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Health system brought stakeholders together
Nurses walked in pharmacists' shoes
One strategy for making certain hospital staff are ready and willing to work with new technology is to thoroughly involve them in the beginning phases of implementation.
Pinnacle Health System in Harrisburg, PA, anticipated workflow issues and buy-in reluctance from the start of its process to move to barcoding technology.
"So we made sure we had all stakeholders involved from the beginning of putting the process in place," says Janice Dunsavage, RPh, MAS, director of pharmacy at Pinnacle Health System. Dunsavage has spoken nationally about how to implement pharmacy technologies.
"We knew this would be one of the toughest initiatives we ever undertook, and we'd need all parties on board if we were going to make it a success," Dunsavage says.
After nearly four years the health system's transition to barcode point-of-care infrastructure can be called a success, she notes.
"On an ongoing basis we see errors stopped by the system," Dunsavage says. "We look at it and are grateful to have a system in place to stop errors."
Dunsavage offers these tips on how to ensure a smooth transition to information technology (IT) implementation:
• Assess readiness to transition to new IT: "When we first took on the barcoding initiative, the first thing we did was get some laptops and software for barcoding and walked around the pharmacy to scan-check every drug," Dunsavage says. "We found that 19% of our medications were ready to scan at the bedside, so we had issues from the start."
Another issue involved checks and balances: In the existing process, the pharmacy had an electronic system while the nursing department used a paper process. This resulted in a natural checks and balance in finding mistakes, Dunsavage says.
So one goal was to build into the new electronic system checks and balances, she adds.
But just transitioning from a paper medical administration record (MAR) to an electronic barcode scanning system in a short period of time is a challenge.
To prevent these types of problems, nurses received advanced notice of the changes and education about how to use the new technology, Dunsavage says.
• Partner with IT vendors and staff: Hospital leaders treated the information technology experts and staff as equal partners in the process.
IT vendors and staff were part of the development and transition process, offering their input along the way, Dunsavage says.
And when it came time to create interfaces for the various electronic technologies used by the hospital, hospital leadership brought together the various IT vendors, many of whom represented competing products, she says.
So the IT vendor for the automated dispensing cabinets would attend the meeting, along with the vendor for the pharmacy information system, etc., Dunsavage explains.
"The idea wasn't for them to share or give up trade secrets, but to help us get to where we needed to be," she says. "We have strong relationships with our vendors and didn't desire to change any of them."
But it was important for the hospital to make changes where necessary to ensure that databases from one system would be able to communicate accurately and effectively with a database from another system, she says.
"We wanted to take our pharmacy information system and have it be the master system," Dunsavage says.
"We built tables to populate downstream systems any time we add, delete, or change a formulary item," she adds. "This assures the systems are in sync and the information matches letter for letter and digit for digit."
The vendors were essential to developing this interface process, and they worked well together despite competitive differences.
"We were all committed to creating better patient care, and if we kept the patient at the center of our focus, it was easy to see how to make this more successful," she says.
This preliminary work was necessary to create a workable system that would connect all of the various electronic components, Dunsavage adds.
"If we kept in mind the goal of better patient care, it was easy," she said.
• Have staff walk in each other's shoes: One way the hospital prevented workflow problems was by giving nurses and pharmacists time to see how the process worked from the other side's perspective.
Nurses were invited to spend a day working beside pharmacists, and pharmacists spent a day with nurses, she says.
This process of having each side walk in the other's shoes worked well.
"When walking in nurses' shoes, we anticipated some issues we could resolve ahead of time, and we put additional checks and balances in place," Dunsavage says.
This process also helped earn nursing buy-in, and the word spread about the transition was positive.
"The nurses who worked in the pharmacy became our ambassadors to other nurses," Dunsavage says.
Pharmacists also began to see how barcoding might be a problem in the day-to-day work world of nurses.
"Pharmacists began to understand how frustrating it is for nurses when they don't have the medications they need; it was eye-opening for both sides," Dunsavage says.
For instance, pharmacists could see how the barcoding process would falter when barcodes weren't easily readable. So they put in a process to test one dose in each lot of medication that comes from the wholesaler each day to make certain its barcode could be read, she explains.
"This way we're not sending nurses barcodes that are difficult or impossible to use," she says. "That doesn't mean there won't be one individual dose that has a wrinkled barcode, but that's a rarity."
The chief problem the barcode testing process avoids is having multiple barcodes from a lot that are difficult to read, resulting in nurses giving up and overriding the barcode scanning process, Dunsavage says.
"We make sure every dose is barcoded, and on our units we have bedside scanning in place so we can scan over 99% of our medications at the bedside," she adds. "So it's rare that something is not scanned."
About the only times something isn't scanned is when there's a life-threatening emergency that could not have been anticipated, Dunsavage says.
• Pilot, roll out, and re-evaluate: The technology change was piloted in a couple of nursing units, so the remaining problems could be identified and resolved before the final implementation stage.
"By the time the pilot units went live, the other units' nurses were interested in getting on board with the change, so it wasn't that difficult to make the transition," Dunsavage says.
"As each unit went live we discussed any problems that might be unique to them," she adds.
Also, as each nursing unit began to implement barcode scanning, its staff helped other staff with their transition, she notes.
"We had a lot of issues teased out in that process," she says.
A group of stakeholders, including nurses, pharmacists, IT specialists, and others met weekly for about a year before the technology change took place. This group helped to identify and evaluate any problems that occurred with the transition, Dunsavage says.
Finally, after barcode scanning was fully implemented hospital-wide, the group of stakeholders continued to meet to analyze data and further improve the process, Dunsavage says.
"The group meets monthly to look at reports that come out of the system," she says.
Initially the group publicized incidents and potential safety risks identified in weekly reports, issued by e-mail and on the hospital's web site, and posted on nursing units, she adds.
"Now we put these out less often," Dunsavage says.