Evolution of a Closed Loop Medication Use Process
Paul J. Vitale, Pharm.D.
Vice President and Chief Pharmacy Officer
The Mercy Medical Center Baltimore, Maryland
Agenda
•
Hospital Background
•
Decisions for EMAR, BMV, and ADCs
•
Description of Closed Loop Medication Use
Process
•
Accomplishments
•
Data Capture and Applications
Mercy Medical Center, Baltimore, Maryland
•
Nonprofit Community Hospital
• Sponsored by the Sisters of Mercy
• 278 Available Inpatient Beds
• 29 Beds Transitional Care
• Teaching Hospital
– Affiliated w/ U of MD School of Med
• Disproportionate Share Hospital
• Inpatient pharmacy
– 24 hours/7 days
– Complete unit dose and IV admixture program
• Anticoagulation clinic
• Outpatient service
• Outpatient Infusion Center Pharmacy
About Mercy Medical Center
• Pharmacy enters approximately 45,000 medication orders monthly
• Dispenses approximately 200,000 doses/ month- cart fill & ADC
• EMAR and BMV
• ADC- controlled substances and certain other line items
– Plan to migrate to all ADC with new tower
• MediTECH
Decision Process For EMAR, BMV, and ADC Technology
Organizational Factors
–
Plans to build a new hospital tower adjacent to current
building- standardization of medication management
process and maintaining service level at multiple sites
–
Commitment to enhancing patient safety at the Board Level
and “C” Suite
•
Medication errors, lab specimen mislabeling
–
Maryland Patient Safety Center MedSAFE Project- Utilizing
the ISMP Medication Safety Self-Assessment
Rtool
Change is coming in Medication Administration in Hospitals
(CMS and “meaningful use” of an EHR)
Doctor Pharmacist
Old fashioned approach:
Patient Writes Rx Reads the
handwriting (or
tries to)
Takes the medicine
New approach:
Computerized
Physician Generated Order; Order Entry
(MOE, CPOE) Nurse Deliver the medicine to a patient Patient Pharmacist Nurse Bedside-Medication-Verification ADC/Robotic/Cart Scan
Mercy’s Approach to EMAR and BMV
•
Initiate bar code technology for medication administration and
lab specimens collections
–
Initial process- patient identification bracelets and bar coding
•
Financial concerns for implementation and maintenance
–
Robotic approach- financial, space, design restrictions
•
Bar coding process was the fundamental key to success
–
Format, scanning process, end user acceptance
–
Reliability at the POC
•
Ability to track each medication dose- “FedEx”
•
Integration throughout hospital data resources
–
Laboratory, allergies, disease states
•
Future plans for all ADC dispensing and medication dose
tracking
A Few Factors To Consider When Implementing
a Bar-Code Scanning Process
• FDA Regulations
• Institutional requirements
• Availability of unit-of-use bar-coded products
• Format of bar codes to be used
• Choice of scanners
• Drug dictionary issues
• Scan ability issues including patient ID bands
• A few obstacles for implementation:
– Human factors
– Infrastructure issues
Hospital-Applied Bar Codes
Must provide the same level of safety and documentation for
all medications the patient receives
• Unit-of-use tablets, capsules, and oral solutions when not commercially available
• If manufacturer-applied bar code is not compatible with system chosen
• Multiple-dose products (inhalers, cream, etc)
• Multiple-dose containers (e.g., Antibiotic suspensions)
• Non-formulary medication
• Patient’s own medication from home
• Dose prepared in specific amount or volume for a specific patient and order
– Specially measured pediatric doses; Breast milk
• Doses prepared from multiple components
– Admixed LVP, IVPB, TPN, Chemotherapy, Extemporaneous compound
Cross- Functional Planning and Implementation Team
•
Pharmacy
•
Nursing
•
Medical Staff
•
Information Technology
–
Nursing and pharmacy background
•
Patient Access- Registration and Admission
–
Patient ID bracelets- restrictions, re-issues
•
Laboratory- initial meetings
Some of the Particular Applications for MMC Barcode (now and future)
•
Institutional Pharmacy Applications to be further developed
•
Support Bedside-Medication-Verification
•
Medication Refill Cart Scan and Tracking System
•
Crash Code Cart Scan and Tracking System
•
OR Medication Tray Scan and Tracking System
•
Bar code repackaging system
•
Screen Medication-Lab Abnormalities
•
Tracking the Medication Management Process using ADCs
•
Patient specific pharmacokinetics (Document, Tracking, Calculations)
–
Aminoglycosides, Vancomycin, Renal impairment dose adjustment,
Hepatic impairment dose adjustment.
•
Pharmaceutical calculations (link to patient’s medication profile and lab
test results)
Pharmacy
Nurse Unit
Bedside
Right Patient Right Drug Right Dose Right Form Right Time Initial Dose Dispensing Refill Cart Dispensing Automated Dispensing Cabinet Distribution
Crash Cart Distribution OR Cart Distribution
Bedside Medication Verification (BMV)
Error-Free Med Filling
Scan Med vs Rx
Automated Dispensing Cabinet
MMC Barcode Model with Clinical Pharmaceutical Data Mining
and Bar Code Technology
Clinically Right Dose (Clinical Pharmaceutical Data Mining)
Clinical
kinetics Medication Tracking
0 0 3 0 0 4 5 0 1 2 3 0 3 9
Medication Refill Cart Scan and Tracking System
Lowers pharmacist labor
Curtails missing medications
Increases pharmacist interventions
Faster, more accurate picking and checking
Ensures each dose is scannable
prior to delivery to nurse Under Development
Prevents dispensing of expired medications with Image scanner
Track and document (FedEx Type) capability for each medication
dispensed.
Striving For Error Free
Refill Cart Filling
WHAT WE ACCOMPLISHED…..
•
100% of all doses bar coded (oral, injectable, topical, rectal etc)
– Oncology the exception
•
Pharmacy infrastructures for Bedside-Medication-Verification
•
Unit dose cart filling and tech checking via scanning
– Scan-ability of doses for nursing approximately 99%
•
Refill code carts and operating room medication supplies using bar coding
technology for expiration tracking and medication utilization
•
Universal mapping process eliminates need for mapping of new products in
intra-pharmacy applications, i.e., repackaging and cart checks
•
Tracking of medication doses from ADC to patient administration times
•
CPDM incorporates information regarding scanned doses administered and
pertinent lab data
Some Future Applications for MMC Barcode
• Institutional Pharmacy Applications to be further developed
• Replicate Cart Fill Efficiencies for the ADC refills, inventory controls and scan ability of all doses
• Screen Medication-Lab Abnormalities
• Patient specific pharmacokinetics (Document, Tracking, Calculations)
– Aminoglycosides, Vancomycin, Renal impairment dose adjustment, Hepatic impairment dose adjustment
• Pharmaceutical calculations (link to patient’s medication profile and lab results)
– Drug dosing, Creatinine clearance, etc)
• Tracking the Medication Management Process using ADCs
– All medications
– Enhance nursing workflow through tracking of medication administration process
– Enhance pharmacy workflow and tracking of staff functions
• True “closed loop” medication management process with CPOE implementation and BMV and all ADC dispensing
A Nursing Executive’s Comments Regarding Collaboration and
Medication Administration Tracking at MMC
• It is becoming increasingly difficult to balance cost, quality and performance management with patient and staff satisfaction. Sometimes the latest electronic
solution becomes the next headache.
• Developed by the Pharmacy, in conjunction with others at MMC, the software program links information from three separate software programs which until recently could not be linked, resulting in a clear, complete and extremely informative data set. Reports can be run to be as general or as specific as necessary.
• Each month reports are generated that provide time line information about the
nursing practice for obtaining and administering narcotics. Within minutes, areas of concern, if any, become apparent. More detailed reports can be generated depending on what additional information is needed. The information can be used as the basis for process improvement discussions.
• To date we’ve been able to uncover the need to enhance the orientation program for all nurses and to provide additional follow-up training for individual nurses. We also identified bad habits, poor performers, those who are very good at creating work-a-rounds as well as those who medicate to their advantage rather than the patient’s need. The data have uncovered suspicious narcotic usage and have been used to help in the identification of individuals at risk, allowing us to provide support and guidance if welcomed.
Thank You
Pharmacy Staff Responsible for MMC’s
Program
Awarded the Maryland Society of Health System Pharmacist
2008 Medication Safety Award
David Park, RPh., Informatics Pharmacist
[email protected] 410-332-9628
Kathryn Higbee, MS, RPh., Director, Pharmacy Operations
[email protected] 410-332-9631
Nicholas Smith, Barcode Specialist
