Barcode Medication Administration Awareness

Resource Patient Management System

Review of BCMA Literature as it Applies to Small Rural Hospitals

 Presenters:

David Taylor
OIT BCMA Federal Lead

Mollie Ayala
OIT BCMA Co-Project Manager

Michael Allen
OIT Pharmacy Consultant

Phil Taylor
OIT BCMA Nurse Lead

Carla Stearle
OIT Pharmacy Consultant

Barcode Medication Administration

 Objectives
• Summarize BCMA Literature as it applies to
Small Rural Hospitals

Special Thanks to:

Diane Cooper, MSLS, AHIP
Informationist / Biomedical Librarian
NIH Library / Office of Research Services / National Institutes
of Health

Barcode Medication Administration

 Current Activities and Concerns
(1 of 2)

• The OIT BCMA Team is conducting a literature

search learning more about the effect BCMA
has had on facilities around the world
• While BCMA has been shown to reduce
medication administration errors in larger
facilities, we have reason to wonder if it is so
in smaller facilities, especially those with
patient loads of 1-2 patients per month

Barcode Medication Administration

 Current Activities and Concerns
(2 of 2)

• One unique factor is the size of the average IHS hospital

and its relation to “small hospitals” cited in literature. The
average “small hospital in the world is between 80 and
120 beds. Most IHS hospitals are not anywhere near that
• We are developing the concept that in facilities with low
census, due to reduced nurse exposure to the BCMA
program in the computer, BCMA may present a new
source of medication errors due to inexperience and the
tendency to forget how to do something when it’s not
being done all the time

Barcode Medication Administration

 Factors that Contribute to
Successful BCMA Implementation
• Properly trained staff
• Adequate Pharmacy Coverage
• Adequate Number of Nursing Staff
• Plentiful Resources
• IT Support
• Administrative Support

Barcode Medication Administration

 Characteristics of Indian Health
Care Hospitals
• Total Number of IHS Hospitals: 37
• Total number of beds: 1185 beds (average
31.18 beds)
• Average occupancy rate of 2.42%
• Low ADPL (Average Daily Patient Load)
• Limited Pharmacy and Information Technology
(IT) coverage
• High staff turnover
• Limited resources
Barcode Medication Administration
 Article Review
• Most articles we reviewed on BCMA discussed
pros and cons on BCMA implementation
• Even the most positive articles still included a
few caveats
• Even the most negative still mentioned
potential benefits under the right conditions
• None failed to mention challenges in money,
time, workload, or cooperation faced by a
facility attempting to implement BCMA
Barcode Medication Administration
 BCMA Benefits
Selected Articles
• Patterson E, et al. “Improving Patient Safety by Identifying Side Effects from
Introducing Bar Coding in Medication Administration”, J Am Med Inform Assoc.
2002;9:540–553. DOI 10.1197/jamia.M1061. Accessed online at
http://jamia.bmj.com/ 2/4/2012
• Lawton G, Shields A. “Bar-Code verification of medication administration in a small
hospital”. Am J Health-Syst Pharm. 2005; 62:2413-5
• Foote S, Coleman J. “Medication Administration: The Implementation Process of
Bar-Coding for Medication Administration to Enhance Medication Safety.” Nursing
Economics. 2008;3:207-210
• Poon E, et al. “Effect of Bar-Code Technology on the Safety of Medication
Administration”, New England Journal of Medicine 2010;362:1698-707
• Maviglia S, et al. “Cost-Benefit Analysis of a Hospital Pharmacy Bar Code Solution”.
ARCH INTERN MED/VOL 167, APR 23, 2007,788-794. Downloaded from
www.archinternmed.com on March 16, 2012

Barcode Medication Administration

 Lawton Article (2005)
• “Bar-Code verification of medication administration
in a small hospital.”
– Purpose: To assess the impact of Bar-Code Verification
(BCV) on medication errors in a small private hospital
– Methods: Observational study performed by documenting
any potential errors that were prospectively identified by
the BCV system
– A 58-bed general acute care hospital implemented a
wireless system of BCV on a new 36-bed combined
intensive care and medical-surgical nursing unit.

Lawton G, Shields A. “Bar-Code verification of medication administration in a small hospital”. Am J Health-Syst

Pharm. 2005; 62:2413-5

Barcode Medication Administration

 Results
• 1438 patient admissions (average daily census of 27, average
length of stay 2.8 days
• Over the nine-month study period, the BCV system detected
and prevented 27 potential medication administration errors
– The Potential Medication Errors Identified:
• 13 (48%): wrong dose
• (15%): administrations for which an order did not exist
• 4 (15%): wrong patient
• 3 (11%): wrong dosage form
• 2 (7%): wrong time
• 2 (7%): wrong drug
• 11% Relative Risk Reduction in the rate of medication events
• Estimated cost savings due to the avoidance of hospitalization
by the reduction in potential errors: $72, 468 to $168,660.
Lawton G, Shields A. “Bar-Code verification of medication administration in a small hospital”. Am J Health-Syst
Pharm. 2005; 62:2413-5 Barcode Medication Administration
 Conclusions
• BCV can reduce the overall frequency of medication
administration errors
• Nursing staff must maintain a high utilization of BCV to achieve
the long-term benefits of reducing errors.
• The pharmacy staff must be readily available to troubleshoot
potential BCV problems
– Accurate and timely order entry
– Consistent Labeling
– Prompt delivery
• 24 Hour On-site Pharmacy Coverage

Lawton G, Shields A. “Bar-Code verification of medication administration in a small hospital”. Am J Health-

Syst Pharm. 2005; 62:2413-5

Barcode Medication Administration

 Maviglia Article (2007)
• Brigham and Women’s Hospital (BWH) is a 735-bed, tertiary, academic,
nonprofit medical center. Its inpatient pharmacy service dispenses
approximately 6 million medication doses for 35 000 admissions annually.
The hospital employs 61 fulltime pharmacists, 45 full-time pharmacy
technicians, and 2500 registered nurses, who are responsible for most
medication administration.
• The study design was based on a pre-post comparison of error rates
• Before bar coding, 0.19% of dispensed doses had errors with the potential
to harm patients (potential ADEs, usually incorrect medication, strength, or
dosage form). After implementing bar coding, the rate of potential ADEs
from dispensing errors decreased to 0.07%. With approximately 6 million
doses dispensed annually, this represents approximately 7260 averted
potential ADEs annually
Maviglia S, et al. “Cost-Benefit Analysis of a Hospital Pharmacy Bar Code Solution”. ARCH INTERN
MED/VOL 167, APR 23, 2007,788-794. Downloaded from www.archinternmed.com on March 16, 2012

Barcode Medication Administration

 Results/Conclusions
• The primary benefit was a decrease in adverse drug
events from dispensing errors (517 events annually),
resulting in an annual savings of $2.20million. The
net benefit after 5 years was $3.49 million.
• The rate at which potential ADEs result in actual
ADEs (13.4%), and the average incremental cost to
the hospital of preventable ADEs ($4600 in 1995
dollars) were used to translate error reduction rates
to dollars saved. Because the savings from an averted
ADE accrue to the hospital
Barcode Medication Administration
 BCMA Potential Problems
Selected Articles
• Goldsein J. “Hospital bar codes not a perfect Rx”. Philadelphia Inquirer, July 1,
2008. Section: National; Inq Health Daily; Pg. A01
• Kean C. “No Surprise – Nurses Often Bypass Drug Bar-coding Safety Features”,
Pharmacy Practice News, Volume 35, August 2008, p.32
• Koppel R, et al. “Workarounds to Barcode Medication Administration Systems:
Their Occurrences, Causes, and Threats to Patient Safety”. J Am Med Inform Assoc.
2008;15:408–423. DOI 10.1197/jamia.M2616
• Casey M et al. “Pharmacist Staffing and the Use of Technology in Small Rural
Hospitals: Implications for Medication Safety.” Upper Midwest Rural Health
Research Center Working Paper. Dec 2005
• Sakowski et al. “Using a Bar-Coded Medication Administration System to Prevent
Medication Errors in a Community Hospital Network.” Am J Health-Syst Pharm.
2005; 62:2619-2625

Barcode Medication Administration

 Goldstein (2008)
• An article written for a Philadelphia
newspaper covering an article by Koppel and
colleagues
– Workarounds to Barcode Medication
Administration Systems: Their Occurrences,
Causes, and Threats to Patient Safety
• J Am Med Inform Assoc. 2008;15:408–423. DOI
10.1197/jamia.M2616.

Barcode Medication Administration

 “A Bar Code is swell, but without a culture of safety,
it is not nearly as valuable as everybody believes.”1

1. David B. Nash, chairman of the department of health policy at Jefferson Medical College. Quoted in: Goldsein J.
“Hospital bar codes not a perfect Rx”. Philadelphia Inquirer, July 1, 2008. Section: National; Inq Health Daily; Pg. A01.

Barcode Medication Administration

• "A lot of the time, the people who develop these
systems think of them in the same way they think
about stocking a Sam's Club," Koppel said in an
interview yesterday, "but hospitals are very active
places where serious things are happening all the
time."
• Goldstein also repeated two of Koppel’s eight
recommendations that bear repeating:
– Hospital executives must spend time actually watching
how the systems are used
– They must also demand that the vendors design systems
for the real world of care
Barcode Medication Administration
 Koppel (2008)
• Koppel’s team spent several years observing
the use of bar-code technology in five
hospitals. They also analyzed half a million
medication scans to examine how well such
systems worked to reduce medication errors

Koppel R, et al. “Workarounds to Barcode Medication Administration Systems: Their Occurrences,

Causes, and Threats to Patient Safety”. J Am Med Inform Assoc. 2008;15:408–423. DOI
10.1197/jamia.M2616

Barcode Medication Administration

 Observations/Results
• The study found practical problems large and small, leading
nurses to develop work-arounds that often undermined the
system's safeguards.
• The researchers found all kinds of improvisation occurring.
Patient bar-code ID bands were taped to doorjambs, nurses'
desks, scanners, drug-dispensing machines and clipboards, and
were also worn as key chains on belts, among other places.
• There were times when the battery on the computer or the
scanner died. Or there was a wireless dead-spot in the hospital
room.
• "In 99 percent of the cases, it ain't the nurse, it is the system,"
Koppel said, "and sometimes it is easily fixed by reprogramming

Barcode Medication Administration

 Casey Article (2005)
• “Pharmacist Staffing and the Use of Technology in Small Rural
Hospitals: Implications for Medication Safety.”
– Purpose:
• Assess the capacity of rural hospitals to implement medication
safety practices and identify the factors that facilitate successful
implementation
• Determine what key facility and environmental factors – such as
hospital size, system membership, accreditation, and degree of
rurality – are related to rural hospitals’ pharmacist staffing, their use
of technology, and implementation of medication safety practice
– Methods: National telephone survey of a sample of 400 rural hospitals
with 100 or fewer staffed beds
Casey M et al. “Pharmacist Staffing and the Use of Technology in Small Rural
Hospitals: Implications for Medication Safety.” Upper Midwest Rural Health
Research Center Working Paper. Dec 2005.

Barcode Medication Administration

 Results (1 of 2)

• Forty-three percent of the responding hospitals have 25 or

fewer staffed beds; 33 percent have between 26 and 50 beds,
and 25 percent have over 50 beds
• 47 percent are accredited by the Joint Commission on
Accreditation of Healthcare Facilities (JCAHO).
• 35% of the hospitals report having a pharmacist on site for
less than 40 hours per week, including 31 hospitals (8%)
where a pharmacist is on site for two hours or less per week
• Seventeen percent of hospitals share a pharmacist with
another hospital, and 13 percent have one or more vacant
pharmacist positions

Barcode Medication Administration

 Results (2 of 2)

• Of the 387 hospitals in the survey, 77 percent use a pharmacy

computer for one or more clinical purposes: to screen for
potential drug interactions, to automatically screen for patient
drug allergies, to identify potential adverse drug events, and
to help determine appropriate medication doses. Forty-one
hospitals do not have a computer in the pharmacy and an
additional 48 hospitals do not use the pharmacy computer for
clinical purposes
• 51% of hospitals surveyed were using computer-generated
medication administration record
• 3% of hospitals surveyed were using bar code technology for
bedside medication administration

Barcode Medication Administration

 Use of Computer-generated Medication Administration
Records and Bar Code Technology for Bedside Medication
Administration (n=346)
Number (Percent) of
Hospitals
Hospital uses computer-generated Medication Administration 199 (57.5%)
Records
Reason for not using computer-generated MARs (n=147)
Limited Technology/system and software problems 49
Cost/budgetary constraints 36
Limited pharmacy hours/pharmacist time 22
In process, implementing in near future 17
Nurses’ resistance/preference for paper 15
Hospital too small/don’t need them/not a priority 10
Just haven’t done it/don’t know 4

Barcode Medication Administration

Use of Computer-generated Medication Administration Records and Bar
Code Technology for Bedside Medication Administration (n=346)
Number (Percent) of
Hospitals
Hospital uses bar code technology for bedside 199 (57.5%)
medication administration
Reason for not using bar code technology (n=335)
Cost/budgetary constraints 197
Limited technology/computer system 53
In process, implementing in near future 30
Hospital too small 19
Bar code technology not standardized/still changing 18
Waiting for system or corporate decision or testing 14
Not a high priority/administration doesn’t support 11

Just haven’t done it/don’t know 10

Staff time (e.g for repackaging unit doses) 7
It’s not mandatory 6
Barcode Medication Administration
 Conclusions
• Limited on-site pharmacy coverage in many small rural
hospitals limits the amount of time spent on medication
safety activities
• Cost is a major reason for NOT implementing specific
medication safety-related technologies
• Improving implementation of key medication safety practices
among non-accredited hospitals will likely require a
comprehensive approach that includes increasing awareness
of the importance of implementing the practices, as well as
targeted provision of technical assistance and financial
incentives.
Casey M et al. “Pharmacist Staffing and the Use of Technology in Small Rural Hospitals:
Implications for Medication Safety.” Upper Midwest Rural Health Research Center Working Paper.
Dec 2005.
Barcode Medication Administration
 Sakowski et al.
2005
• Purpose: To describe the effect of implementing a
bar-coded medication administration system on
medication administration errors in a network of
community hospitals
• Methods: A retrospective audit was conducted of
warning and error reports generated by a Bar Code
Point of Care system from six hospitals in the
network (79-403 beds)

Sakowski et al. “Using a Bar-Coded Medication Administration System to Prevent Medication Errors in a
Community Hospital Network.” Am J Health-Syst Pharm. 2005; 62:2619-2625.

Barcode Medication Administration

 Observations/Results (1 of 2)

• BCMA issued alerts/warnings on 42% of all

attempted administrations
– This illustrates a real danger of users becoming
desensitized to warnings
• 33% of all attempted administrations required the
nurse to verify something
– Nurses used the override in 78% those attempts
• 10.98% of those overrides resulted in either the drug administered
at the wrong time, the dose differing from the written order, or a
drug for which there was no order.

Barcode Medication Administration

 Observations/Results (2 of 2)
• Approximately 70% of warnings were due to an error in
setup or process
– Fixing setups, including administration schedules and drug
units was required
• 1.1% of all attempted administrations were stopped by
discovery of a problem, averting medication
administration errors. The top three types of errors
prevented included:
– Doses administered too early
– System had no record of a particular medication being
ordered
– Attempted administration of a medication for an order that
was discontinued or expired
 Conclusions (1 of 2)
• The use of a bar-coded point of care system can
prevent medication errors
• BCMA systems accentuate setup and workflow issues
that can result in a number of inappropriate warnings
• Addressing system and workflow issues identified by
BCMA reduces the number of inappropriate warnings
and improves the effectiveness of the system
• Hospital Medication Administration is a
multidisciplinary process and errors can be caused by
any entity involved, not just nurses
 Conclusions (2 of 2)
• Recommendation: “Periodic assessments to confirm
that users are adopting BPOC [BCMA] as expected
(including “walk arounds” to observe the entry of
orders and administration of medications), repeat
training to reinforce best practices, and continuous
monitoring of BPOC system-generated reports are
needed to reduce the potential for system-caused
errors”
• Facilities must plan to dedicate resources to BCMA not
only at implementation, but must also provide for
continued maintenance and upkeep to assure its
proper operation into the future
 Literature Search Summary (1 of 3)
• BCMA, through its ability to detect errors, has been
shown to prevent medication administration errors in
large hospitals
• Because of its complexity, BCMA is, itself, a source for
medication administration errors
• Staff using BCMA must be well trained and
experienced. Training and competency must be
continuously monitored for optimal benefit from
BCMA
• BCMA does not replace clinical judgment
Barcode Medication Administration
 Summary (2 of 3)
• Setting up and properly optimizing supporting
pharmacy files for BCMA is critical to user satisfaction,
proper use, and patient safety
• The hospital must foster a culture of safety, of which
BCMA is only a tool
• Optimal use of BCMA may represent a cost (and
reputation) savings through minimizing drug
administration errors
• BCMA is for life. Continuous maintenance and upkeep
are required
Barcode Medication Administration
 Summary (3 of 3)
• BCMA requires coordination of efforts and
cooperation between nursing, pharmacy, and
Information Technology departments
• Hospital medication administration is a complex
process and must be optimized to avoid possible
points of failure:
– technology issues (hardware, network, software)
– Personnel issues (staffing, policies and procedures)
– Communication between departments

Barcode Medication Administration

Questions & Discussion

Barcode Medication Administration