"It's the right thing to do": eMAR improves patient safety

Fewer than 10% of healthcare facilities have fully implemented medication bar coding technology, despite its proven role in reducing medication errors. But this figure didn't prove daunting to Tomah Memorial Hospital, a critical access facility in Tomah, Wisconsin, when it was looking for a way to further improve patient safety. This technologically-progressive facility has implemented a fully-integrated bar coding system with nurses bar coding medications at the bedside.

Darla Wilson Pharmacy Director Tomah Memorial Hospital Tomah, Wisconsin Critical Access Hospital with 25 staffed beds

LaVonne Smith Information Services Director Tomah Memorial Hospital Tomah, Wisconsin Critical Access Hospital with 25 staffed beds

Poised on the shore of lovely Lake Tomah in Tomah, Wisconsin, Tomah Memorial Hospital (TMH) does what it has done for over 50 years: provide quality healthcare services for the residents of western Wisconsin.

So it was no surprise when members of the newly-formed Medication Safety Committee at the critical access hospital started to ask some tough questions: "What more could we be doing? How can we improve patient safety?"

Committee members, including the Director of Nursing, the Quality and Compliance Officer, the Med-Surg Supervisor, the OB Supervisor, nurse representatives from the ER, OR, Med-Surg and OB, the Pharmacy Director and the IS Director, wanted to raise the bar to ultimately reduce the number of errors related to medication administration processes.

Nationwide, on average 85-percent of medication errors are preventable. A review of records over the last three years indicated that about 45-percent of medication errors at TMH could have been prevented. But instead of touting its below-national-average standing, TMH decided they could do better. Bar coding would be their answer to improving patient safety.

TMH Pharmacy Director Darla Wilson and Information Services Director LaVonne Smith led the committee's charge to improve patient safety by initiating medication bar coding at the 25-bed facility.

"As a JCAHO-accredited [Joint Commission on Accreditation of Healthcare Organizations] facility, we wanted to comply with the National Patient Safety Goals in order to create a culture of patient safety," Wilson relates. "Bar coding is an important part of that goal."

The only question now was, "How?" TMH officials knew that such a venture could present a few challenges, since only 10 percent of healthcare facilities in the U.S. use bar coding technology.

Staff gets on board

Gaining staff involvement was the first step. They compiled a number of years of statistics and showed the staff the potential negative outcomes of each incident. They then took this data and presented to the staff, through Skills Fairs, staff meetings, memos, posters, etc., the errors that would have been eliminated with bar code scanning. "The statistics pretty much did the talking," Wilson recalls.

"Once we got every department that would be affected by this process on board, we decided that phasing in the bar code technology would make the most sense at that stage of the technology," Smith says about implementing the standard.

TMH started by implementing HMS eMAR and getting nurses accustomed to scanning the patient's wristband, an action supported by hospital administration which instated a "no tolerance" rule.

Directly scanning a patient's wristband attacks the Right Patient directive on two fronts. First, that action automatically pulls up that patient's electronic chart. Second, should the facility choose, HMS eMAR also offers a picture for visual confirmation of the right patient.

TMH officials also concluded that the HMS eMAR Bar Code Utilization Report helped staff become accustomed to making scanning a normal part of their daily routine. The report serves as a valuable tool in that users who are not scanning the patient and/or the medication are identified by the system. This is important because the consequences of not scanning can be dire.

Both Wilson and Smith recalled a fatal medication error that occurred at a nearby medical facility near the beginning of TMH's first steps into bar coding and hastened their commitment to the new technology. "They were a facility to look up to, an early adopter of bar coding technology," according to Wilson.

Smith agreed, "The event affirmed our decision; we knew we couldn't compromise our dedication to patient safety."

Growing the technology

After the process of verifying patient identity was fully in place, TMH began expanding their bar coding processes to verify the correct medication, which proved to be a bit more challenging.

TMH had originally used patient medication drawers to administer medications. This process consisted of medications dispensed from a pharmacy fill list drawn from HMS Order Communications. This process was altered slightly so when the medications were bagged in the pharmacy according to the fill list, the bag was affixed with an order label. In order to administer the medication, the nurse would scan the patient wristband bar code and then the order number on the bag.

It was a good intermediate step (in addition to the Right Patient, they were now electronically confirming the Right Time every time the order number was scanned), but the accuracy depended on the right drug and dose being in the bag, a manual process.

Wilson recalls a good catch by a TMH nurse that confirmed the need for further improvements to the system: "In the bag were two small pink pills that looked alike, but upon closer inspection, one was the correct drug and one was wrong."

The final steps

According to Wilson, the Bar Code Verifier in the HMS Pharmacy module helped TMH take the final step toward medication bar code scanning. The Bar Code Verifier uses the HMS system along with MediSpan to cross check the bar codes and to confirm the "scannability" of the actual bar code before the medication is dispensed.

This process is necessary because, as TMH officials discovered, different NDCs are used for therapeutically equivalent medications. A generic product identifier (GPI) enables the system to recognize a drug correctly no matter what, and the medication bar code verification program displays the drug name, generic name, strength and form to make sure that is matches the expected entry in the formulary.

The result is an increase in efficiency and a decline in hassle. "Using the verification process in the pharmacy is nice; if it scans there, it will scan at the bed side," Wilson says of the new system.

New image bar code scanners also helped TMH overcome the final hurdle: "Image scanners pick up more [than linear bar code scanners], so it doesn't matter that all medication bar codes are not in the same format," explains Smith.

Even though TMH officials are waiting on data to measure the success of bar coding at their facility, they have already concluded that it was a process that not only took the facility to the next level, it ultimately confirmed its mission to provide quality care.

"Whether you phase in or jump in, it's just the right thing to do. Patient safety is, as always, paramount," Wilson concludes.