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Bar-code/eMAR combo reduces errors
Order transcription, med administration studied
A study of a patient safety strategy at Boston's Brigham & Women's Hospital that incorporated bar-code verification technology within an electronic medication-administration system (bar-code eMAR) showed a significant reduction in errors, according to an article published in the May 6, 2010, issue of the New England Journal of Medicine.1 The study was funded by the Agency for Healthcare Research and Quality.
The researchers observed 14,041 medication administrations and reviewed 3,082 order transcriptions. Here's what they found:
"We are not the first hospital to implement the technology," shares Eric G. Poon, MD, MPH, who is with the division of general medicine primary care at Brigham and Women's and the lead author of the article. "The VA has done it for quite a few years, and we learned from them as we designed our own."
Studies have been tried in other settings, but have not necessarily shown an impact. "This is partly, as I understand it, due to the fact that some users may not have embraced the technology, while others have done studies in a fairly limited setting like one unit," notes Poon. "We're glad to be able to show how this worked in a larger hospital across multiple typical units."
System developed internally
The Brigham & Women's system was developed internally when the facility decided to embark on the technology about 10 years ago, says Poon. "We did not feel the vendors out there really supported what we needed," he asserts. Since then, he adds, they also have looked at other vendors; some systems had what his did not, and vice versa.
"In general, having it internally developed allows us a lot more flexibility," he declares. Still, he notes, vendor systems are "very much catching on" within Partners Healthcare (the system to which Brigham & Women's belongs), and the system has implemented similar initiatives using vendor technology. "Many have an eMAR component and are looking to implement a bar-code scanning component; more and more vendors will be interested in this," Poon predicts.
Since, as Poon notes, compliance may have been the cause of more disappointing results in earlier studies, how did he ensure a higher level of compliance at Brigham & Women's? "The great illustration of how to implement this is that it is not a single event, but more of a journey," he explains. "At the beginning, not all nurses might have embraced it, but what we heard was as soon as it catches the first error they really embraced it, which is the traditional adoption curve.
"What we also found was a lot of times nurses wanted to scan, but there were technical issues; certain drugs had bar codes per the FDA and some were harder to scan than others, just as they are in the grocery store," he continues.
There were some cases, he adds, where the hospital actually had to switch pharma vendors to get better bar-codes. "IV bags were particularly challenging," he notes. "In another case we got around the problem by having an in-house re-packaging center; we were able to put those drugs in a little plastic baggie with their own bar code."
An 'invasive' intervention
Poon continues: "This is a reasonably invasive intervention particularly for the nursing staff. About a quarter of what nurses do is around administrating medications."
For other organizations considering such an intervention, says Poon, "They should not think of this as just scanning a bar code at the point of giving meds, but as a whole process: how to make sure the pharmacy sends the right medication doses to units in a timely way; how we make sure there is good communication between the pharmacy and nursing staff when there is a question about a medication order; and that there is reasonable response time to approval of pharmacy orders."
For instance, he points out, the Brigham & Women's system says a nurse can't administer a drug by scan unless the pharmacist has approved the order.
In addition, says Poon, "Other organizations need to understand this is not just about buying technology and training nurses on its use, but also about whether they are willing to take a critical look at what nurses spend a lot of their time doing. For instance, they may need to do work redesign in conjunction with the technology.
"That in my mind is where projects either fail or succeed," he continues. "Do you have the leadership to say, 'Gee, we need to come up with a way of giving meds that makes sense' even if that means changing what you've been doing the last few decades?"
Finally, says Poon, "You need to keep working on this. There will be folks who may not embrace it; in some ways it's just like CPOE."
[For more information, contact: Eric Poon. E-mail: firstname.lastname@example.org.]