by Brian Peters, PharmD, MS

THE HEART CENTER OF INDIANA (THCI) IS A THREE-YEAR-OLD SPECIALTY hospital in Indianapolis that handles more than 5,500 admissions each year. As the first freestanding medical campus in Indiana devoted entirely to the diagnosis, treatment, and prevention of cardiovascular disease, THCI employs 138 physicians, including 95 cardiologists, who perform more than 7,000 cardiac catheterization procedures annually. THCI also works with 20 cardiothoracic surgeons and 13 vascular surgeons who perform more than 1,000 surgical procedures annually. THCI’s facilities include four surgery suites and four catheterization labs. THCI’s “universal bed” concept makes the facility essentially an 80-bed ICU. In other words, the patient is able to stay in one room for the entire period of hospitalization. There are also 21 outpatient beds in the short-stay unit, and six beds in the heart emergency unit. THCI is currently ranked number one in Indiana in overall cardiac services, cardiology, and cardiac interventions based on measurements including mortality rate and length of stay, and according to HealthGrades, an independent health care quality company, is ranked among the top 5% of U.S. hospitals for overall cardiac services.

Challenges
THCI faced several medication safety issues related to both our growing size and complexity. The high acuity and high turnover of our patients also created more opportunities for medication errors. For example, admission and discharge are the most dangerous parts of the patient care continuum at any hospital, and at THCI, we turn over one third of our beds every day. On the other hand, our open-heart surgery patients require longer stays, but also very intensive drug therapy regimens. We administer some 40,000 to 50,000 doses of drugs each month.

To address these unique needs, THCI began to explore the use of information technology, specifically, an inhouse, bar-code-driven medication administration documentation system. A site assessment revealed that our nurses fully expected to use advanced technology for medication management. Their positive attitude was critical to our plans, as was the exceptionally collaborative relationship amongst nursing, pharmacy staff, and hospital leadership. Everyone was very committed to the common goal of patient safety.

Before proceeding, we examined what our colleagues at other institutions were doing, and what had contributed to the success or failure of their bar code systems. We determined that bar coding had to be an allor-nothing proposition: For the system to work at THCI, all doses administered to patients had to be bar coded, with no exceptions. This presented a significant challenge, as many products arrive at the hospital with no bar codes, and many more have different types of bar codes that cannot be read by the majority of handheld scanners on the U.S. market.

Unfortunately, the drug manufacturing industry has yet to create a unified, consistent bar code system. In addition, drug wholesalers often do not assist hospitals in identifying which products are properly bar coded and which are not.

To resolve the bar coding problem, THCI took on the daunting task of coding or recoding over 50 percent of the drugs our pharmacy carries. We now spend two to three hours a day applying bar codes to a total of 20,000 to 30,000 doses per month. This repackaging has been a tremendous undertaking, requiring us to add approximately one-half of a technician FTE.

Implementation & Training
When we partnered with Siemens Medical Solutions to begin this project, THCI had paper-based orders, a paper MAR with electronic documen-
tation of IV infusions, voluntary medication error reporting, and unit dose drug distribution using Pyxis MedStations for 98% of doses dispensed. Among the Siemens IT systems now in place as part of our medication management solution are Siemens Pharmacy, INVISION, ChartAssist, and Med Administration Check (MAC). Utilizing bar code scanners, MAC allows our nurses to verify the five rights of medication administration. If there is a mismatch, the system immediately notifies the nurse with an audible alarm and a visual alert. Clinical checks for allergies, duplicate therapy, appropriateness of individual and cumulative doses, and drug interactions can also be performed.

Rather than implement MAC on mobile carts, at THCI, we chose to install it on Draeger Medical Infinity Explorer monitors that are stationary at each patient bedside. MAC is also available on desktop PCs at the nursing stations and in the pharmacy to facilitate order verification and practitioner access to charted data. The MAC bar code scanners are tethered in the short-stay (catheter) unit, and are wireless in inpatient areas. Both pharmacists and nurses have individualized access to their patients’ medication profiles depending on their role.

To initialize MAC, THCI built 1,800 items in a medication cross-reference table that links the bar codes to the drug master entries in the pharmacy. We also tried to get parts of the system running early, preparing the first bar code drug labels about 30 days before go live, as well as patient ID wristbands seven days prior to go live. Our nurses already had bar code IDs from the Pyxis system.

During our pilot launch in the short-stay unit in spring 2005, we determined that the MAC software was not ideally designed for use with bedside PCs or for an outpatient environment with a high throughput of patients. We made several adaptations to suit THCI’s particular needs. For example, we changed pharmacist order entry patterns and the design of the predefined common orders in Siemens Pharmacy, and created a “hold” unit, so a patient can be in a bed prior to medication administration (since doses do not show up on the nurse’s worklist unless that patient is assigned a bed).

After completing the pilot, we conducted extensive staff training to ensure that the system was ready for full operation in July. We discovered there were clear, distinct training needs as follows:

• Nurses: train them how to fix mistakes in the MAR
• Physicians: increase their acceptance of the system, especially of how meds were displayed and reported
• Pharmacists: increase their understanding of what the nurses would see, as well as explain to them why changes in their order entry practices were necessary to facilitate nurses’ use of MAC

Results
MAC is currently used everywhere in THCI except the OR, ER, and cath labs. This includes all routes of administration (even respiratory therapy treatments) and all dispensing processes (Pyxis, unit dose, and batch manufacturing). The only exception for medication charting is during cardiopulmonary arrest, where all meds are charted on the code one flowsheet. It is also important to note that the medication data charted in MAC feeds directly into the INVISION EMAR, where it is accessible to all clinicians, regardless of their familiarity with MAC.

Overall, we achieved our expected medication error outcomes. We experienced an increased number of reported near misses, but reduced our actual errors. As for MAC-preventable errors, such as omissions, patient ID mix-ups, and wrong drug errors, the rates decreased in spite of the rapidly changing environment that THCI was experiencing during this same time period, including higher patient volume, increased acuity, higher volume of surgeries and cath procedures, and an influx of new nurses.

However, we did identify new error types as a result of the project, such as pharmacist order entry, procedural/diagnostic areas not using MAC (leading to an incomplete EMAR), incorrect bar coding, and reduced attention to detail (overreliance on the system). Diligent system monitoring is also required to ensure that the system remains fully functional and that all drugs have usable bar codes, despite changes in pharmaceutical manufacturing and packaging practices.

The biggest improvements, according to a satisfaction survey we conducted of our nurses, have been in pain assessment at the time of administration, overall safety, and the ease of viewing the medication history. The nursing and RT staffs’ overwhelming acceptance of the system was clearly demonstrated when we once had downtime due to a hardware problem; we were constantly being asked, “When is MAC coming back up?” We also believe we have increased everyone’s awareness of patient safety by facilitating a medication error reporting culture, which remains
completely voluntary.

The Future
THCI will be expanding MAC into the ER by the end of 2005. The OR, cath labs, and other procedure areas require a chronological record of the patient’s vitals, procedures, and drugs. So it is not yet practical to use MAC in these areas. THCI is anticipating further system enhancements from Siemens that would allow MAC to be used practically and efficiently in these areas, as well as modifications to facilitate use of the system at stationary bedside PCs and enable us to charge for supplies and procedures that are not pharmacyor drug-related.

Brian Peters, PharmD, MS, is the pharmacy process leader for the Heart Center of Indiana in Indianapolis. Peters received his pharmacy degree from Purdue University and his masters in health-system pharmacy administration from the Ohio State University. He also completed a pharmacy practice residency at the Ohio State University Medical Center.