The problem is more widespread than most realize and often flies under the radar. I knew about the issues, but wasn’t prepared to deal with them until we went live with our bar-code medication administration (BCMA) system. A side effect of the BCMA system is that it tends to catch things like late and/or early medication administration. That means no more mythical med passes with all medications administered at exactly the same time.

One thing to remember here is that the problem does not reside with the nurses, per se. There are many factors involved. Nurses are frequently asked to do too much with too little time and resources, thus forcing them into undesirable situations. The system is the problem. And as much as it pains me to say, this is one problem where a technology-only solution is not the answer.

The solutions are simple, but not always obvious or practical for many health care facilities. For example, the 30-minute rule could be changed to a 60-minute rule, i.e. medications would need to be administered within 60 minutes before or after their schedule administration time. This was recently done by the American Association for Respiratory Care (AARC) in a position statement that basically said that inhaled medications shouldn’t be held to the same CMS 30-minute rule because “Inhaled medication administration incorporates a unique methodology and has a recognized delivery time between 9-20 minutes, depending on the delivery device used for administration.” The AARC statement is supported by CMS. Or perhaps the facility could stagger standardized frequencies to give nurses additional time to admister medications, i.e. not have all morning medications due at 9:00 am. It may be as simple as moving some medications like aspirin, warfarin or HMG-CoA reductase inhibitors, i.e. atorastatin  and the like to the evening time. How about this one: hire more nurses. I know, easier said than done, but very practical nonetheless. It’s important to remember that this is first and foremost about safe and effective patient care.

Ultimately there isn’t a one size fits all approach to the problem and it is clear that it will be some time before we have a solution, but it is certainly something that needs to be addressed. Unfortunately this isn’t a problem that immediately available technology can fix. ADCs are not designed to be a time saver for nursing. Neither are Bar-code Point of Care (BPOC), a.k.a. BCMA, systems or Computerized Provider Order Entry (CPOE). All these technologies are designed with the idea of improving patient safety through the reduction of hospital related medication errors. We’re going to have to look somewhere else for a solution. Just a thought.

The MedReady system is a solution that can effectively help those with bad memories stay compliant. The small, smoke alarm looking device is designed to hold up to 28 separate medication doses with frequencies up to four times a day.

The system is designed with simplicity in mind. Power the device on, load it with medication, spend a few minutes setting up the dosing schedule and voila, you’re ready to be reminded when to take your medicine. Reminders include both a flashing light and audible alarm. And if that’s not enough for you, there is an available option with built in modem that is used to access a remote monitoring service. The service can send emails or call up to three separate phones to keep the patient on schedule.

The MedReady system offers 48 hours of battery backup to keep the device operational during emergency outages or when the patient simple wants to take the device away from their home.

While this system isn’t for everyone, it might just be the simple solution someone needs to remain compliant with their medication regimen. It’s certainly worth a try for someone with a historically bad track record.

From the MedReady website:

Low Price
MedReady, at a price of $175.00, is the low price leader. Competitors’ systems range in price from $249.00 to over $1,000.00. Be assured that the price savings does not come at the expense of quality, as you can see from the list of features below.

Safety
MedReady conveniently utilizes AC power, but in the event of an outtage or short-term travel, switches automatically to included rechargeable batteries.

Security
MedReady is tamper-proof to provide the maximum in security. Instead of employing a latch, our system utilizes a real lock and key, and the edges are secure. With access by key-only, caregivers can load MedReady and monitor patient compliance.

Useable Clock
The extra large LED read-out is easily viewed from any angle and is self-illuminating so it can be seen in any light.

Medication Card Holder
MedReady provides a card holder on the bottom of the unit for a printed copy of the prescriptions for all medications in the dispenser.

Easy-to-Set Alarms
Setting the timers and alarms is as easy as setting a digital alarm clock.

A little bit of information on our labeling process may be in order. To generate a bar-code label with our software we have to enter the particulars of the drug into the application database. One piece of information, perhaps the most important piece, is a unique identifier. We’ve settled on the NDC number, which is often contained in the bar-code on the manufacturers product. With me so far? Good. So to make things easy we typically scan the bar-code on the medication package, which in turn automatically populates the unique identifier field. We do this to mimic the bar-code on the manufactured item as closely as possible; works great most of the time.

Now the problem. Take a look at the image below making sure to pay particular attention to the numbers beneath the bar-codes. Notice the similarities. The first 11 digits, highlighted in yellow, are the same for the drugs on the top and the bottom. The same is true for the first 11 digits on the second and third drugs, highlighted in green. Unfortunately these are completely different drugs. The second item is a 1mL vial of midazolam 5mg/mL injection and the third item is a 2mL ampule of fentanyl 50mcg/mL injection. No problem because the last five digits of the number in the bar-code are different, right? Sort of. Our labeling system truncates the information at 11 digits. So when the pharmacist attached these drugs to our cross-reference file the BCMA system couldn’t tell the difference. Doh! The solution was simple, but only after the mistake was caught. I won’t tell you how we caught the error, just know that it was caught.

The system broke down in several places and no blame is necessary. However there are some important lessons to take away from the experience: pay close attention to what you’re doing, be careful, check the product after you label it and before it goes out, and know the limitations of your technology.

Update (6/28/10):
Some people have asked me how we handled the bar-coding issue above. The issue is actually being handled from two different directions. The solution on my end was really quite simple. For items like those mentioned in the post I remove the first five digits from the unique identifier after scanning the bar-code information into our AutoLabel system. It just takes a second and eliminates the duplicates. See, I told you it was simple.

The second piece is coming directly from Talyst. Someone at Talyst read my blog post and shot me an email regarding the issue. I gave them a little more detail and they put me in contact with a couple of their engineers responsible for the labeling system. They’re currently working on a more technical solution.

The concept is simple and goes something like this:

1) Place labels containing the drug name and associated bar-code on the pockets of your code boxes, anesthesia trays, transport boxes, etc.

2) Pull items that need to be placed in these trays/boxes from pharmacy stock.

3) Scan the bar-code on the pocket followed by the bar-code on the medication. If the bar-codes match you get a stamp of approval and proceed to enter the lot number and expiration information found on the medication for tracking. If the bar-codes don’t match the software gives you a rude warning in the form of a visual queue that says “No Match!” in big red letters. In addition to the “No Match!” warning, a pop-up window appears that prevents the user from continuing.

Pretty simple, but effective if used properly.

In addition to the safety features offered by RxVerify, the system offers various reports for tracking and record keeping purposes. The ability to track lot number and expiration dates is a big plus.  One of the reports that is of particular interest to me is the “Med Error Prevention Report”. This report identifies what I like to call “bad scans”. Basically it tracks potential errors caught by the system. Of course not all the bad scans would result in a drug error, but the information can be useful nonetheless.

You can watch a video overview of RxVerify here. The video contains information on more than one product, but the the section specific to RxVerify begins at around the 12 minutes mark and runs through about 18:45.

Simple, yet cool.

From the RxVerify website:

RxVerify© (Prevent pharmacy restocking errors with a proven and effective control measure: The medication barcode!)

RxVerify© is software which uses the medication barcode to ensure quality assurance for the restocking process. The medication barcode is a proven and effective control measure for preventing medication restocking errors. This software is commonly used by pharmacy technicians for accurately restocking the following medication storage location types:

Anesthesia/surgery Medication Trays
Code Cart Med Trays
Emergency Med Boxes
Med Transport Kits
Surgery Med Carts
Any medication storage kit/box

RxVerify© not only provides quality assurance for medication selection, but it also prevents medications which are expired or nearly expired from being used for restocking.

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iPhone version

Created with consumers in mind, the iPhone application delivers information about OTC products using the barcode located on the medication package. Users simply type in the numbers on the barcode and receive a picture of the medication along with important drug facts.

By simply touching the picture of the medication, a screen will appear where users can view the medicine’s active ingredients, warning, dosage information, and comparable generic products.

To compare multiple medications users can touch “Check Interaction” located on the main screen. A green check means the OTC medications are ok to take at the same time; a red stop sign means you should not take the medications together and consult with a pharmacist.

Android OS version

The Medilyzer Android Application is very intuitive and easily navigated. To enter anOTC medication, simply touch the “Scan Medication” button. This button activates the camera and the barcode is captured using an easy point and shoot method.

When the product barcode correctly appears in the window, the phone will blink green then display the name of the scanned medication. Users can view information such as product warnings and comparable generic products.

To check OTC drug interactions simply touch “Scan Medication” once more to learn if two OTC can be taken at the same time.

I find it interesting that you can scan the bar code image on the Android version of the software, but have to manually enter the UPC code on the iPhone. I wonder if it has anything to do with the quality of the cameras on the devices or if it is an issue with actual operating system? Anyway, I loaded both my DROID and iPhone with Medilyzer and took it for a test run.

The Android version had difficulty scanning bar codes on any surface other than the flat side of a box. In other words I couldn’t get it to scan bar codes on bottles. When it did pick up the bar code image the software worked as advertised. On the iPhone everything went smoothly. The only issue I have with the iPhone version is the need to manually enter the UPC.

In theory Medilyzer is a great application and has tremendous potential for consumer safety, but I can’t recommend it for Android devices because of the extreme difficulty I had getting a clean scan off surfaces that weren’t completely smooth and flat. The iPhone version works fine if you don’t mind entering the UPC code by hand.

Part 1 - the beginning, i.e. the pharmacy:
Earlier this week I briefly touched on the ASHP Statement on Bar-code Verification During Inventory, Preparation, and Dispensing of Medications. As clearly stated in the title of the paper, ASHP’s position is aimed squarely at what happens from the time a medication arrives in the pharmacy until it is dispensed, i.e. sent to the patient or placed in an automated dispensing cabinet. The document concludes that “Prudent use of bar-code scanning in inventory management, dose preparation and packaging, and dispensing of medications can enhance patient safety and the quality of care.” I can agree with that, especial the part that states “prudent use of bar-code scanning”. Technology won’t do much for you if it is implemented poorly or used recklessly.

Part 2 - the end, i.e. the patient:
By now everyone in healthcare has read, or at least heard of, the study by Poon, et al “Effect of Bar-Code Technology on the Safety of Medication Administration” in the May 6 edition of the New England Journal of Medicine. You really need to read the article if you haven’t. Error reduction in the article breaks down like this:

• Drug treatment errors, including incorrect medicine dosage, fell by 41%; 11.5% before and 6.8% afterward. This is probably the crown jewel of the information presented.
• Transcription errors occurred with 6.1% of orders before bar-code use. They were completely eliminated bar-coding was adopted. This makes sense as the documentation becomes electronic.
• Medicine errors deemed to have potential for serious harm fell from 3.1% to 1.6%. That’s a relative reduction of about half.
• Timing-related errors, when a drug is given at least an hour earlier or later than intended, fell by 27%. I’m not sure what impact this has on patient care. One thing to take away from this particular dataset is that bar-coding may have uncovered a nursing practice issue. It doesn’t mean the nurses are doing something wrong. It means the process needs to be dissected.

There are some important takeaways from the NEJM article. First, don’t get caught up in the numbers. The article provides valuable insight into the potential for using bar-code technology at the point-of-care. The reader gets to see the overall process, which is important. Second, remember to look at the data critically and apply it to your situation. Every facility is different. Take what you can from the article and leave the rest. Remember, the data was collected in 2005.

Part 3 - tying it all together:
TMIT is offering a a free webinar on Barcoding End-to-End Solutions: From Pharmacy to Bedside to help bring together everything I mentioned above. The webinar features an incredible list of speakers including David Bates, MD, Eric Poon, MD, AHSP’s very own Karl Gumpper, RPh and a host of others. Do a PubMed search for some of those names and see what you come up with. Needless to say the webinar has some serious firepower in its list of speakers.

From the webinar website:

As many as 10% of hospital inpatients experience an adverse drug event. Serious medication errors are common in hospitals and often occur during order transcription or the administration of medication. To help prevent such errors, technology has been developed to verify medications by incorporating bar-code verification technology within an electronic medication-administration system.

This webinar will address the bedside barcoding aspect of the following Safe Practices:

Safe Practice 16: Safe Adoption of Computerized Prescriber Order Entry

Safe Practice 18: Pharmacist Leadership Structures and Systems.

The webinar site also contains links to some useful bar-code references.

So there you have it. A triplet of things offering readers the chance to see bar-code technology in healthcare from every angle. I’m really looking forward to the webinar; I’m already registered. I recommend taking advantage of the opportunity to hear such a distinguished panel of speakers present.

I’ve been a pharmacist for more than 10 years now and I’ve make my fair share of mistakes. I would like to think that none of those errors caused harm, but that would be naïve to say the least. And forget about the errors that were never detected because one can only speculate about those.

During my early years of staffing I entered anywhere from 300-400 orders per shift; more with overtime, extremely busy days, etc. Assuming that I was 99.9% accurate, which is a ridiculous assumption, let’s do a little math.

- 300 orders per shift x 4 shifts/wk x 50 weeks/year (hey, everyone gets a vacation) = 60,000 orders entered annually

- With 99.9% accuracy, don’t laugh, that means I committed approximately 60 errors per year. Now I know that accuracy rate is a crazy estimate. I’d believe 60 errors per week, but 60 errors per year, c’mon.

- Anyway, assume 60 errors annually for 10 years = 600 medication errors that reached a patient

- Based on numbers from various sources I’m going to assume that a majority of these errors were harmless. Using similar sources I’m also going to assume that approximately 3% of my errors inflicted damage in one form or another. That means I managed to harm approximately 18 patients during a ten year span in my career. How many of those 18 patients were seriously harmed or even killed secondary to one of those mistakes? We’ll never know.

For those pharmacists that think they don’t make mistakes, think again. There is zero chance that you won’t harm a patient during your career. If you’re fortunate you’ll never know. If you’re unfortunate you have the potential to be fired, lose your license, or end up in prison like Eric Cropp. So much for just culture.

We don’t mean to make mistakes. No one rolls out of bed and says “hey, today it’s my turn to make an error”. By definition an error is unintentional (from Merriam-Webster an error is “an act involving an unintentional deviation from … accuracy“) and everyone makes them. So how do we eliminate them? We can’t because they’re unintentional or weren’t you listening. As long as humans are involved in the process there will be mistakes. And I don’t believe that you can remove humans from the practice of pharmacy because in certain circumstances you need insight and experience that no amount of automation can emulate, yet.

We can, however find ways to reduce errors. I firmly believe that technologies like CPOE, BCMA, CDS, robotics, or some yet to be developed system will prove beneficial in reducing medication related errors, but they will never completely eliminate them. I also believe that diligence and exploration into ways to incorporate new dispensing techniques, better practice models, evidence based practice and workflow modeling can help reduce pharmacy related errors as well. It’s silly to think that technology is the only solution.

There you have it; something I neither wished for nor desire to keep, but remains nonetheless. Just a thought.

I recently heard of a case where a hospitals ED system wasn’t interfaced with the rest of the facilities information systems and disastrous results ensued. A patient came in through the ED with a very specific allergy; noted in the ED system. The information wasn’t available in the nursing or pharmacy systems. The patient was admitted and transferred to the floor. The little detail about the allergy wasn’t passed on during report and the patient ended up receiving that very medication based on the attending physician’s order. To make a long story short, the patient had an anaphylactic reaction and won a three day, all expenses paid trip to the hospitals intensive care unit.

I wonder how often things like this happen due to short sided HIS implementation and deployment. Technology might not be the answer to all our problems in healthcare, but you have to admit it certainly could have helped in this particular example.

For the rest of us there is Alaris Auto-ID.

“The Alaris® Auto-ID module lets you incorporate bedside IV barcoding, independent of your broader barcoding or IT strategy. Designed to attach directly onto the Alaris® system, the Alaris® Auto-ID module helps simplify clinical workfow and provide additional safety at the point of care. This unique, highly scalable solution makes it easy for any hospital to gain the benefts of patient, clinician and IV drug recognition at the point of care, regardless of existing IT infrastructure.”

Alaris Auto-ID is a module that attaches directly to Alaris Smart Pumps. The module is designed to upload patient specific infusion information directly from the bar code on the medication label generated from the PhIS. Scanning the bar code on the infusion label results in the verification of the patient, selection of the correct drug and the correct concentration by the pump. Once the user has verified the information is correct the infusion is started and the information is relayed to the electronic medication administration record (eMAR).

Although the Alaris Auto-ID module doesn’t offer an automated upload of information to the Alaris pump directly from the PhIS, it is certainly one step ahead of manually programming the pump. The addition of automated eMAR documentation makes it technology worth investigating.

Most consumers don’t do a very good job of keeping track of their medications; much less the medication names, dosages, what they are used for and when they were last taken. It’s not uncommon on admission to the hospital for a patient to say things like “I take a blood pressure pill” or “a pain pill” or “a water pill”. As a pharmacist I can make gross generalizations about these medications, and can narrow the options down with aggressive questioning, but can rarely be sure without seeing the medication for myself.

The Electronic Health Record Incentive Program, a.k.a. Meaningful Use guidelines, calls for medication reconciliation to be used for at least 80 percent of “relevant encounters and transitions of care” (page 95). In addition “the capability to perform medication reconciliation is included in the certification standards for certified EHR technology.” This is easier said than done.

Most medication reconciliation begins in the Emergency Department. It is typically a manual system of information collected by nurses who in turn pass it off to the physician for approval. Unfortunately many physicians don’t take the time to scrutinize the medication list which is often inaccurate or incomplete.

The ideal list of medications currently being taken by a patient wouldn’t be generated by the patient at all. Instead the list would be downloaded from a nationally standardized e-pharmacy. Of course no such thing exists, but that doesn’t mean it shouldn’t.

In theory all medications taken by patients are filled in a pharmacy, whether that is a chain pharmacy, community pharmacy or mail order pharmacy. Modern pharmacies are computerized and connected to the internet so that insurance adjudication can take place. The same data should be transmitted to a centralized e-pharmacy where it would be stored and accessed by hospitals during patient admissions. The list would follow the patient throughout their admission and be finalized on discharge. After all, the medication use profile is never more accurate than at the time of discharge.

In the absence of a centralized e-pharmacy, several vendors offer software applications designed to help hospitals maintain a digital medication reconciliation record. Most of these applications can be integrated into the pharmacy information system, making the process a little easier. The solution is not ideal, but it is better than a manual system with pen and paper.

Some vendors that offer medication reconciliation software are listed below.

RxReconcile
MedsTracker
RcopiaAC
MediRec
Mediware’s ClosedLoop Clinical Systems
HCS Medication Reconciliation