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IT director offers tips on achieving transition to bedside barcoding
Never underestimate people factor
When hospitals make the transition to barcode technology or when they update the barcode system they currently employ, it's essential to develop a process that will work both physically and culturally.
"Each hospital pharmacy will do it a little differently," says Michael D. Schlesselman, PharmD, FASHP, director of information technology program management at Lawrence & Memorial Hospital in New London, CT.
"The important step is to define a process so when the drug comes in the door from the wholesaler you have a way to ensure that medication is barcoded and gets into the system," Schlesselman says. "If you have a good process in place to capture that barcode at the beginning when it comes in, then you'll have fewer problems downstream."
Lawrence & Memorial Hospital has used bedside barcode technology for several years, long enough to resolve many workflow issues, he notes.
"We have a packaging machine to make sure all medications are barcoded," Schlesselman says.
The hospital also uses automated dispensing cabinets, order scanning technology, and other technology, he adds.
Barcodes often change from the manufacturer or when a different product arrives, so hospital pharmacies have to make certain they have a process that will ensure the new barcode is entered into the system, Schlesselman says.
Also, if the pharmacy puts a prescription number on the barcode and then makes any changes to that prescription, it might create a new prescription number, he explains.
"If you do that then any product with the old barcode will be a mismatch," Schlesselman says. "So how do you deal with that?"
Schlesselman offers these tips on making the transition to bedside barcode technology as smooth and efficient as possible:
• Assess barcode technology readiness: Schlesselman used the barcoding readiness assessment tool developed by the American Hospital Association, the Health Research and Educational Trust, and the Institute for Safe Medication Practices.1
"It's a publicly available tool, and I found it very helpful," Schlesselman says. "I used it as my framework as I got ready to implement the system to ensure I wasn't missing anything and I was going down the right path."
The 54-page tool includes details about environmental factors, including poor lighting, cluttered work spaces, and noise, and workflow issues, including whether pharmacists consistently follow existing processes for medication distribution.1
• Initiate system for capturing barcode: "Some organizations put a double-check in place so that any medication getting ready to go up to the floor is scanned to make sure it can be scanned before it goes out the door," Schlesselman says.
Hospitals also could check a barcode's ability to be scanned before it goes up to the pharmacy unit, he adds.
"There are a number of places in that process to put checks and balances in place," Schlesselman adds.
"What we do is have two checks," he adds. "We have someone check it when it comes in the back door from the wholesaler, and then we have it checked after it's packaged."
• Assess nurses' environmental workflow issues: "One of the issues you have to look at and address is what kind of computing devices nurses use," Schlesselman says. "Do they use a computer on wheels or a workstation on wheels?"
And if nurses are taking their computers into patients' rooms, are they ergonomically sound and will the computer's wireless work?
"If you're using this method, then you need to make sure the wireless network is robust enough to not have dead spots so the nurse who goes to the patient in a far corner won't lose the signal," Schlesselman explains. "If you're using a computer in the patient's room you can only eliminate the wireless if you actually have a computer that physically stays in the room."
Another nursing issue is making certain the scanner will read all of the different technology and symbols on barcodes, he notes.
"Make sure that whatever scanner is used on the nursing unit can read all the barcodes from medications," he adds. "Make sure the scanners are reliable and rugged enough to handle day-to-day nursing activity."
If nurses use a cordless scanner then there need to be extra batteries in each unit. If nurses use corded scanners then there might be problems with the scanner's cord draping over a patient's dirty linen, Schlesselman says.
Likewise, someone should assess how often the nursing computers will last before they need to be plugged in and recharged, and the plugs must be compliant with fire codes, he adds.
"And you need to make sure you have an adequate number of computer devices for nurses," he says. "If you have nine nurses administering medications and only eight devices, then someone has to borrow a computer to dispense medications and that's decreased efficiency."
It's also advisable to have spare computers and scanners so that nursing workflow isn't interrupted when a device breaks, Schlesselman says.
"You need a back-up," he adds.
• Prepare for continual changes and workflow issues: Just as American consumers have become accustomed to the idea that they must change and update their computers every so often, so should hospital pharmacists plan to update and replace barcode scanning technology.
"Your laptops are used quite a bit, so you have to have a process for replacing those laptops or repairing them as time goes on," Schlesselman says.
The barcoding system should provide good reporting and feedback measures to managers so they can appropriately monitor the system and counsel staff where needed, Schlesselman says.
Sometimes the initial compliance with new technology is high, but it decreases as time goes on, and hospital leadership might not be prepared for the change.
"The biggest issue is that nurses will find a way to work around it if the technology doesn't work efficiently," Schlesselman says. "So you need to provide feedback to ensure their compliance because sometimes it won't be efficient to do barcoding on a patient as you administer medications."
• Anticipate wristband barcoding problems: "The wristband has a barcode that serves as a confirmation on the computer that the nurse is administering the medication to the correct patient," Schlesselman says.
But for this to work as designed, the wristband's barcode must be easily read by the scanner, he adds.
"Also you need to make sure it's in the right format for your information system to read," Schlesselman says. "And you may have to adjust it to find the right format."
Also, as the patient is moved around and bathed, there's the potential for the barcode to become stewed or wrinkled or wet, and the coding might bleed, which could impact scanning, he says.
"Depending on what kind of barcode you have, the lighting in the room could be a factor in how well or poorly the patient's wristband is scanned," he adds.
"So when using a barcode on a wristband, you need to be cognizant of other systems using the barcoding, such as a lab system that reads the barcode on the patient and attaches the barcode to the blood they've drawn," Schlesselman explains.
"They have confirmation they have the right patient, and they might use some other type of handheld device," he says. "Everyone is using the same wristband, but they might have different devices they're scanning with, so you have to make sure everyone can read the barcode."