proposal for barcoding for medication...

Running head: PROPOSAL FOR BARCODING FOR MEDICATION 1

Proposal for Barcoding for Medication Administration

Susan Cody, Terresa Roulhac, Harleen Kaur

National University

System Management and Planning

HTM 660

Susan Leonard

May 16, 2015

PROPOSAL FOR BARCODING FOR MEDICATION

Proposal for Barcoding for Medication Administration

Susan Cody

Executive Summary

This proposal presents a plan for acquiring and implementing a barcoding system at

Community Memorial Hospital. This project is very important to this healthcare system,

as it will assure a decrease in costly medication errors, streamline workflows for various

departments in the HC entities, and decrease costs in the long run of the program.

Included in this proposal are the necessities that are key to the project: an efficient, well-

oiled team, functionality of the barcoding system, and budget issues, goals, and

constraints of the system.

Project Summary

As operational expenses continue to increase and stricter regulatory standards

have come into place, automated data collection has become a necessity in the healthcare

industry. ("Barcoding.com," “n.d.”) Community Memorial Hospital (CMH) also has a

vested interest in protecting and ensuring patient safety, as well as increasing

productivity, and reducing medication errors. A system that can identify the correct

patient, the correct supplies, medications, procedures is critical to CMH, its patients, and

its employees.

Statement of Need

Barcoding is a system that can be utilized on any computer equipment,

and facilitates the hospital admission process. It is also used for tracking and identifying

patients, managing inventory, and administering medication. Medical personnel can

easily access patient information by scanning the patient's wristband. Point-of-care


(POC) technology can cut costs, enhance efficiency, and prevent harmful medication

errors. Scanners can also be used to ensure that lab functions, prescriptions and even

food trays are associated with the correct patient.

Barcoding offers a number of hardware and software solutions to automate the

inventory process in the pharmacy, and provides efficacy in management, maintenance,

and distribution of medical supplies and materials. When medications are

being administered, barcoding can verify the patient information as well medication and

dosage information to avoid errors.

Because patient safety is a goal of this healthcare facility, and Community

Memorial Hospital has already instituted a Pyxys system, this proposal will be

specifically addressing barcoding in the medication administration process to prevent

medication errors. The National Coordinating Council for Medication Error Reporting

and Prevention (NCCMERP) defines a medication error as "...any preventable event that

may cause or lead to inappropriate medication use or patient harm while the medication is

in the control of the healthcare professional, patient, or consumer". (Cummings, Ratko, &

Matuszewski, 2005) Research has shown that errors that occur earlier in the medication

process are more readily detected, while very few errors are caught in the administration

phase. (Cummings et al., 2005) For this reason, error reduction strategies have received

significant attention. Scanning patients at POC has become a very effective tool in

prevention of medication errors by ensuring the "5 rights": the right patient, the right

drug, the right dose, the right route and the right time. (Brusco, 2012)

Barcoding has become the go-to technology in assurance of accuracy in the

delivery and recording of medication administration. This proposal includes a plan to


distribute handheld scanners, barcoding printers, and other hardware and the software

required to achieve a comprehensive system to assure that the 5 rights are being met. The

Pharmacy will be able to ascertain the medication levels in the Pyxis units, track

medication delivery to patients, monitor administration levels, as well as medication

allergies and interactions. (Cummings et al., 2005) The nurse will be able to scan the

barcodes of the patient and the medication, in addition to charting the medication on the

eMAR. Quick Response (QR) code, or 2-D technology, allow other departments such as

Radiology, Laboratory, Admitting, Materials Management to easily be “rolled in” as

CMH’s budgetary and data expansion plans are developed.


Project Goals

The goals for this proposal are to improve patient safety, streamline the current

workflow, reduce costs over the long term, and to develop improvement cycles for future

implementation of ancillary departments. Metrics to determine the value of these goals

are:

1. Fewer errors in the medical records. Crosschecks are imbedded in the

programming to alert users to possible errors in documentation, and to when

medications are due to be delivered.

2. Improved access to data is enhanced via documentation that is available to all

authorized healthcare personnel.

3. Patient and provider satisfaction is increased due to availability of information

to both interested parties.

4. There is diversity in a single investment. Changing to the barcoding program

will allow integration of EHR, laboratory, radiology, referral systems, dietary,


etc., thereby reducing costs and improving service and productivity as CMH

plans to integrate other departments.

The scope of this proposal covers barcoding for medication administration, and, at this

time, does not address barcoding for the departments of Materials Management,

Laboratory, Radiology, or Admissions.

Constraints

Some constraints to the system, however, will be budgeting, choice of hardware

and software, and training for all employees. Time management is critical to the success

of the plan. It will also be important to establish a steering committee that is well-versed

in the technology, and in the current hospital systems, to create a smooth transition in the

planning of the project. The depth, breadth, and efficiency of cooperation between nurses,

pharmacists and information technologists are pivotal to the success of the plan. In

addition, selection of the appropriate vendor and software that is compatible with our

needs and our existing Pyxys functionality must be considered. CMH must be prepared to

provide the support necessary at go-live and for a time thereafter to ensure the successful

adaptation of the new system by hospital staff. Logistics will determine where equipment

will be placed in proximity to the patient and the nursing personnel, availability of space,

proper utilization of resources, etc.

Terresa Roulhac

Timeline

Project will begin on July 1, 2015 pending approval, and be completed by

December 1, 2015. Installation of the barcoding system to CMH’s inpatient pharmacy

will take place July 5, 2015 and continue until 01 August 2015.


01 August 2015 – 15 August 2015-Vendors will be brought to CMH for five

workshops. In order to cut down on the amount of disruption of workflow, the workshops

will be spread out among the three main shifts. Vendor workshops will have a Monday

and Wednesday training at 0700 a.m., Tuesday and Thursday training at 1530 p.m. and a

Friday workshop at 1730. The workshops will be held in the main conference room at

CMH, and each workshop will last approximately two hours.

15 August 2015 – 30 August 2015-Training for all end users will begin. There

will be a total of 10 available workshops for all end users, and times and dates will be set

to mimic the day and times of the vendor workshops to guarantee that everyone has the

opportunity to learn the new systems prior to the go live date.

01 September 2015 – 01 October 2015-Testing begins on the test barcode system.

During this time system hardware will be examined for accuracy and workflow

discrepancies. Common infrastructure metrics that will be closely examined will be how

often the barcoding system has unscheduled downtime, the speed it takes the system to

recover from downtime, and any other issues that affect applications within the system.

(Wager, Lee & Glaser, 2013, p. 428-429)

01 October 2015 – 01 November 2015-Staff surveys via email will be sent out

and collected for review for the steering committee. Completion of the rollout to entire

hospital will be done by 01 December 2015.

01 November 2015 -- Barcoding system goes live

01 November 2015 – 01 December 2015-Steering committee meeting to evaluate

the new bar code system, Patient surveys sent out via email and text.


Costs & Risks

There are three elements for consideration of cost for any barcode system. The

origin source for the barcode can either have the ability to produce preprinted labels or

print them on an as needed basis. Also, the system must contain a reader that includes

input devices so that he barcode can be scanned as well as convert symbols to ASCII text.

(Barcoding Sales and Inventory, n.d.) ASCII stands for the American Standard Code for

Information interchange and “is the most common format for text files in computers and

on the internet”. (What is ASCII (American Standard Code for Information Interchange)?

Definition from WhatIs.com, n.d.) The third element for consideration is the computer

system that will process the barcode information. The system chosen will have either

single-user, multi-user, or have a network system. (Barcoding Sales and Inventory, n.d.)

Understanding the risks associated with new projects is important. Barcode

systems are fragile and often overlooked, but barcodes are the link to help systems run

properly. The technologies, both hard and soft, must work together. If a barcode fails,

tracking becomes difficult, and the potential risk for errors increases. Barcodes track a

number of items. For example, barcodes help verify the manufacture and expiration dates

of pharmaceuticals as well ensuring that right patient is receiving the right dose at the

right time. Another risk associated with barcoding is the failure to recognize barcode

quality and the implementation of the minimum requirements as a part of the policy and

procedure manual. By not qualifying the barcode quality, organizations are putting

themselves at risk for future increase in costs and unnecessary problems in the future.

Testing of barcode equipment can be obtained easily to help determine and control risks


related to barcode systems. No organization can afford to overlook the potential financial

and safety risks. (Nachtrieb, 2013)

Other risks include challenges of introducing the system to the organization.

Strategies must include quality improvement and addressing barriers to ensure training is

sufficient; vendors are involved in the first phase of implementation and available

throughout the process. Also it is important to understand any limitations and to keep

communication channels open and clear. (Wager, Lee & Glaser, 2013, p. 156)

Below is the proposed budget plan for the barcoding system. The budget includes

fifteen workshop and training sessions. Refreshments and handout expenses are included.

The equipment includes 175 Intermec SD20B Healthcare 2D Imagers. These imagers are

chosen because the product is ideal for a number of healthcare applications and for their

ease of capturing data. (SG20 Healthcare 2D imager, n.d.) Also, four stand-alone

computer systems will be dedicated to the new barcode system. The Intermec Labelshop

Ultra Barcode with two licensures and the Zebra HC 100 Barcode printer are also

included in the budget proposal. The Zebra HC 100 was designed to print patient ID

wristbands at a cost effective price. This particular printer is a thermal printer with

cartridges that anyone will be able to load and unload. The thermal printer enables CMH

to print wristbands on demand and cuts down staff performing multiple steps of loading

special trays, printing labels, applying the label to bands, and laminating the band prior to

placing the wristband on the patient. (Zebra HC100 Wristband printer, n.d.)


Other items included in the budget are software version updates that will take

place every 33 months. Software maintenance and hardware maintenance will have a

combined yearly allotment of $30,187.80. All items such as blank printable wristbands

and ink for the printers are included in the hardware maintenance.

The committee understands that initially the cost of implementation is large, but

the return of investment will prove that the barcoding system is a much-needed

investment. In order to determine a positive return of investment the committee will take

a look at patient satisfaction surveys as well as surveys from CMH staff. Ideally the


reduction of medication errors and a functional closed loop of healthcare services will be

determining factors for the return on investments.

Benefits & Opportunities

Barcoding systems help reduce the number of times a patients is interrupted while

receiving medications. A BCMA can reduce deviations from regular sequences.

Barcoding systems help streamline routines and allow for healthcare providers to

anticipate activities and find inaccurate actions. The potential of barcoding in a healthcare

system can increase productivity; improve patient safety and the quality of care. Along

with a more streamline process is the reduction of labor costs, fast and reliable data

collection, improved supervision, and better decision making for management. Many

studies have shown that errors happen at many stages in the medication process. These

errors often occur at the ordering stage, dispensing stage, administering stage and even

when medications are only being monitored. Barcoding systems are highly effective in

decreasing medication errors at all stages of medication administration process. Studies

have shown a 40%+ reduction in medical errors was linked to organizations that

implemented barcoding systems. (Wager, Lee, & Glaser, 2013, pp. 154 -155)

Generating positive public relations with the local community by improving

patient satisfaction and improving nursing staff job satisfaction are opportunities that can

be gained with the implementation of a BCMA. A case study done at Beloit Memorial

Hospital in Beloit, Wisconsin showed that job satisfaction increased because of the

implementation of a barcoding system. The nursing staff felt the organization was

dedicated to improving quality of care with the investment of new technology that would

improve patient safety. Briefings were conducted in the early stages of implementation,


and patients were briefed about the new BCMA system. The staff at Beloit Memorial

reported patient and families were happy for the briefing. Local media were contacted

and the exposure increased relationships between the local community and the hospital.

(Work, 2005)

Alternative Impact

The costs associated with new technologies are usually the determining factors of

choosing one product over another. The alternatives to the barcoding system include the

UHF RFID and the RTLS. The RFID is a radio frequency identification system that has

two components, readers and tags. The reader emits radio waves and has one or more

antennas that also obtain signals from RFID tags. Patients with pacemakers, implantable

cardioverter defibrillators are not ideal candidates for RFID because of the potential

interference. (U.S. Food and Drug Administration, n.d.) One concern of an RFID scanner

is that there is no way to control who can read the tag and that can lead to serious privacy

issues. Also, another security issue is that RFID information can be read from a distance

and these scanners may not be able to function in a heavy use environment causing the

system to not function properly. (Evans, n.d.)

Real – Time Location Systems (RTLS) is the other alternative to the barcoding

system. RTLS provide tracking and management of medical equipment, patients and staff

in real time. RTLS help healthcare organizations capture workflow efficiencies, lower

costs, and improve quality care. The systems components include badges and different

types of tags as well as different types of platforms to send and share information. (Intro

To Real Time Locating Systems (RTLS), n.d.) There are three main considerations

associated with RTLS in Healthcare.


The first consideration for RTLS is whether or not there are accurate room and

sub-room locations for the technology. Also, the ability for the system to operate with

other mission-critical systems is important. Software is the second consideration of RTLS

systems. “RTLS is progressing beyond locating assets and expanding further into

managing patient flow, beds, rooms, staff, and other departmental activities and

workflows. (Critical Considerations for RTLS in Healthcare, n.d.)” Other considerations

for RTLS are that tags and readers cost more than barcoding systems, and RTLS systems

must be custom developed to customize the needs of the organization. (RTLS Solution

Comparison, n.d.)

The last consideration for RTLS is the combination of technology and people to

guarantee highest productivity and reduce redundancies and “busy” work. (Critical

Considerations for RTLS in Healthcare, n.d)

Although both the UHF RFID and RTLs provide many of the same features that

the barcode system does, the costs associated with the alternatives do not align with the

goals and objectives of CMH. Figure 1 gives a breakdown on the cost of each product,

visibility frequency, and the ideal environment that each product has.

Harleen Kaur

Why CMH needs Barcoding?

Medication management is a complex process, which involves numerous steps,

including: prescribing, transcribing, dispensing, and administration. Medication data was

extracted directly from the SaaS database used at the CMH and exported in Microsoft

Access 2000 format. A quantitative analysis will be performed to examine where in the

medication process the error occurred (prescribing, transcribing, dispensing,


administering, monitoring), and the disciplines involved (physicians, pharmacists,

nurses). An analysis of medication errors revealed that around 38% of errors in our

system occurred around the medication administration phase.

A large sum of money is lost because of the medication errors at the CMH. The

records revealed the occurrence rate of 650 adverse drug events per year. Last year, more

than 2 million dollars were spent on the medication error issue. The analysis of the issue

showed nursing was the number one discipline involved in the error process. Further

analysis showed that these errors could be avoided if intercepted during the medication

administration process. Therefore, bringing the Barcoding medication administration

(BCMA) technology to the CHM is critically important. The introduction of BCMA

fulfills the AIM of CMH of expanding the efficiency of the healthcare operations.

Project fit

The BCMA technology can help CMH to expand the domains in forming more

integrated healthcare delivery system. The functionalities (physicians, nurses, and

pharmacists) involved in the drug administration process can interact efficiently with this

technology. Drug administering is greatly “influenced by the efficiency of the

communication, coordination and cooperation (C3) between the functionalities”. (Duffy,

2009) Before implementation of BCMA, a work analysis will be conducted to obtain an

understanding of the work processes between nurses, physicians, and pharmacists.

With Barcoding, the dispensing and administration errors will significantly

decrease. There is growing body of evidence demonstrating a 54-87% reduction in errors

using BCMA. (Agrawal, 2009) With this project we will get closer to our organization’s

goal of forming a safer environment for patients by having a more integrated delivery


system. We will also have increased revenue by losing less money on the adverse drug

administration issue, which we are facing right now.

Pilot testing

The introduction of the new technology can be intimidating for the stakeholders

involved in the process. To reduce the unexpected outcomes and concerns regarding the

new introduction of BCMA, a pilot implementation will be conducted on a smaller unit.

This implementation will be carried out for three weeks on ten beds before it is rolled out

to the whole hospital. During this time, special attention will be paid to glitches faced by

the staff using the technology, and proper steps would be put in place to ensure that full

technical support is available. After the staff is satisfied with the new workflow, the

technology will be expanded to other units of CMH.

Implementation Process

The implementation process will be carried out in five phases. Phase one will be

planning where a multidisciplinary steering committee will be formed with heads from

the pharmacy, IT, nursing, and admitting departments. They will meet biweekly for the

duration of the project to provide strategic direction, make key decisions, and resolve

project issues. Phase II will consist of design and quality assurance. During this phase the

planning activities and system specifications will be gathered and the BCMA software

application will be configured. Phase three will be about training. A 10-hour training

session will be provided to unit staff before unit’s go-live. It will be focused on new

technology adoption, including ample practice time using the new scanners on

medications and wristbands. Phase four will be going live with BCMA. New technology

will be implemented in all inpatient units and seven other specialties associated with


CMH. To help stakeholders with the new onset, on-site go-live support will be provided

for at least one week on each unit for 24 hours/day. Phase five will be post

implementation monitoring. Case studies have shown that this is an integral part of the

implementation process. During this phase, evaluations about the Barcoding will be

carried out, and new issues like wrong drug, wrong patient, or wrong form used will be

cited. (Agrawal & Glasser, 2009)

Workflow

With BCMA technology, CMH will we be required to follow a new workflow.

When administering the medicine to patients, nurses will be required to scan both the

patient identification bracelet and the medication being administered at the point-of-care.

This workflow would include issues such as “charting in patient’s rooms, downtime

procedures, and procedures for ensuring the ‘Five Rights’”. (Agrawal & Glasser, 2009)

With time there might be a need to modify additional policies concerning how and when

scanners should and should not be used.

BCMA will be a big step towards forming a complete, closed-loop medication

management system. With this loop, we would be able to offer a safe administration of

medications to patients. As explained by Fruzsina, one of the directors at LMC, “The

closed-loop system requires four things: an active medication order; an electronically

identified provider (nurse); a bar-coded drug; and an electronically identified patient”.

(Pataky, 2014) In this system, clinicians will be able to receive and review orders online,

and the relevant information will be documented seamlessly.


Addressing the Constraints

Special measure will be taken to ensure that all the constraints are addressed and fully

resolved. To address the issues regarding the safety and processing of this technology,

prospective hazard analysis will be used. During this analysis, the risk factors of the

system, devices and the process will be monitored. Predictions will be made for all the

possible ways in which failure can occur, and areas where improvement can occur will be

closely evaluated. A rating system will be formed to identify and rank the hazards on

seriousness levels. This table shows some of the expected constraints and resolutions.


To address the issue of BCMA network failure, special procedures will be developed. An

online help-desk system will be established to ensure timely communication between

nursing, pharmacy, IT, and the project management team. The issues such as unscannable

medications, hardware failure, or system enhancement requests will be addressed and

resolved timely. (Agarwal & Glasser, 2009)

PROPOSAL FOR BARCODING FOR MEDICATION 19

References

Susan Cody

Barcoding hospital data capture solutions. (“n.d.”). Retrieved from

http://www.barcoding.com/hospital-acute-care-facility-data-capture-solutions.shtml

Barlow, R. (2013, October). Raising the bar on tracking products, people, equipment.

Healthcare Purchasing News. Retrieved from http://www.hpnonline.com/inside/2013-

10/1310-PS-Barcode.html

Brusco, J. M. (2012, July). Incorporating barcoding into the perioperative setting. AORN

Journal, 96(1), 86-88. http://dx.doi.org/10.1016/j.aorn.2012.04.026

Cummings, J., Ratko, T., & Matuszewski, K. (2005, September/October). Barcoding to enhance

patient safety [Article]. Patient Safety & Quality Healthcare. Retrieved from

http://psqh.com/sepoct05/barcodingrfid1.html

Lan, M., Zhu, L., & Zhou, Q. (2013, February 19). Medication administration errors made by

nurses reflect the level of pharmacy administration and hospital information

infrastructure. Journal of Clinical Nursing, 23(5-6), 894-895.

http://dx.doi.org/10.1111/jocn.12495

Terresa Roulhac

Barcoding Sales and Inventory Control. (n.d.). Retrieved from: http://www.kcsi.ca/

barcoding_adv.html

Critical Considerations for RTLS in Healthcare. (n.d.) Retrieved from:

http://teletracking.h2web.com/rtls/rtls_overview/critical_considerations.html


Evans, K. (n.d.) What Does RFID Stand For? Retrieved from:

http://science.opposingviews.com/rfid-stand-for-18664.html

Intro to Real Time Locating Systems (RTLS). (n.d.). Retrieved from:

http://www.centrak.com/intro-to-rtls/

Nachtrieb, J. (2013). Raising the Bar on Barcode Risk. Retrieved from:

http://www.rmmagazine.com/2013/10/01/raising-the-bar-on-barcode-risk

RTLS Solution Comparison. (n.d.) Retrieved from:

http://store.abr.com/Solutions/RTLS/Comparison

SG20 Healthcare 2d Imager. (n.d.). Retrieved from:

http://www.intermec.com/products/SG20HPHC index.aspx

U.S. Food and Drug Administration. (n.d.) Retrieved from:

http://www.fda.gov/Radiation-EmittingProducts/RadiationSafety/

ElectromagneticCompatibilityEMC/ucm116647.htm

Wager, K., Lee, F., Glaser, J. (2013). Introduction to Health Care Information. In Healthcare

information systems: A practical approach for health care management (Third ed.). San

Francisco, CA: John Wiley & Sons

What is ASCII (American Standard Code for Information Interchange)? Definition from

WhatIs.com. (n.d.). Retrieved from: http://whatis.techtarget.com/definition/ASCII-

American-Standard-Code-for-Information-Interchange

Work, M. (2005). Improving Medication Safety with Wireless Mobile Barcode system in a

Community Hospital. Retrieved from: http://psqh.com/mayjun05/casestudy.html

Zebra HC100 Wristband Printer. (n.d.). Retrieved from:

http://www.barcodesinc.com/zebra/hc100.htm


Harleen Kaur

Agrawal, A. (2009). Medication errors: prevention using information technology

systems. British Journal of Clinical Pharmacology, 67(6), 681–686. doi:10.1111/j.1365-

2125.2009.03427.x

Agrawal, A., & Glasser, A. (2009, September 3). Barcode Medication. Retrieved May 28, 2015,

from http://www.himss.org/files/HIMSSorg/content/files/jhim/23-

4/JHIM_Fall_Agrawal.pdf

Duffy, V. (2009). Analyzing the Effects of a BCMA in Inter-Provider Communication. In Digital

human modeling second international conference, ICDHM 2009, held as part of HCI

International 2009, San Diego, CA, USA, July 19-24, 2009 ; proceedings (p. 749). Berlin:

Springer

Pataky, F. (2014, July 3). Closed Loop Medication Management for the Safety Win. Retrieved

May 30, 2015, from http://cstproject.ca/news/closed-loop-medication-management-

safety-win

http://cstproject.ca/news/closed-loop-medication-management-

http://www.himss.org/files/HIMSSorg/content/files/jhim/23-


Appendix

Figure 1.

The Costs of the Alternative sytems would have a negative impact due to the increase in cost that CMH

would gain.

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