Director of Pharmacy
Stillwater Medical Center
The promise and realisation of improved patient safety using barcoding technology and bedside point-of-care (BPOC) systems for medication administration is driving the acquisition of this technology by hospitals. Before implementing a BPOC system, the hospital pharmacy must address all barcoding challenges and provide a complete solution for all medications the hospital will dispense and administer. This solution must encompass formulary medications, multiple-component medications and nonformulary medications. Nonformulary and multiple-component medications must be barcoded to maintain the same level of safety for all drugs a patient receives. As you will learn, because of their nature, nonformulary and multiple-component medications are the most challenging types of order for the pharmacist in terms of ensuring that the same level of patient safety is maintained. This article will briefly review one hospital’s solution to maintaining a consistent level of safety regardless of whether a medication is on the formulary, is nonformulary or has multiple components. The article is intended to stimulate the reader to think about all possible dispensing situations and the solutions they may need to develop in their hospital.
Stillwater Medical Center is a 120-bed rural, community- owned US hospital providing intensive care, general medical, surgical, maternal/child and rehab/skilled nursing care to our service area. We fill about 500 orders and dispense about 1,400 doses per day. We use a Meditech hospital information system, Pyxis MedStations and the IntelliDOT wireless BPOC system to dispense safely and document medication administration.
There are two types of orders that require a patient-specific barcode as opposed to a drug-specific barcode. Nonformulary medications and multiple-component dosages require a barcode that is specific to that order for the BPOC system to manage their administration properly and safely. Figure 1 shows both types of labels discussed below as examples of how we provide the necessary information.
The first type of order is the nonformulary medication. While we maintain an extensive formulary, some patients require medications that are not on our formulary. If the patient cannot be switched to a drug on our formulary, we either use the patient’s supply from home or obtain a supply from a retail pharmacy. Regardless of the source of supply, the medication must have a barcoded label generated by us and attached to the container for our system to be able to recognise the medication and document its administration by the nurse. We must be able to provide quickly a barcoded supply of the drug without having to enter the nonformulary drug into our Meditech or IntelliDOT drug dictionary databases. The system we developed is flexible and supports continuous order entry “on the fly” without the user having to leave the order entry system for database maintenance.
The second type of order is the pharmacy-prepared, multiple-component dose. Extemporaneous compounds, large-volume parenteral (LVP), total parenteral nutrition (TPN) or intravenous piggyback (IVPB) solutions are all examples of this type of order. Because these are multiple-component orders and the number and strength of the drugs combined will vary, they cannot be tied to only one drug dictionary. But again, the BPOC system must be able to recognise each of these as it would a single drug entity, including a screening for drug–drug and drug–allergy interactions.
The key to success with our system was barcoding individual patient orders for nonformulary and multiple-component drugs. Pharmacy and information systems staff worked together to develop and locate a barcoded drug order number on the patient-specific drug label generated by the Meditech system. We also worked with the IntelliDOT BPOC system vendor to ensure their system would recognise the barcoded order number on the Meditech label. The barcoded order number that Meditech generates and IntelliDOT uses via an interface is the common link between the two systems.
Because the BPOC system will not let a nurse easily administer a drug without our barcoded label, we also are assured that the nurse will send us the patient’s medication before they can give it to the patient. This ensures that the pharmacist has the opportunity to verify the contents of a patient’s prescription bottle.
I have discussed the advantages of this system of barcoding. But, as with any system, there are disadvantages as well. Because we do not enter the nonformulary drug into the Meditech system, the Meditech system cannot automatically screen these orders for drug–drug or drug–allergy interactions. That is left to the pharmacist to do as part of the safety checks before completing the drug order. It is preferable for an automated system to perform this check, and we are thinking of a solution for the future. We learned several lessons as we developed this small but vital piece of our BPOC system:
- Choose a BPOC vendor whose system has the flexibility to adapt to your current practices as much as possible. We found our BPOC vendor to be very cooperative. They were able to adapt to our label requirements, and worked with us to integrate our order number into their system as the link between the BPOC and our Meditech system.
- Thoroughly review your current process and develop and test solutions before you take the system live. We developed this system in order to deal rapidly with the nonformulary and multiple-component orders we receive.
- Remember that you must maintain the same level of patient safety for any medication you dispense and administer in your facility. A BPOC system must be able to provide this safety consistently.
- We had to ensure that the barcoding system did not use number values that might be used elsewhere in our system. We added a leading “N” character to our order number so that the plain order number would never be confused with any other record number containing only numerical values.
- When certain aspects of an order change, the Meditech system will generate a new order with a new order number. Because the labels we generate are for a now-discontinued order, we must generate and apply new labels for the products. This has not caused much extra work but is an important point to remember for inclusion in work processes.
- Finally, remember that no computerised system is totally flexible. You will need to make changes to your processes that, to some extent, will cause your dispensing and administration systems to change. However, in the end your patients’ safety is greatly improved, documentation is more thorough, and nursing and pharmacy staff will work much more closely as a team.
Stillwater Medical Center