Cook Children’s Medical Center, a 428-bed facility in Fort Worth, Texas, has achieved wide adoption of an electronic barcoding system that verifies that medication delivery is correct before pediatric patients receive it. The hospital reports that recent scan rates of medications and patients before treatment are more than 97 percent.

Cook Children’s story was featured in an in-depth case study, “Changing the Culture: One Hospital’s Journey to Improve Care Delivery with Bedside Medication Verification,” developed by the Ann Arbor, Mich.-based College of Healthcare Information Management Executives (CHIME), intended to highlight how information technology can improve healthcare delivery and to detail how providers are successfully implementing technology to promote sharing of best practices in IT implementation.

Cook Children’s bedside medication verification uses integrated technology to check in real time, before medication is administered to a patient, to make sure the right medication is being given in the right dose to the right patient at the right time and in the correct manner.

Before Cook Children’s implemented a bedside medication verification system in November 2010, it first had to identify its technological weaknesses. At the time Cook Children’s electronic health record (EHR) provider Meditech (Westwood, Mass.) did not have a well-developed barcode system, so the hospital started shopping for other vendors.

“The problem is, if you don’t use a barcoding system that is the same as your current system, you have to use an interface engine, and that brings in the need of using a second eMAR, electronic medication administration record,” says JoAnn Sanders, M.D., the organization’s patient safety officer and the project sponsor for the bedside medication verification program. “So any time you use a second eMAR, you introduce the risk of higher medication errors, and I wasn’t on board with that concept.”

After some industry research, Cook Children’s decided to wait for Meditech to develop its barcoding system, and in the meantime redesigned its pharmacy by implementing a carousel and re-packager.
    
To implement the new bedside medication verification, an implementation team was formed with participants from a variety of departments within the hospital, including various nursing leaders, the pharmacy department, and IT. The team worked together to map out a phased implementation in the facility, and then a strategy to use data to encourage the barcoding system as they treated every patient.

Educating Staff to Increase Adherence

Education was essential to achieving widespread adoption of the technology by clinicians. An education department assigned educators, masters-educated nurses, to every unit to regularly perform patient safety rounds. When go-live occurred, IT provided round-the-clock support to all units, with staff physically on units having “eyeball to eyeball collaboration” with nurses.
 
Cook Children’s is continuing to beat the drum for staff to remain consistent and maintain as close to 100 percent for scan rates as possible. “Even after we started, we tried to remain positive when we went around for our patient safety rounds, we would go to a unit that had a 100 percent and thank them and to celebrate their success,” says Sanders. “We also went to a unit with not-so-good scan rates, and instead of saying, ‘why aren’t you doing it,’ we asked them to tell us what their barriers were. So it really sent this message of ‘you are the ones who can help us make this better.’”

Early on, Cook’s Children had a bump in the road with its patient ID bands. For one, the bands were not always on every patient; sometimes the band was too big or too small for the patient. Another issue was the initial band selected was not durable and often was difficult to scan, with an average scan rate of five times per patient. After a few nurses attended a barcoding conference, they identified a non-degradable band used by a hospital with a high scan rate. Cook’s Children piloted that particular band in a couple of med/surg units, before doing a full rollout.

Continuous Improvement through Collaboration

More than a year after implementation of the technology, the core implementation group continues to meet  to enable maintenance of the program and continuous process improvement, underscoring the importance of bedside medication verification to Cook Children’s patient safety program. System improvements—like fixing scanners that were not recharging correctly by moving the charging holster from the back to the front of the cart on wheels (COW)—are continuing to be made to support optimal usage. Sanders notes that the team is “hyper vigilant” when monitoring usage and step in when they see nurses create workarounds for established processes.

While bearing responsibility for the installation of the technology, Cook Children’s IT department was at the table to enable the project, but not to lead it, said Theresa Meadows, senior vice president of information services and CIO for Cook Children’s Health Care System, in a statement. “It wasn’t an IT project,” Meadows said. “It was driven by the clinicians, and that made a huge difference.”

“A lot of IT departments tell you what you can have, and I think the lesson learned for me was that IT has to see us as their customers,” says Sanders, “and they need to ask what you need and deliver that.”

Placing the project as a patient safety initiative under direction, and with the input from the core team, cast the project in a different light, Sanders says, and members of the core team sought out feedback for how the project would change care delivery and what would be needed to make it work.

Sanders admits that big implementations like this are difficult, but acknowledged this project was well-run and rolled out. Part of its success was due to the leadership holding clinicians accountable, she says. IT ensured clinicians had the right technology, like engaging nurses to help select technology, like scanners, and made sure they worked. Also, nurses were encouraged to report wireless and computer issues immediately and were encouraged to log a reason when a band was not scanned.

“I think having that ‘just culture’ in place where people knew they were accountable for their behavioral choices [is important],” concludes Sanders. “But also they can report any system problems without impunity. I think that was huge for us.”