Eighteen years after the Veteran’s Administration first implemented bar coding technology in the hospital, 59% of hospitals nationwide have adopted BCMA.¹ While patients of all types benefit from the safety advantages of BCMA, adopting such a system at a pediatric hospital is especially complex, as the technology has been designed for use in hospitals treating adults. Thus, special consideration must be paid to customizing BCMA to maximize its value for protecting neonates and children.

Cook Children’s Health Care System is a not-for-profit, pediatric, integrated health care system in Fort Worth, Texas, comprising eight companies. The medical center houses 428 inpatient beds, a level II trauma center, an emergency department that serves more than 100,000 patient visits each year, and over 60 specialties and subspecialties. The tiniest patients can be found in the 106 private or semi-private rooms in the level IV neonatal intensive care unit (NICU). 

BCMA discussions began seven years ago when the hospital leadership, under the direction of the patient safety officer, recognized an opportunity to improve the safety of medication administration with the use of integrated bedside scanning technology. To plan and implement these changes, a diverse, multidisciplinary work group was created—including the senior vice president of quality, the patient safety officer, risk management, nursing directors and managers, frontline nurses, IT, customer service, education, pharmacy, medication safety, project management, and respiratory therapy. The goal was to create a reliably functioning bar coding system that would give end users little reason to circumvent it, thus ensuring consistent use. The BCMA rollout was implemented gradually, and was completed in all inpatient areas by January 2011. 

Preparing for BCMA
One of the first steps taken by the BCMA work group was enlisting frontline staff to map out the existing workflow for pharmacy, nursing, and respiratory therapy. A bar coding readiness self-assessment and failure mode effects analysis was then performed to identify areas of potential risk. Several implementation requirements—unique to pediatric patients—were identified (see Table 1). 



A key factor in the success of BCMA is establishing effective medication dispensing practices. The number and diversity of medications that require readable bar codes before reaching a patient can be daunting. This is especially true in a pediatric facility, as the need for the in-house pharmacy to apply bar codes to multi-additive IV solutions, pediatric dosage forms, and pharmacy-compounded products can be greater compared to preparing adult medications. 

Redesigning Pharmacy Workflow 
Ten months prior to the BCMA implementation, the inpatient pharmacy began the first phase of a complete redesign of pharmacy workflow and technology use. These changes were driven by the pharmacy director, based on the strategy that successful bedside scanning depends on all medication doses being scanned into and out of the pharmacy to verify bar coding accuracy. The new process strategy included more frequent deliveries of patient medications, expanding standardized doses of common medications, scanning medications in and out of storage locations, and utilizing bar code scanning against medication orders to improve dispensing accuracy.

The bar codes used for medication verification are composed of either a manufacturer’s NDC number or a unique prescription number assigned to the patient and medication order. Patient doses that are not commercially available in a ready-to-administer fashion—for example, caffeine citrate 12 mg—rely on a prescription number bar code applied by the pharmacy at the time the dose is dispensed. Throughout a patient’s hospital stay, adjustments made to a medication order result in the creation of a new prescription number. Any doses already dispensed containing the old prescription number thus require a new label and bar code in order for BCMA to match the medication with the administration record. 

To address this, the pharmacy moved from a once-per-day batching system (ie, dispensing a 24-hour supply of medication to patients once each day), to delivering four to five batches each day, so that only a few hours’ worth of medication are stored on nursing units. The multiple batch process not only reduced the need to update bar codes on previously dispensed doses, but it also reduced waste by an estimated AWP of $5,000 per week, as well as several types of medication administration errors. For example, a nurse cannot accidentally give a patient a pm medication in the am if it is not available. In addition, the multiple batch method reduced omission errors; if only a few hours’ worth of medications are on the unit at a time, nurses can see that all doses were given on this medication pass. The empty medication bag is an effective visual aid for nurses. 

In addition to switching to multiple batch deliveries, pharmacy led a collaborative effort with physicians and nurses to expand the use of standardized doses. High-use products were targeted for standardization, which allowed pharmacy to package and apply NDC bar codes in advance, thus avoiding the challenges associated with using prescription number bar codes.  

Updating Automation Technology 
At the beginning of BCMA implementation, pharmacy estimated that approximately 85% of medications used in the facility required repackaging to meet the needs of neonatal and pediatric patients. To maximize medication safety, unit-dose products were purchased when available from manufacturers or third-party pharmacies, with the remainder repackaged in-house. Thus, it made sense to purchase a high-speed tablet repackager to create unit-dose tablets that were not commercially available. 

In addition to implementing the high-speed repackager, the hospital required enhanced medication storage to prepare for BCMA. Hence, the team decided to further automate the process with carousel technology. Drugs had been stored on library-like bookshelves, which provided little medication security and left the pharmacy prone to look-alike/sound-alike stocking errors. To more effectively house and distribute these medications, the shelves were removed and a 1.5-ton carousel was installed. 

During the implementation process, as a drug was received from the distributor it was scanned into the electronic health record, ADC, and carousel system to confirm bar code recognition, as well as appropriate pairing with the correct medication. Next, the item was sent to the pharmacy carousel and the product scanned, triggering the carousel to rotate its shelves and flash a light in front of the appropriate bin location. The pharmacy technician scanned the bin for verification and placed the item in the bin to complete the stocking process. If an incorrect bar code was scanned any time during this procedure, the process was halted until the issue had been corrected. 

This new technology greatly improved storage and dispensing accuracy, reduced dispensing errors—most notable wrong drug and wrong concentration errors—and assisted in the identification of products in need of pharmacy-applied bar codes. For patient dose dispensing, medication orders arrived in the carousel’s electronic work queue, the carousel printed a label, and the shelves rotated once more to the storage location. The product was removed, its bar code scanned, and then its medication label was scanned to ensure a match, which completed the product verification and dispensing process. 

Shortly after BCMA was rolled out, the pharmacy took on the next step of adding bar code verification for the preparation and dispensing of sterile products. Technology was implemented in each step of IV compounding, dilution, and reconstitution; bar codes are scanned and medications photographed to ensure accuracy and allow for pharmacist verification.

Training Processes for Nursing Staff
Because the staff had been using the eMAR for over six years, the initial training was designed specifically to address BCMA. Staff completed a mandatory, computer-based training module that addressed why BCMA was being implemented, the BCMA process, and how to address various alerts, and it included a variety of documentation scenarios. Completion was a prerequisite to attending a 30-minute, hands-on class, which covered hardware and correct scanning procedures, and presented numerous medication administration test scenarios using ID bands and training medications. The safety benefits of BCMA were stressed throughout the training process to ensure staff buy-in.

In addition, each unit designated superusers, who received further training and provided support to their coworkers during the go-live in each unit. After a successful rollout on the pilot unit, one or two units went live each week, for a gradual implementation that took approximately two months to complete. An implementation team, consisting of a pharmacist, nurse informaticist/educator, nurse managers, and IS staff members, provided additional support to the superusers and staff. 

New hire nurses attend a three-hour class where they receive hands-on training on procedures for using the eMAR and bar code scanners. Sample medications and armbands are used, allowing the instructor to lead nurses and paramedics through scenario-based learning. 

Updates and tips on appropriate scanning policies and procedures are communicated to all staff utilizing BCMA via a monthly newsletter. Struggling nurses are identified via regular reports of each nurse’s scan rates, and just-in-time training is provided for these nurses on correct technique. In addition, a collaborative Web site that houses training tips and cheat sheets is available to all staff via a quick link directly from the EHR.

Understanding Alerts
During implementation, a strong emphasis was placed on the safety and value of BCMA alerts, along with checking the eMAR’s response to a medication or patient scan. Keep in mind a 2011 ISMP medication safety alert that stressed that the beep that results after a medication or patient is scanned does not indicate that the item is correct, only that the item has been scanned.² Training was provided to remind staff not to simply listen for the beep or vibration upon scan, but to actually review the alert on screen to verify accuracy. Useful alerts at Cook Children’s include a warning that medication is not on the patient’s profile, preventing a potential medication error; and a warning to prevent medication administration to the wrong patient. The alert documentation against a future or past dose has proven unhelpful, as it occurs too frequently, contributing to alert fatigue while providing little customization. 

Measuring and Monitoring Success 
Post-implementation, representatives from nursing, pharmacy, IT, and risk management created a core group responsible for ongoing management of the BCMA project. Several data points are tracked to ensure the continued success of BCMA:

• Scanned/Not Scanned report for ID bands and medications, including:
  • Overall hospital rates
  • Unit rates
  • Staff members who maintain a 100% scan rate. These employees are recognized for their success with a specially designed t-shirt identifying them as a 100% scanner
  • Scanning rates in response to implementation of new strategies to improve rates
  • Low performers
• Difficult-to-scan medications
• Hardware issues (COWs and scanners)

In addition, it was determined that utilizing an electronic BCMA reconciliation form to send automatic email messages and track challenges staff encountered would ensure continued optimization and timely resolutions to the bar coding process (see Figure 1). 



Benefits of a Robust BCMA System
Bar code technology ensures the development of a safety-driven workflow, drug label customization, audit trails, automatic dose and dilution calculations, and access to a vast amount of data to further improve processes. Furthermore, BCMA improves dispensing accuracy and efficiency, enhances medication tracking, allows for electronic inventory management and automatic reordering, and delivers valuable data on dispensing practices. However, the principal advantage continues to be the confidence that results from knowing patient safety is protected. 

Today, two years after implementing BCMA, staff have scanned over 2 million doses and the medical center is maintaining 97% scan rates. Future plans include implementing BCMA in the ED, and later in the outpatient hematology/oncology clinic.

References

1. The 7th Annual State of Pharmacy Automation: Results from PP&P’s National Survey. BCMA. Pharm Purch Prod. 2012;9(8):72-76.
2. ISMP Web site. ISMP Medication Safety Alert (June 30, 2011). Scanner Beep Only Means the Barcode Has Been Scanned. http://www.ismp.org/newsletters/acutecare/articles/20110630.asp Accessed January 4, 2013.

Lorraineá Williams, PharmD, is the medication safety officer at Cook Children’s Health Care System. She obtained her Doctorate of Pharmacy at the University of Texas at Austin and completed medication safety training at the Institute for Safe Medication Practices. 

Tips for Effective Bar Coding

Factors to consider in ensuring the safety and quality of dispensing bar coded products include:

• Identify space on labels and packages to add a bar code while maintaining legible print, Tall Man lettering, and attention to the drug name and total dose 
• Test different formats of bar codes. The size and length of traditional linear bar codes present scanning challenges in a pediatric hospital. Conversely, 2D, Aztec, and stacked bar codes might not be compatible with all scanning technologies 
• Investigate an in-house bar coding system and evaluate the process to create, protect, and track these codes
• If bar coding is outsourced to a third-party pharmacy, carefully evaluate the labeling and dispensing practices of the third party
• Create a process to verify that product bar codes scan easily utilizing a scanner identical to the one used during medication administration 
• Review the process of dispensing patient-specific doses. To prevent the need to update the patient-specific bar code due to a change to the medication order, consider a multiple batch or just-in-time dispensing system 
• Determine how the department will meet the extra repackaging demands resulting from BCMA implementation

Address these issues in the early stages of the project to ensure a smooth rollout and prevent unforeseen challenges later on in the process.

Bar Coding Expansion: Breast Milk Tracking 

By Sheralyn Hartline, MSN, BSN, RNC-NIC, Assistant Director, NICUCook Children’s Health Care System

• Breast milk tracking technology can improve safety by eliminating identification errors, detecting expired milk, and denoting correct feeding containers and storage locations. A separate bar coding software system (in place before BCMA was implemented, but using the same bar code scanners) is utilized in Cook Children’s NICU to track human and donor breast milk to ensure each baby receives breast milk from his or her mother, or the correct donor breast milk. This system also tracks any additives to breast milk for premature or low birth weight neonates—for example, human milk fortifier that provides essential minerals and protein to human breast milk, whey protein isolate, micro lipids, and higher calorie formulas that provide increased calorie count and protein. 

Medication Administration Challenges

By Nancy Russell, MS, RN-BC, CPN, Nurse Informaticist, and Lynsi Garvin, RN, BSN, Nurse Informaticist, Cook Children’s Health Care System

Following implementation, a few scanning challenges were identified:

• Patient charts contained a patient-identified bar code for use in medical records, which created a potential workaround as the nurse could scan the chart instead of the patient’s armband. To prevent this, programming was added to the scanner to allow only scanning of the 2D bar code on the bracelet; the labels used in charts contain only linear bar codes. 
• As children often have difficulty staying still, scanning a small wristband can be problematic. In addition, parents often discourage nurses from waking a sleeping child to perform the scan. Thus, we adjusted the armbands to include 2D bar codes that repeat over the entire length of the band; consequently, nurses do not need to adjust the band or wake the child to get an effective scan angle. The multiple bar codes improve the ease of capturing an effective scan from a squirming child. 
• In addition, the first armband we chose utilized printed patient labels that slid into a clear section of the band. Unfortunately, the clear sheath interfered with effective scanning and the label often was damaged or bent during the attempt to slide it into place. The label also was easily damaged during bathing. To remedy these problems, we adopted the use of Zebra printers and armbands, which print patient information directly on the band. These armbands are user-friendly, adjust to fit patients of all sizes, and are durable when they come into contact with water.