Ocean Medical Center is an acute care hospital with 281 acute beds, 40 rehabilitation beds, 15,339 admissions and 68,000 emergency visits annually. It is part of Meridian Health, a healthcare organization in New Jersey, comprising six hospitals and partner companies.
Recently, hospital leadership recognized the need to use information technology to collect medication safety data. The goal was to find solutions that would aid in the prevention of serious adverse drug events.
In June 2010, with that goal in mind, Ocean Medical Center implemented an electronic medication administration record (eMAR), a system that includes bedside barcode scanning technology to monitor and safeguard the administration of medications.
Not surprisingly, implementation of the new system posed a significant change for the medical staff, pharmacy staff and information technology department. Managing change at a healthcare facility comprised of 530 physicians and 1,400 total team members required buy-in from everyone in the organization. To achieve that support, team members and providers needed to understand how the initiative would benefit not only the hospital, but also their jobs and patients.
Reducing Adverse Drug Events
More than 450,000 adverse drug events (ADEs) occur in hospitals each year, according to a study published in the Journal of the American Medical Association.1 Approximately 34% of those ADEs occur at the time of administration.
In 2010, Ocean Medical Center already had begun to use Computerized Prescriber/Physician Order Entry (CPOE) for approximately 75% of medication orders. With CPOE, pharmacists verify prescriptions in an average time of 33 minutes. Once verified, the clinicians use automated dispensing cabinets that contain 80% of the most common medications used at the hospital.
Reports showed that most of our errors (48%) occurred during the ordering phase. While pharmacists intercepted many of those errors, 36% of errors occurred during the administration process.
So leveraging CPOE was only a first step; hospital leadership wanted to take technology a step further by implementing an eMAR. This system, however, required an additional task in workflow: an electronic bedside medication administration check (MAK), where a healthcare provider scans the barcodes on both a patient's wrist and the medication to help reduce errors at the administration stage.
Essential to any successful MAK transition is education prior to implementation and the achievement of buy-in from all hospital team members - not only the nurses, but also staff in the pharmacy, information technology and respiratory departments. Additionally, administration and leadership must be committed to the project, which included proper education and training for the staff and making sure there was adequate support staff during and immediately after implementation.
To that end, the educators providing MAK training at Ocean Medical Center emphasized the goals of the initiative on both global and personal levels to ensure that everyone was engaged. Those goals were to:
- increase patient safety;
- reduce costs (for the hospital and patients); and
- reduce redundant nursing workflow patterns.
The hospital leadership expected that barcoding and MAK would improve verification of the "5 Rights of Medication Administration," a commonly known memory aid used to help avoid medication errors. Those "rights" are:
- Right drug
- Right patient
- Right dose
- Right route
- Right time
With "5 Rights" as the guiding principle, the new workflow developed at Ocean Medical Center now starts with CPOE, which is verified by a pharmacist. Providers then begin their routes using secure mobile carts, stocked with medications and equipped with a laptop computer and barcode scanner, which they roll to patient bedsides.
The carts, developed by Rubbermaid Medical Solutions, have lockable drawers so nurses can take medications to patient rooms securely, without having to make separate time-consuming stops at the pharmacy for each patient. Through a secure wireless intranet connection, providers access each patient's electronic medical record and complete necessary documentation at the point-of-care.
At the bedside, they scan the medication and patient's wristband barcodes. The eMAR system helps verify the "5 Rights" with color-coded warnings for potential errors.
Although the hospital experienced immediate improvements after implementing MAK, there were unexpected outcomes as well. Some early benefits included the elimination of paper from the medication administration process. The mobile carts also made clinicians more efficient by eliminating steps between patient rooms and medication cabinets or the pharmacy.
Staff at Ocean Medical Center also appreciated having a mobile computing system available to help them remember crucial pieces of information. Managers and administrators often benefit from reports generated by the system that help monitor providers' compliance with the new workflow.
Medication error metrics showed impressive declines soon after implementation. Within the first 3 months:
- administration errors decreased from 36% to 29%;
- moderate-severe administration errors decreased from 35% to 21%; and
- the wrong patient receiving medication decreased from 7% to less than 1%.
Before MAK, the three medications most commonly involved in errors were insulin, hydromorphone and heparin. After the implementation, insulin and heparin were still linked to the most errors, but hydromorphone dropped out of the top three.
Contrary to the hospital's expectations, medication administration omission and wrong-time errors actually appeared to increase after MAK, from 8% to 17%. On closer inspection, it was found that the automation offered current time documentation and made providers more aware of missed or late doses. Late medications now are flagged with a different color in the system, which provides an opportunity to improve.
Aside from the error reduction, other benefits of the MAK implementation include:
- decreased incidental overtime (because workflow is more efficient and documentation is completed immediately);
- more timely documentation (because mobile workstations at the bedside reduce the need to walk to a charting station); and
- an increased perception of provider presence among patients.
Ocean Medical Center's leadership intends to continue studying the data to identify prevented medication errors in order to further refine workflows to better reduce error rates. They share this data with providers in the hopes of continuing to show the value of heeding the system's alerts.
As eMAR processes are rolled out at other Meridian Health facilities, one lesson learned at Ocean Medical Center was evident: encourage buy-in by getting everyone involved early in the process. One of the chief reasons for Ocean Medical Center's eMAR success is that team members quickly understood not only how to use the system, but why it was beneficial - both for them and their patients.
Ensuring the successful use of eMAR technology requires that facilities keep a close eye on key metrics, such as medication ordering or administration error rates, as well as the amount of nursing overtime (which can be indicative of workflow issues). While eMAR may not eliminate all medication administration errors, leveraging technology at the patient bedside certainly can help reduce mistakes and improve workflow efficiency. As Ocean Medical Center has seen, fewer medication errors mean greater patient safety, lower costs and improved patient and team member satisfaction - primary goals at any successful healthcare organization.
Bates, D.W., Cullen, D.J., Laird, N., et al. "Incidence of adverse drug events and potential adverse drug events." JAMA. 1995; 274:29-34
Joan Harvey, DNP, MSN, RN, CCRN, is a nurse educator at Ocean Medical Center, a member of Meridian Health in Brick, NJ.