Survey Results
2003 Compared to 2000
Concord Hospital - At a Glance
(photo by Rixon Photography)
Concord 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
& Medication Safety
as 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
Administration Safe at
Concord 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
MEDICATION ADMINISTRATION PROCESS
Right Patient, Right Medication, Right Time, Right
Dose, Right Route
1
2
Purchasing &
Inventory
Unit Dose Prep
4
Pharmacy
Order Entry
7
RN Prepares
To Administer
3
MD
Order
5
6
Medication
Preparation
Medication
Dispensed
8
Medication
Administered
To Patient
9
Monitoring &
Follow Up
Components of Medication
Bar-Coding 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 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”
in a Complex Process
1
2
Purchasing &
Inventory
Unit Dose Prep
3
MD
Order
4
5
6
Pharmacy
Order Entry
Medication
Preparation
Medication
Dispensed
7
8
9
RN Prepares
To Administer
Medication
Administered
To Patient
Monitoring &
Follow Up
“Hidden Benefits” of Medication
Bar-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 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 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
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
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?
 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
It Really Matter?
The Victims of a Medication Error
1.) The Patient
2.) The Nurse
Lessons 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 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!