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What to make of the BCMA workarounds study -July 2008

I’ve been thinking about thirty-one, body mass index, automobile restraints, and how hospitals should not do bar coding at the point of care.

I dropped by Baskin Robbins the other day. It had been a while, and I had forgotten how much I enjoy nutty coconut. Nearly half my life ago, some neighbors celebrated my thirty-first birthday with a big bowl of thirty-one scoops of all thirty-one flavors—-some more enticing than others. Chocolate chip disappeared well ahead of pink bubble gum. Coincidentally, since 1979, I’ve packed thirty-one—a pound a year.

I’ve been thinking about physicians, bar coding, and WIIFM?

Recently, while pondering why the physician community has been seemingly immune to the bar-coding-at-the-point-of-care (BPOC) bug, I had an idea. Maybe it’s because they’ve been dialed in to WIIFM—not an FM radio station for Nintendo’s Wii but the abbreviation text-messaging types use to ask “What’s in it for me?”

My idea arrived while rereading Dr. Robert Wachter’s 2 May 08 blog entitled, Should Hospitals Install Bar Coding or CPOE First? Why I’ve Changed My Tune. While asking himself the question why CPOE had gained so much more momentum than bar coding over the past decade, the pioneer of hospitalist medicine suggested a theory:

I’ve been thinking about nurses, horses, guns, and hugs.

We all were infuriated when we read about the man last March who walked into a Georgia hospital and shot a nurse he blamed for his mother’s death. How could anyone do such a thing? Then I recalled a phrase from the Bible commenting on the human penchant for passing judgment on others while we do the very same things. (Romans 2:3)

Hardly anyone barges into hospitals like the man the AP article described as “armed with a three-year grudge and more guns than he could hold.” But with nurses who have been involved in unintentional medication errors, do we “shoot our wounded?” We used guns of blame, with bullets of shame, and charges of felony in the case of Julie Thao, RN, of Madison, WI.

I’ve been thinking about the power of “un” for analyzing, selecting, implementing, and using patient-safety technologies wisely.

It all begins with understanding the relative value of addressing one point of risk before another. For example, six times as many medication errors reach patients from mistakes in administering than in dispensing drugs. Therefore, hospitals stand to achieve greater safety gains by implementing bar-code point-of-care (BPOC) systems than by replacing or adding automated dispensing machines (ADMs).

I wonder if our friends at Cedars are questioning their technology priorities over the past few years. Last November, adult doses of heparin would not have reached the three babies in the neonatal unit had either ADMs or BPOC been purchased and put to work and properly used. Instead, Cedars spent a reported $34 million and countless hours over several years on developing a computerized prescriber order-entry (CPOE) system, which they canned three months after implementation. Users reported the technology created more opportunities for error than were mitigated. Oh, as valuable as CPOE can be, even the best system would not have prevented the heparin errors.

I’ve been thinking about politics, comics, and bedside scanners.

Hospital bar-coding initiatives involve numerous decisions. None are more controversial than what type of data-collection scanners nurses will take to points of care.

As intensely as political parties debate the value of smaller versus larger government, caregivers divide over the preferred size of bar-code point-of-care (BPOC) devices. Nurses on one side lobby for full-screen computers on wheels (COWs). Their colleagues across the aisle throw their support behind handhelds that fit into pockets. Of course, both parties have their limits when small reaches too small and big becomes too big.

I'VE BEEN THINKING about the plethora of viable candidates in the 2008 presidential race and the herd of caregiver ID technologies vying for the lead position in our hospitals.

I’m writing on the heels of Super Tuesday, considered the homestretch of the Republican and Democratic primaries when the derby typically narrows to two. However, today is looking more like the opening turn at Beaumont with four or five hopefuls still in the running, including candidates aiming to be the first woman, African American, POW, or Mormon to have a desk in the Oval Office.

Likewise, the healthcare user-ID technology race has fielded a large number of viable and variegated candidates—for a long time.

I've been thinking about preachers, camels, and commitments.

In response to my November 2007 column, in which I appealed to America’s hospitals to lay off the snooze button, wake up, and get on with bedside bar coding, I received a thoughtful letter from the director of pharmacy at a “moderate-sized, rural county hospital.” The affirming brother let me know that I was preaching to the choir.

However, his evangelization efforts for bar-coded medication administration (BCMA) have not yet succeeded in converting his organization, primarily because their coffers do not contain enough to fund the initiative. Being a former preacher, I was tempted to do something religious, like take an offering.

Counting Blessings and Learning Lessons

I’ve been thinking about twins, overdosing, and snooze buttons.

It was posted on the Internet, reported on CNN and written up in the LA Times. The story even popped up on the gossip tabloids at our local checkout lines. I’m talking about the drug overdosing of the twins. This time it wasn’t about the daring adventures of the Olsen look-alikes flying high on Melrose Avenue. It was about the frightening episode the newborn Quaids experienced down the street at Cedars-Sinai.

For any of you who were off the planet for the holidays, let me beam you back to reality. On Thanksgiving Sunday, Dennis and Kimberly Quaid’s newborns’ intravenous catheters were mistakenly flushed with a concentration of heparin that was 1,000 times higher than protocol. Fortunately, caregivers discovered the errors and quickly administered protamine sulfate to reverse the heparin’s harmful effects. Hospital officials reported that neither patient—thank God—suffered any adverse effects from the event. A year ago, you will recall, several babies in Indianapolis were not so fortunate.

I'VE BEEN THINKING about parents, Plymouths, pills, and packaging.

My dad’s the Zen master of documentation. A few months ago when he turned in his car keys (at age 85), there in the glove box we found the little spiral notebook in which he had faithfully registered his fueling activity (e.g., date, gallons, price per gallon, miles, and miles per gallon). I first witnessed the ritual while sitting shotgun at the Texaco in our new 1955 Plymouth.

Pops would have been great in a pharmacy. These days he has his neatly organized drawer of amber vials, blister packs, drug monographs, and a pill splitter. Methodically, he dispenses his and Mom’s pills into their little blue patient-specific SMTWTFS boxes. And, true to form, he meticulously charts each administration in the columns of another little spiral notebook (e.g., drug, time, and date). I’d wager that he has a low error rate.

I’ve been thinking about the pros and cons of utilizing radio-frequency identification (RFID) technology in hospitals.

In the middle of the Bible, a poet puts a rhetorical question to God: “Where can I flee from your presence?” A few lines earlier, he had answered his own question:

You know when I sit and when I stand;
you perceive my thoughts from afar.
You discern my going out and my coming in;
you are familiar with all my ways.

I imagine the concept of his never being out of range was at once comforting and disturbing. This reminds me of the ambivalence some hospital caregivers are feeling about the prospect of being tagged with radio-frequency chips.

I’ve been thinking... about beeps, rings, and dings.

As a kid, I couldn’t wait for weekends. Monday through Friday the parents tried to get us to start the day on NBC with Ding Dong School. Miss Frances, the Mister Rogers of the 1950s, opened each snoozer of a show by ringing an annoying handbell. The ritual almost cured me of television. However, Saturday morning’s Looney Tunes revived my confidence in the tube. Almost in a trance, my brother and I guffawed and groaned as Road Runner perpetually escaped justice. In vain we longed for just one episode in which Wiley E. Coyote would capture and devour the wiry desert fowl whose obnoxious “Beep! Beep!” drove us nuts. Somewhere tucked into all that were the ominous, but thank God, occasional flatline signals from the Emergency Broadcasting System. We were relieved they were only tests and that the Russians hadn’t pushed the button.

CLOSE IS NOT GOOD ENOUGH

I've been thinking...about patient names, drug names, look-alikes, and sound-alikes.

A few years ago, a charity mistakenly channeled my donations into the account of another donor named Mark Neuenschwander. One evening a United gate agent called me over the PA but was looking for another traveler with the same name. Not long ago, a greeting card showed up in the mail, addressed to yours truly, expressing congratulations on the arrival of a new baby—long after my five kids were grown and gone. Then there was the time an overseas client Googled my name and assumed that I moonlighted as a mean bass player doing gigs in Tampa. Hilarious, harmless mix-ups.

Hospitals in Pennsylvania increasingly are adopting health IT to reduce errors, increase efficiency and attract patients, the Philadelphia Inquirer reports.

Two South Shore hospitals now using wristband technology

Patients admitted to Milton Hospital and New England Sinai Hospital and Rehabilitation Center should take a closer look at the bracelet wrapped around their wrist.

No longer just pieces of plastic with a barely legible name on them, bracelets at the two hospitals now have an electronic bar code that could prevent a life-threatening drug reaction.

Read the entire article in the attached PDF.

I've been thinking...about alcohol, chicken, drugs, and rising intelligence quotients—more specifically about beer labels, meat packaging, medication labels, and how bar codes are getting smarter.

As seen on TV, Coors Lite bottles now come wrapped with temperature-sensitive labels. The silver image of the Rocky Mountains changes to blue when the chilled beer dips to what Coors believes is the idyllic drinking temperature. Then the label retreats to silver as it migrates back toward lukewarm.

It's a pretty cool idea. But, if you ask me, simple touch/taste tests have served us pretty well over the years. Not to mention that people argue over the ideal temperature of beer. Just ask a German.

I've been thinking...that I'm wary and weary of hearing the "workaround" excuse.

Not many, nevertheless too many in the healthcare community persist in pooh-poohing bar-code point-of-care (BPOC) systems as an effective safety measure by arguing, "Nurses just find ways to work around them." They imply this is the norm rather than the exception. Hmm. I wonder if they are using the argument to justify their own hospital's slowness to implement scanning at the point of care.

Last month, I talked with Bill Churchill, Director of Pharmacy at Brigham and Women's Hospital (BWH). A crushed ankle (from taking out the garbage) recently landed him in his own hospital as a patient. He contrasted this stay with a previous stint a few years earlier. "In the first go-around," he noted, "nurses never checked my wristband. This stay, they scanned my wristband every time. You know, it really gave me peace of mind."

I've been thinking...about the FDA's bar-code rule one year later and about the complaining that has followed.

The FDA Bar Code Rule, requiring pharmaceutical manufacturers to include bar codes on all immediate drug packages, went into full effect on April 26, 2006. The past twelve months, however, have witnessed a good bit of complaining—even by those who praised the FDA when it happened. I hear pharmacists groaning about how drug companies have dropped the ball by dropping unit-dose packaging. I hear nurses gripping about the quality of too many bar codes on manufacturer drug packages being too poor for their scanners to read. And everyone goes nuts when the package arrives without a barcode at all.

I’ve been thinking . . . about the Joint Commission’s 2008 National Patient Safety Goals (NPSGs). Along with some favorite swear words.

Last year at The unSUMMIT on Bedside Barcode Technology in Practice, the esteemed Kenneth Barker received the Way-Paver Award—”honoring the exceptional contributions of individuals and institutions that have helped clear a path and pave the way for bar-code point of care (BPOC) in America’s hospitals.” After graciously accepting the award, the world-renowned pharmacy-practice sage got to the point with a handful of words. He simply noted that over his long career, he has always argued that you start with a study. “Well,” he added, “we have done enough study on bar-coding. It’s time to get ‘er done.”

I’ve been thinking about points.

Ah, the ambiguity of the English language. Without more context, how could you possibly know what I have in mind by points?

I’m writing this article from the skies above one of the Dakotas—roughly, the halfway point between Boston and Seattle. A moment ago, I was wondering how many points I’ve amassed in my Marriott Rewards account. Right now, another road warrior is rehearsing a presentation on his laptop, the power points of which are large enough for me to read from three rows back. However, that’s all beside my point. I’m really thinking about the point of care.

The authors outline the practical considerations in developing a medication patient safety program, including establishing a blame-free environment and collecting and analyzing error data.

The Directors Forum series in Hospital Pharmacy is written and edited by Robert Weber and Michael Sanborn and is designed to guide pharmacy leaders in establishing
patient-centered services in hospitals and health systems. Another specific goal of this column is to address many of the key challenges that pharmacy directors face today, while providing information to foster
growth in pharmacy leadership

This is a policy guidance document from the Department of Health in the UK for the use of auto-identification and data capture technologies such as bar codes across the NHS.

HMT reporter Richard Rogoski investigates how bar codes and drug information databases are helping to reduce medication errors. The article introduces us to hospitals that not only have invested in new technologies, but now regularly review and update their policies and procedures pertaining to the ordering and distribution of medications.

Link: http://www.healthmgttech.com/archives/0207/0207manic_medication.htm

Kerry Clark, CEO of Cardinal Health, in an interview discusses how new technologies should be employed to prevent hospital deaths from drug errors and hospital-acquired infections. Clark says Cardinal already works with some solutions, including a medication dispensing system, which verifies that when the medication is drawn at the nursing station, it is checked against the patient record, confirming time and dose. The New York Times (2/17)

This article discusses the weaknesses inherent in using the five rights for medication use as absolutes and suggests that they instead serve as broad goals to support safe medication practices.

Source: ISMP Medication Safety Alert! Acute Care Edition. January 25, 2007;12:1.

I’ve been thinking Seattle, New York, Indianapolis and Madison.

I spent the too-be-forgotten Father’s Day of ‘95 on the front row—just past the dugout on the third base line—at a Seattle Mariners’ baseball game. It turned out to be the opportunity of a lifetime. Three balls were fouled my way.
I dropped the first and took the heat—from my five kids, no less. This hardly boosted my confidence for the next grounder, which I also dropped. While one understanding dad offered me his glove, “Here buddy, just in case,” other nearby fans ragged on me. You guessed it—I bobbled the third. The entire merciless crowd booed when the scoreboard flashed “FAN ERROR.”

I’ve been thinking about shower curtains, seat belts, and the increasing expectations on America’s hospitals to utilize bar-code point-of-care (BPOC) systems.

While shaving this morning in the Harrisburg Hilton (CNN mumbling in the background), I recalled something I read thirty-five years ago. Someone asked Barron Hilton if he had any advice for America’s businessmen. “Yes,” he answered, “put the shower curtain inside the tub.” Those nagging expectations, ubiquitous on hotels’ tiled-tub enclosures in the 50s and 60s, disappeared before Hilton’s granddaughter, Paris, was born. Yet, to this day I’m compliant, even though I’ve never heard of anyone being busted for getting water on a bathroom floor.

A tool used by nurses to report interrcepted medication issues.

A sample letter built from BPOC system compliance reports that encourages nurse managers to work with individuals identified as having poor scanning complinace.

A tool to determin NOW doses for all medication dosage forms (i.e. IV, PO, SC, IM).

Case study: By instituting bar code technology from the pharmacy to the patient's bedside, Opelousas General Health System reduces its medication error rate.

This white paper will explain why a dedicated thermal printer is the superior choice for bar code label printing in hospitals.

A PowerPoint overview of the VA's history with wireless PDA software.

This article describes a multidisciplinary effort across the Sisters of Mercy Health System (Mercy) that promises to have the greatest impact on patient safety ever achieved in Mercy's history. Mercy Meds, a comprehensive
transformation of the medication use process, incorporates technology, strategic partnerships, supply chain management and improved work processes to bring an enchanged level of safety and efficiency to the medication process. In summary, the initiative seeks to ensure the five rights of medication
safety: the right dose of the right drug through the right route at the righ

A PowerPoint presentation of detailed eMAR lessons learned including nursing impact, quality control implications, pediatric recommendations, respiratory therapy lessons, and infection control practices.

A PowerPoint describing the first 5 years of eMAR experience within HCA hospitals.

A PowerPoint overview of the HCA experience with barcode point of care technology.

PowerPoint Presentation of BPOC background and Centennial Medical Center's experience to date.

A seven-part series of articles on the deployment of a 5 Rights Medication verification system at St. Clair Hospital, in suburban Pittsburgh, PA.
Part I - The Decision: Move to 5 Rights, or Remain Wrong
Part II - The 5 Rights Platform: Carts or Handhelds
Part III - Deployment in the Wireless Environment:The Burrito Effect
Part IV - Refinements: Discoveries and Refinements The Real World Live Environments
Part V - Results: Analyzing the Post Activation Data
Part VI - The Future: What's Next
Part VII - To Err is Human: To some extent

The purpose of this study was to assess the impact of bar code verification (BCV) on medication errors in a small private hospital.

Since hospital-based repackaging centers are rare, studies of design,
implementation, quality control, and generation of medication errors are
rare. The objective of this study was to identify errors generated in the repackaging center and to identify and implement system improvements to
reduce future errors.

Results of the 2005 ASHP national survey of pharmacy practice in hospital settings that pertain to dispensing and administration are presented.

Conclusion. Safe systems continue to be in place in most hospitals, but the adoption of new technology is changing the philosophy of medication distribution. Pharmacists are continuing to improve medication use at the dispensing and administration steps of the medication-use process.

The Pharmacist Toolkit for Implementing a Bar Coding Medication Safety Program is provided by the American Society of Health-System Pharmacists Research and Education Foundation and was made possible by an unrestricted educational grant from Omnicell. To begin development of the tool, in August 2003 the ASHP Foundation assembled a panel of experts on the application of bar coding to prevent medication errors. This panel established the initial framework for this document and served as reviewers as content was developed. Writing, editorial, and project management services were provided by IDentityHealth, Inc. of San Diego, CA.

The purpose of this worksheet is to guide the hospital in calculating the potential savings resulting from the implementation of technology to reduce medication errors. The amount of savings will vary, depending on organizational characteristics and the technologies under consideration. Suggested users include senior management and department leaders involved with product evaluation, selection, and purchase.
The results of this worksheet can help to direct the hospital toward technologies that offer the most value for the organization in terms of medication safety and financial return. Sources of information would include the results of the organizational assessment and IT vendors.

This table is intended to help the hospital assess its needs (i.e., features that are "must have" versus "nice to have") and evaluate the capabilities of competing products. It can be used by a medication error prevention implementation team that is charged with (1) determining the hospital's priorities for interventions to prevent medication errors and (2) selecting vendor products that can meet those needs.

The purpose of this checklist is to help the hospital plan for the implementation of new technologies and record its progress over time. It is meant to be used initially by senior management and departmental leaders, and then updated regularly by a multidisciplinary implementation team.

This tool is intended to help the organization assess the various processes involved in the delivery of medications and identify areas that would benefit from technological support. It may be used by senior management and departmental leaders at each step of the organization's medication use process.

A comprehensive annotated bibliography of BPOC-related publications.