Incorporating bar code scanning into medication management processes has continued to expand over the past 15 years. According to Pharmacy Purchasing and Products’ 2014 State of Pharmacy Automation Survey, 75% of facilities of all sizes have adopted bar code medication administration (BCMA).1 Nonetheless, procedural areas, outpatient care areas, and emergency departments (EDs) tend to lag behind other units in the implementation of this important technology because of challenges unique to their practice. Providers in the ED, for example, are accustomed to, and require, the ability to provide expedited, timely medication therapy to their patients. For this reason, there has been concern about the feasibility of implementing BCMA in this area and the expectation of high scanning compliance rates. With careful planning, however, BCMA implementation in the ED can be a success.
Nebraska Medicine is a two-hospital health system comprising an academic medical center and a community hospital licensed for a combined 697 beds. The medical center ED serves approximately 55,000 patients annually, and the smaller community ED services about 25,000 patients annually. Nebraska Medicine uses a charge-on-administration billing structure with automated dispensing cabinets (ADCs) throughout the organization. The medical center ED has a pharmacist on staff 24/7, while the community hospital covers ED medication orders from a centralized pharmacy location.
Our health system implemented a new electronic health record (EHR) in 2012. The goal was to bring BCMA online in the two EDs at the same time the EHR went live. Even though bar coding of emergent medications traditionally was sporadic, the hope was that the EDs could attain the organization-wide bar coding goal of 97%.
Implementation: Evaluating Auto-Verification
The first step was to develop a multidisciplinary team that comprised nursing and pharmacy leadership, information technology analysts, and health care providers. Key elements of the planning phase included leveraging functions within the EHR and ADCs, as well as implementing robust surveillance of frontline staff.
The first function the group evaluated was EHR auto-verification. Based on defined criteria, a security option can be established in the EHR to allow auto-verification of orders placed by designated users. Setting this function effectively bypasses pharmacist prospective review, although auto-verified medications still are presented to pharmacists for retrospective review, which provides the opportunity for any necessary intervention. This option was provided to ED physicians only for all medications housed in the ED ADCs. Auto-verification security was not provided to ED nursing staff or providers based outside of the ED in order to ensure patient safety and to support the CPOE initiative. In addition, auto-verification was not extended to certain high-alert medications, such as heparin boluses and infusions. Initial bar code scanning compliance rates when using the auto-verification function alone were 70% to 75%.
Activating the profiling setting on the ADCs was the next step toward improving scan rates. With an activated profiled setting, provider orders automatically populate the medication fields of patient profiles for nurse selection. Typically, many EDs and procedural areas utilize non-profiled ADCs, allowing medications to be removed regardless of the provider orders placed. The belief is that this facilitates the most expedient care.
But we discovered that profiling the ADCs yielded a far higher BCMA success rate and that it was vital for aligning provider-ordered products with the medications nurses pulled from the ADCs. Prior to profiling the cabinets, achieving this alignment was challenging. Because providers are not involved in the medication dispensing process, they are not always sufficiently specific when placing orders. Furthermore, while the CPOE ordering system should guide accurate product selection, if it does not, the nurse may pull the incorrect product.
Consider the example of a provider who orders morphine 2 mg/mL carpujects to fill an 8 mg dose. The system expects the nurse to pull 4 morphine 2 mg/mL carpujects from the ADC. However, most nurses recognize that a 10 mg/mL carpuject is a better way to achieve this dose. If the profile setting is not activated, the morphine 10 mg/mL carpuject selected by the nurse will fail upon scanning because the system is expecting 2 mg/mL carpujects to be pulled. The profile setting allows the nurse to identify this mismatch prior to pulling the product and provides the opportunity to round back to the provider for order optimization. In short, profiled ADCs allow nurses to view exactly what providers ordered for patients, minimizing the risk of removing—and dispensing—incorrect medications, such as look-alike/sound-alike drugs.
For profiled ADCs to be successful in a high-acuity area, such as the ED, it is necessary to scrutinize the medications on the override list. A multidisciplinary team of ED physicians and nursing staff should determine which medications to include. The list should be limited to only medications that would be utilized in a medical emergency, as overrides will evade the established checks and balances (ie, provider order, nurse acknowledgement, pharmacist verification, and nurse administration).
Because the EHR and ADC interfaces populate the nursing medication administration record (MAR) with the medication that was pulled from the override list, the nurse can still scan the product, even if it was pulled without a provider order. In addition, the override pull creates an order on the MAR so that nurses can reconcile override pulls with physician orders. It is important to note that override lists provide an opportunity for misuse, and, thus, should be monitored regularly via ADC or EHR reports.
Workflow revisions were required throughout every care area following the EHR implementation. Routine monitoring and surveillance were suspended organization-wide during the immediate post-go-live phase; however, a 6-month review was conducted, which revealed a decline in scanning compliance on the inpatient nursing units. Following this discovery, the medication safety team re-launched a monthly report of bar code scanning compliance on department, hospital, and organizational levels. The data are provided to senior leadership following quarterly pharmacy and therapeutics (P&T) committee review and approval. The P&T committee also adjusts targets as necessary and supports action if the targets are not within the desired range.
The organizational goal for average scanning compliance is 97%. This target was only recently achieved, nearly 2 years after the EHR implementation (see FIGURE 1). Scanning compliance rates for the EDs track slightly lower than those for the organization as a whole (see FIGURE 2).
ED bar code scanning rates were monitored closely during the implementation of the EHR. Throughout the initial months following implementation, scanning compliance was approximately 75%. Nursing staff struggled with reliable scanning of product, and reported that medications removed from ADCs often did not match provider orders. Monitoring of nurse-reported concerns was integral to the decision to utilize ADC profiling.
ED scanning compliance is now monitored monthly, and nursing leadership performs follow-up with any nursing staff members whose scanning rates fall below 90%. This active surveillance and follow-up has proven to be a critical element in sustaining compliance and identifying scanning barriers (eg, poor medication labeling, scanner not available, scanner not working, medication bar code not scanning, etc). FIGURE 3 illustrates the 70% to 75% performance without the profile setting and the subsequent increase following implementation of profiling. This figure also illustrates the importance of committed ED nursing leadership follow-up, which led to our recent achievement of near 95% scanning compliance. The EDs strive for the organizational 97% goal; however, nursing leadership has shared anecdotal reports that 90% to 95% is in alignment with other high-performing EDs.
Key Elements of Success
Key elements of a successful BCMA implementation include leveraging functions within the EHR and ADCs, as well as robust monitoring and surveillance by leadership. While the safety benefits of BCMA are well established, typically, it is the inpatient care areas that are most experienced with this technology. In-house bar code data tell us that nurses who treat a high percentage of code and trauma patients have a lower medication scanning compliance rate.
The time we invested in multidisciplinary planning with ED personnel and leadership supported our medical center ED’s review of workflow and translated into those team members responding promptly when opportunities for improvement were identified. These lessons were shared with our community hospital and were implemented there following the medical center’s improvement in scan rates. Ongoing monthly surveillance provides the opportunity for real-time feedback, as well as the identification of any systems issues that may unexpectedly impact BCMA.
One of our future goals is to improve ED medication documentation for trauma and codes. Currently, trauma cases and some codes are documented on paper. Documentation via the EHR would provide the benefit of the medication being selected in the same system where it is ordered, charted, and administered, with a single keystroke by the documenting nurse. This approach would eliminate an extra bar coding step, as the medication would already be charted within the code/trauma workflow of the EHR.
Another functionality we plan to explore is the implementation of bi-directional information flow between the BCMA and EHR systems. With this approach, once a medication is scanned into the BCMA system, administration data automatically flow back to the EHR, essentially reversing the order of our current functionality for medications that are ordered for critical patients in fast-paced environments. This concept has been discussed among anesthesia providers as a means of leveraging bar code medication scanning within the OR environment to reduce duplicate documentation and improve provider efficiency.
Lastly, the technologies we have put in place offer an array of opportunities for data analysis, which we have identified as another area for future focus. As noted earlier, while the override list is an important and necessary tool in the medication management process, it also introduces opportunity for misuse. ADCs and the EHR both offer the reporting capabilities necessary to monitor and follow-up on overrides, but we have found that comparing override dispenses with unreconciled dispenses—orders that have not been matched to a corresponding provider order—is more valuable. Data regarding occurrences of unreconciled dispenses, which should be rare, can be generated from the electronic medication record.
Other data analysis opportunities include ongoing BCMA surveillance, incident report monitoring (captures ADC narcotic discrepancies), ADC override pulls, ADC unreconciled dispenses, and BCMA near misses. The latter will assist us in implementing safety systems to minimize risk in future patient care activities. We also are looking forward to pump integration, which will provide real-time data to improve pharmacy operations efficiency.
Attaining and Sustaining Success
Introducing new technologies in high-acuity environments, such as the ED, can be challenging, but multidisciplinary partnership, coupled with leveraging various functions of the technology, can help ensure that the launch and ongoing use of such additions is successful. Moreover, continuous oversight from nursing and pharmacy leadership, combined with medication safety team surveillance of bar code scanning compliance, can help sustain success over the long term.
Katharine Reisbig, PharmD, BCPS, is a clinical pharmacy manager for ICU and ED pharmacy services at Nebraska Medicine in Omaha, Nebraska. Her clinical area of practice is emergency medicine pharmacy, as she has recently transitioned from roles in medication safety and pharmacy informatics. Katharine’s professional interests include emergency medicine, medication safety, pharmacy informatics, and pharmacy leadership development.