The pros and cons of bar coding

Accreditation Connection, August 15, 2003

The Food and Drug Administration's (FDA) proposed bar coding rule, released this March, would make it easier for administrators interested in bar coding technology to install such a system in their facilities, say experts.

The rule would require manufacturers to bar code all drugs and blood products, thus cutting costs and the effort it takes for pharmacy staff to affix bar codes themselves.

Hospitals that have already installed bar coding applaud its benefits, but caution that the process can be a challenge. If you're considering a bar coding system at your hospital, read on to learn how one Midwestern hospital went about it.

Med errors drop at St. Marys
A multidisciplinary team at St. Marys Hospital Medical Center in Madison, WI, tried to reduce the organization's medication error rate for years, but nothing seemed to make much of a difference.

More than 60% of the hospital's medication errors occurred at the point of administration. "We knew if [we] influenced the administration phase we could definitely impact our medication error rate," says Wendy Wittwer, RN, BSN, coordinator of the hospital's bar coding system initiative.

Installing a bar coding system looked like the natural next step; in 1999, St. Marys signed on to test and implement Bridge Medical's new "MedPoint" software. By the fall of 2000, the hospital's pilot units were up and running. Now five adult inpatient units, including medical/surgical, intermediate care, and neuro-intensive care, use the system, and the hospital is working to expand it to the rest of the facility.

The benefits made the installation efforts worthwhile. Within six months of implementing the software on the first nursing unit, medication errors decreased by 59%, says Wittwer.

However, as with any new technology or system, implementation was-and still is-a challenge. For instance, St. Marys did not initially dedicate enough staff to the project, says Wittwer. It should have established a lead person from both the information systems (IS) department and the pharmacy department, as well as dedicated a full-time employee (FTE) with a nursing background to coordinate and train staff on the new system, she says.

Here's some advice from hospital administrators, based on the other lessons staff learned:

1. Provide pharmacy with adequate time
The hospital underestimated how much time it would take pharmacists to set up and maintain a formulary, says Denae Bachmeier, RPh, a clinical pharmacist at St. Marys and the pharmacy lead for the MedPoint project. "Initially, we thought 'Oh, it's just a nursing documentation system. It has nothing to do with us,' " she says. "We've learned that's not the case."

Bachmeier estimates that maintaining the formulary alone takes her and another pharmacist approximately one-quarter of an FTE. In addition, the hospital has approximately 30 pharmacists who must now enter all orders into the computer system and help nurses troubleshoot problems, such as medications not appearing on the screen properly.

TIP: Facilitate troubleshooting by tracking recurring problems. St. Marys' MedPoint planning group now logs all of the calls it receives about system issues. Group members document each problem and its resolution.

Though having bar codes on all medications would be ideal, the hospital hasn't yet been able to accomplish this time-consuming task. Pharmacists welcomed the FDA's proposed rule, because placing bar codes on medications eats up technicians' time-they must run a machine that affixes the bar codes to containers-and is also time-consuming for pharmacists, who must then check the labels.

As of now, if medications don't have a bar code, nurses pick the correct medication from a touch screen. "It still documents that [the nurse] gave [the medication], but it doesn't check that it's the right medication, which is the number one thing that you're trying to [do]," Bachmeier notes.

Staff currently purchase medications in bulk rather than in unit doses, and bar code the whole bottle at one time. They also try to purchase more medications from manufacturers that supply their own bar codes.

2. Include the IS department
Hospitals that want to implement a bar coding system should bring the IS department on board from the start. Even if you're just beginning to investigate software, IS staff need to know what role their department will play. They can also offer valuable advice.

"There are pieces of these systems that only IS understands, like server requirements, hardware requirements, or interfacing [issues]," says Wittwer. "They need to be at the table to address those pieces when people are planning for these systems."

In addition, Wittwer found that IS staff needed some extra education on how to deal with systems that directly affect patient care. "We have to take care of this and stick to our timelines," she says. "If there's downtime that occurs, it has to be dealt with immediately, because we need it to take care of our patients."

3. Set aside enough training time
Training is no small task. Wittwer and another nurse must train not only nurses, but also respiratory therapists, student nurse instructors, float pool staff, housekeepers, and some pharmacists and IS staff. Students (approximately nine at a time) review a study guide for about an hour, and then attend a three-and-a-half-hour training class. "I try to train people within two weeks of their go-live date, so that [the information is] reasonably fresh," says Wittwer.

TIP: Consider all the departments that will need to be aware of the new system when you plan your training. For instance, telecommunications staff will have to wire the system and maintain firewalls. Housekeepers will have to clean the equipment (in St. Marys case, that means a laptop computer, a mouse, and a bar code scanner in each patient's room).

4. Be prepared for staff reluctance
Many nurses at St. Marys looked forward to the bar coding system, but others were skittish about using the new technology. "It is major change for them," says Wittwer.

Although scanning every medication adds an extra step to the caregiving process, nurses also save time in other areas. For instance, the system automatically produces documentation when nurses confirm that they administered a medication. "They don't have to physically transcribe orders, which [also] helps with transcription errors," remarks Wittwer.

TIP: Involve all affected employees in the process. That way, they'll be more likely to adopt it quickly.

TIP: Look for informal leaders among nurses. They can help you gain staff support, identify problems their peers experience during implementation, and help you communicate the information to the whole nursing staff.

In the end, nurses came to like the system. "We've done a nursing satisfaction survey pre- and post-implementation, and nurses are definitely more satisfied with the overall med process with MedPoint than without it," says Wittwer. In fact, some nurses have told her that they now feel uncomfortable working in units that haven't yet installed bar coding scanners.

5. Get ready for future improvements
St. Marys chose laptops for its bar coding system hardware so that it can add additional applications more easily in the future. For instance, it hopes to integrate a pharmacy order entry system that will allow clinicians access to labs and teaching tools. It also hopes to eventually use electronic medical records.

TIP: Even if they're not directly affected, keep physicians in the loop when you install electronic systems. Some physicians at St. Marys recently expressed interest in looking at patient information online.

"We've given them access as they've shown interest," says Wittwer. She hopes that this way, leaders will emerge who can help other physicians get on board with future technological initiatives.

Wittwer cautions other hospitals not to install the system in the whole facility at once. Because it is a big change, staff need a fair amount of handholding and support-and most facilities won't have the resources to focus on more than one unit at a time.

Has it all been worth it? "It's a step in the right direction," says Bachmeier. "I'll be surprised if most hospitals within the next five to 10 years don't have some sort of bedside verification." Editor's note: St. Marys Hospital Medical Center is a 350-bed, level II tertiary community hospital. It received the Magnet Recognition for Nursing Excellence in 2002 and is part of SSM Health Care, which won the Malcolm Baldridge National Quality Award in 2002.

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