Bar-coded Medication Administration

Introduction

Each year, an estimated 7,000 deaths are linked to medication errors [1].  These errors occur at all stages of the medication-use process, including ordering, transcribing, dispensing, and administration. One widely discussed method of reducing errors during the "administration" phase is bar-coded medication administration (BCMA). BCMA pairs implementation of an information technology solution called "Electronic Medication Administration Record" (eMAR) with item-specific identification (bar-coding).  BCMA helps users to be in compliance with the "Five Rights" of medication administration: right patient, right dose, right route, right time, and right medication [2].

Although adoption of BCMA is proceeding slowly in the United States, the Agency for Healthcare Research and Quality (AHRQ) has provided leadership by funding eleven organizations in a variety of care settings in implementing bar-coded medication administration projects and exploring the effects of BCMA on health care quality, safety, cost, and other outcomes.  Information regarding AHRQ-funded bar-coded medication administration projects can be found at the links provided at the end of this document.  While the projects described are not yet complete, some key "lessons learned" have emerged from the grantees' experiences in implementing BCMA. This brief highlights early findings from the AHRQ-funded BCMA projects. These findings focus on implementation considerations for BCMA:

  • Communication and Workflow
  • Technology Placement and Usability
  • Training and "Go-Live" Preparation

Communication and Workflow

Lesson 1:  Implementing BCMA requiresworkflow modifications for nursing, pharmacy, and other stakeholders, with changes in culture, attitudes, and practice, to achieve the benefits of this technology.

  • BCMA introduces significant workflow changes for nurses, requiring targeted change management strategies.  To measure and prepare for this change, AHRQ grantees have utilized workflow redesign tools, such as workflow and process diagrams, to plan for and communicate changes in clinician workflow before their systems went live.
  • Prior to implementation, grantees reported that nurses have generally viewed BCMA systems favorably, in anticipation of the benefits of the technology on patient safety. Nurses and nurse managers have suggested that, after an initial learning period for the technology and adjustments in medication administration workflow, use of BCMA helped clinical staff foster improved safety practices. Of all stakeholder groups affected by BCMA implementation, nurses are the most impacted.  Consequently, organizations transitioning to BCMA should focus significant training and workflow redesign resources on nurses. 
  • Redesigning the medication administration process as part of implementing BCMA required increased collaboration and communication among nursing and pharmacy staff.  While breaking down these organizational barriers resulted in a more integrated work and information flow, it forced the grantees' nursing and pharmacy staffs to confront and re-define longstanding perceptions around roles and responsibilities.  For example, one grantee organization encountered significant strains between its nursing and pharmacy staff due to different perspectives regarding the information that should be displayed and available in the eMAR software.  
  • While grantees expect improved patient safety from implementing BCMA, they do not expect to achieve time savings.  According to grantees, BCMA often has no net impact onthe efficiency of nursing staff and can create additional work for pharmacy staff.  
  • A key benefit of BCMA identified by grantees was improved accountability and measurement of the medication administration process.  Reporting capabilities of many BCMA systems support analysis of when a medication was administered, who administered it, and whether medication information was scanned or manually entered into the system.

Technology Placement and Usability

Lesson 2:  The placement, accessibility, compatibility, and durability of equipment are essential to effective implementation of BCMA.

  • The size of mobile carts and pharmacy equipment can present human factor challenges to implementation of BCMA. Oversized medication carts, computers on wheels ("COWs"), and pharmacy equipment can obstruct the movement of people and equipment, especially in close quarters. Grantees found that it is critical that equipment is easy to move and manipulate in patient rooms.  
  • To make BCMA usable, nurses need to have computers located nearby so they can scan patients' medications or update their eMARs.  The preferred configuration selected by the majority of grantees for facilitating BCMA was "one computer and scanner per room." While locating a BCMA computer and scanner in each patient room might require hospitals to spend more on equipment, AHRQ grantees found that configurations with fewer than one set of BCMA equipment per room (for example, rotating computers on wheels among rooms or locating scanning stations outside of patient rooms) impacted the productivity of the nursing staffs and resulted in less use of the BCMA solution. 
  • Prior to purchasing them, hospitals should test scanners for compatibility and functionality with the actual barcodes that they will use.  Some grantees found that scanners that they purchased were not able to read the majority of barcodes used in their organizations.
  • Durability of patient wristbands and barcodes is an important consideration, because broken or unreadable codes and wristbands negate the benefits of BCMA systems.  Grantees suggest that hospitals should test wristbands and barcodes and purchase only those that are durable enough to withstand the rigors of routine hospital use.
  • As part of BCMA implementation, grantees found that organizations must plan resources for re-packaging and bar-coding medications at the unit-dose level.  While a new FDA rule on bar-coding that mandates that hospitals place linear barcodes on medications at the unit dose level, grantees found that drugs and supplies often are not currently packaged or labeled in this manner by manufacturers.

Training and "Go-Live" Preparation

Lesson 3:  Training staff and modifying policies to address issues relevant to BCMA administration are key steps in preparing to go live with a new system.

  • Each AHRQ grantee provided dedicated training for its nurses on the use of BCMA scanners and eMARs.  Although the precise structure and resources provided by a training program varied by grantee organization, three grantees cited that a successful nurse training should (1) last at least 4 hours and (2) incorporate an element of experiential learning, or practicum.
  • Implementation of BCMA technologies requires modifying hospital policies on medication administration and patient identification. Common revisions addressed issues such as charting in patients' rooms, downtime procedures, and procedures for ensuring the "Five Rights." There may be a need to modify additional policies regarding how and when scanners should and should not be used.  For example, one grantee implemented policies for allowing exceptions for bar-coding mental health patients and during medical emergencies.
  • AHRQ grantees recommended using a phased rollout by unit or pilot unit. Several grantees suggested planning for initially piloting BCMA technology and associated workflow adjustments in units that are small and house less acute cases. These units serve as ideal test beds for fixing glitches and ensuring availability of sufficient technical support staff before the rollout proceeds to larger and more complex parts of the organization.  
  • Having visible "superusers" and other support staff is critical to successful roll-out and implementation of BCMA.  Grantees defined a "super-user" as a nurse, pharmacist, or other clinical staff member who has received extra training on the new system and has demonstrated the ability to provide peer-to-peer support during implementation.

Measuring the Impact of Bar-coded Medication Administration

The AHRQ -funded projects listed below are measuring the impact of BCMA on health care quality, safety, and efficiency.

1. Institute of Medicine.  Kohn LT, Corrigan JM, Donaldson MS, eds. To Err is Human: Building a Safer Health Care System. Committee on Quality of Health Care in America. Washington, DC: National Academy Press; 2000.

2. Perry A, Shah M, Englebright J. Improving Safety with Barcode-Enabled Medication Administration. Patient Safety and Healthcare Quality.  May/ June 2007.