unSUMMIT 2011 Presentation (#unSUM11)

I uploaded the presentation I gave Thursday at the unSUMMIT in Louisville, Kentucky. You can see it below, although some of the slides came out a little rough when I uploaded it to slideshare. It looks like it may have something to do with the font I used. If I find time I’ll correct it later.

The presentation focused on the often overlooked things that need to be done following implementation of something like BCMA. Healthcare systems have a bad habit of not providing enough resources, both labor and monetary, to maintain and optimize technology once implemented. I simply suggested five things that healthcare systems could do post-implementation to make sure their BCMA implementation didn’t crumble right before their eyes.

And now that the unSUMMIT presentation has been delivered I am officially retiring from the role of presenter. Unlike some people I know, it takes me a concerted effort and a fair amount of time to put one of these things together, and I just don’t feel like doing it again. Enjoy.

Preparing for the unSUMMIT (#unSUM11)

I’m sitting in a hotel bar in Louisville, Kentucky having a salad as I prepare to register for the unSUMMIT. This is the second year in a row I’ve made the trek to the unSUMMIT. I felt that the experience I had last year was definitely worth a second look.

From the unSUMMIT website:

Conventional summits deliver a something-for-everyone survey of the landscape with little or no depth on any given topic. This warp-speed flight provides only a 30,000-foot view of the terrain below. Nurses, pharmacists, and IT professionals return to the trenches of their own hospitals no better equipped to dig in and implement change.

The unSUMMIT is different. It delivers a steadfast focus on barcode point-of-care technology. Attendees are outfitted with practical tools, insight, and inspiration for leading their institutions to carefully select, implement, and harness the quality-improvement power of BPOC systems.

Truly an unconventional convention, The unSUMMIT is designed to get you out of the clouds and into the weeds, where the union of technology and practice can be more easily realized through the shared expertise of your experienced colleagues.

I think most people believe that the unSUMMIT is nothing more than a bunch of people sitting around talking about BCMA, but it actually goes beyond that. Last year I heard presentations on not only bar-coding medications, but integrations of smartpumps into eMARs, the use of RFID tags, how to conduct observational studies and so on.

This year looks to provide a similarly broad scope of information. While reviewing the list of presentations I saw topics on mobile technology, accountability, technology roadmapping, workflow design and of course a lot of stuff on bar-coding medications.

The unSUMMIT begins officially tomorrow morning. I will be presenting on Thursday, April 28 at 2:00pm. I haven’t decided if I’m going to post the presentation here or not. I’ll let you know.

If you’d like to know what’s going on during the conference you can follow the Twitter stream at #unSUM11.

 

FMEA and BCMA, two acronyms that work well together

During my time as an IT pharmacist I was fortunate enough to be part of two Failure Modes and Effects Analysis (FMEA) groups; one for CPOE and another for BCMA. The FMEA process is labor intensive and time consuming, but well worth the effort in my opinion. In both the CPOE and BCMA instances several important pieces of information were discovered that may have otherwise gone unnoticed.

I don’t often see articles that talk about using FMEAs, which is a real shame secondary to their value. So it was a pleasant surprise to see a recent article in Pharmacy Purchasing & Products on the use of an FMEA post BCMA implementation. I’m not familiar with using an FMEA after the fact, but it makes more sense to me now after reading the article.

According to the author, they “had conducted an FMEA prior to initially employing BCMA; however, we never performed any post implementation follow-up on the system.” An all too common occurrence in healthcare, i.e. implement and forget. We did something similar at Kaweah Delta when I worked there, but we referred to the process as a gap analysis rather than calling it an FMEA. Regardless of the verbiage, the results were similar.

The reason cited for the second FMEA was an increase in errors associated with the BCMA system. “Errors were primarily due to unscannable bar codes, mislabeled medications, the wrong medications being dispensed, and most commonly, nursing staff’s failure to scan.” This sounds familiar. The errors cited are simply side effects of the implement-and-forget mentality. Regardless of the system in place, humans inevitably develop bad habits and workarounds. We need to be constantly reminded to do the right thing. Implementation is only a small part of the work involved with any new system. Follow-up, maintenance and optimization is when the real work begins.

And the results of the second FMEA? “Three months after completing the FMEA, the team compared the before and after scan rates. We found significant improvements in the scanning of both the patients and the medications throughout the system. In addition, we have witnessed a culture change: nurses now become anxious if they cannot scan a product.” Not bad.

Read the article, it contains some good information.

BCMA Technology: Characterization of Med Triggers and Workarounds (Article)

There’s an interesting article in the February 2011 issue of The Annals of Pharmacotherapy dealing with BCMA and what the author describes as “clinical workarounds”.1

Abstract

BACKGROUND: Bar code medication administration (BCMA) technology is gaining acceptance for its ability to prevent medication administration errors. However, studies suggest that improper use of BCMA technology can yield unsatisfactory error prevention and introduction of new potential medication errors.
OBJECTIVE: To evaluate the incidence of high-alert medication BCMA triggers and alert types and discuss the type of nursing and pharmacy workarounds occurring with the use of BCMA technology and the electronic medication administration record (eMAR).
METHODS: Medication scanning and override reports from January 1, 2008, through November 30, 2008, for all adult medical/surgical units were retrospectively evaluated for high-alert medication system triggers, alert types, and override reason documentation. An observational study of nursing workarounds on an adult medicine step-down unit was performed and an analysis of potential pharmacy workarounds affecting BCMA and the eMAR was also conducted.
RESULTS: Seventeen percent of scanned medications triggered an error alert of which 55% were for high-alert medications. Insulin aspart, NPH insulin, hydromorphone, potassium chloride, and morphine were the top 5 high-alert medications that generated alert messages. Clinician override reasons for alerts were documented in only 23% of administrations. Observational studies assessing for nursing workarounds revealed a median of 3 clinician workarounds per administration. Specific nursing workarounds included a failure to scan medications/patient armband and scanning the bar code once the dosage has been removed from the unit-dose packaging. Analysis of pharmacy order entry process workarounds revealed the potential for missed doses, duplicate doses, and doses being scheduled at the wrong time.
CONCLUSIONS: BCMA has the potential to prevent high-alert medication errors by alerting clinicians through alert messages. Nursing and pharmacy workarounds can limit the recognition of optimal safety outcomes and therefore workflow processes must be continually analyzed and restructured to yield the intended full benefits of BCMA technology.

The study described in the article utilized a combination of retrospective analysis and direct observation to identify alert triggers generated by a BCMA system. In addition the study looked at various workarounds utilized by nursing as well as pharmacy. The article is a much more limited version of the one by Koppel in 2008.2

The Annals article identifies some disturbing trends at the Medical University of South Carolina (MUSC) where the study took place. Examples include failure to document override reasons for 77% of alert messages and 468 directly observed workarounds during 121 administration attempts over a 6 hours period. Those number are a sure sign of a poorly designed system and lack of institutional oversight. It certainly has nothing to do with BCMA and the overall effectiveness of the technology. Sounds like some disciplinary action is in order.

One other thing I found unusual in the article was the classification of pharmacy workarounds. “Specific pharmacy workarounds included duplicate orders, lack of medication order verification, medications within the incorrect section of the eMAR (prn vs standard administration time), and incorrectly timed medications causing administration too late/early for the nursing staff.” I’m not sure how you see this, but a duplicate order isn’t a workaround, it’s an order entry error. Same goes for entering an order as PRN instead of SCH. Not sure what the author had in mind when he made the decision to classify these as workarounds. Weird.

  1. Daniel F Miller, Christopher R Fortier, and Kelli L Garrison Bar Code Medication Administration Technology: Characterization of High-Alert Medication Triggers and Clinician Workarounds Articles Ahead of Print published on 1 February 2011, DOI 10.1345/aph.1P262. Ann Pharmacother ;45:162-168.
  2. Koppel R, Wetterneck T, Telles JL, et al. Workarounds to barcode medication administration systems: their occurrences, causes, and threats to patient safety. J Am Med Inform Assoc 2008;15:408-23.

RFID still a solid alternative to barcoding

There’s an interesting article in the most recent issue of Patient Safety & Quality Healthcare (PSQH) about the use of RFID technology in healthcare and what advantages it may offer over current barcoding technology.

I’ve been interested in the use of RFID technology in healthcare for quite some time. I think there’s real value in the use of RFID secondary to the ability to encode significant amounts of information in the tag. The information contained in an RFID tag could potentially include a patient’s medication regimen, allergies and medical condition. The value become obvious when you consider the possibilities during medication administration in the acute care setting.
Continue reading RFID still a solid alternative to barcoding

Standardized Numerical Identifiers (SNIs), say what?

A couple of weeks ago a friend and colleague shot me an email asking me if I’d heard about the new “pedigree stuff on barcoding”. I consider myself pretty well informed for the most part, but I had no idea what she was talking about. Upon further inquiry she sent me a PDF document titled “Guidance for Industry Standards for Securing the Drug Supply Chain – Standardized Numerical Identification for Prescription Drug Packages” (the SNI document). The document is also available in non-PDA format at the FDA website here. I asked other pharmacists about the SNI document while at the Siemens West Coast User Group Meeting on September 16, but no one had a clue what I was talking about; not event the Siemens product manager that was in attendance.
Continue reading Standardized Numerical Identifiers (SNIs), say what?

Laser etched bar-code may help curb counterfeit drugs, among other uses

One Nucleus: “The technique will allow faster identification and resolution of any manufacturing quality problems but will also prove invaluable as an anti-counterfeit measure because the specific coding and validation systems are almost impossible to copy.

Currently most components within diagnostic kits, medical devices and other healthcare products and equipment are ‘stamped’ with a lot code at the point of manufacture. However, these codes are of limited use for quality improvement unless products are produced in very small batches. As a result, regulatory bodies across the world are now putting manufacturers under increasing pressure to invest in much more sophisticated traceability systems, while manufacturers are looking for effective ways to prevent the growing problem of counterfeiting of pharmaceuticals and other healthcare products.

The breakthrough approaches being developed by Innomech will enable manufacturers to mark products with a code that is either unique to the item or shared by only a small number of items produced together.

The codemark is an unobtrusive two-dimensional dot matrix identifier that is linked to a look-up database. In effect the matrix code acts as a ‘key’ to access much more detailed information, such as the specific batch codes of raw materials used during production, the time of manufacture, the production line and so on. A version of the database could be accessible online for anyone to verify the item is genuine.

The codes can be printed or laser etched onto products, applied to virtually any substrate and can even be added onto the surface of pharmaceutical capsules or coated tablets. Matrix codes can be as small as 2 mm by 2 mm holding the code for up to 10 billion numbers. The codes can be read by widely available readers or in many cases from a picture taken with even the simplest camera phone, making them ideal in the battle against counterfeit medicines.”

This is an interesting approach to an age old problem. I wonder if this technology could be used to embed drug information directly on the medication as well, an idea that I hijacked from the Nursetopia website where Joni Watson muses that “Both companies and pharmacies could add a QR code/Microsoft Tag to the medication label for patients and/or healthcare professionals to scan and directly access the patient medication information sheet.” Why not put the QR code directly on the medication itself? Why not indeed.

Automated unit-dose packagers for acute care pharmacy

State of Pharmacy Automation. Pharm Purch Prod. 2010; 8

I was doing a little Sunday morning reading and came across an interesting set of slides at the Pharmacy Purchasing & Products (PPP) website  (registration required to access the slides). I haven’t spent much time reading PPP Magazine, but I should because they always seem to have something good about pharmacy automation and technology in just about every issue.

Anyway, I’ve been looking at various automated packaging machines lately and thought the information at the PPP website was rather timely. According to information found at the site “After a slight dip in the number of facilities packaging medications in bar coded unit dose in 2009, this process realized a significant rebound in 2010. Nearly three quarters of all facilities now have such an operation in place. Hospitals taking advantage of the increased data capacity offered by two-dimensional bar codes also bounced back this year. In conjunction with these improving adoption rates, pharmacy directors are also reporting rising satisfaction rates with their operations. Despite a staunch minority that sees no need for a unit dose packaging operation, the vast majority of those without such a system plan to implement one shortly.” The graph in this post is from the PPP slide deck and shows the percentage of facilities using bar-code unit dosed packaging for medications over the past several years. This comes as no surprise when you consider the relative inexpensive nature of this technology when compared to other pharmacy automation, the ease of which it can be implemented and the push for BPOC in healthcare. Call it a perfect storm.
Continue reading Automated unit-dose packagers for acute care pharmacy

Quick Hit – A couple of interesting bar-coding tidbits

There were a couple of things about bar-coding in the web-stream that caught my attention today.

The first item was a tweet from @hospitalrx mentioning an application at USA.gov for the iPhone and Android OS that can be used to identify product recalls. The application is appropriately called Recalls.gov.

Now, those recalls are right at your fingertips, thanks to the new RECALLS.GOV mobile application. Whether you’re at your child’s day care center or a yard sale, whether you’re at a store or at home, you can now type a product’s name into your phone and learn immediately whether that product has been recalled because of a safety concern. You can also see photos of recalled products and learn what to do with recalled products in your homes.

Even though the website is lacking detail, the application does offer the ability to scan the bar-code on a given item to determine its recall status, although I have not tested this functionality. Additional mobile applications from USA.gov can be found here.

And from Barcode.com: “Motorola has released a tiny new barcode scanner called the CS3000. The CS3000, shown below, is just about 3.5 inches long, 2 inches wide and less than an inch thick. It weighs only 2.45oz according the Motorola spec sheet. It is capable of scanning 1D barcodes and has a 24 hour battery life. The CS3000 has a USB connector and also Bluetooth. It’s 512MB of flash memory can hold roughly a million bar codes.“

These things are neat. You can download the spec sheet for the Motorola CS3000 scanner here (PDF).