The six rights of medication administration is a process that most nurses should be somewhat familiar with when treating a patient. Those rights include right patient, right medication, right dose, right route, right time, and right documentation.
This familiarity is especially strong at Children’s Hospitals and Clinics of Minnesota, a 381-bed facility in Minneapolis, thanks to the hospital’s infusion pump/electronic medical record (EMR) integration initiative, which uses smart pump technology from CareFusion (San Diego). According to Bobbie Carroll, R.N., senior director of patient safety and informatics at Children's, the integration takes the six rights of medication administration to its fullest extent, having it done within the EMR.
“What we’ve developed is the ability to wirelessly transmit clinical information from the electronic medical record to auto-pump programming, where we’re pre-programmed the pump with specific data. Then the nurse basically validates that information then starts the infusion. [Information on the volume of the] fluid that’s infusing to the patient will wirelessly flow back to the EMR for documentation,” Carroll says.
This integration is done via barcode scanning. When a medication will be administered via the pump, nurses scan the barcode on the pump, which transmits that information. The nurses review what’s been transmitted and infuse it. That’s when the information goes back to the EMR (from the Kansas City-based Cerner Corporation), updating the input and output record.
The Safety Net
The decision to integrate the EMR with the infusion pump system stems from Children’s overall ideals, which state that technology should be leveraged for patient safety. Having already implemented smart fusion pumps, which put limits on drug dosages, the hospital took a number of steps which ultimately brought this medication administration directly into the EMR.
“We were looking at the whole medication continuum and literature would say 42-45 percent of medication errors were at that point of writing, the prescribing of the medication. A lot of times you wouldn’t be able to read the order, there was a legibility issue. Like many organizations, we adopted computerized physician order entry (CPOE). That cuts down the medication errors at the front end,” recalls Carroll.
Once CPOE was successfully implemented within EMR, Children’s then looked at medication administration. After all, this is the last point where a clinician can catch an error, Carroll says. While having a general interest in barcode scanning, it was coincidentally around this time, she says, that the organization was approached by Cerner and CareFusion to be a develop partner around this integration.
“We knew we wanted to do barcoding and typically the majority of hospital do barcoding at the bedside. So they barcode their patients, they barcode the med, and it does the six rights checking in the EMR. But then they go and hang the medication at the pump. There’s no safety-net to make sure what’s being hung is being programmed at the right rate. For our [technology] you’re sending data that was entered by the physician [through CPOE], verified by a pharmacist, reviewed by a bedside nurse, and then you have a safety-net of technology coming in and rechecking everything through barcoding technology.”
To test out the technology with complex medications, ensuring its validity, Children’s conducted a pilot in one of the most critical units within the hospital, the pediatric intensive care unit (PICU). The pilot lasted 8-to-10 weeks. From a finite perspective, it was a clear success. The hospital reduced adverse events by about 70 percent, from a rate of seven errors per 10,000 doses, to two per 10,000 doses.
However, at a broader level, Carroll says the organization had goals around workflow, how the nurses interacted with the technology, and whether or not the technology could prove to be reliable. While there were technical and operational challenges along the way, specifically with medications within the drug library, the PICU pilot was enough of a success in this regard that Children’s decided to bring the technology to other units.
Over the course of the last 18 months, Children’s has done just that, rolling out the EMR/infusion pump integrated technology hospital wide. Carroll says the hospital brought the integrated technology to one unit at a time, allowing for that area to standardize workflows that fits its specific needs.
To get an idea of how many practitioners are utilizing this technology, Children’s has tracked medication scanning compliance rates as well as the percentage of medication that’s put into guard rails, which is the safety software that limits dosages. Both of those measures, Carroll says, show increased utilization of the interoperable EMR/infusion pump technology across the board.
“That’s exciting because we know we are delivering safer delivery of medications,” Carroll says.
A nurse administers the interoperable smart pump technology via scanning. Credit: Children’s Hospitals and Clinics of Minnesota
Next Up: PCA
Despite the fact that the technology has been implemented across all units of the hospital, Children’s will continue to optimize it, working with various departments. It also will expand this initiative with Cerner and CareFusion, developing it for patient controlled analgesia (PCA). This is when a patient can push a button to dose themselves with a narcotic.
“That interoperability hasn’t been developed yet,” Carroll says. “We’re going to work with Cerner and CareFusion over the next year to develop that technology. I’m totally up for being the pediatric partner in that development.”
For those interested in implemented EMR/infusion pump interoperability, Carroll says it’s important to invest in infrastructure. This is not only from at technological perspective, she says, but also personnel to support it. “You can’t just put it in there and hope it works,” Carroll says.