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Pharmacy Practice
Bar Coding: An Effective Strategy... macy.5 At the bedside, the use of bar code technology to verify a patient’s identity and the medication to be administered has been shown to be an effective strategy for preventing medication errors, and its use has been increasing. The US Department of Veterans Affairs, for example, pioneered the way by instituting a national bar coding program in 1999 in its hospital system.6,7 Bar code medication verification at the bedside is usually implemented in conjunction with an electronic medication administration record (eMAR). This combination of technologies allows nurses to automatically document the administration of drugs by scanning their bar codes6 to ensure the correct medication is administered in the correct dose at the correct time to the correct patient. Because the eMAR imports drug orders electronically from the physician’s order entry or the pharmacy system, its implementation may reduce transcription errors.6 Bar code plus eMAR technology is not without its drawbacks. One study
found that although medication management improved, the system studied was difficult to implement.8 Furthermore, other studies have highlighted certain unintended consequences of eMAR implementation, such as hospital staff relying too heavily on the technology, bypassing some of the hospital’s safety processes, or overriding the system’s alerts, thus increasing the risk for new errors.9,10 Study examines efficacy and safety of bar code technology in hospital setting Given the uncertainties with bar code plus eMAR technology, my colleagues and I at Brigham and Women’s Hospital evaluated its implementation in 35 adult medical, surgical, and intensive care units in our 735-bed tertiary academic medical center to assess its effects on administration and transcription errors, as well as associated potential ADEs.6 During the 9-month study, we compared 6723 medication administrations
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on patient units before the bar code plus eMAR technology was introduced with 7318 medication administrations after the technology was introduced. We also reviewed order transcriptions in both time frames.6 Results Of the 1272 nontiming errors observed, 776 occurred in medication administration on units without the bar code plus eMAR system (an 11.5% error rate) compared with 495 such errors on units that used it (a 6.8% error rate), corresponding to a 41.4% relative reduction in errors (P <.001). The rate of potential ADEs (associated with nontiming errors) fell from 3.1% without the use of the bar code plus eMAR system to 1.6% with its use, representing a 50.8% relative reduction (P <.001). A 27.3% (P <.001) reduction was seen in the rate of timing errors in medication administration, but the rate of potential ADEs associated with timing errors did not differ significantly.6 Transcription errors also were re-
duced with the bar code plus eMAR system. Of the 3082 transcription orders reviewed, 1799 orders were on units without the technology. We found 110 transcription errors, of which 53 were potential ADEs, corresponding to 6.1 transcription errors and 2.9 potential ADEs per 100 medication orders transcribed. In the 1282 medication orders reviewed on units with the bar code plus eMAR system, transcription errors were completely eliminated.6 Clinical implications of bar code technology This study demonstrates that bar code plus eMAR technology can be an important intervention to improve medication safety. Because the study hospital administers approximately 5.9 million doses of medications per year, use of the bar code plus eMAR is expected to prevent approximately 95,000 potential ADEs at the point of medication administration every year in this medical center. The electronic Continued on page 6
COMMENTARY
Bar Code Medication Administration and Computerized Physician Order Entry: A Pharmacist’s Perspective By Mahro Ershadi, PharmD Director of Pharmacy, Suburban Hospital Healthcare System, Bethesda, Maryland
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lthough bar code technology has been used widely in the pharmacy for dispensing medications, many new challenges are faced when the bar code technology and computerized physician order entry (CPOE) are used for medication administration at the patient’s bedside. This new technology requires every medication dispensed from the pharmacy to have a bar code that identifies the medication. The bar code allows for the correct medication to be dispensed based on an order in the CPOE. Most important, the bar code will identify the right patient for administering the prescribed medication. All this must be done in an effort to ensure patient safety.1,2 Obtaining medications with a manufacturer’s label that includes an identifying bar code is essential, when possible.3,4 However, many products do not come from the manufacturer with a bar code, for example, compounded products or admixtures. In addition,
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there are many instances when the manufacturer’s bar code is not readable by the facility’s scanner. The pharmacy also must be able to produce bar-coded labels when needed. It is essential to have an automated packager to produce bar-coded packages/labels for oral medication. For products that are compounded by the pharmacy (such as intravenous admixtures), a computergenerated label with bar code must be used.3-5 One of the challenges faced with bar coding is when the medication is switched from one manufacturer to another, which results in a change of the bar code and the information programmed for that specific medication. Thus, it becomes essential that as medications change, either due to manufacturer switch or shortage, the computer system is updated so the order entered via CPOE is linked to the right medication available in the pharmacy.3,4 Another challenge many pharmacies face is the readability of the bar
codes. All bar codes must be readable by the scanner the hospital chooses.3-5 Studies have found that manufacturers’ bar codes are sometimes the hardest to read.3 It is critical that the bar codes be readable; otherwise manual overrides at the patient’s bedside become the norm, as nurses cannot get bar codes to read properly and regularly. To ensure successful bar code implementation, the pharmacy must ensure that the following steps are taken: • Have resources to extemporaneously package and repackage products that are not available with bar-coded unit-dose packages • Ensure that all products leaving the pharmacy to patient care areas are bar coded • All automated systems for dispensing medications must be able to apply a bar code • The bar-coded labels must be attached carefully to avoid curvature of the container or crinkles
that would not allow the complete bar code to be scanned • Ensure that all products received from the manufacturer or distributor are scanned before adding the items to the inventory. This will assure that all items received match current products on the shelf • Ensure that each medication has a bar code linked to it in the computer system so it can be scanned. References 1. Traynor K. Details matter in bedside bar-code scanning. Am J Health Syst Pharm. 2004;61:1987-1988. 2. Section on Pharmacy Informatics and Technology, American Society of Health-System Pharmacists. ASHP statement on bar-code-enabled medication administration technology. Am J Health Syst Pharm. 2009;66:588-590. 3. Mims E, Tucker C, Carlson R, et al. Quality-monitoring program for bar-code-assisted medication administration. Am J Health Syst Pharm. 2009;66:1125-1131. 4. Paoletti RD, Seuss TM, Lesko MG, et al. Using barcode technology and medication observation methodology for safer medication administration. Am J Health Syst Pharm. 2007;64:536-543. 5. Helmons PJ, Wargel, LN, Daniels CE. Effect of barcode-assisted medication administration on medication administration errors and accuracy in multiple patient care areas. Am J Health Syst Pharm. 2009;66:1202-1210.
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