Patient Safety Concerns Could Spur Bar Code Adoption

Christine Wiebe

Disclosures

August 22, 2002

More than a decade ago, a nurse from Topeka, Kansas, rented a car and was struck by how efficient the process was. The agent scanned a bar code on Sue Kinnick's rental agreement, then took her to the car and scanned another code there. The transaction was complete in a few simple steps.

She thought, "If they can do this with cars, we can do this with medicine." When Ms. Kinnick returned to work at the Eastern Kansas Veterans Affairs (VA) Medical Center, she convinced administrators that a hospital bar-code system would streamline the process for delivering prescription drugs to patients and reduce medical errors. Pharmacists there worked with Ms. Kinnick, now deceased, to develop a prototype that eventually was adopted by the entire VA system and now is being studied closely by private hospitals as well.

On August 13, for example, Sutter Health Network, a large not-for-profit hospital system in northern California, unveiled a $50 million patient safety project that includes a bar-code system for medication delivery and bedside computers that will be used at the 26 hospitals to scan codes that keep track of patients' medication and dosing information.

Bar-code technology -- a familiar sight in supermarkets across the country -- is used in many industries to manage inventory and document transactions. Yet, it still is relatively rare in healthcare. Analysts say that drug companies have been reluctant to label products with bar codes until more hospitals have scanners to read the codes, and hospitals have been waiting to invest in scanning technology until more coded products are available.

Uniform Labeling in the Offing?

Now, the federal government is considering a requirement that would end the waiting game and produce uniform labeling across the entire healthcare industry.

Patient safety is a driving force. The federal government estimates that 770,000 medication errors occur each year in US hospitals, a number that could be reduced significantly with the widespread use of bar coding.

At the Topeka VA hospital, errors involving the wrong medication or dosage have been cut by two thirds. Errors involving the wrong patient or the wrong time for a medication to be given have been reduced by more than 90%.

"We know that it works," said Michael Cohen, President of the Institute for Safe Medication Practices (ISMP), a nonprofit research group that advocates for patient safety.

This is how it works: Hospital patients are given a bar-coded wristband. When a nurse scans the wristband with a handheld device, patient information appears on a portable laptop computer, listing the patient's prescribed medications and any drug allergies or other relevant health information. The nurse then scans the bar code on an individual drug dose, and an alert appears on the screen if the medicine, dosage, or timing is wrong.

"When you scan a medication at the bedside, not only are you assuring that the right medication is getting to the right patient at the right time, but you're also documenting exactly what was given," said Cohen. "Bar-coded systems can even tell you what wasn't given that should have been given.

"It really, really helps to reduce medication errors."

Blazing the Trail

Once the Topeka VA project caught the attention of national VA administrators, plans were developed to get the entire network up to speed, said Jeff Ramirez, PharmD, Chief of Management and Clinical Information Systems for the Veterans Health Administration, a division of the US Department of Veterans Affairs. No commercial system was available in the mid 1990s, he said, so the VA developed its own software for reading, analyzing, and storing all the bar-coded information.

VA medical center pharmacies have been following the lead of the Topeka office in repackaging and labeling products that arrive without a bar-coded label. Implementation has been incremental, Ramirez said. By the summer of 2000, nearly all the hospital beds in the national VA system were covered by the bar-coding system. Initially, only oral and injectible drugs were included in the bar-code program, but a recently released software version includes packaging for intravenous drugs.

Individual medical centers have kept their own data about the financial investments and the outcomes involved with installing bar coding, Ramirez said, so no figures are available yet to determine the economic return nationwide.

"It's hard to quantify how many hospitalizations were averted," he said, for example. If every medical center avoids even 1 hospitalization a week by preventing a medication error, he said, the savings would be significant.

Nurses who use the computerized system have grown accustomed to the pop-up window warnings or the big "X" that appears on their computer screen if the wrong drug or dosage is about to be administered. Grievous errors are less common than those related to timing, said Joyce Green, a nurse manager at the North Chicago VA Medical Center, because nurses sometimes are unable to deliver a medication within the window of time allotted by the computer program. When that happens, the computer lets them know.

"It's valuable to the nursing staff when that happens," she said, adding that nurses tend to view the alerts as reminders, not alarms. Reminders to give the right number of pills, for instance, have eliminated the problem of "leftovers" at the end of a shift, she said.

Helping the nursing staff view the bar-code system as an asset rather than a hassle also took some time and education.

"There was a lot of resistance initially," Green recalled. Scanning each medication makes the dispensing process longer for nurses already under time constraints. But when they saw reports that medication errors were being reduced, most nurses were convinced.

"We've come to appreciate the benefits of the system when it comes to the safety of our patients," Green said.

Hurdles Remain

As obvious as it may seem to incorporate bar coding into healthcare systems, some barriers remain. For instance, a recently launched patient safety program does not even mention bar coding as one of its goals.

"We really looked for areas that would have the greatest impact on strengthening medication safety and that were implementable," said Kathryn Pelczarski, Associate Director of the health systems group for ECRI, a nonprofit health research agency. She helped design a patient safety program for a coalition of hospitals in southeastern Pennsylvania.

"Conceptually, there is tremendous merit to the idea of bar coding," she said. But project leaders decided not to include it because of difficulties with implementing it at this time.

"This technology works best with a unit dose concept," she explained, "and not all medications are available in unit dose form or have bar codes." Many drugs are shipped in bulk packages from the manufacturer to pharmacies, where they are divided into individual or "unit" doses. Most pharmacies are not equipped to bar code unit doses themselves, she added.

This barrier to acceptance is further complicated by drug manufacturers' recent trend toward packaging their products in bulk orders instead of unit dose packaging in order to cut costs, according to an ISMP study.

Another barrier is the general resistance to new technologies at healthcare institutions. Many healthcare providers feel that drastic changes interfere with their ability to provide quality patient care.

"This is a huge culture change," said VA official Ramirez. "Nurses are used to doing things on paper." Pushing around laptops on carts and scanning patient wristbands was a radical concept at first.

The success of new technologies is heavily dependent on integration with established practices, appropriate education and training, and wide acceptance within the organization, Ramirez said. "For an institution to do this, you have to really have a commitment."

Tracing Medication Pathways

In addition to catching potential errors at the bedside, bar coding offers broader patient safety benefits from the information that is collected.

"There are a lot of things you can learn by analyzing the process," said Ramirez. For instance, if nurses on a particular hospital ward consistently give medications later than prescribed, it may indicate a need for better staffing, he said.

In one case, the rate of late medications dropped significantly when a nurse went on vacation, then went up again when she returned, he said. That signaled a need for supervisors to focus their educational efforts on that one individual.

In general, however, advocates of bar coding insist that the information should be used for quality improvements and not for punitive actions.

"We want to use this as a learning tool so we can improve our patient practices," said nurse manager Green.

In fact, sometimes a recurring problem helps uncover other related issues. If a patient routinely requests medication before the prescribed time, for instance, it may signal a need for the prescription to be changed, she said, or for the patient to be counseled about the prescribed therapy.

Pressing Forward

The full benefits of bar coding will not be realized until the entire healthcare industry participates, said Chris Tucker, Pharmacy Systems Manager at the Topeka VA Medical Center. He helped design the software now used throughout the VA network and has witnessed its evolution and success. But he still encounters problems with packaging and labeling that could be overcome with uniform standards.

In July, the Food and Drug Administration held a public hearing about a proposed rule requiring bar codes on drugs. Hospital groups and patient safety advocates urged the agency to move quickly in passing the rule, which has been bandied about for over a year.

Pharmaceutical trade groups have expressed concern about the costs of installing bar-coding systems, but many individual drug companies already are committed to the idea, said the ISMP's Cohen. "It's true it's going to cost them more money, but many of them realize they have a responsibility here," he said.

The market eventually will dictate bar coding as more and more large organizations install their own systems, he said. Government intervention could speed the process, however, and reassure hospital and drug company executives that their efforts will pay off in the long run.

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