Unique Safety Requirements for BCMA in the NICU

November 2011 - Vol. 8 No. 11 - Page #42

The implementation of bar code scanning technology undoubtedly improves accuracy in medication distribution and administration, and thus decreases potential medication errors and adverse drug events in patients. In addition to providing baseline assurance that the five rights of patient medication safety are automatically incorporated, BCMA also improves medication ordering and documentation. The challenge lies in implementing this automation facility-wide. Departments such as the NICU require the design of unique safety processes in order to protect their highly vulnerable patients.

Brigham and Women’s (B&W) is a 793-bed teaching affiliate hospital of Harvard Medical School. In the early 1990s, B&W embarked on an important mission to implement technology to significantly improve patient medication safety. In 1993, computerized practitioner order entry (CPOE) implementation resulted in a 55% decrease in the serious medication error rate.1 This success prompted hospital leaders to review additional areas where technology could impact patient safety. In 2000, a multidisciplinary project team that included attending and resident physicians, senior pharmacy and nursing leadership, staff nurses, clinical pharmacists, and information system department development team leads initiated a critical evaluation of the entire B&W medication use process. With senior hospital leadership support for improvement, the team evaluated the intricate interplay of all electronic and manual medication use systems. Three major recommendations were made as a result of this evaluation: 

  • Redesign the pharmacy information system (PIS) as a Web-based application, able to use bar code technology in the preparation, check, and distribution of medications
  • Develop an electronic medication administration record (eMAR)
  • Implement BCMA at the patient bedside

Thus, B&W began the complex process of implementing these important patient and medication safety improvements throughout the inpatient units, and later in the NICU and newborn nurseries. 

Putting BCMA into practice in newborn care areas presents unique challenges compared with other hospital departments. Because NICUs are high-risk environments that care for extremely vulnerable patients, special emphasis was placed on maintaining and improving neonatal patient safety from the initial discussions throughout the length of the project.

Medication Use Process Redesign
Revamping the pharmacy system began in 2001, prior to eMAR design and development; this complete redesign of medication preparation, checking, and distribution processes included the application of bar code technology. A study was completed during the development of the new systems to assess the accuracy of the former pharmacy distribution process. The results indicated that an error rate of 0.92%, meaning 181 of 19,746 dispensed first-dose medications, would have reached a patient in error.2 Because B&W pharmacy services dispense more than 6 million doses annually, this error rate corresponds to approximately 55,000 pharmacy dispensing errors, confirming the vital incentive to improve distribution accuracy. The redesigned pharmacy system was composed of several components to improve medication safety, including:

  • Bidirectional order information interface with existing CPOE and the future eMAR
  • Ability to prioritize physician orders in dynamic pending order queues
  • Incorporation of bar code scanning in medication preparation, checking, and distribution
  • Detailed medication distribution location information (ie, FedEx-like tracking)
  • Standardized times of administration and prioritization 
  • Provision of comprehensive clinical laboratory and drug information
  • Use of data matrix bar codesn Use of 2D bar code optical scanners

BCMA development required infrastructure changes for pharmacy and nursing services, including wireless communication throughout patient care areas and medication use processes; bar coding of all medications, employee IDs, and patient ID wrist bands; hardware to support pharmacist and nurse mobility; and software application designed to improve mediation safety and complement patient care workflow processes. By 2009, the majority of the inpatient care areas had implemented BCMA; the most recent addition was the redesigned chemotherapy order entry and pharmacy information and eMAR system in the hematology-oncology service. Our next implementation was to the NICU and neonatal care areas.

Preparing for BCMA in the NICU
In early 2010, after critical evaluation of available resources, other hospital project contentions, consideration of our facility’s clinical information system strategy for FY11-12, and additional review to address newborn patient safety concerns, the newborn BCMA and eMAR development project received final approval. The NICU needed to have the same safe, closed-loop medication process established in other patient care areas. Additional goals were improved documentation through the elimination of transcription, assistance in prioritization of medication orders, increased accessibility to clinical decision support information, and improved communication among CPOE, pharmacy, and newborn eMAR.

To optimize efficiency, the newborn BCMA executive and business owner committees decided to combine the separate adult and NICU systems and retire the current NICU PIS. The two had shared the same preparation and distribution programs within pharmacy operations, but were interfaced to separate CPOE systems. Plans were made to redesign the adult PIS to accept newborn CPOE orders and incorporate program designs that provided optimized safety considerations for newborn patients. For example, these designs included maintaining a sophisticated newborn IV compounding guidance and documentation system; visually differentiating medication profiles for each patient population; customizing total parenteral nutrition order screens; and adding new, age-appropriate medication dosing clinical decision support tools, support for different order setups, and approval configurations for IV medication preparation and labeling.

The development of a newborn eMAR required enhancement of the existing adult eMAR to accommodate this new patient population. Applications were designed to incorporate NICU triage and well-baby patient movements within the newborn care areas, as well as to accommodate respiratory therapist workflows. A unique customization was the design of the newborn BCMA system and eMAR documentation to handle the ordering, preparation, and administration of human milk. The newborn eMAR design also included the addition of two pain scales for the documentation of pain assessment in administration of PRN pain medications to both premature and full-term neonates. Information resource links specific to newborn patients, their medications, and other clinical information were well received by nurses and physicians.

Due to limited space in the B&W newborn environment, hardware configurations and placement were important decision points prior to the go-live date. Newborn-unit clinicians approved wireless laptop and scanner formats. To avoid potential risks of tripping for staff and patients, a battery exchange model was selected for the laptops to avoid using electrical outlets at the bedside. Infection control considerations supported a platform of one laptop per neonate location, with hardware and battery bays established in each room. The changes in physical layout impacted workflow in each room and required adjustment by nursing staff. This model is continuing to be evaluated for opportunities to maximize the efficiency of nursing.

Collaborate for Success
The newborn BCMA venture benefitted from the lessons gleaned from the previous adult inpatient BCMA project, using the same high level of collaboration and effective project management. Experienced BCMA project members knew that a significant criterion for project success was securing the support of dedicated project leaders from every discipline. The public health sciences information systems department, B&W newborn physicians, nurses, respiratory therapists, pharmacists, and ancillary staff collaborated extensively during the project, and support from public health sciences and B&W senior leadership was especially critical for success. 

The primary groups responsible for a successful project were the newborn eMAR/pharmacy business owners and the newborn eMAR/pharmacy work group. The business owners are senior department leaders from pharmacy, nursing, and the NICU and newborn nurseries; their charge was to work together to define, plan, develop, and implement the project. The work group was comprised of participants from nursing, newborn medicine, respiratory therapy, pharmacy, nutrition, and information systems; their role was to be champions for the project, assist in decision-making, and develop detailed program functionality, testing, and implementation of BCMA in the NICU and all newborn nurseries.

BCMA Staff Training
Training staff in preparation for BCMA is an important component of a successful implementation. Earlier B&W BCMA project training methods and resources demonstrated that staff education is critical to frame a clinician’s belief that BCMA will positively affect medication safety, and therefore become an accepted and integral part of patient care workflow. Therefore, all NICU nurses attended mandatory, off-site, 4-hour training classes designed to mimic actual use of the system, from orders received, medications scanned, milk bottles retrieved, and documentation required. Super-users received sixteen hours of extensive training. Nurses from the newborn nurseries were already familiar with the BCMA process because they had been using it for the administration of medications to mothers using the adult eMAR, so this group required only abbreviated training on the bar code scanning method for human milk.

From previous implementations, we learned that developing confidence in the art of BCMA and optical scanner use is as important as learning the science of this particular tool to improve patient safety. Computer-based training modules supplemented and reinforced classroom training experiences. Our dedicated, on-site super-users, information systems analysts and consultants, and pharmacists already extensively experienced in the use of BCMA supported nursing staff throughout the go-live period. 

Implementation Support
Implementation of BCMA and eMAR across the NICU and newborn nurseries took approximately six weeks. Both business owners and project work teams met regularly to support the continual improvement of the newborn BCMA and eMAR. The implementation process officially reached its conclusion at the end of September, 2011. Throughout the process, clinicians have gained experience with the new medication administration system and have been requesting enhancements to assist in care workflow and improve medication safety; this work began in October, 2011.

Feedback from rounds and online eMAR and pharmacy systems, as well as clinicians’ help-desk calls, are monitored and reviewed weekly by the eMAR and pharmacy teams, and prioritized for future fix or enhancement. Information system development teams for CPOE, pharmacy, and eMAR triage issues for immediate resolution if considered critical for patient safety. The complexity of health care and ordering processes prevents the incorporation of all possible issues into an application, but through program information gathering and soliciting clinician feedback, a safe, efficient, and productive application was developed to ensure patient safety.

Overcoming Implementation Obstacles
Despite the benefit of having learned from previous BCMA implementations, several issues were encountered during the NICU BCMA project.

Workflow Changes

  • Capturing newborn workflow and documentation processes required a significant amount of project team time. It is important to establish a robust, proactive gathering process and then evaluate the accuracy of these functional program specifications to optimize project team testing and limit any time-consuming program redesign.
  • Extra care was needed when manipulating the baby ID ankle bands, as the additional administration of human milk affected their durability. 

Technology Adjustments

  • The newborn environment had more dynamic dose and infusion rate order changes than experienced in previous implementations in adult care areas. Initially, each infusion rate change order automatically disallowed continued bar code scan program acceptance—for example, for IV solutions already hanging. The high level of dynamic order change required several application adjustments to accommodate efficient order approval, scheduling, and eMAR documentation. The effect of multiple order changes on preparation, distribution, and administration scanning has created improved software functionality for both the newborn and adult populations.
  • Adjustments were necessary because expiration of IV solutions based on CPOE order and pharmacy approval dating rules did not correlate effectively to the NICU practice allowing hanging of bags for 72 hours. This change resulted in an institution-wide review of infusion hang time policies, with the goal of standardizing wherever possible across both adult and neonatal care areas. 
  • Quality data capture and reporting capability should be in place prior to BCMA go-live. The ability to critically review scan data (eg, scans of wrong medications) will bring focus to important BCMA-associated issues and make program improvements easier. 
  • Hardware issues, such as laptop battery life, initially caused staff frustration. Work continues with the laptop manufacturer to increase battery life. 


  • Request that practitioners create realistic orders for application testing purposes. These orders should be used for the training of practitioners and super-users, and must extend to all development test areas. 
  • Build on test script scenarios by sharing feedback between project and information sciences development teams to improve thoroughness of application development. 
  • End users should be involved in the program testing process as early as possible, regardless of the time constraints of the implementation. 
  • All program code must be developed and in place for the first day of super-user training, as the success of super-user training has a direct impact on go-live success. 
  • If external consultants are engaged to assist with a go-live, ensure they are as well trained in the application and support/issue escalation processes as all other project staff. 
  • The project team should play a critical role as facilitators between newborn clinician staff and information system hardware and facility work teams.
  • Be prepared for variances in clinical staff acceptance of the changes that BCMA can have on care practice. Offer additional education for staff members as needed.

The newborn staff and leadership were anxious to complete the process successfully to ensure newborn patients receive the same safety benefits as the adult inpatients already protected by the technology. Some workarounds, related to lack of experience or confidence in the new system, impact of the new technology on daily patient care workflow, and becoming proficient in the art of bar code scanning and hardware issues were identified, although there were significantly fewer than those uncovered in previous BCMA and eMAR implementations. 

One distinct success factor was the robust interest and participation of the newborn nurses on the project development team. The commitment and dedication of the nurses and other clinicians resulted in a BCMA and eMAR product that enabled a smooth and efficient implementation. The information system project team documented lessons learned as the project progressed through development, go-live, and post-implementation. 

Proposed Improvements
While we were able to capture basic practice data from the system, such as scanning compliance rates, the data was not sufficiently sophisticated to demonstrate causes of unusual scanning activity. More advanced data collection was necessary to drive system improvements. As we moved to implement BCMA in our specialty areas, we simultaneously initiated a quality data warehouse project to develop improved BCMA data capture and reporting. This project will reach completion in the coming months. Until the quality data warehouse project is finished, the information captured presents only a high-level view of scanning data. 

Future expansion of newborn BCMA is unfolding in connection with other new program growth projects across B&W. As staff gains more experience in BCMA use, they will bring forward new and innovative ideas for program improvement. Currently nurses are required to confirm and input certain doses prior to administration, but the program does not calculate exact volume for the liquid or injectable doses to be administered. Via our online feedback system, many users have proposed improvements to online medication dose calculations prior to medication administration. Forthcoming enhancements include bringing smart infusion pumps onto a wireless network integrated into the pharmacy and eMAR that will use BCMA as a component of the infusion administration process. Incorporation of bar code scanning technology as a secure double-check of baby transfer to parents or other family members in well-baby nurseries also has been requested.

At the outset, the NICU BCMA endeavor was defined by clearly delineated objectives and distinct team roles. Because these were well communicated, the result was a project that progressed efficiently and was delivered on time. Implementation of BCMA into other areas of B&W is part of the clinical system strategic plan for the next few years. Future BMCA projects include incorporating BCMA into the labor, birth, and recovery areas, as well as into mixed inpatient-outpatient units, such as postanesthesia care and the catheter-angiography/recovery unit. We anticipate coming BCMA implementations will progress efficiently as a result of being informed by our NICU project.


  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 pharmacy medication errors go undetected? Jt Comm J Qual Patient Saf. 2006;32(2):73-80.

Thomas Cooley, RPh, MBA, is the director of pharmacy informatics and support 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. He received his BS and MBA from the University of New Mexico.


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