Bar-Code Medication Administration: A Systems Perspective

Ronald Schneider, B.S.Pharm., M.H.A.; Jonathan Bagby, R.N., M.B.A., M.S.N.; Russ Carlson, R.N., B.S.N., M.H.A.

Disclosures

Am J Health Syst Pharm. 2008;65(23):2216-2219. 

In 1994, inspiration came to a nurse from the Colmery-O'Neil Veterans Affairs Medical Center (VAMC) in Topeka, Kansas. She noticed the bar code that a rental car company used to track vehicles and surmised that similarly applied bar-code scanning technology could enhance patient safety by reducing medication errors through a series of electronic checks and balances that would augment, but not replace, a nurse's clinical judgment. A prototype system was developed at the Colmery-O'Neil VAMC and later became the model for the award-winning bar-code medication administration (BCMA) system used throughout the Veterans Affairs (VA) health care system beginning in 1999. By 2003, throughout the VA health care system, all inpatient care areas were consistently using positive patient identification at the point of care to document activities associated with medication administration through the use of BCMA. VA administers over 600,000 medication doses daily through BCMA. Over 1 billion doses have been administered in the VA health system since 1999 through the automated monitoring system.

VA has developed an integrated electronic health record via the computerized patient record system (CPRS). It enables clinicians to enter, review, and continuously update all order-related information connected to any patient. Within the CPRS, a clinician can order laboratory tests, medications, diets, and radiology tests and procedures; record a patient's allergies or adverse reactions to medications; request and track consults; enter progress notes, diagnoses, and treatments for each encounter; and enter discharge summaries.

BCMA is an integral part of the electronic health record. Nurses administer all medications, including i.v. piggy-back medications and i.v. large-volume medications, through BCMA. All information is documented with a time stamp for improved accuracy of clinical information. The documented administration information is available throughout the medical center to any clinician or pharmacist as part of the integrated health record. This information is also available to all VAMCs nationwide if a veteran needs medical care outside of his or her usual VAMC.

In 2003, the BCMA Program Office was established to plan strategic direction, to facilitate quality-control reporting, and to serve as the liaison between VA facilities and other stakeholders. The BCMA Program Office has been renamed the Bar-Code Resource Office (BCRO) to emphasize the importance of point-of-care bar-code scanning technology in VA. The BCRO is aligned under the Veterans Health Administration's (VHA's) Office of Information and Chief Health Informatics Office. An intranet website, quarterly newsletters, and biweekly conference calls serve as communication tools to aide in the mission of the BCRO. Training updates on software enhancements as well as training aides developed by VHA field "superusers" are presented on the conference calls and made available on the intranet site. The training is a collaborative effort; each facility does not have to develop its own training materials. An annual face-to-face conference brings BCMA facility staff together to learn about quality-improvement techniques, lessons learned, and evidence-based best practices to improve veteran patient safety.

In 2004, two bar-code verification laboratories were established by the BCRO. VA facilities send problematic bar-coded products to either of the verification laboratories. The bar codes are run through the verification process to verify that the bar-code print quality meets American National Standards Institute (ANSI) and International Organization for Standardization (ISO) bar-code print-quality criteria. ANSI and ISO standards use a grading system of A through F for bar-code verification tests, with A being the best possible bar-code quality and F being the worst. All bar codes are compared to nine international parameters. A failure in any one of these parameters leads to a bar-code failure. Acceptable industry standards for bar-code verification grades is C target A (i.e., grade C is acceptable but grade A is preferred).

A program was developed to track bar codes tested and scored by the verification laboratories. A database tracks all problematic bar-coded products–a manufacturer's bar-coded product or a bar code that is generated within VA such as i.v. labels, wristbands, or automated packaging products–and trends the results of bar-code verification testing. If a manufacturer's bar-code verification results in a grade D or F, both a letter and the bar-coded product are sent to the manufacturer requesting help to resolve the issue. This information is also sent to the VA National Acquisition Board, VA Pharmacy Benefits Management, Food and Drug Administration, and Global Standards 1. If a VA-produced, bar-coded product grades D or F, recommendations are sent to the facility to help resolve the print-quality issue. This program has led to modifications in print quality and more reliable scanning of bar-coded products. Another direct result of this program is a bar-code quality clause which has been written into all VA medication purchase agreements. All products purchased as part of the VA national purchasing agreement must be grade C target A.

Although a number of scanning failure points exists within a BCMA system, patient wristbands are the first failure point. In May 2005, an annual wristband media and printer combination survey was conducted by the BCRO. Each VAMC provided wristbands to the BCRO for evaluation. The results of the survey provided VA, for the first time, a means to identify combinations of products resulting in the most reliable and durable wristbands. As an end result of this survey and additional market research, wristband and printer guidelines were developed to determine "best in breed products" to be used in VA. These findings led to VA Directive 2006–069, "Purchasing Bar Code Scanners, Wristband Printers, and Wristband Print Media for Use with Bar Code Clinical Application Software." This required that all BCMA scanners, wristband print media, and wristband printers be purchased from a BCRO-approved list, which resulted in a level of equipment standardization for BCMA that was unavailable in its early years of implementation.

In February 2005, VA's undersecretary for health approved the roles and responsibilities used to establish a BCMA coordinator staff position at each VA facility. The BCMA coordinator is the primary point of contact for all BCMA-related issues at the facility and functions as a liaison among the local facilities, the BCRO, VAMC staff, and VA central office leadership. Approximately 14% of the BCMA coordinators are pharmacists. The majority of the remaining coordinators are nurses.

VA facilities created a BCMA multidisciplinary committee to meet at least once a month. The multidisciplinary approach to BCMA has been stressed since the use of BCMA in VA. This committee provides advice and guidance for the facility's management of BCMA and related medication processes, creating accountability and an ownership approach to using, assessing, and trending BCMA and standardizing clinical, technical, and operational direction. The committee also recommends policy and procedural changes to optimize BCMA use and plans for enhancements and future direction of BCMA.

VA Directive 2006–008, "Quality Directive for Unit Dose Packaging and Bar Code Labeling," established guidelines for testing bar-coded products before they leave the pharmacy and for observing the scanning of medications at the point of care. There are five monitors that directly involve pharmacy monitoring of the bar-code quality for medications. Quarterly reporting of bar-coded products held facilities to a 95% scan-success for each monitor. All manufacturers' bar-coded products are scanned into the synonym field of a drug file database to ensure that the bar code is in the system and that there are no improper entries. A sample of five products per day from manufacturers' products is scanned daily to ensure that no products have been missed. All controlled substances' bar codes are required to be scanned every quarter. Whenever a roll of labels is changed or any adjustment to the printer is made, three i.v. labels are scanned into Word or Notepad from each batch that is run daily. This helps to identify when a print-quality issue has occurred. When a print head has a bad element, many times it is not obvious by looking at the label. The same procedure is done for any repackaging machines or relabeling machines that the pharmacy may use. The emphasis of this directive was for the pharmacy to develop and maintain a quality-control program. The pharmacy's work should reduce the number of products that do not scan at the point of care. If the medications can be eliminated as a source of problematic bar codes, then other factors can be evaluated, such as wireless dead spots, faulty equipment, or user problems.

In order to improve software and hardware interaction by the end user, the BCRO became the first VA program office to staff a full-time human factors engineer. Human factors engineering improves the design of tools and processes so that they fit the capabilities and limitations of people in the context of the work they are performing. User-centered and human factors-related activities in support of BCMA include usability testing of software enhancements, analysis of work that influences software and hardware design, and methods introduced to the facilities to improve the assessment of computerized medication carts and other equipment to bring point-of-care technologies to the bedside for BCMA with the primary focus on patient safety.

What started as one person's dream is now an integrated and widely accepted process throughout VA, with the goal of improving patient safety and reducing medication errors. A multidisciplinary approach to the implementation and upgrades of the BCMA system was extremely important in its success and acceptability within VAMCs. VA is now standardizing processes to improve BCMA clinical business practices by requiring facilities to check and validate bar-coded products before they reach the point of care and working with manufacturers and other agencies to improve the bar codes on products used in all VAMCs.

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