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.”
In her new site, Wolff found cabinets to be another tool that optimized the nurse administration process. Once the robot puts drugs in an envelope (one for each patient), pharmacy techs bring them to nurse servers, which are wall-mounted, locked cabinets. “We put nurse servers in every room,” says Wolff. “We have two servers, one per bed. That was part of the whole process design that said, ‘Make it easy for the nurse, have the medication right there, don't make her go into the medication room.’” In addition to the nurse servers, Wolff is also using McKesson AcuDose cabinets for PRN and controlled substances.
Both Wolff and Roscoe use bar coding to increase safety. But what about the fact that not all pharmaceuticals are bar coded? At Sisters of Mercy, McCurry's bar code/distribution system has earned him hundreds of site visits from other hospitals. “We solved the problem that a lot of people struggle with, in that only 55 percent of manufactured meds are available at the unit-dose bar-code level,” he says. “We looked around and didn't find anyone doing anything with that figure. So we decided to see if we could solve it ourselves.”
The Sisters of Mercy solution is born out of supply chain logistics using AmerisourceBergen (Valley Forge, Pa.), and is a classic example of the fact that solutions can come from anywhere, if the CIO is willing to listen.
Mercy has dedicated supply logistics routes to each and every facility every day. “We decided to bring all drugs, even the ones with bar codes, into our distribution center, and then bar code and repackage drugs that don't have unit dose bar codes available,” says McCurry. “The supply chain guys drove this.” The organization was initially looking to track items with high costs.
At first, McCurry faced skepticism from people who thought that meds might not be a good fit with supply chain. “A lot of people were struggling with medication, asking, ‘Do you really want to put that in the warehouse?’ In six months it went from this crazy idea the guys in supply chain have, to everybody wanting to take credit for the idea.” As a result, 100 percent of the drugs used at Mercy at the patient bedside now have bar coding.
McCurry says his system is a simple process for the nurse, but technically more intricate and challenging IT-wise. He uses Omnicell (Mountain View, Calif.) cabinetry, the Omni Central inventory management system and reordering system for the drugs, thermal printers from Zebra Technologies (Vernon Hills, Ill.), Cerner Bridge for eMAR and EMR, and a combination of Lawson (St. Paul, Minn.) financials. “We integrated all of those systems and we've integrated very robust logistics; so it's got trucking and warehouse management, lot tracking, and the ability to break down units, keep track of them, and add bar codes.”
It's very simple for the nurse, he says. “(Cerner) Bridge receives an ADT (Admission, Discharge, Transfer) feed dynamically. Nurses simply go to their medication cabinet.” The cabinets wirelessly receive updates from Bridge. Nurses go into the system, look up their patients, and then go to the Omnicell cabinet. “Because Bridge and Omnicell are integrated, the nurse is able to pick all of the drugs from the cabinet, load it into her cabinet and go to the patient bedside,” he says. “Bridge takes over and it's very seamless to the nurse; they don't even know that they're in a different system.”
Most agree that once the drugs are at the bedside and ready to administer, best practice is for the nurse to use the five rights; bar code the patient, the drug and sometimes her ID, respond to any alerts, then administer and document at the bedside. But there are classic workarounds. “I have the highest regard for nurses. And every good nurse can find a workaround for anything,” says Wolff. “They're interested in expediting care for patient; consequently there are ways to beat the system.”
Bar-coded labels are a classic example. Most hospitals, at admission, print a page of labels along with the armband for the patient. “There's nothing that would prevent the nurse from not bar coding the patient, but instead bar coding the page,” says Wolff, who already has a solution to this classic problem. “We're going to change the requirement so that there's a special character in the patient ID that's only on the armband, not on the labels.”
Mercy doesn't use sheets of labels. “The reason people use sheets is to keep track of drugs being administered that don't have a unit dose level,” says McCurry. “They create it and put it on a sheet.” Mercy does have patient info sheets that are part of the record but they're not very accessible, and McCurry says it would be more trouble for a nurse to pull it out. “I'm not here to tell you that there's never been a workaround,” he adds, “but we categorized them into (four categories from low to high), and we've had no administration errors get beyond those first two low categories. “As a matter of fact,” he adds, “we've lowered our reserve for lawsuits because we've eliminated the mistakes.”
LePar says the biggest workaround is not following the five rights. “If a nurse has been caring for a patient for five days, the nurse is almost embarrassed to say, ‘Let me look at that armband,’ so sometimes nurses don't.” She says the first time a nurse doesn't follow the process, she needs to be disciplined as a lesson to others. “If this is what you are doing, you will be held accountable for it.” LePar says a culture change toward safety needs to be pervasive, and patients need to be in the loop about why they're being asked for their name every time. “It's always important to educate our patients about what we're doing and why we're doing it.”
Wolff agrees with the importance of process. “It's not really about the technology; it's about the process. I would say get nurses and pharmacists passionate about patient care and safety and get them involved in the process design. The nurses who did our process are evangelists for patient safety and would lay down their lives rather than see something bad happen.”
Process is important for McCurry too, who focused on drug storage, shipment and administration. He says if those processes can be logically tracked, there's a good chance of automating them. “But if you've got a hole in your process, and 50 percent of what's going to happen is an exception, you're swimming uphill,” he says. “When you introduce a variation into a process, that's where mistakes happen. At Mercy, there is no variation in the process. Every drug administration happens the same way.”