In the early 1990s, Brigham and Women’s Hospital (BWH) placed a major focus on developing technology to improve medication and patient safety. In 1993 computerized physician order entry (CPOE) was implemented, decreasing serious medication errors by 55%.1 Despite this advancement, there were still challenges with our medication-use system, so we employed a multi-disciplinary team to critically evaluate our entire medication-use system. In June 2000, the team put forth the following recommendations:

• Redesign the pharmacy information system (PIS) to support the use of bar code technology in the preparation, checking, and distribution of medications
• Develop an electronic medication administration record (eMAR)
• Implement a bar code point-of-care (BPOC) system at the patient bedside

Redesign of the PIS
In 2001 we began to redesign our PIS. While developing the new PIS, a study was completed to assess the accuracy of the existing pharmacy selection and distribution processes. Of 19,000 medication doses dispensed from the pharmacy, a pharmacist’s initial check intercepted 393 (2.03%) errors.2 A recheck revealed an additional 179 errors missed by the first pharmacist, demonstrating that 0.93% of medications dispensed would have reached a patient in error. For a hospital dispensing six million doses annually, this represented over 57,000 pharmacy dispensing errors. These study results confirmed that an improvement in how the pharmacy prepared, checked, and distributed medications was necessary.

The redesigned PIS was finally implemented in 2003, prior to going live with the eMAR system. Rolling out the systems this way allowed pharmacy to incrementally fix any program issues associated with the bar code technology program or any preparation/distribution issues before eMAR went live in November 2004.

Features of the new PIS include:

• Incorporation of bar code scanning in medication preparation, checking, and distribution
• Bi-directional interface capabilities with eMAR
• Ability to prioritize the review and approval of physician orders
• Creation of detailed medication location information (i.e., Fed-Ex-like tracking) during distribution
• Medication loop closure by providing information back to CPOE
• Use of data matrix bar codes
• Use of 2-dimensional bar code optical scanners
• Integration of the multi-component distribution system consisting of automated dispensing cabinets, carousel inventory restocking systems, and robotic preparation of IVs

Medication Distribution Processes
With the new PIS and BPOC systems in place, we were able to implement new processes for distributing medication from the pharmacy to the patient. Now, scanning is performed when a pharmacy technician selects the drug from stock, during the preparation process, when the medication is delivered to the patient care unit, and when the medication is finally administered to the patient. All user information and points in time when scanning is performed are captured on a tracking screen for all medications and all patients. This allows for the monitoring of drug preparation timeframes as well as being able to track where the medication was delivered.

After a pharmacist approves the medication order, the PIS determines where the medication will be prepared and distributed. If the medication is stored in the patient care unit’s automated dispensing cabinet, the order information is immediately made available on the cabinet’s patient medication profile to ensure timely administration to the patient. The patient’s nurse obtains the medication from the cabinet, scans the medication bar code against the eMAR medication profile for accuracy, and then completes the medication administration process by also scanning the patient identification bracelet prior to administration to assure the correct patient has been selected.

When medications are to be prepared and distributed by the central pharmacy, information is sent to the appropriate pharmacy preparation area. If the medications do not require sterile compounding or are not premixed IV products, a “session” label with a data matrix bar code corresponding to a session number is generated. The session label lists all recent medication orders for the patient that were approved and require preparation and distribution. After printing, the session of medication orders must go through several steps (preparation, check, sent, and delivered) to complete the distribution process to the patient care unit. When a pharmacy technician scans the session label bar code, the complete list of medications are displayed on the patient preparation/distribution screen. When the technician scans the product’s NDC bar code (linear, 2-dimensional, RSS, etc.), it is checked for accuracy against the pharmacist-approved order. If accurate, the technician is permitted to file the preparation. If inaccurate, a warning box is displayed alerting the technician of the error. Once all medications are scanned and filed as accurate, the pharmacist enters the PIS by scanning the same session label and checks the orders against the same type of distribution screen that the technician used during preparation. Once all medications are determined to be accurate, the pharmacist files the session for distribution. At the time the medication is to be sent to the patient care unit, a “sent” scan is filed, and when the medications are delivered, a bar code at the patient care unit is scanned to indicate final delivery location. A check is performed by the system for accuracy of delivery at this time, and alerts are generated if the medication has been delivered to the wrong location. If a patient moves to a new location during medication preparation and distribution, technicians are allowed to perform a documented override during the delivery scan process.

When an IV or other sterile product must be prepared, information is directed to the pharmacy IV service. An individual final bag label is printed for each sterile product and contains a unique “RX” number in the form of a data matrix bar code, along with the typical information (patient, medication, expiration, etc.). The sterile product preparation goes through several steps (set-up, preparation, check, send, and delivery) using bar code technology. At set-up, an IV technician collects all components required to make the sterile product and scans each product for accuracy against the order that had been approved. The components required to compound the sterile product are then passed on to the technician who will prepare the product. After preparation, the components used during compounding are scanned again for accuracy to assure that there were no changes against the set-up information. After preparation, the sterile product then goes through the check and send scan functions prior to delivery.

Distribution Tracking System
All points of the distribution process are documented at the time of bar code scanning. The distribution tracking system in the PIS also is configured to categorize the process status of a particular session or sterile product order. For session labels (i.e., non-sterile products), the tracking system assesses how long the session has been sitting in a particular distribution step (see Figure 1), broken down into categories of greater than two hours (yellow letters-red highlighting), one to two hours (red lettering), and less than one hour (blue lettering). This alerting scheme is intended to draw attention to those orders that should be focused on to assure timely delivery to patient care units and accurate administration times to patients.

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Lessons Learned
The implementation of the new medication-use system at BWH impacted every practitioner involved in the ordering, preparation, and administration of medications and required changes in workflow, use of new technology, and application of new medication distribution and administration processes.

The ability to scan medications efficiently required practice, and the placement and quality of bar codes also impacted efficient and rapid processing of medications. Pharmacists, nurses, and technicians who accepted the learning curve required to gain the safety benefits of BPOC and did not apply short-cuts in preparation, checking, documentation, or patient care engaged the new system well. Staff easily frustrated with the new system created process workarounds or chose not to perform required scanning steps. Discovered workarounds included:

• Not scanning individual units of medication required for the order (i.e., scanning same medication multiple times)
• Cutting and pasting NDC information from the pharmacy database instead of scanning
• Photocopying drug package bar codes by pharmacy technicians for use
• during preparation and distribution instead of scanning product bar codes
• Over-using manual and emergency over-ride options during medication
• administration scanning
• Attaching the patient identification bracelet to the patient chart outside the patient room and scanning it there
• Administering medication from a “stash,” then scanning pharmacy-supplied medication after administration process is complete

Continued reinforcement of the safety and accuracy reasons for implementing bar code scanning, additional on-site training, hardware and software enhancements, and responding to user feedback all helped to minimize workarounds. We conducted monthly “eMAR rounds,” where nurses were visited on the patient care units and queried about how the new system was working for them. This allowed us to uncover program deficiencies and respond to them in a timely manner, as well as to discover where user education was needed. Nurses responded positively to their ideas being taken back to the project team and software developers for incorporation into future enhancements.

In order to better ensure that the new technology is used initially, staff, especially the end-user nurse, must be involved in the evaluation and decision-making processes regarding hardware and software functionality, implementation, and staff training. It was not until after we implemented the system that we realized the physicians would rely so heavily on the eMAR for patient medication profile information. So, an additional screen display called the “Medication Overview” had to be developed and implemented after eMAR went live so the physicians would have a medication list they could interpret easily and quickly. The new screen displayed active and inactive medications with the actual time of patient administration. Had we thoroughly engaged medical staff prior to implementation, this could have been avoided.

Post-implementation Study Results
After implementing the new system, pharmacy and nursing performed post-implementation studies. Pharmacy demonstrated an 85% dispensing error reduction during their distribution processes by implementing medication bar code scanning. This decrease in dispensing errors also represented a 63% decrease in potential adverse drug events.3 Results from a cost-benefit analysis of the pharmacy system using bar coding indicated a net five-year cumulative benefit of $3.2 million, with a break-even point reached within one year after going live with the system.4

Nursing’s study of eMAR error prevention over two different periods after BPOC implementation also demonstrated positive results in a short period of time (see Figure 2).
Nursing performed a concomitant study to examine nurses’ satisfaction with the new BPOC by comparing satisfaction levels before and after its introduction. A total of 1,087 nurses’ satisfaction scores were assessed in three areas: efficacy, safety, and access. Pre-conversion, nurses were satisfied with the existing systems (average Likert score = 4.1). Post-conversion, nurses were more satisfied (average Likert score = 5.1).5

Conclusion
Improving patient safety and reducing medication errors can be achieved by implementing BPOC technology and supporting systems, but requires practitioner commitment, information technology resources, and time. By implementing a medication-use system that incorporated bar code technology and instituting improvements in it over four years, we have substantially reduced both pharmacy dispensing and nursing administration errors.

BPOC and eMAR implementation in the hematology-oncology patient care units was completed in the fall of 2009, and BPOC/eMAR implementations in the emergency department and procedural areas are being planned for the future. Recently we incorporated bar code technology into the robotic preparation of chemotherapy IV solutions. In addition, we are considering closing the medication loop even further by implementing 2-dimensional “smart” bar codes for the auto-identification of care providers and patients, as well as going wireless with smart pumps that will directly interface with the PIS and eMAR systems. This would also involve a feedback loop to pharmacy to coordinate timely preparation and delivery of IV medications.

Thomas W. Cooley, RPh, MBA, is assistant director of pharmacy services for Brigham and Women’s Hospital in Boston, Massachusetts, where he is responsible for pharmacy informatics and technology with a focus on designing, developing, and implementing safer medication administration systems across the institution. Thomas also manages the investigational drug service and ambulatory pharmacy. Thomas received his BS and MBA from the University of New Mexico.

References

1. Bates DW, Teich JM, Lee J, et al. The impact of computerized physician order entry on medication error prevention. J Am Med Inform Assoc. 1999;6(4):313-321.
2. Cina JL, Gandhi TK, Churchill W, et al. How many hospital pharmacy medication errors go undetected? Jt Comm J Qual Patient Saf.2006; 32(2):73-80.
3. Poon EG, Cina JL, Churchill W, et al. Medication dispensing errors and potential adverse drug events before and after implementing barcode technology in the pharmacy. Ann Intern Med. 2006;145(6):426-434.
4. Maviglia SM, Yoo JY, Franz C, et al. Cost-benefit analysis of a hospital pharmacy barcode solution. Arch Intern Med. 2007;167(8):788-794.
5. Hurley AC, Bane A, Fotakis S, et al. Nurses’ satisfaction with medication administration point-of-care technology. J Nurs Adm. 2007;37(7-8):343-349.