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The DoseEdge Pharmacy Workflow Manager, formerly IntelliFlowRx Workload Management Software by Baxa, is a system designed to track and manage intravenous (IV) medication dosages prepared by pharmacy personnel in a clean room environment. The system is touted as “The world’s first and only fully integrated workflow manager for the IV room.”

The system is designed to flow something like this:

- IV medication orders entered by the pharmacist, or other healthcare professional, are sent to the DoseEdge system where they appear on the DoseEdge touchscreen.
- When the technician, or pharmacist in some cases, accesses the order via the touchscreen instructions for preparation of the product are displayed.
- The product label is generated.
- The barcode on each injectable ingredient used for the preparation of the IV product is scanned to ensure the correct medications have been selected. Items identified as incorrect result in an audible message of “product not allowed for this dose.”
- The barcode on the IV product label generated by the pharmacy is scanned to ensure that ingredients are appropriately matched.
- Each ingredient is drawn into a syringe.
- An image of the syringe with appropriately drawn medication is taken for review by the pharmacist, or technician, whichever the case may be. This is a nice feature as it allows one to see the actual amount of drug drawn into the syringe prior to shooting it into the fluid bag.
- Ingredients are injected into the fluid bag and an image of the final product is taken.
- A final scan of the product barcode is done to complete the fill.

Part of the process of implementing barcode medication administration (BCMA) is evaluating hardware; mostly scanners. There are several makers of barcode scanners including Honeywell, Symbol, Metrologic, Datalogic and Code Corp. Having so many choices always makes the selection process interesting.

One suggestion from several hospitals I spoke with that were already live with BCMA, was to use the same barcode scanner on the nursing floors that were used in the pharmacy. That sounds logical, right? Sure, if the barcode scans correctly in the pharmacy, then nursing should be able to scan the same barcode using the same scanner.

The scanner of choice in our pharmacy department is the the Code Reader 3500 from Code Corp. So of course this is the scanner I recommended in my report to the BCMA hardware sub-committee. For whatever reason, the committee decided to go with a different brand of scanner. Unfortunately the scanners we purchased won’t scan some of the more complex barcodes coming out of pharmacy, making them virtually useless. The scanners purchased by the hospital are on their way back to the wholesaler as I patiently await for round two.

Take away lesson: use the same barcode scanner for the nursing units that the pharmacy department uses to meet their barcoding needs.

This week's Cool Technology for Pharmacy is the OnDemand 400 for RxMap from MTS, a company that specializes in adherence packaging systems.

According to the MTS website:

OnDemand ® 400 for RxMap ® is the first pharmacy automation equipment system designed specifically for multi-med adherence packaging.

This efficient system uses OnDemand technology to dispense multiple medications for a single patient quickly and accurately and in a fraction of the time it would take to do it manually. This pharmacy automation equipment system utilizes a custom interface to work with your existing information systems, enabling automated workflow management in the pharmacy. This single data input process reduces input time and the possibility of data entry errors. OnDemand ® 400 for RxMap ® uses bar-code technology to accurately dispense multiple medications into one compartment - as many or as few as needed. RxMap ® Adherence Packs vary in size and shape to meet the needs of the customers you serve. The finished product is a patient - specific adherence package filled “just-in-time” for your customer.

Actor Dennis Quaid gave the key note at the recent ASHP Midyear Clinical Meeting.   Initially I found it to be fantastic presentation.  Shortly after I felt cheated and conflicted.  Soon after the speech I ran into some folks that knew a lot of about the specific incident that brought Mr. Quaid to speak to the pharmacists organizations.  It turns out that he either took artistic license to embellish his presentation or out right lied about the details of the tragic medical error.   Either way, my respect for him was crushed.

His new born twins were victims of an awful medication error.  While the twins survived and are fine now, it was a horrible error.  This blog post does not mean to minimize the error.  As a father of twins, I was close to tears during the speech, and can not even imagine the emotional toll it must have had on him.

Mr. Quaid could have taken the large settlement from the hospital and rode into the sunset.  Instead he works to help bring attention to the issue of medication errors.  For that he is to be commended.   So why he would make up aspects of the incident is perplexing and disturbing.  I trust my sources of the details of the incident completely, therefore, believe them and not the details that Mr. Quaid recounted.  So here are some positive and negative specifics and selected commentary of the speech.

The complete speech can be downloaded here.
http://www.ashp.org/DocLibrary/MCM09/MCM2009-Dennis-Quaid.aspx

“You may have a nagging question – why is he here? He is not a pharmacist…he is an actor.”

In the December 2009 issue of The Joint Commission Journal on Quality and Patient Safety, there will be an interesting article on some extraordinary results in decreasing medication administration errors.

A coalition of 9 hospitals implemented best practices for medication administration reporting an astonishing 88% [link] reduction in medication errors.  These best practices did not include bar code medication administration (see listing below). 

So my question and challenge is why are so many hospitals spending millions on BCMA instead of implementing these ‘best practices” first?

Adherence to these best practices decreased medication errors more than the reported literature of BCMA and for far less time and money (speculation).

The ultimate study would be to compare an implementation of these best practices with BCMA.  Who is up for that?

This quote is telling:  The solutions "have to be low tech because we, as staff nurses, don't have the money or ability to make high-tech changes," said Celeste Arbis, a registered nurse in the medical-surgical unit there (UCSF). "Something as simple as changing the process just a little bit can make a big difference." [Link]

CalNOC (the California Nursing Outcomes Coalition) “best practices” for medication administration: 1. Compare medication to medical record 2. Keep medication labeled until administration < 3. Check two forms of patient identification 4. Immediately record medication administration in chart 5. Explain the medication to the patient 6. Minimize distractions and disruptions during the administration process  

"With the American Recovery and Reinvestment Act earmarking billions of dollars for healthcare information technology adoption, the phrase meaningful use is echoing through hospital hallways across the country. Federal funding and looming penalties provide added incentives to the already urgent need for hospitals to adopt meaningful-use of automated-medication administration technology. Will your hospital be ready by 2013?"

My point is that Barcoding is NOT mentioned nor required for meaningful use.  The wording from the Office of the National Coordinator for HIT is “Conduct closed loop medication management, including eMAR and Computer-assisted administration”. (2013)"   While this might include bar code medication administration (BCMA) but I do not read into this that it must.  The studies on BCMA fall way short of best practice, IMHO.

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Jerry Fahrni » A failure modes and effects analysis on bar code medication administration

Jerry has a wonderful post regarding a failure mode for BCMA. This is the first I have seen from a pharmacy perspective. With regards to data management, I am already seeing the benefits from a small pilot with my institution. We get data by unit, by user, time of day, and most importantly medication. We can quickly identify which users need more training, and which medication barcodes need to be reviewed by the pharmacy.

A few points I will take back to my facility:

1. Different audible warnings for a good vs. bad scan.

2. Ensure post live training is available for nurses that need a little extra help, and make sure they can play with the devices they are expected to use.

Unlike pharmacists, nurses have not used computers extensively in the workplace. We should be able to help them understand more about these new devices in the hospital, and how best to learn their value.

The Office of the National Coordinator for Health Information Technology really listens to reasonable comments.  Here is Exhibit A.

One of my comments from the June 16^th round of input was as follows:

Conduct medication administration using bar coding – This objective should not be included until the benefit of bar-code medication administration (BCMA) technology is proven to promote safe and efficient care to patients.  The Committee should consider replacing this 2013 objective with “documenting medication administration with an electronic medication administration record (eMar).” 

Bar-coded medication systems reduce pharmacy dispensing errors.  However, the evidence to date does not suggest that such systems are as effective in reducing administration errors due to design and implementation faults and resulting staff workarounds that mitigate the efficacy of barcoding.  If evidence is produced in the near future to support the claim that BCMA is safe and efficient, this would support the inclusion of BCMA in the 2015 objectives.

The changes they made are:

Meaningful Use Matrix of June 16th

“Conduct medication administration using bar coding”

Changed to:

Matrix of July 16, 2009:

“Conduct closed loop medication management, including eMAR and Computer-assisted administration”.

As part of a wider effort the VA is halting 45 IT projects.  Ouch.   The Department of Veterans Affairs (VA) announced last week plans to temporarily halt 45 IT projects that are either behind schedule or over budget to assess whether the VA should continue pursuing them.

Below are the pharmacy projects on the chopping block.  It would be really great if someone from the VA could give us a perspective.  Please post a comment on the ASHP list serv or at http://rxinformatics.com (anonymously if needed).  That would be really great.

Below is a pharmacy related list of projects temporarily halted (site reference):

·       Pharmacy Re-Engineering Pre .5

·       Pharmacy Re-Engineering Pre1.0

·       Barcode Expansion

·       BCMA Inpatient Medication Request for SFG IRA

·       Problem List Standardization

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Computerized Order Entry
Karl F. Gumpper and William A. Zellmer
[Extract] [Full Text] [PDF] [Reprints & Permissions]   
       

        Computerized Order Entry: The Authors Respond
Jos Aarts and Ross Koppel
[Extract] [Full Text] [PDF] [Reprints & Permissions]   

"We agree that bar-coded medication administration systems will reduce pharmacy dispensing errors. However, the evidence to date does not suggest that such systems are as effective in reducing administration errors because of design and implementation faults and the resulting staff workarounds that mitigate the efficacy of bar-coding."  [Uh, ya!]

In a reasonably good observational study in the July 1, 2009 AJHP, there is an inappropriate statement and study used to justify it.  While it maybe conventional wisdom, it ain’t so.

This is a landmark study on bar code medication administration systems. Take a look. The authors do a good job in writing this up and is well worth the read. http://www.ajhp.org/cgi/content/abstract/66/12/1110

Some new BCMA reference to review.  More analysis to come.

Effect of bar-code-assisted medication administration on medication error rates in an adult medical intensive care unit  Jaculin L. DeYoung, Marie E. VanderKooi, and Jeffrey F. Barletta

Am J Health Syst Pharm 2009;66 1110-1115
http://www.ajhp.org/cgi/content/abstract/66/12/1110

Quality-monitoring program for bar-code-assisted medication administration

Elizabeth Mims, Chris Tucker, Russ Carlson, Ron Schneider, and Jonathan Bagby

Am J Health Syst Pharm 2009;66 1125-1131
http://www.ajhp.org/cgi/content/abstract/66/12/1125

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The blog post below from the NYTimes below is outstanding. I also believe that is the current state of Bar Code Medication Administration (BCMA) Practice.  Of course this practice makes sense, there is just zero evidence that it works.  The pharmacy profession is drunk with the notion that BCMA works for patient safety, in the face of little to no evidence.  While this may change with better study, read on.Same type of phenomenon is articulated in this brillant piece on medical treatments.http://well.blogs.nytimes.com/2009/04/02/the-ideology-of-health-care/ April 2, 2009, 10:46 am — Updated: 1:36 pm --> Believing in Treatments That Don’t Work

As Washington debates health care reform, emergency room physician Dr. David H. Newman explores how medical ideology often gets in the way of evidence-based medicine.

By David H. Newman, M.D.

In the early throes of a heart attack, caused by an abruptly clotted artery, the stunned heart often beats quickly and forcefully. For decades doctors have administered “beta-blockers” as a remedy, to reduce consumption of limited oxygen supplies by calming and slowing the straining heart. Giving these drugs in the early stages of a heart attack represents elegant medical ideology.

But it doesn’t work.