Stopping Errors at ‘The Pointy End of the Stick’

A nurse hangs another IV bag and prepares to hit the start button on the infusion pump — she’s entering 15 cc’s and as she taps the numbers in, she believes her entry for the number 5 didn’t take, so she hits it again and begins the intravenous infusion into her patient.

She leaves the room. The pump has been programmed at 155 cc’s because she unwittingly punched numeral 5 twice.

“It happens every day — people just don’t realize it,” said Regan Baron, R.N., national sales manager, Bedside Care at Cerner Corp. “According to a study some years back, 51 percent of the errors that cause the real morbidity and mortality happen at the IV pump.”

Want to keep more patients safe from harm and even death caused by medication errors? Clinicians, IT professionals and device manufacturers agree there’s a certain and infallible way to see instant reduction in these tragic events — implementation of bar coding at the point of care (POC) and the latest leap for the technology today is at the IV.

CIOs say their No. 1 priority right now is to reduce medical errors and promote patient safety, according to the 2006 HIMSS Leadership Survey sponsored by ACS Healthcare Solutions. And one of the top applications they intend to adopt by the end of 2007 is bar coded medication management.

But the real adoption figures don’t seem to line up: only 20 percent of U.S. hospitals are live or contracted with bar coded POC (BPOC) systems today — it’s pretty much of a 50-50 split, meaning only 10 percent are live and 10 percent have selected their BPOC vendor.

It begs the questions: What’s going on with the other 80 percent of hospitals and what are they doing with FDA’s April ‘06 requirement for medication manufacturers to put a bar code on every med?

“You would think that [hospital BPOC adoption] is 90 percent,” said Baron. “We’ve been bar coding our green beans for 30 years. It’s crazy, but healthcare is always slow to adopt technology. Hospitals have so much on their plates that they start in other areas and it is also a massive process change for the organization to go to bar coding.”

Administering IV is, of course, a more complex and involved process than the discreet, singular event of giving a shot or a pill, which is not repeated for another six hours or so. With an IV, there are numerous interactions, reprogrammings and rate or dosage adjustments, not to mention nurse shift changes, which, compiled, create a continuous administration process.

And, borrowing from the lingo of the airline industry’s crew resource management techniques, nurses find themselves at the ‘pointy end of the stick,’ says Dawn Straub, R.N., CNNA, B.C., director of Nursing Resources and Development, The Nebraska Medical Center. Her hospital has partnered with Cardinal/Alaris in the testing and development of the company’s IV First system.

“It’s the point where the medication actually gets to the patient, that responsibility [despite] everything that has happened prior — it all culminates right there,” said Straub. “What is our final check to help that nurse, right at that pointy end when a mistake will actually get to the patient? That is why [BPOC] is so important.”

Too Important to Ignore

The immeasurable patient safety benefits of incorporating bar coding into IV pumps are everyone’s No. 1 reason for praising and using the technology, but money is one of the top reasons hospital administrations have not acquired it. Hospitals also complained loudly when JCAHO made recommendations for BPOC two years ago, says Baron, but she believes that stronger JCAHO language, public awareness and a unified demand from clinicians and administrators would lead to more rapid adoption.

“Nobody can make a case to say that bar coding doesn’t make sense,” said Baron. “Everybody said [in response to JCAHO’s recommendations] ‘that’s too soon, that’s too strongly worded and we can’t get it done.’ The fact of the matter is there are many suppliers of bar coding software out there today. It is not expensive technology when you look at the ROI and the cost savings in the patient safety aspect of it. It pays for itself in the first 12 months.”

Some of the leading BPOC technologies for IV pumps in the market today include:

• IV First from Alaris (Cardinal Health),

• MedNet Safety Software from Hospira and

• Bridge Medication Administration and Millennium POC from Cerner.

Tim Vanderveen, PharmD, MS, vice president, Cardinal Health’s Center for Medication Safety and Clinical Improvement, indicated that his company expects to launch its newest IV BPOC development in the near future — Directed IV Orders, not commercially released yet, will created a seamless process from physician’s order through the pharmacy review to the bedside, with information transmitting wirelessly to the infusion device.

Indeed industry is driving the technology toward that next level of sophistication. Barbara Trohimovich, RPh, director, Clinical Development, Medication Management Systems at Hospira, says that the next advance will be the incorporation of wireless communication into IV infusion pumps.

“It will open a whole new world for this group of devices,” she said. “The wireless technology gives us the ability to develop server-based systems that can offer the decision support capabilities along with the positive identification provided by bar code scanning.”

With built-in layers of guardrails that ensure the 5 Rights of safe medication administration — including scanning of nurse badge, patient wristband and IV bag — IV BPOC systems also facilitate (or will in the near future) automated documentation of the nurse’s interactions with the IV.

Baron at Cerner says that an additional enhancement to nurse workflow entails linkage of the medication cabinet to the IV BPOC, enabling the nurse to know, before even approaching the patient's room, that (s)he has the right med for the right patient in the right dose at the right time and, because all data is scanned and sent straight to the pump, the pump is always programmed correctly.

What’s Next

The future of IV BPOC may actually hinge on the arrival and acceptance of something that replaces the bar code, some sources believe. Both Trohimovich and Straub point to RFID (radio frequency identification) technology as the ultimate, ideal enterprise-wide solution.

“As RFID becomes more affordable, it will revolutionize the way hospitals track and monitor assets, including infusion devices,” said Trohimovich.

Easier to scan (especially on the patient) than a bar code, says Straub, RFID offers the advantage of putting more information into a tiny chip, and “the potential for it to streamline from the scanning perspective is great. Plus, a lot more information can be held in an RFID chip related to back-end processing, inventory, expirations dates, etc.,” said Straub.