In this three-part series on medication administration, HCI looks at the information exchange points in the process where errors are most likely to be made. In June, our first installment looked at the initial patient encounter and physician order. Last month, we took a look at the pharmacy, and how drug orders are received and filled. In our final installment below, we turn to the last step in medication delivery — the bedside transmission of drugs from nurse to patient.
Bedside administration is the last line of defense in preventing medication errors — and the place where most of them slip by. According to a 2008 HCI webinar, (see graph) 98 percent of medication errors that occur at the bedside reach the patient — as opposed to only 50 percent of errors made in the initial ordering.
While CPOE has long been touted as the be-all and end-all in closed loop medication. in practice, many CIOs are finding that the bedside is the place to eliminate medication errors, and the numbers seem to back that up.
“We did a lot of research on the reasons for mistakes, and how many make it to the patient,” says Mike McCurry, CIO at the 18-hospital Sisters of Mercy Health System, based in Chesterfield, Mo. “With CPOE, the checks in place in the pharmacy eliminate most of the errors and only 2 percent get through. But for mistakes in administration, only 2 percent of the mistakes are getting caught.” McCurry, who is on a Cerner (Kansas City, Mo.) legacy system will soon be on CPOE. Ironically, he's eliminated most of his errors without it. “Clearly, if you want to solve your most urgent medadmin mistakes, fix the administration process, not your CPOE process.” he says. “Since our (bar-coding) implementation in '03, we have not had a medication mistake get through to the patient.”
But before that final scan and click by the nurse, there are a lot of pieces involved — and a lot of processes. “There's an old adage,” says McCurry, “you can't automate chaos.” Before medications can even be scanned at the bedside, they have to be repackaged into unit dosing, bar coded, and moved to the patient. Hospitals are using a variety of systems to do this, whether they use a core vendor for most of the steps or not.
Joan Roscoe, CIO of six-hospital Valley Health in Winchester, Va., has seen big improvements since she started using bedside barcode scanning. “We were doing what every other hospital is doing — eyeballing the medication and the patient's ID,” she says, describing the organization's past practices. Roscoe now uses McKesson (Alpharetta, Ga.) as her core vendor for CPOE, charting, pharmacy and medadmin, which including nursing documentation. So far, only her 25-bed Shenandoah Hospital is fully live on CPOE. “The computerized provider order entry is up and running at three sites, but it's running for nursing as a base order entry, and it's only for physicians at our 25-bed hospital.”
She also uses a McKesson robot in her 400-bed flagship hospital to package meds. Once packaged and bar coded, the meds come to the floor in a Pyxis (from Cardin Health, Dublin, Ohio) cart interfaced with McKesson. Medication orders show up in the nurse's queue for administration, and the nurse bar codes both the patient's wristband and the nurse ID badge using a handheld device. The McKesson software matches both to the order and drops a bill into the McKesson billing system upon administration.
At NCH Healthcare, a two-hospital, 600-bed system in Naples, Fla., CIO Susan Wolff also uses McKesson's Robot-Rx, but is using Cerner for her EMR, Malvern, Pa.-based Siemens for her billing, and Cerner PharmNet as components. When she opened a new hospital tower, bedside bar coding was one of her first “to do's.”
“In 2004-5, we brought up the eMAR and were documenting meds with no bar coding. In 2007, when we opened a new six-story patient tower on our north campus, we decided to put a computer in every patient room and open the hospital with nurses using bar-coded administration. We wanted to be paperless, as automated as possible and as clinically safe as we could be,” says Wolff.
Kathleen LePar, vice president of professional services at Beacon Partners, says new construction is a great place to start. “Look at the architecture of your organization first.” She says that when new hospitals are being built, executives should think of patient safety workarounds in structuring a nursing unit. “It's important to take your eMAR carts into a room, so the rooms need to be big enough. Ease of use will make people much more compliant.”