Barcoded Medication Administration
Adverse drug events (ADEs) not only threaten patient safety but are also costly due to prolonged patient stays, increased monitoring and complexity of care, and litigation. The 1999 Institute of Medicine report estimated that between 44,000 and 98,000 patients die annually due to medical errors, with medication error being a major source. An IOM update report in 2006 estimated between 380,000 and 450,000 hospital drug errors each year and nearly 800,000 people suffered in long-term care facilities due to drug mistakes [1].
Medication error can come from any of the four stages in the process: ordering, transcribing, dispensing and delivering, and administrating. In a study by Bates et al. [9], it was estimated that errors resulting in preventable ADEs occurred most often at the stages of ordering (56%) and administration (34%); transcription (6%) and dispensing errors (4%) were less common. While comptuerized physician order entry (CPOE) targets at resolving ordering errors, there is another system designed to reduce errors in medication adminstration.
Barcode medication administration (BCMA) system was developed to reduce medication errors during administration and help ensure the “five rights” of medication administration: right patient with the right drug and right dose at the right time with the right route. The use of BCMA systems to improve patient safety has been recommended by many organizations, including the Institute of Medicine, the National Patient Safety Foundation, the American Society of Health-System Pharmacists, and the National Alliance for Health Information Technology [6]. FDA has also mandated barcode labels on all human medications and biological products by 2006 in an attempt to reduce medication errors. FDA has predicted that the ruling will prevent nearly 500,000 adverse drug events and transfusion errors over the 20 years that follow, at a cost savings of $93 billion [2].
BCMA systems features
While the specific features and user interfaces of various BCMA systems differ, the basic functionalities are all largely the same. When administrating drugs to patient, clinicians scan barcodes on patients (often in the form of patient wristbands), drugs (encodes the National Drug Code (NDC), which includes the drug company labeling the package for sale, the name of the drug and its dose, and the type of packaging [4]), and their own staff barcode (often on staff badge). The software then verifies the five rights, and if any of it is violated, warnings and/or errors will be issued. The software also automatically documents the actual administration of the medication as part of patient’s record. Often, systems also allows data to be stored so reports can be generated to review omitted or late medications, investigate errors during the administration process, and resolve reported discrepancies.
BCMA benefits
The biggest benefit of BCMA is patient safety. BCMA is generally believed to be effective in preventing medication administration errors [3, 7, 8]. In addition, BCMA systems automatically capture and time-stamp drug administration steps for workflow analysis and accurate documentation, allow multiple users to access administration information, and decrease potential for missing medications to be administered [8]. PRN effectiveness can also be documented and measured with required pre and post measures [5]. In addition, when BCMA is interfaced to CPOE and Pharmacy system, the integrated system enhance communications among the care team and share information on the ordering, dispensing, verifying, and administrating steps, and further help reduce chance of medication error.
Challenges
Cochran et al. [4] analyzed reports of errors submitted to MEDMARX, a national database of voluntarily reported medication errors, and discussed the frequent BCMA-related challenges and errors. Mislabeling was found to be the most frequently reported problem, with 27% of these errors reaching the patient. The second most frequently reported problem is medications without barcodes (e.g., such as IV, partial doses, multi-dose containers, and inhalers). Other reported problems included smearing or fading of barcodes on medications or patient wristbands and differences in equipment used (e.g., pens vs. hand-held devices).
There are also human factor challenges with nursing resistant to change and fear of tracking errors generated from the system. BCMA is often perceived to increase nursing workflow because nurses need extra steps to scan in several barcodes during the administration stage, so nursing often found “workarounds” to the barcode scanning. Some nursing bypass barcode scanning in the system due to fear of punitive actions resulted from error tracking. To overcome this human factor challenge, good selection of equipment, proper training and education, and proactive pharmacy involvement to ensure barcodes on medication packages are scannable are all important.
References:
1. Woolston C. Ills and Conditions: Hospital medication errors. Caremark. http://healthresources.caremark.com/topic/hospitalmederrors
2. Wideman MV, Whittler ME, Anderson TM. Barcode Medication Adminsitration: Lessons learned from an intensive care unit implementation. Advances in Patient Safety: Vol 3. http://www.ahrq.gov/downloads/pub/advances/vol3/Wideman.pdf
3. Sakowski J, Leonard, T, Colburn S, Michaelsen B, Schiro T, Schneider J, Newman JM. Using a Bar-Coded Medication Administration System to Prevent Medication Errors. Am J Health Syst Pharm. 2005 Dec 15;62(24):2619-25
4. Grotting J.B., et al.: The Effect of Barcode-Enabled Point-of-Care Technology on Patient Safety: Literature Review by Bridge Medical, Inc., October 2002. http://www.bridgemedical.com/pdf/whitepaper_barcode.pdf
5. Bar Code Medication Administration. Pharmacy Health Care Solutions. Volume 1, issue 5.
6. Patterson ES, Rogers ML, Render ML. Fifteen Best Practice Recommendations for Bar-Code Medication Administration in the Veterans Health Administration. Joint Commission Journal on Quality and Safety. July 2004 30(7): 355-365
7. David W Bates. Using information technology to reduce rates of medication errors in hospitals. BMJ. 2000 March 18; 320(7237): 788–791
8. Johnson CL, Carlson RA, Tucker CL, Wilette C. Using BCMA software to improve patient safety in Veterans Administration Medical Centers J HealthcInft Manag. 2002 Winter; 16(1) : 46-51
9. Bates DW, Cullen DJ, Laird N, Petersen LA, Small SD, Servi D, Laffel G, Sweitzer BJ, Shea BF, Hallisey R. Incidence of adverse drug events and potential adverse drug events. JAMA. 274(1):29-34
