US Pharm. 2006;10:129-138.

BAR  CODE  TECHNOLOGY  CUTS  HOSPITAL  ERRORS
Most hospital personnel would probably agree that the proliferation of technology in their facility has made their jobs easier and more efficient. Many will say that technology, specifically the use of bar coding, is making patients' hospital stays safer, particularly in the area of medication dispensing errors. A study published in the Sept. 19 issue of the Annals of Internal Medicine (2006;145:426-434) found a positive relationship between bar coding and reduced drug dispensing errors, according to data gathered by Dr. Eric G. Poon, MD, MPH, and his research team at Brigham and Women's Hospital in Boston.

During their review of general hospital conditions, the researchers found that medication errors were fairly common, with pharmacy dispensing errors contributing significantly to these errors. From a statistical viewpoint, the overall number of dispensing errors was relatively low; however, this rate can be misleading due to the high volume of prescriptions dispensed on a daily basis. Based on some estimates, more than 100 undetected dispensing errors occur every day in a busy hospital, with only about one third caught by nurses before administration of the medication to the patient.

In April, the FDA mandated that all medicines used in hospitals carry a bar code. While it has been widely assumed that the FDA dictum would lower the number of dispensing errors, few studies have been conducted to study the impact of this technology. Dr. Poon and his team performed a before-and-after evaluation of dispensing errors and adverse drug events (ADEs) over a 20-month period in a 735-bed tertiary care academic medical center, where approximately 5.9 million doses of medications were dispensed per year from the central inpatient pharmacy. During the bar code conversion process, the pharmacy built a repackaging center that affixed a bar code onto every dose of medication if the manufacturer had not already applied a bar code.

A trained research pharmacist inspected the medications that had already been dispensed to look for errors, while two board-certified internists independently reviewed and rated the severity of each dispensing error by using an explicit set of criteria. Physician–reviewers determined whether the patient could have been injured if the error had reached the patient, classified these errors as potential ADEs, and further categorized the level of potential harm as significant, serious, or life-threatening. The researchers then matched each post–bar code process according to the types of medications dispensed with its equivalent pre–bar code process and compared the rates of dispensing errors.

The authors found that, "The rates of target dispensing errors and potential ADEs substantially decreased after the implementation of bar code technology: The target dispensing error rate decreased by 85%, and the rate of all dispensing-related potential ADEs decreased by more than 60%."

However, the researchers added that these data should be considered only within the specific parameters of the study. For example, the study examined the effects of bar coding on patient safety in only one urban academic medical center that cares largely for adult patients. Another factor that needs to be considered is the individualized dispensing processes of other hospitals. Their study was significant only given the target hospital's processes. Additionally, the investigators point out, "Neither participants nor assessors were blinded to the purpose of our before-and-after study." Yet, even with all the caveats, the researchers say their study suggests that bar code technology in hospital pharmacies is moving in the right direction.

MCLEOD HEALTH RAISES THE BAR ON MEDICATION ERROR REDUCTION
In 2001, McLeod Regional Medical Center, a 371-bed community hospital in Florence, South Carolina, launched a multipronged pharmaceutical clinical and dispensing program with one purpose in mind: To reduce medication errors. The foundation of the new program was the acquisition of an automated drug dispensing system, with the phased-in addition of bar coding, electronic medication administration records, deployment of pharmacists to the nursing floors, drug reconciliation, and a universal medication form. Aside from dramatic reductions in the hospital's rate of harm, the system improved drug inventory control, lowered the number of errors, and improved charge capture with drug administration.

Introduction
In the aftermath of the 1999 publication To Err is Human--the Institute of Medicine's groundbreaking report on the high rate of medication errors in U.S. hospitals--McLeod Regional Medical Center began to investigate new tools and approaches to reduce the rate of harm (ROH).

At the time, McLeod's ROH (the number of doses per thousand that cause adverse reactions) was 3.5, on the low end of the national average (2 to 8). However, as illustrated in the Institute of Medicine report, the status quo was no longer acceptable. A 3.5 ROH translates into harming 35 patients a day, based on the 10,000 doses dispensed daily through the pharmacy. With the singular goal to improve medication safety by reducing the ROH, the Medication Safety Redesign Project was launched in 2001.

Pharmacy Management Needs
McLeod's pharmacy was operating in 2001 much the same way it had for the last 20 years, even though the business of pharmacy management had changed significantly. The existing system was not designed to accommodate the number of medications now available, the entirely new types of drugs (many of which required special storing conditions), or the often immediate need for pharmaceuticals at the bedside. For example, the old system of drug delivery entailed 17 separate steps, each of which represented a new opportunity to introduce errors into the system. An automated system was the first step needed to solve this problem.

Real-time inventory monitoring and control were functions that were badly needed. There were no clinical programs and almost no pharmacist interventions being done. The medication delivery process was labor-intensive and poorly designed. Instead of consulting with clinicians and patients, the pharmacists were overbooked filling prescriptions.

The purchase of a single product was not going to resolve all of these issues. After an extensive search, McLeod entered into a contract with Cardinal Health Pharmacy Management. Cardinal Health was chosen primarily because it offers technology and business solutions, including pharmacy management, automation, and wholesaler distribution. This was not going to be a quick fix, and McLeod needed pharmacy logistical expertise to help find workable solutions.

McLeod's initial efforts involved a needs assessment based on workflow trends, clinical utilization, inventory control, and of course, the financial needs of the pharmacy. An on-site clinical coordinator provided valuable trend data and strategies to optimize drug utilization. This helped with operational strategies for controlling costs and in-service training, illustrated the best practices from around the nation, improved clinical accountability, and enabled McLeod to have access to clinical resources and trend data that would have been difficult to acquire on its own. Cardinal Health also helped find hidden value with current data on reimbursement levels for pharmaceuticals to ensure the hospital was receiving full compensation.

After choosing Cardinal Health in 2001, McLeod began working with an interdisciplinary team to redesign the Medication Safety Committee and forge a vision that would be instrumental in the work to follow. The question it asks of every new system is: Does it make it easy for caregivers to do the right thing and impossible to do the wrong thing?

Evidence-Based, Data-Driven, Physician-Led
The Medication Safety project followed the same principles used in any work McLeod did to improve clinical efficacy. McLeod's pharmacy decided to make changes based on proven strategies from scientific literature. The data-driven process involved vigorous consultation with the medical staff.

It was clear that the old system of drug delivery had to end. The Medication Safety Committee reviewed available products and decided on the Pyxis Profile MedStation medication administration system and Pyxis Connect physician order management system, made by Cardinal Health. The cost of deploying the technology was considerable, but McLeod was fortunate to be one of five U.S. hospitals chosen to receive a Robert Wood Johnson Foundation "Pursuing Perfection" grant, which helped underwrite part of the technology expense.

Nurses and Pharmacists Free to Focus on Consultation
In the first phase of the project, the new system was installed in every unit that medications are administered. Nurses could access drugs only for a specific patient and only for orders that the pharmacy had verified. To prevent mix-ups between patients, nurses could obtain drugs for just one patient at a time and only for one dose.

Switching from a system where drugs were stored on a centralized cart to one where drug-dispensing units were positioned throughout the hospital but only obtained via a computer was an immense undertaking and became an unexpected culture shock for the nursing staff. As inefficient as the old system was, they were used to it. In fact, many nurses were so opposed to the change that they threatened to quit. However, they became quick fans of the ease of use of Pyxis Products and the ready supply of medication at every unit. Many would now threaten to quit if McLeod returned to the old system.

Automation cut the number of medication steps from 17 to five, and it freed the hospital's pharmacists to operate on the nursing units instead of "in the basement," dispensing pills. Today, McLeod's pharmacy staff is 100% decentralized, and pharmacists work directly with nurses, physicians, and patients on the units and in pediatrics, the emergency department, and operating room. The number of drug interventions has grown from near zero in 2001 to 33,219 in 2005.

In a hospital setting, the greatest value that pharmacists provide is consultation on complex drug regimens with physicians, nurses, and patients. Patients generally have multiple physicians and multiple drug priorities; the pharmacist is key in determining the safest, most effective medication program. Enabling pharmacists to focus on consultation has a vital role in McLeod's overall medication safety strategy.

Bar Coding: MAC and MAR
Based on McLeod's initial success with dispensing automation, the Medication Safety Committee decided to convert to the Medication Administration Checker (MAC)--a bar-coding system that is now fully implemented at McLeod. Under the MAC, there are bar codes on every nurse's badge, every patient's wristband, and every drug. The system also includes bedside bar coding and electronic Medication Administration Record (MAR) as part of the hospital's strategy to develop an integrated electronic medical record that could be shared across the three-hospital system.

However, getting the right bar codes on the drugs proved to be a challenge, as there is currently no industry standard. McLeod uses a system from Siemens Pharmacy and Medical Packaging, Inc. that allows it flexibility to deal with some of these challenges. Today, about 80% of the drugs McLeod receives has a bar code it can use, and the other 20% it does itself.

When drugs are administered, the MAR is electronically updated. The nurse can now document everything online. In addition, all records, plus lab results and other pertinent data, are available on every physician's handheld wireless unit.

Drug Reconciliation
With McLeod's emphasis on recordkeeping, its medication safety team was tasked with drug reconciliation in the last half of 2001. The first challenge was determining what home medications were being taken when patients were admitted.

The existing system was anything but a system. Physicians simply noted, "Continue all home medication" as the order. However, McLeod had no way of determining if the home medications were contributing to, or causing, the problem that triggered the hospital visit. Therefore, it no longer accepted blanket orders. Instead, the team created a computerized "Admission Assessment History Form," which the nurse fills out at the initial patient assessment. In addition to talking with the patient and family, the nurse may also call the patient's pharmacy. The physician reviews this medication list, either online if using a Computerized Physician Order Management (CPOM) system or on paper. The electronic form then goes to the pharmacist for verification, cutting transcription errors to nearly zero. McLeod is currently rolling out a pilot CPOM system with a small group of physicians. In addition, it has begun using a system that involves reconciliation during patient transfers to ensure that when patients change locations and levels of care, their medications are reconciled for accuracy and safety.

McLeod is working through a multidisciplinary Clinical Effectiveness team composed of physicians, pharmacists, nurses, other health care team members, and most importantly, patients, to develop a system where admission reconciliation will be pharmacy-driven. It is closing the loop between admission, transfer, and discharge medication reconciliation with a completely automated system.

Universal Medication Form
The final step of the reconciliation process is providing each patient with complete and accurate medication information upon discharge. For this, the team worked with the South Carolina Hospital Association to develop a Universal Medication Form, which has since become the statewide standard and is under investigation by several other state associations.

To develop the form, the team consulted with focus groups, church groups, senior citizen centers, retail pharmacies, and all 25+ physician practices that admit to McLeod. It also worked with its competitor hospital to ensure that both hospitals would be doing the same thing. When it comes to safety, there are no secrets.

Results
Before McLeod initiated these changes, the hospital's ROH was 3.5, well within the national average of 2 to 8. Today, the ROH is about 0.5. Other notable accomplishments include:

•   Number of steps to administer drugs was cut from 17 to five steps
•   Drug turnaround time was reduced from one hour, 45 minutes to seven minutes
•   Interventions increased from near zero in 2001 to 33,219 in 2005
•   MAC "saves" per 1,000 doses: about three (equivalent to 30 saves/day for McLeod's dosing level of 10,000/day)
•   Increased reported errors from 70 in 2000 to more than 150 average per month
•   Shared results through four seminars offered on a national level

GLOWCAPS DELIVER PATIENT REMINDERS
PAR3 Communications and Vitality, Inc. have joined forces to provide retail pharmacies, pharmaceutical manufacturers, and health system administrators with a new approach to improving medication adherence.

GlowCaps, designed to replace standard pill bottle caps, are integrated into Vitality's proprietary network and use low-cost wireless technology to continuously monitor patients' dosing behavior. To use GlowCaps, patients plug the GlowCaps Nitelite into any power socket in their home. The GlowCaps pill cap then communicates wirelessly with the Nitelite to provide a glowing visual reminder when pills need to be taken. If doses are missed, the pill cap glows brighter and more insistent.

If further intervention is needed, interactive motivational, instructive, and diagnostic voice or text messages are delivered to patients or caregivers through PAR3's advanced communication solutions. GlowCaps also mails a monthly health report to patients for motivational purposes and submits refill requests to pharmacies before prescriptions run out.

"By addressing dosing behavior in real time, rather than weeks after a compliance lapse, we can improve patient health, while reducing the rising costs associated with nonadherence," said Dr. Michael Ross, Vice President of Healthcare at PAR3. PAR3 and Vitality's integrated GlowCaps will be available by early 2007.

PURDUE PHARMA'S NEW ELECTRONIC ORDERING SYSTEM
In an effort to make the purchase and tracking of controlled substances more secure, Connecticut-based Purdue Pharma L.P. unveiled new technology that electronically tracks the purchase of controlled substances, satisfying the Drug Enforcement Administration's (DEA) mandate of strict security requirements.

The DEA's controlled substance ordering system (CSOS) requires that the chain of custody be verified and documented at every step in the transaction process. To accomplish this, Purdue chose nuBridges e222 CSOS to manage the order and customer verification steps necessary in the electronic workflow. It transmitted its first CSOS orders to two of its wholesale business partners, HD Smith and Value Drug.

 "This is a pivotal moment for Purdue and for controlled substance pharmaceutical manufacturing as a whole," said Michael Celentano, Associate Director, Supply Chain Systems for Purdue. "With nuBridges e222 solution, we can reap the benefits of electronic CSOS compliance, knowing that our processes are secure, scalable, and extremely efficient."

The new system not only provides secure data transmissions, but also cuts down considerably on paper-based ordering. A study by the DEA found that pharmaceutical companies and distributors can reduce costs with electronic processing, compared to the use of traditional paper models. According to the report, processing a single order via paper can cost up to $60, while electronic processing averages $6 and can be completed in real time. Prior to the development of electronic ordering, buyers were limited to using a 10 line-item paper form (DEA Form 222) when ordering controlled substances. Orders that exceeded 10 lines required processing multiple forms.

The nuBridges e222 CSOS application is one of the industry's first systems to be certified according to DEA's strict requirements. Messages are encrypted to ensure that only authorized recipients can access their content. Digital signatures assure identity, including return receipts, and audit trails account for all stock received, distributed, or disposed of.

PATIENT CARE MODULE FROM LEXI-COMP
Lexi-Comp recently introduced its Patient Care Module, a component of Lexi-Comp ONLINE, that allows users to access and print customized medication leaflets with concise information on diagnosis, procedures, and medications.

The module combines the company's patient advisory leaflets (Lexi-PALS), which cover over 1,700 adult and pediatric medications, with the new Health-PALS patient education tools. Health-PALS provide patients with take-home information pertinent to their diagnosis and includes information on more than 900 diseases, conditions, and procedures.

"Traditionally, Lexi-PALS have only included drug information," noted Steven Kerscher, president and COO, Lexi-Comp, Inc. "By expanding into conditions and procedures with Health-PALS, we are giving caregivers one access point to customize important information for patients. If patients have something to refer back to after their hospital stay, they are more likely to follow all of their instructions--ultimately improving chances for a better outcome."

Via the Patient Care Module, users can print a take-home packet by conducting a search by drug name, condition, or procedure. A list of relevant PALS for each category will appear. Users can then select the number of copies, language, and font preference. The packet can be customized with the hospital logo and contact information, patient's name, and signature line. Lexi-PAL materials are evidence-based and have undergone a review process to ensure accuracy and efficacy to patients.

SCRIPTPRO'S NEW PRODUCT LAUNCHES
The SP Central Pharmacy Management System, recently released by ScriptPro, integrates hardware and software to automate prescription fulfillment from the point of entry to the point of sale. Features of the pharmacy system include interactive voice response, telepharmacy, mobile dispensing and electronic signature devices, in addition to medication therapy management and long-term care modules. The product is designed to eliminate the obstacles that pharmacy operators may encounter when dealing with multiple sources for technology, integration, and support. To help increase productivity, the SP Central Pharmacy Management System also includes electronic exception queues, automated faxing for refill and insurance prior authorization, e-prescribing, and back office third-party billing and reconciliation modules.

ScriptPro also recently introduced SP 50, joining the SP 100 and SP 200 robotic prescription dispensing systems already on the market. The new system is targeted for pharmacies with space constrictions or lower prescription volumes (i.e., <150 prescriptions per day). The robotic arm of the SP50 takes a prescription vial to a medication cell for hands-free dispensing and labeling. The cells can be calibrated on site to handle all tablets and capsules. Bar code scanning ensures the correct drug is being dispensed. The pharmacist can then compare the pills in the vial with the computer image from ScriptPro's drug database.

"ScriptPro's master plan for pharmacy technology is built from the ground up with the foundation of advanced robotics, communications technologies, and pharmacy industry best practices," said Mike Coughlin, the company's President and CEO. "Our mission is to provide technology to help pharmacies deliver the maximum contribution to the health care system."

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