Today’s technology affects the delivery of care and patient safety in different healthcare setting. Due to the increasing errors in the healthcare environment, the Joint Commission and other healthcare organizations mandated ways to improve proper and safer patient identification. The use of bar code scanning technology gave a big leap of improving errors in the healthcare field. Nowadays, the barcode scanning can be seen in patient’ wristbands, medical records and laboratory slips or requisitions. With this growing technology, a small pilot study using barcode scanning was initiated in an ICU setting in a local hospital. The barcode scanning was used to accurately and efficiently identify patients when taking blood glucose fingerstick at the bedside. This study will show how it improves the accuracy and efficiency in performing the task. Even at the end, there are flaws that were identified in the study. There is a two percent error in scanning the barcode wristband in the study. But the areas of improvement were identified. The bedside nurse need to verify the medical record number scanned and must match what is in the armband. With this technique, 87.5% of the bedside nurse find this technique a much accurate and efficient in taking blood sugar fingerstick in the ICU setting. The nurses also need to measure its efficiency in identifying patients correctly using barcode scanning technique. Time is measured between manually entering MRN versus scanning a barcoded wristband. It is found that 100% of the eight bedside nurses find it more faster technique than manually entering the MRN in the Surestep glucometer.
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Patient safety encompasses prevention of errors and mistakes of action and judgment, making errors visible and mitigating the effects of error. “In 1997, a study of 1,000 hospitalized patients in a large teaching hospital found 177 of these patients received inappropriate care that resulted in serious adverse events” (Barach, 2003). It is a growing evidence of the number of medical errors throughout the healthcare system in the United States and this became a signal to the healthcare system that improvement in patient safety and delivery of care is needed with the use of technology. As we all know, technology plays an important role in improving the delivery of care in any hospital settings. There had been an increasing problem in the healthcare environment when it comes with medication error. It is becoming a serious public health threat.
According to a landmark 1999 Institute of Medicine report, between 44,000 and 98,000 Americans die annually due to medical mistakes (Kohn, et al). As part of its ongoing efforts and responsibility to improve patient safety, the U.S. Food and Drug Administration (FDA) ruled on April 4, 2004, to make barcodes mandatory on the labels of thousands of human medications and biological products by the year 2006″ (Kohn, et. al). The FDA expected that the ruling will help prevent nearly 500,000 adverse events and transfusion errors over the 20 years that follow, at a cost savings of $93 billion. Although the ruling makes the National Drug Code (NDC)-format barcodes mandatory only on medication packaging produced by drug suppliers, there is hope that this policy and recommendation will bring about technological advancements in prescription ordering, drug dispensing, and medication administration across all arms of the nation’s health care system. “A critical method for providers of care to reduce adverse events associated with medication errors is to focus on the ways of improving the system of delivering care.
In order to sustain and improve upon established level of care, it is critical that health care facilities evaluate options to integrate information systems as a mechanisms to eliminate preventable medication errors” (Patel, 2004) and even procedural errors such as checking blood sugar at the bedside. As we can see the use of medication barcode technology grows, the health care institutions will need to be aware of related changes in accreditation and compliance policies. These are important and necessary to comply within several regulatory organizations, including the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and the National Committee for Quality Assurance (NCQA).
The Support of the healthcare accreditation and other organizations
Under the conditions of The Joint Commission (previously JCAHO) and other accreditations, the heathcare organization is now faced with increasing pressure to proactively look and address medical errors that can happen in any health care settings. In July 2002, the Joint Commission called national attention to the basic source of error by establishing correct patient identification as one of the six National Patient Goals of 2002 and “by January 2004 would affect the organization’s accreditation and status. The goals included more accurate patient identification, enhanced communication among health care providers, reduction or elimination of wrong-site, wrong-patient, and wrong procedure surgeries, and improvements to key equipment such as clinical alarm systems” (Mello, M., Kelly & Brennan, T., 2005). This accreditation body has given emphasis on medical administration, it is also important in any other aspects of patient care delivery. They support the proper identification and safe delivery of care in different areas and activities in healthcare settings.
Taking Technology with Patient Safety and Security
Patient security is further enhanced with technology. It is also important to include and identify staff employees that are administering medications, tests, or procedures. These not only offer an important (and time saving) record of the provider/patient interaction, but they also provide an extra check to help avoid errors or mistakes.
Much of the important technology to achieve these results already exists. Even more is in development-especially as hospitals move toward the electronic medical record and its special consideration. Again, hospitals and other health care settings now are mandated by law to be compliant with the HIPAA law and electronic medical information. But the reality remains: hospitals must balance these opportunities with bottom line financial considerations. Finding the solution will require careful selection of a software provider who can meet current and future needs of the provider-who will partner with the provider for today and the future. The choices surrounding this opportunity will vary wider but the stakes have never been higher or the rewards for patient safety are much more compelling.
What is the current practice? “Patient safety and medication administration safety are important hospital priorities. General initiatives designed to improve safety include adopting a institutional culture conducive to safe practices, optimizing infrastructure and clinical practices to remove sources of errors and studying errors that occur to determine the source and potential ways to prevent errors” (Cumming, et. al., 2005). Before and even until now, nurses are used of visually checking the medicine and following the five patients’ right.
Today’s nursing working force is burdened with increasing larger patients’ loads and much more sicker and higher acuity patient levels than ever before together with multiple co-morbidities. Everyone agrees that ensuring patient safety is a top priority for healthcare providers. The first step lies in accurately identifying the patient. Every practicing nurse is taught that the first safeguard against medical error or positive patient identification by looking at the 5 rights: right medication, right time, right patient, right dose and right route. This sounds easy but often are missed and causing an error. Technology is providing some outstanding advances in this area, but more needs to be done. Balancing the need for patient privacy and security presents some special challenges, but the two really do work in concert-when a provider uses a system that will accommodate and grow with its growing needs.
Bar-coded wristbands are most beneficial when institutions such as hospitals assign barcodes to their product such as medication, blood products, laboratory tests and procedures. Patients traditionally receive the all-important wristband during the admissions process. Again, a cost-effective solution that can accommodate bar coded wristbands can help in accurately identify patients in providing patient care in the hospital setting. Increasingly, providers are seeing the bar-coded wrist band as an important patient safety check: scanning the band will help ensure correct patient identification for medication administration, lab work, transfusions, testing and other procedures.
The Bar Coding Technique
Bar code technologies are now being utilized for other health care applications outside of medication administration. The bar code was found in 1974 and was used initially in the food industry. It was in 1991 when the first bar code appeared in a medication package. “In 2004, the FDA issued a final rule requiring bar codes on most prescription and non prescription drugs commonly used in the hospital to reduce the risk of medication errors” (Churchill, 2005). Bar coding technology can effectively look at medications in two levels. “First, the use of bar codes on medication packaging can ensure appropriate use of medications. Second, bar codes can be used as unique patient identifiers” (Patel, 2004) to patients. Bar-code enabled bedside nurses to properly confirm patient identification and accurately perform bedside tasks from medication administration, lab work and as simple as fingerstick check at the bedside. This will enable the nurse to verify the right patient, right medication, right procedure, and right blood glucose fingerstick check. In essence, “barcode technology is a replacement for a traditional keyboard data entry. It requires a conversion of an identifier to a symbolic representation-the barcode-that can then be printed on, or affix to, an item, subsequently read by a light source and fed into a computer” (Grotting, et al, 2002). Standard barcodes are like the ones we see in grocery stores or like our license plates.
The Advantages of Barcode Scanning
The use of barcode technology brings a number of valuable advantages to the healthcare environment. Bar code scanning is much more accurate than the human eye or the flick of a finger. “Tests have shown that barcoded information has an accuracy rate of 1 error per 10,000,000 characters. Compare that to key board entry error rate of 1 error per 100 characters.” (Grotting, et al, 2002). The barcode scanning technology gives opportunity to decrease or prevent errors in gathering data while performing it in a fraction of a time instead of doing things manually. Another advantage is its ease of use. Participants can master the equipment in shorter amount of time. It also accrued through a standardization of codes or practices that is a well developed technology. The barcode technology gets better every time and provides accuracy and efficiency.
It is believed that implementing this technique in the health care setting can provide financial benefits in addition to clinical outcomes. There will be preventable longer length of stay and decrease cost in the hospital stay. With this technique, “millions of dollars per year, not including malpractice costs, readmissions and litigation costs, or the costs of injuries to patients (Grotting, et al, 2002)” will be saved. Litigation alone can be financially burdening to the hospital. “On average, jury awards for medication errors reached $636,844 per award in 2000” (Jury Verdict Research Group, 2000).
Factors that affects the Barcode Scanning
There factors that affects technology such as barcode scanning. The sensor factors, human factors, system architecture factors are some of the factors and can become challenges.
For sensor factors or a barcode scanner, one should look at the design. Every sensor is identified by a baseline measurement error that can be part in the engineering, design, type and purpose of the sensor. It is dependent upon the precision and accuracy of it. It is needed to ensure that high quality sensor data and equipment is used to deliver a fine precision and accuracy. It is important to consider that we have to use for the medical needs of the patients in the healthcare setting. The quality of manufacture needs to reflect the trust in the sensor manufacturing process. Also, every product, every sensor needs to be calibrated. It is common that overtime, any product, will decrease its accuracy. Therefore, it needs to be calibrated. The sensor and product must be reliable when in use.
Any health monitoring system involves human participants. This can be the patient, caregiver or health care providers such as nurses. It is necessary for every participant to carry out specific roles in using new equipment. The participants need to trust and have confidence on the new equipment for it to become successful. They should believe on its “identity (authenticity), responsibility (performing the role when expected), competence (performing the role correctly), and motivation (willingness to perform the role)” (Sriram, et. al, 2002).
Since there are a lot of policies that a hospital or health care setting to comply with, one should consider that health information are sensitive. Every health care provider whether they are doctors or nurses are required to comply with HIPAA privacy policies. Therefore, a system should ensure that no leak regarding patient information will happen and must be reliable. It should not be weak that could break healthcare information. It is important to consider its integrity and vulnerabilities.
The Barcode Pilot Study in ICU Setting
Being a quality improvement representative of our unit, I was able to identify some deficiencies in the inaccuracy in identifying patients during bedside blood sugar monitoring. It was two years ago when bedside intensive care unit nurses are still entering medical record number in the Surestep glucometer to accurately identify patients. It gave an idea to do a small project for the unit. Not all hospitals are using bar codes in identifying their patients. It was also two years ago when the hospital where I am working started bar codes in patient armbands to increase proper identification of patients especially in performing lab test. This is a first step in improving in accurately identifying patients in our hospital. I have worked in other hospitals and most of the hospitals I’ve worked at are using a glucometer that scans the barcodes in the patient’s armbands. The glucometer that was used in the other settings are the same glucometer used in my hospital. Therefore, I started a small project in the Surgical Intensive Care Unit to pilot a barcode scanning in obtaining blood sugar fingerstick to our intensive care unit patient population.
The Objective of the Study
First, I discussed with my co-Shared Governance members about the idea. I have presented to them why I am doing the project. This project will increase the accuracy and efficiency of obtaining blood glucose fingerstick at the bedside. The patient populations we are looking at are patient with Diabetic Ketoacidosis and Open Hearts patients. Both of these populations require an every one hour fingerstick. With the current procedure we have in the ICU, the bedside nurses are still manually entering the medical record number of the patient whenever a blood sugar fingerstick is needed. The amount of time and the amount of error is higher when the bedside nurses are doing this. After discussing the project with the Shared Governance of the unit and our nurse manager and got their consensus, I started looking at how to collect the data.
Data Collection of the Project
There will be two part of the study: measuring accuracy and measuring efficiency. I compared the old protocol of taking blood glucose fingerstick and wrote a different protocol for the project. This will help the ICU nurses follow the instructions (see attachment #1). I used a small pilot study that can collect fifty data. The data will be within one week or until fifty data are collected. The participants will enter in the generated template for the study (see attachment #2). The goal is to have 50 samples of MRN barcode scanning during fingerstick checks. The armband of the patient has a preprinted barcodes. This can be utilized in the project. There is no extra cost for developing a barcoded wristband. It is already in the hospital admitting system of a patient; therefore, we will be using this for the project. There will be no added cost to the budget of the unit.
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The participants, all nurses of the shift was given instructions and inservice of the project. They will first make sure the patient is right candidate for the study. They can be the Diabetic Ketoacidosis (DKA) and open heart patients. Both of this population requires every hour fingerstick because of the insulin drip that is running.
Surveying the Bedside Nurses
After collecting fifty data for the project, a survey was given to every participant. It asked for different things: What type of patient population used? Was the use of bar code scanning much more efficient that the manually entering MRN? Was the use of bar cod scanning much more accurate in identifying patients that manually entering MRN? Would you recommend using this new method than the old one? (See Attachment #3)
I will look at gathering 50 data from the bedside nurses. Also, I will be providing a survey form for the bedside nurse to compare the current procedure versus the new barcode scanning technique (see attachment #3). There will be no additional cost for buying the equipment to do the project. The glucometer, Surestep, has a capability of barcode scanning. Therefore, the extra feature of the equipment is already in the machine and just need to be utilized to perform this small project.
The project will run for a week starting February 24th until 50 data is collected. All bedside nurses on all shifts were inserviced in the incoming project. It was discussed with them what patient population that can be part of the study. Only the open heart patients and Diabetic Ketoacidosis are the patient population allowed at this time because of their every hour fingerstick. They were instructed that that every patients who participated in this study must have a barcoded wristband. They also need to make sure that there is imprinted medical record number (MRN) on it. The wristbands must not have any wear or tear prior to the scanning. If they find that any of the wristbands has any sign of wear or tear, they were asked to replace them. This will prevent any inaccurate results that can affect the study.
Scanning the Patient and Completing Survey Form
Each operator will get a template to enter the result of the study (see Attachment #2). They will first put the date, time, operator’s initial, actual MRN, scanned MRN, and enter YES or NO if the scanned MRN matched the imprinted MRN. If not, they will need to repeat the procedure, but must leave a comment how many times it scanned incorrectly. This collection will continue until fifty data is collected.
Every bedside nurse (operator) must complete the survey form at the end of their shift. All the forms will be placed in an envelope provided.
Analysis of the Project
The project ran from February 24 until March 2. It was almost a week of testing fifty barcode scanning of armbands prior taking blood glucose fingerstick. With the fifty data collected and compared with manually entered MRN and bar code scanned, one data did not scan the MRN correctly. It was at the second scan when the scanned barcode matched the imprinted barcode in the patient’s wristband. Therefore, there was a two percent chance of scanning a barcoded wristband with inaccurate MRN. The operator was asked if there is any tear or unclear barcode in the armband of the patient. The operator stated that there was no tear or unclear barcodes in the wristband. What caused this inaccuracy?
There were total of eight bedside nurses (operator) in doing this project. All of the bedside nurses completed the survey. Here is the breakdown of their results: 100% of the 50 data collected has barcoded wristbands with the same MRN that is imprinted, 25% of the patient population was an open heart patients and the 75% was Diabetic Ketoacidosis patient, 7 out of 8 bedside nurses felt that it is still accurate to barcode scan the MRN, 8 out of 8 bedside nurses felt that it is faster to scan the MRN than manually entering it, lastly, 8 out of 8 nurses want to recommend this new barcode scanning technique in entering the MRN than manually entering every single digit in the machine.
Even with the one error from the fifty data collected, there was a back up plan for it. The bedside nurse still needs to compare the scanned MRN with the patient’s wristband to assure the proper patient identification during the simple blood glucose monitoring at the bedside.
Acceptance of the Project
The project was successful because of the willingness of the nurses to be involved in the study. They do not have to go through a long training to use the equipment. They are familiar with the glucometer. Sometimes lack of involvement and interest from the participants can add to the flaw of the study. “We learned that engaging nurses early helps them to avoid adverse incidents and technology related stress” (Weckman, H., & Janzen, S., 2009). These nurses are excellent source of ideas and suggestions on how to improve any part of the process. It is believed that “careful listening to the nurses’ comments was crucialâ€¦because the technology changes in practice have the potential to create a ripple effect in other aspects of their work flow” (Weckman, H., & Janzen, S., 2009).
The Surgical Intensive Unit accepted this new barcode scanning technique in entering MRN in the Surestep glucometer. They felt that it is accurate and faster in entering MRN compare in using their fingertips. The other unit started to ask if they can apply the technique to their unit, based on the hospital’s policy, it needed to be approved by the laboratory personnel who are assigned in gathering data for the glucometer. I presented the project to her and she rejected the project to be shared to the other unit. She said that there is a high percent of error that can happen. It is ten times more blood glucose fingerstick that is taken daily in the hospital. If there is a two percent error, it will have an equivalent of ten inaccurate MRN scanned. This is just a daily blood glucose monitoring. What more if is translated to monthly and yearly? They wanted to call the vendor if the wristband barcode is the right barcode for the glucometer. There are different sizes and formats of barcoding and his must be one of the inadequacies of the technique. Even with the rejection of the laboratory personnel to have it dispersed in other unit, the nurses in the Surgical ICU are satisfied with the new technique. Therefore, the barcode scanning technique was only done in Surgical Intensive Unit with the approval of the unit’s nurse manager. The bedside nurses in this unit recommend this and prefer to do this technique because it takes less time than manually entering them.
Problems with scanning arose initially because the use of multiple barcode formats, sizes and location. The quality of the barcode scanner reader can have an impact on the accuracy of its use. Is the quality of the printed barcoded wristband affecting its scanning capability? It can also be a human factor. Human factors can happen and become a barrier in the proper and successful implementation of a project. It can change its accuracy in scanning a medical record number (MRN). But the question still exists is it better than the old technique? With the survey results, 100% of the bedside nurses prefer to carry out the new technique. They are aware of the error and flaws in the system, but they learned that they need to verify the scanned MRN with the imprinted MRN in the patient’s wristband.
In summing up, in implementing a barcode technology really helps in improving healthcare delivery to our patients. Many of the hospitals are now using barcode scanning in the patient’s wristband, medication administration, laboratory test and even small procedure such as blood sugar fingerstick. These improvements can results to improved satisfaction in the patients as well as the bedside nurses.
All of us personally want safe health care, and most assuredly we want to make certain that our patients have safe care. Safe care means a care that is administered without errors and harm. Error or harm means anything that can have a negative impact on the patient’s well being. Everyone deserves a quality care. To me, it means excellence or has high standards. Within this topic, we can say that safe and quality can be interchangeable. Nevertheless, the emphasis is on safety and the goal is to improve our health care delivery system.
According to Richard Paoletti, director of pharmacy services at Lancaster General Hospital, barcoding implementation is not a stand-alone initiative; it is a cultural change (Kaufman, 2008). It is proven in an observational study in some hospitals that it gives a cost saving of millions of dollars to the organizations. The cost of the barcode scanning machines depends on the institution size. The maintenance, servers, and calibration are needed to be considered when taking a new equipment or machine in any facility. For this project, extra machines or materials are not needed because the Surestep glucometer has it capability of scanning a barcode. The calibration of the machine can be sent to the vendor. What will be the training cost? There will be a minimal training cost since this will happen at the actual bedside nursing care for patients who are requiring blood sugar monitoring. A volunteer will be measuring the time using a stopwatch during the study. There is a minimal cost for this project but will be “avoiding cost associated with treating patients who suffer from preventable medication errors such as length of stay or increased intensive care unit length of stay” (Cummings, et. al., 2005).
Barcode technology will be a standard of care few years from now. Therefore, “hospitals should begin planning, budgeting, evaluating technology and preparing hospital infrastructure” (Cummings, et. al., 2005) in meeting the requirements in barcode technology related to healthcare system.
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