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Since the industry-wide wake-up call prompted by the Institute of Medicine's landmark report To Err Is Human (2000) and the follow-up report Preventing Medication Errors (2006), patient safety has become one of the foremost concerns in healthcare, with the prevention of medication errors in acute care settings as a key priority. In seeking solutions for medication errors, experts in the healthcare field such as David Bates, MD, PhD, recommend healthcare professionals focus their efforts in certain key areas. While CPOE is often mentioned as the top priority in preventing medication errors, many hospitals have found it difficult to adopt. Stillwater Medical Center implemented a BPOC system with hardware that was custom-designed for a nurse's use. Adoption rates of BPOC systems are also increasing, but not all installations have been successful. Bonnie Peterson, vice president of patient services at Stillwater Medical Center in Stillwater, Oklahoma, stated, "We looked at BPOC systems based on the COW model, and immediately knew this was not the right choice for our nurses. Marc Rafferty, pharmacy manager at Jane Phillips Medical Center, a 144-bed hospital in Bartlesville, Oklahoma, stated, "Preparation for a BPOC System requires careful planning. As these challenges are coming into focus, the evolution of BPOC systems appears to be on the verge of a renaissance of sorts. Changes are also occurring on the hardware side, with a new generation of technology that addresses the unique needs of caregivers at the bedside. In any hospital setting, a successful implementation of a patient safety technology at the point of care or BPOC, requires a champion for the technology within the organization. Nurse managers are often the first to appreciate the ramifications of improved safety measures at the bedside, and are the first to recommend point-of-care technology for medication administration.
Eileen Dennis, chief nursing officer at Parkview Medical Center in Pueblo, Colorado, said, "We first looked at a patient safety solution, not because we thought we had a problem per se, but out of a desire to give the very best care to patients in our community.
Nurses at Jane Phillips Medical Center use a handheld BPOC system to verify medication administration at the patient's bedside. However, in order to gain advocates on a hospital-wide basis, Dennis found she needed to engage her entire nursing staff, work closely with the hospital pharmacy staff to accommodate their needs, and build enthusiasm for increasing the use of technology to enhance patient care and reduce costs caused by ADEs. The fact is, implementing a safety check for medication administration adds another step in a nurse's busy day. Nurses have expressed their dissatisfaction with consumer-style PDAs or big, bulky electronic devices. Nurses are often the first to admit that they are not "techies," so the software that drives the device must be easy enough to use and intuitive to the daily routine.
For convenience and integrity of process, make sure that the system you deploy has one device for each clinician on shift who administers medications or takes lab specimens, and that the battery lasts for a whole 12-hour shift. Avoid duplication of data input by making sure your system seamlessly integrates eMAR with pharmacy and hospital-wide systems.
The next generation of BPOC systems needs to be designed with recognition of the vast workload that nurses encounter in an average day and integrate easily into the nurse's workflow from the beginning, decreasing the amount of time nurses spend on paperwork while improving safety at the bedside.
The use of a BPOC solution should create improvements in workflow and streamline ways for nurses to document medication administration, including the ability to create an eMAR that is seamlessly integrated into a pharmacy system, and automation of end-of-day charting requirements for medications delivered during the day. During medication administration, the handheld technology should guide the nurse through the process, receiving prompts and warnings as configured by the hospital's pharmacy. Under these best practices in point-of-care technology, nurses get more accomplished than just completing medication error checks, confirming the "Five Rights." They are also able to better organize their work while at the bedside.
Nurses frequently become strong advocates for BPOC technology once experiencing a "near-miss" error that was caught by the system.
However, even armed with all of the benefits that a point-of-care system provides to prevent medication errors, some hospitals will still face resistance from nurses. Dennis recently spearheaded a team at Parkview Medical Center in the implementation of a system, and acknowledged that not all nurses want to change.
In this new era where technology is available to hospitals to prevent many medication errors from occurring, it is not enough to create a tool or system that simply prevents errors. The best practices in second-generation point-of-care technology turn over a new leaf for hospital management. Furthermore, if the tool improves patient care and patient safety while actually streamlining the nurse's workflow, it becomes dramatically easier to demonstrate the advantage of the tool to nurses and paves the way for high levels of compliance.
Many first-generation systems have also hit roadblocks in adoption because they have not addressed the intricate relationships between teams in the hospital. Pharmacists are understandably anxious about what instituting a new system will mean for their work.
When installing a point-of-care system in a hospital, it is likely that 50% to 60% of the initial work will fall on the pharmacy. Pharmacists not only must label each of these medications, but also streamline and revise their computer order entry of medications to be compatible with the new system. Rafferty reports improved documentation for hospital pharmacists, as their BPOC documents complex medication administration information, including near-miss data configurable by patient, time, user, and medication.
Additionally, specialized reports reconcile medications administered prior to pharmacy review and order entry with subsequently received medication orders. For example, a hospital pharmacist may enter a patient's aspirin order for twice a day, and arrange for it to be administered at 9 a.m. Bonnie Peterson at Stillwater Medical Center said, "The use of our BPOC has really supported our efforts to improve the relationship between nursing and pharmacy. This built-in tool for dialogue is so important when it comes to reducing medication errors, because both teams have distinct and critical roles when it comes to patient care and safety. Like hospital pharmacists, physicians appreciate the improved documentation that comes from second-generation BPOC systems, including a summary of medications in an eMAR right from the handheld device.


The healthcare industry is filled with skilled, dedicated, and compassionate professionals, all of whom are deeply committed to the safety of their patients. Fortunately, as listed by David Bates, there are specific technologies that can be implemented to address these errors.
Medication errors are not a new phenomenon in healthcare, but they can now be effectively addressed and largely resolved through the use of available technology that can meet healthcare's demand for integrated, practical, and efficient solutions.
Dave Swenson has an extensive background in hospital pharmacy, having spent more than 15 years working in acute care settings, including the Swedish Hospital Medical Center in Seattle.
The reports estimate that at least 1.5 million preventable medication errors occur each year in the United States, many of which result in adverse drug events (ADEs). This has been due to several factors including the lack of support for change from physicians, complexity of the systems both to install and to use, and multiple other infrastructure enablers necessary to make CPOE work. CADM, in a limited form, has been a feature in most hospital pharmacy information systems for years; however, this functionality is now moving beyond pharmacy as a standard offering in CPOE and electronic health record (EHR) systems. The system has improved communication between nursing and pharmacy, and enhanced the level of patient care. According to the Cain Brothers research (2007), 14% of hospitals now have BPOC systems fully implemented, compared to just 5% three years ago.
Systems must be put in place not only to barcode those medications that lack a manufacturer barcode, but to capture new barcodes that enter our inventory supply in the daily deliveries from our distributors. This technology is coming in the form of hardware designed specifically to meet the workflow and ergonomic needs of nurses, so the devices are intuitive and easy to use, simplifying and improving the human-system interaction. Typically, the champion is serving a role in nursing or pharmacy management, but generally these individuals are characterized by their passion for patient safety and their dedication to both patients and hospital staff. If nursing finds a system with a device that they find effective and easy to use while allowing for more time with patients, they will become one of the most vocal champions for implementation. In addition to confirming the "Five Rights," this system streamlines workflow by organizing the necessary tasks at the bedside and automating end-of-day charting requirements. A system that is difficult to use and does not have buy-in from the nursing staff may cause workarounds and will eventually be discontinued. If the system that you deploy doesn't give back added benefits to nurses, that is, reduces effort and work in other tedious or time-consuming tasks, it will become a hindrance, not a help. Let the software easily prompt nurses through the safety check steps in medication administration. This allows for continuity and ease of use, as well as increased compliance and reporting capabilities. According to Rafferty, "In the first three weeks after going live, we prevented a number of possible medication errors." In one instance, a nurse picked up a patient's medications, only to have the handheld device alert her at the patient's bedside that the blood pressure (BP) medication was incorrect.
Yet, in order to create buy-in and enthusiasm for patient safety technologies at the point of care, hospital executives must take into consideration the daily routine and needs of clinicians using the tool. There should not be difficult or complicated software to learn; screens should be intuitive and in plain English.
If the system is intended to make the workflow easier for nurses, it should document information at the bedside, preferably using just one hand. However, once nurses using the system has a "near-miss moment," where the advantage of the system is made clear, they become passionate advocates for the technology.
Dennis said, "I can only engage my nurses if I institute a system and device that are reasonable to use.
There are major implications for how nurse managers are able to supervise their staff, including increased reporting capabilities and visibility into nursing metrics where there was little before, such as: Are medications being given on time? This is also significant for training nurses on the system, which becomes more straightforward and less time-consuming with a tool that is simple to use. Nurses are on the front lines of care at the bedside, and they certainly comprise an influential portion of users.
Often the pharmacy will ask, "How will the system affect computer order entry of medication orders?
For example, once a system is installed, every single medication that a nurse administers to a patient must be labeled and tracked with a barcode.
Because when a nurse identifies the patient at the bedside, the computer needs to be able to identify the medication, even if it is one of several generic equivalents stocked in the pharmacy. Medications and IV orders entered by pharmacists can be sent real-time to nurses carrying a wireless handheld device. Pharmacists also gain added confidence in that the handheld device carries caregiver-specific reminders for required tasks and prompts for required documentation. First-generation BPOC systems do not have an emphasis on synchronicity between teams, particularly nursing and pharmacy, which is vital in the hospital. We thought we had the same set of dosing schedules, but through this learned the two departments had different procedures and standards. The aspirin example, while relatively harmless, is representative of the countless decisions that are made throughout the day in the hospital that jointly involve pharmacy and nursing.
This in turn supports the hospital's needs in complying with JCAHO requirements, such as documenting pain scale after pain medication is administered, or blood pressure readings after administration of a blood pressure medication.
For BPOC, second-generation technology prevents medication errors while being highly usable for the clinician. Swenson's interest in improving patient safety motivated him to join Pyxis Corporation in 1990, where he shared responsibility for the launch of innovative medication and inventory management systems. Bates listed four specific modalities as key components in medication error prevention: computerized physician order entry (CPOE), IV administration "smart pumps," computerized adverse drug event monitoring (CADM), and barcode point of care (BPOC) medication safety systems.


However, Cain Brothers also reports that an additional 12% of hospitals have attempted installations that failed or remain incomplete. Louis, Missouri, tells of her experience purchasing a BPOC system: "After we bought the software from our HIS company, I asked about hardware. In a BPOC environment, all of these medications must have a barcode applied to each unit dose, ready to be scanned by the nurse at the bedside. UnSummit workshops allow those with successful BPOC implementations to share best practices regarding managing a barcoding program in the pharmacy, formulary management, and many other topics related to operating these essential technologies.
The technology can offer options for both barcode and RFID tag recognition, assuring both accuracy and the greatest comfort for patients.
No one will trust the information generated and therefore go to the trouble to keep the system up to date and working. And don't forget, the best systems are built to last despite routine abuse in hospital settings.
Don't be locked into one HIS vendor for an end-to-end solution, but rather pick the best solution for your hospital, as long as the vendor can assure integration.
In the brief period of time between obtaining the medication to entering the room, the doctor had written the order to stop the medication, the order was sent to the pharmacy, and the pharmacist had entered it into the system. If the tool adds more work and fails to streamline processes, it will likely be met with resistance. This configuration sets the stage for a host of clinical functions, including personalized reminders assuring documentation to hospital standards, in line with JCAHO requirements.
The handheld devices also should allow nurses to capture and document vital sign information. This has to be something that is practical to introduce into the nurse's everyday work." Part of the success of these second-generation solutions is that they offer tools easy enough to use that a hospital can hold nurses responsible for using it and following procedure. However, pharmacy plays an equally vital role in the care process, and the pharmacy's concerns and questions about how the system will affect their department must be carefully considered.
Each nurse's handheld receives the orders, along with configurable warnings and other clinical information. The best practices in second-generation technology not only recognize the needs of each team to allow them to work efficiently, but also provide for built-in dialogue between nursing and pharmacy, to get each team in sync and allow them to work more closely. However, the nurse may not agree, in that the patient may like to have the aspirin on the same schedule he or she adheres to at home, yet the nurse does not have a way to change the order. Where the first generation saw low rates of adoption, the second generation, representing improved technology for human-system interfaces, has seen momentum and acceptance by the healthcare industry. He is co-founder and COO of IntelliDOT Corporation, which is leading efforts in healthcare to facilitate the adoption of handheld, wireless, BPOC technologies, in order to prevent medication errors at the bedside, as well as improve workflow for nurses.
Cain Brothers' summary research report released following the 2007 Health Information Management System Society (HIMSS) meeting in New Orleans in March estimated that 27% of hospitals now have a computer order-entry system in operation for medication orders. The reply was, 'You can use any hardware you want.' This illustrates the usability problems with current first generation systems.
Thanks to the FDA rule passed in April 2006, all pharmaceuticals sold to hospitals must print a barcode on the smallest unit of measure — the size dispensed to the patient. Information can be seamlessly integrated with pharmacy systems, electronic medication administration records (eMAR), and hospital information systems, using an industry standard HL7 interface.
This does not refer to just the computer hardware, but to the human interaction with the system, which makes the system dynamic and viable. As the nurse prepared to administer the medication, the wireless handheld device alerted her that the BP medicine was no longer prescribed for that patient.
Likewise, nurse verification of pharmacy order entry allows nurses to double-check medication orders that were computer-entered by a hospital pharmacy.
The complexities of pharmacy order entry are a crucial part of enabling nurses to perform their tasks at the bedside. Despite the 2006 FDA ruling requiring barcodes on the smallest unit of measure, pharmacists still report that as many as 20% or more of drug stock requires supplemental barcoding.
Medications administered prior to pharmacy screening are checked for allergy and drug interactions using industry standard databases.
That is why Rafferty appreciates the nurse verification of pharmacy order entry feature on his hospital's BPOC system.
Nurses often report that traditional BPOC systems based on off-the-shelf wireless PDAs or a computer on wheels (COWs) are difficult to use. Despite the ruling, pharmacists still report that 30% or more of their drug stock requires supplemental barcoding.
Moreover, the clinician's workflow process can actually be streamlined, despite the added step of verifying medication at the point of care. The second-generation technology is able to provide these metrics and usher in a new era of accountability, as well as the ability to document every step in medication administration and more generally in nurse workflow.
This information on operational variability among units and various shifts can be used to determine and proliferate best practices, thus improving operations in areas beyond medication administration.



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