Cool Pharmacy Technology – RxAdmix

In this issue of The Imaginary Journal of Pharmacy Automation and Technology (IJPAT) we take a look at RxAdmix, a system designed to provide barcode scan verification in the IV room. Now why didn’t I think of that? Great concept when you consider the dangers associated with compounding an intravenous medication incorrectly. Doxorubicin? Daunorubicin? Eh, what’s the difference.
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Bar-code-assisted medication administration in the ED

In reference to the following article:

Including emergency departments in hospitals’ bar-code-assisted medication administration. Am J Health-Syst Pharm. 2012; 69:1018-1019 (don’t bother trying to access the article unless you have a subscription -#fail)

EDs are terrible places for medication administration because the healthcare providers are always in a hurry secondary to the nature of this particular patient care area, i.e. emergencies. All too often medications go unchecked during the medication use process. And to make matters worse, the ED is often times the last place to get BCMA in a planned rollout. It’s also the place where things like BCMA get the most pushback from physicians and nurses.

According to the article “Emergency departments (EDs) are patient care areas that are prone to medication errors. For this reason, we recommend that EDs be considered in any roll-out of BCMA. Studies have shown that the medication administration error rate in EDs is approximately 7%, with 40% of medication errors reaching patients.4,5 The results of these studies suggest that BCMA could reduce ED medication errors, yet this technology is noticeably absent from the ED.” Pretty much what I just said.

In order to benefit from BCMA you have to be willing to deploy it to all areas of the hospital, including the ED. I heard a similar message earlier this year at the unSUMMIT when one of the speakers said that most facilities are far from 100% BCMA compliant because of areas like radiology, infusion centers, EDs, etc.

Makes one wonder how accurate things like the 2011 ASHP National Survey of Pharmacy Practice are. Food for thought.

How Barcode Scanners Work [Infographic]

I’ve been meaning to put this up for a while. I thought the infographic below on How Barcode Scanners Work was awesome! “In our world today, we’re accustomed to seeing barcodes, but most of us don’t have the slightest clue as to how these black and white striped graphics work, or even how they are properly read with a barcode scanner. Better yet, how can barcodes boost efficiency and productivity in small businesses? Not to worry. We’ve outlined a few barcoding basics, including how a barcode scanner works in our latest Infographic.
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Observational time-motion study comparing trational med administration to BCMA in an ICU [Article]

The article below compares medication administration between paper-based medication administration (PBMA), i.e. the traditional method and bar-code medication administration (BCMA). Unfortunately, as is the case with much of the literature in journals these days, the information is quite old. The data for this observational study was collected in two short spans in 2008 and 2009. The numbers are small, but interesting nonetheless. The results pan out as expected. Items of particular interest were that the nurses in the BCMA groupd spent more time talking to their patients compared to the PBMA groupd, but at the same time spent a heck of a lot more time on drug prep. The first item makes sense, but I’m struggling to understand the drug prep numbers.

The article can be found in the May 2012 issue of Hospital Pharmacy. It is is available for free with registration.
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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


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.

The National Drug Code (NDC) is a gremlin in the works of pharmacy

The National Drug Code, or NDC number as it’s affectionately called in pharmacy, is a set of numbers used to uniquely identify “human drugs and biologicals“. Every pharmacist is familiar with the NDC number, but if you’re not it’s basically a  unique number assigned to each package of medication. It’s an 11 digit number in a 3-segment format, i.e. XXXXX-XXXX-XX.

The first segment consists of five digits and indicates the manufacturer of the drug. The second segment is four digits used to identify the medication and strength. And the final segment of two digits represents the package size.
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