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Hospital medication technology can cut mistakes by tens of 1000s
Potential ADEs fell by half
Barcode technology combined with a barcode electronic medication-administration system (eMAR) can reduce potential adverse events related to medication errors by more than 50%, according to a new study funded by the Agency of Healthcare Research and Quality (AHRQ) of Rockville, MD.
Investigators observed 14,041 medication administrations and reviewed 3,082 order transcriptions. They found an 11.5% error rate of non-timing errors in medication administration among units that did not use barcode eMAR, versus a 6.8% error rate among those that did use barcode eMAR.1
Also, they found that the rate of potential adverse drug events fell from 3.1% without the use of barcode eMAR to 1.6% with its use, representing a 50.8% relative reduction.1
Barcode eMAR also resulted in a 27.3% reduction in the rate of timing errors in medication administration and an elimination of transcription errors, which occurred at a rate of 6.1% on units without the barcode eMAR.1
"We found a pretty dramatic reduction in errors made in the process of giving patients medications," says Eric Poon, MD, MPH, an assistant professor of medicine and director of clinical informatics at Brigham and Women's Hospital of Boston, MA.
"We projected the technology at our hospital is preventing about 90,000 serious errors a year," Poon adds. "These are errors that could potentially result in patient harm."
While these numbers are large, they still represent a small percentage of total doses administered at a large hospital.
"To put it in perspective, with or without the technology, health care providers are very good at giving medications to patients," Poon says.
"The catch is that hospitals give a lot of medications for example, we give 6 million doses a year," Poon says. "So even a very small error rate could translate into a large number of errors, which is why a high reliability safety net like barcode scanning at the point of medication administration can have a big impact."
The hospital began with barcode verification and the pharmacy in its initial quest to redesign the medication use system to make it a safer process, says William W. Churchill, RPh, MS, executive director of pharmacy services at Brigham and Women's Hospital.
"We published an article in the Annals of Internal Medicine and showed dramatic results in the incidence of medication dispensing errors and a dramatic reduction in potential adverse drug events from using that in the pharmacy," Churchill says.
The goal was to learn all they could while testing the system in the pharmacy before they rolled it out to the hospital's nurses. This worked very well as the hospital then rolled out barcode verification at the bedside, he adds.
"We rolled that part out with a lot better results and less difficulty than we had in the pharmacy," he says.
Earlier research also demonstrated a strong economic benefit in implementing new barcode technology.
"When you look at all the costs associated with the technology, including five years of development and implementation and a $1.3 million one-time development cost, there is a net benefit after five years of $3.5 million from the decrease in adverse drug events," Churchill explains.
"The break-even point for a return on investment occurred within one year of the system becoming fully operational," he adds. "So it was pretty substantial."
The most relevant finding in the latest research in the New England Journal of Medicine is related to the 51% relative reduction in incidence of serious errors with potential for adverse drug events, Poon says.
These included mistakes where the wrong drug dose was given, as well as documentation mistakes, such as when a nurse gives a dose but neglects to document it on paper, Poon explains.
This type has a potential for harm if another nurse were to administer a second dose because of the lack of documentation, he adds.
"We keep track of errors that our system intercepts because every time a nurse gives a medication, the computer checks to see whether the right medication is being scanned, and if it's scanned, the computer registers a warning," Poon says. "We tracked the number of warnings the system issues, and we found the number of warnings to be stable."
Poon's future research may include a formal cost benefit analysis that looks at the avoided costs of preventing adverse events due to medication errors.
When hospitals install barcode scanning and eMAR, their chief obstacles involve workflow issues.
"I think this technology is complex and to pull it off successfully, you need to invest the right amount of resources in designing the workflow," Poon suggests.
"You have to make sure your front-line clinicians are ready to take advantage of this opportunity," he adds. "They need to look critically at how to take advantage of the technology, thinking about how to do things differently."
There should be adequate training for clinicians, along with ample support for them as the new technology is implemented.
"It's hard to argue with anything that reduces errors by more than 50%," Poon notes. "But the question remains: 'How can we have hospitals use this technology more easily?'"
Hospitals installing barcode scanning and eMAR technology will need the right financial and human talent resources to make it work, he adds.
Health systems that make training and support a priority might prevent some of the workflow problems that can occur with the installation of new technology.
No technological system is perfect, and medication mistakes still occur.
"The results from this study reflected our results early on during implementation, the 6-8 weeks after we rolled out the technology," Poon says. "We continue to work on the technology and have made quite a few improvements."
For instance, the hospital has provided staff with a tool called the Scheduler that helps nurses and pharmacists decide when patients should get their medications. Also, the eMAR screen was changed to provide more information, per a suggestion staff made.
"This makes it much easier for disciplines to work together and come to the best decision," Poon says. "And it's a good example of how we have had to listen to front-line clinicians to make the system better."
Also, the hospital tracked any trends regarding difficulty scanning medications to see if certain brands and manufacturers created the most problems. When they discovered a trend of one type of medication not scanning well, they made suggestions to medication manufacturers to change how they print barcode on the drugs to make these easier to scan, Poon says.
"Or sometimes we would go with the manufacturer who gives us a scannable barcode," he says. "It's to their advantage to change the barcodes because they see this technology as something to benefit patients."
The chief benefit is improved medication use safety, but there also have been benefits related to better collaboration between nursing and pharmacy and medical staff, Churchill says.
"We work off the same information, same dataset, and we know when drugs are ordered and reviewed by pharmacists, and we know when drugs are due and needed on the unit," he explains. "I think nursing and pharmacy have grown together and have become very close colleagues and allies in working together as we make medication safety a priority."
The big question for hospitals that lag behind in electronic technologies is whether their initial technology investment should be with a barcode eMAR or with computerized provider order entry (CPOE), Poon notes.
"CPOE can prevent medication errors, and this technology can prevent errors," he explains.
So which should a health care system choose to install first?
"CPOE tends to catch errors of cognition, physician errors, the kind of mistakes made because of a lack of knowledge or information," Poon explains. "Whereas, bar code scanning makes sure the therapeutic plan arrived at can be implemented as planned."
Brigham and Women' Hospital installed CPOE first, a technology the hospital has had for more than 15 years, he says.