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Bar Code Medication Administration(BCMA) Definitions, Impact on Medication Errors, Fundamental Essentials, and Using Data

to Improve PerformanceBill Templeman, Pharm.D.

Inpatient Pharmacy Quality SupervisorKaiser Permanente

Riverside Medical Center

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Disclosure

The speaker had no conflicts of interest to disclose

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Learning Objectives

Understand the definitions of BCMADescribe the effect of BCMA compliance can

have on medication errorsIdentify the essential components of a successful

BCMA programExplain how using reporting data can improve

system and user performance

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Definitions of Barcode Medication Administration

BCMA is an additional layer of safety to ensure the correct patient is identified and medication is administered The nurse, at the time of administration, will scan:

The patient’s armband to assure the correct patient

Scan the medication bar code to assure the correct medication is being administered

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BCMA Override

A BCMA override is when a nurse electronically documents a medication administration, even after the system displays an alert that indicates there is a problem with patient identification, drug strength, dosage form or administration time.

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BCMA Overrides

BCMA overrides are acceptable under certain circumstances:Medication administered in the

operating roomMedications administered during a

code or urgent procedural sedation situation

Computer downtime

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BCMA Medication Override Warnings

This Medication was not scanned prior to administration

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BCMA Medication Override Alerts

# Alert Name Alert Description Alert Example

1 Barcode Not Recognized Alert

Bar code scanned is not recognized in KP Health

Connect

Product bar code not recognized

2Wrong

Medication Alert

Bar code scan is recognized in KP Health

Connect but the medication is not on

the patient’s MAR

No administrable medications were

found in this patient’s record

3 Other AlertsMedication scanned is no longer active on the

patient’s MAR

No active orders were found in this patient’s

record

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BCMA Override Reason Documentation

“ACTION” “PT. NOT SCANNED” “MED NOT SCANNED”

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Medications Errors Originate and are Intercepted

Prescribing• Origination 39%• Interception 48%

Transcribing• Origination 12%• Interception 33%

Dispensing • Origination 11%• Interception 34%

Administration• Origination 38%• Interception 2%

Leape LL, Bates DW, Cullen DJ, et al. Systems Analysis of Adverse Drug Events. JAMA. 1995;274(1):35-43

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ISMP Estimation of Inpatient Medication Errors

In 2001, Institute for Safe Medication Practices (ISMP) estimated, in the United States’ hospitals, daily there were approximately 320,000 medication errors:

100,000 during medication administration

35,000 during drug dispensing

ISMP Acute Care Edition, July 25,2001

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Medication Errors

Each year, an estimated 7,000 deaths are linked to medication errors [1].BCMA assists personnel that administer medication in compliance with the "Five Rights" of medication administration: right patient, right dose, right route, right time, and right medication [2].

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.

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Effectiveness of Error Reduction

From “Words on Design and Life “ by Cassie McDaniel

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The Swiss Cheese model by James Reason

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An Example of Swiss Cheese

Magnesium 2gm on shortagePatients identified, monitored no harmRoot cause conducted

• Pharmacy- Wrong product ordered and placed in floor stock• Look-alike medication• Nurses not scanning medication in real time

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BCMA Effect on Medication Errors

A study of 14,041 medication administrations showed1:

Error rate of 11.5% on an unit not using BCMA and 6.8% on a unit using BCMA; a 41.4% relative reduction in errors

Rate of potential adverse drug events fell from 3.1% without the use of the bar-code eMAR to 1.6% with its use, representing a 50.8% relative reduction

1 Poon, et al. “Effect of bar-code technology on the safety of medication administration.” N Engl J Med. 2010 May 6;362(18):1698-707.

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Kaiser Permanente Riverside Data: BCMA Compliance Related to Medication

Errors

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

5

5.5

6

6.5

7

20

30

40

50

60

70

80

90

100

110

1Q09

2Q09

3Q09

4Q09

1Q10

2Q10

3Q10

4Q10

1Q11

2Q11

3Q11

4Q11

1Q12

2Q12

3Q12

4Q12

1Q13

2Q13

3Q13

4Q13

1Q14

2Q14

3Q14

4Q14

1Q15

%

Override

Med

Errors

Doses/Qtr

Kaiser Riverside Medication Errors Compared to Patient and Medication Scanning Override %

Medication Errors- Doses/Quarter

Medication Scanning Override %

Patient Scanning Override %

Decreased Medication Errors and IncreasedCompliance with

Barcoding

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Use of Bar Code Technology to Decrease Dispensing Errors

Scan on automated dispensing cabinet (ADC) medication fill

All medications need to be checked by a pharmacist prior to distribution from the pharmacyThe technician is to scan all medications prior to filling the ADC

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Use of Bar Code Technology to Decrease Dispensing Errors

“Dispense Prep” and “Dispense Check” The technician and pharmacist scan the computer

generated order bar code and then scan the medication If the scanned medication matches the scanned

medication, the screen will turn green If the scanned medication does not match, a warning of

the mismatch will display

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Dispense Check Screen Shot

The product from the Health Connect label matches the product scanned

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Use of Bar Code Technology to Track Items Used in

Intravenous Compounding

Additives for IV compounded products are scanned

Lot number, manufacturer and expiration date is entered into an electronic IV compounding log

Pharmacist checks and initials compounded item label

Scans label bar code and also verifies base solution and additives electronically

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Essential Foundations of a Successful BCMA Program

Teamwork: IT Pharmacy Nursing and Nursing

Managers Data and usable reports Impact on decreasing medication errors

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Essential Foundations of a Successful BCMA Program

Software Reliable EMR software and computer

network The computer medication system is

compatible with the scanners being used The scanners can transmit the data to

the medical record The scanners are correctly linked to the

computer system (either mobile or stationary)

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Essential Foundations of a Successful BCMA Program

Hardware Functional and

reliable barcode scanners

Plenty of workstations Scanners are working properly

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Information Technology’s Essential Role After Implementation

Ensure scanners are working properly

Ensure identified issues are addressed in a timely manner

Ensure system is reliable with minimal downtime

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Pharmacy’s Role in a Successful BCMA Program

Develop a method for adding the correct bar codes for multi-dose products

Inhaler, creams, ointments, insulins, multi-dose containers

Develop a bar coding label hierarchy

Pharmacy placed bar code label- > manufacturer’s bar code-> computer generated order ID bar code

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Pharmacy’s Essential Role in a Successful BCMA Program

All drugs dispensed from the pharmacy have readable barcodes

All dispensed drugs are built in EMR database

One medication record for multiple manufacturers’ product

The correct ordered product is dispensed from the pharmacy

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Pharmacy’s Role in a Successful BCMA Program

The pharmacy computer generated bar code label should only be used as a last resort

Pharmacy compounded products Medications not in the pharmacy database

The pharmacy generated bar code label usually displays the order number, which does not ensure the correct product was dispensed.

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Nursing Management’s Role in a Successful BCMA Program

Education of staffHolding staff accountable for workarounds and non-compliance with correct BCMA work flowUsing data to identify and counsel non- compliant usersStrong relationships with: pharmacy, informatics, nursing staff and the IT department

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Nursing’s Role in a Successful BCMA Program

Buy in with capitalizing on initial successes and increased patient safetyPerforming BCMA compliant with established workflow :

Not using BCMA labels not attached to a medication

Not scanning in real timeReporting medications that do not scan or scanners that do not work

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BCMA Report Content

Contents:Overall Medical Center

compliance Unit specific compliance User specific complianceHour and date Scanning compliance by

medication

DepartmentPatient

Scanning Compliance

Medication Scanning

Compliance

Total Administ

rations

# of Admins

With Patient

Not Scanned

# of Admins

With Medicati

on Not Scanned

# of Admins

With Neither

Medication Nor Patient Scanned

Unit 1 100% 100% 1Unit 2 95.16% 90.32% 62 3 6 2Unit 3 99.11% 98.54% 7199 64 105 38Unit 4 99.47% 98.83% 7699 41 90 34Unit 5 99.39% 98.72% 11970 73 153 43Unit 6 99.29% 98.58% 10775 76 153 65Unit 7 99.26% 98.62% 13167 97 182 64Unit 8 97.14% 97.14% 35 1 1Unit 9 100% 100% 3Unit 10 98.64% 98.01% 3671 50 73 45Unit 11 98.98% 97.53% 1173 12 29 11Unit 12 99.22% 98.65% 12991 101 176 64Unit 13 98.87% 97.25% 2838 32 78 30Unit 14 99.11% 98.51% 4034 36 60 35Unit 15 91.67% 100.00% 12 1Unit 16 98.96% 98.96% 1053 11 11 6Unit 17 100% 100% 1Unit 18 99.06% 97.94% 7855 74 162 66Unit 19 99.94% 97.60% 3288 2 79 2Unit 20 99.23% 98.73% 14095 108 179 61Totals 99.23% 98.49% 101922 782 1537 566

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BCMA Report Content

BCMA compliance by Medical Center and unit type

High Alert medication overrides Top twenty medications overrides and

rationale foroverrides

Raw data on armband and medication overrides

Wrong medication alerts

Total Administrations

Facility

# of

Admins

With

Patient

Not

Scanned

Patient

Scanning

Override %

# of Admins

With Medication

Not Scanned

Medication

Scanning

Override %All Drugs

Hospital 1 1120 1.05% 1812 1.70% 106600

Hospital 2 756 0.79% 1387 1.45% 95804

Hospital 3 2006 1.32% 3056 2.01% 151971

Hospital 4 2828 1.70% 4290 2.59% 165935

Hospital 5 1072 1.32% 1578 1.95% 80934

Hospital 6 3941 1.84% 5525 2.58% 214142

Hospital 7 306 3.02% 185 1.82% 10146

Hospital 8 416 1.21% 794 2.31% 34431

Hospital 9 874 0.99% 1405 1.59% 88237

Hospital 10 610 0.87% 810 1.15% 70463

Hospital 11 769 0.88% 1226 1.40% 87422

Hospital 12 3762 1.92% 4902 2.50% 195990

Hospital 13 1234 1.22% 2289 2.26% 101095

Hospital 14 1463 1.62% 2392 2.65% 90265

Hospital 15 881 0.95% 1443 1.55% 93037

Total 22038 1.38% 33094 1.97% 1,586,472

Armband Medication

SCal Consolidated BCMA Report Prepared by: Michelle Larsen, Project Manager - Pharmacy Operation

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BCMA Report Content

Wrong medication alerts Respiratory BCMA

compliance Many other data sets and

graphs

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Overall User Summary Table

# Users not meeting 98% Armband Scanning Goal

105

# Users not meeting 98% Armband Scanning Goal

and 97% (96% for ED) Medication Scanning Goal

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% Users not meeting 98% Armband Scanning Goal

15%

% Users not meeting 98% Armband Scanning Goal

and 97% (96% for ED) Medication Scanning Goal

11.3%

# Users not meeting 97% (96% for ED) Medication Scanning Goal

139

% Users not meeting 97% (96% for ED) Medication Scanning Goal

19.8%

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Users with No Overrides

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High Outlier Summary

# outliers/# total* % Of all users% of All

adminsitrations% Armband Overrides

% Medication Overrides

% Both Overrides

% 3.97% 7.3% 35.5% 30.1% 39.8%# outliers/# total 29/730 6385/87422 273/769 369/1226 249/625

Also did not meet 98% armband scanning 22/29% Not meeting 98% armband

scanning75.9%

* 135 or more administrations less than 97% med scanning ( ED threshold is 96%)

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High Outlier Report

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Conclusion

The number of medication errors can be decreased by a robust BCMA process.

It takes teamwork with pharmacy, nursing and IT for a successful BCMA program

Bar coding is just not for administration anymore, pharmacy can use this technology to dramatically reduce

the number of dispensing and ADC refilling errors Reporting can be used to increase compliance and identify

system issues

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Acknowledgements

Don Kaplan, Pharm.D., Inpatient Pharmacy Practice Coordinator, Kaiser Southern California Region

Michelle Larsen, Kaiser Southern California Region Inpatient Pharmacy Project Manager

Kal Khoury, Pharm.D, Area Pharmacy Director Kaiser Riverside Dale Timothy, RPh, MBA, Inpatient Pharmacy Director, Kaiser

Riverside Christel Cheng, BSBA, Administrative Assistant Kaiser Riverside

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