By Tom Inglesby

	Sharon Cox, RN, of the Beloit Memorial Medical Surgical Unit takes a reading of her patient's barcoded wristband.

Various reports indicate that the use of barcodes for medication and patient tracking has made a minimal penetration in the critical care environment. Roz Ben-Chitrit, vice president of business development for patient safety at The St. John Companies in Santa Clarita, Calif., comments, "Generally speaking the market has been very slow to adopt, except at some progressive hospitals and health systems, including HCA on the private side and the VA. They've been pretty aggressive in adopting it from a patient safety prospective. It seems to me that people are beginning to move more and more quickly in the direction of using barcoding, for patient wristbands primarily. When we talk about patient safety, I normally think of it as barcoding for point-of-care type applications such as medication administration and lab labeling."

As for statistics, Robert Chadwick, president of Endur ID, Haverhill, Mass., says that the numbers don't look good — yet. "Barcoding is finally starting to take hold. About 10% to 12% of hospitals have barcoding, and the rest of them are looking to implement it soon. Barcode medication management seems to be more mainstream and a required part of medication management."

He adds, "Right now we're replacing a lot of systems or working with a lot of hospitals that have no barcoding presently and are going to barcoding. So our wristbands will be the first barcoded wristbands they've had in-house. Barcoded wristbands are number one, you have to do that first before the rest can be done."

At Beloit Memorial Hospital in Beloit, Wisc., Doris Mulder, vice president of nursing, explains how their facility got started with patient identification. "For us, it started in 2001. At that time, we decided to take a look at our medication administration process from the time the physician thought of the order to the time it was documented by the nurse. We flow charted every single one of those steps, and even though we work with this every day, we were still amazed at all the steps that were there. And, of course, with every step there is a potential for error, so we tried to eliminate some of the steps if we could, if we were being redundant in some way, because then we knew we would also eliminate the opportunity for error to occur."

She recalls, "That was about the same time that the first IOM (Institute of Medicine) study came out talking about the number of medication errors and how many patients are actually harmed by being in the hospital. So we decided to look at CPOE — computerized physician order entry — to see if that might be a good fit for our hospitals and ours physicians."

The results? "It didn't seem to be," Mulder admits. "The software that was out there at that time wasn't that good and many of our physicians weren't open to it. So then we went back to the drawing board and said, 'Okay, let's not look at when the doctor is prescribing orders — if an error is made, then a pharmacist is going to review that, and a nurse is going to review it before he or she gives it — but at the time of administration. As many as 38% of the errors occur there, and there is no second check. A nurse can give a wrong medication and not even be aware of it."

That led to further examination of the flow of medication and medication information. "We started looking at barcoding at the bedside and identifying the patients with the barcodes," Mulder remembers. "We looked at a number of different vendors using an interdisciplinary team. That team chose Care Fusion because we didn't want something that was just going to be a solution for medication, we wanted something that we would eventually be able to use for lab collection, for blood transfusions, for breast milk in the nursery, maybe for specimens in OR, for radiology patients getting contrast, for our dialysis patients. We didn't want to have a tool belt of different things that the nurses had to carry around — we wanted it to be something that could run off a single platform. At that time, Care Fusion was the only company that really had that vision."

The flow chart at Beloit Memorial is fairly typical of barcode usage. According to Mulder, "The patient comes into the hospital, gets an ID band with a barcode in the admitting department. When the nurse is ready to give the medication — ordered by the physician, reviewed by the pharmacist, entered into our system — he or she uses an OmniCell medication dispensing machine. The nurse goes to the OmniCell and identifies the patient and takes out the medications that are due at that time."

At a typical medication pass, he or she would scan the barcode on the nurse ID badge, and then enter another identification that is known only to the nurse. "We do that so if somebody leaves an ID badge lying around or if it falls off of their jacket, nobody can get into our system just by having it," explains Mulder. "So there is a second layer of protection.

Then the nurse scans the patient's wristband. Beloit uses a Symbol Technologies 8800 hand-held that can be set up to display all of the medications due in a given time frame. "We use an hour before and an hour after," says Mulder. "You can look at just the as-needed or PRN medications that are ordered, you can look at just the I.V. medications that are ordered, or you look at everything."

The nurses at Beloit Memorial tend to use the scheduled medications and not look at the PRNs when they are administering meds at a scheduled time. Mulder continues, "The medications that are due will come up, the nurse scans the medications at the patient's bedside, one at a time. If everything is correct, the medication is given to the patient. It is all charted and documented on the electronic medication administration record."

But, if there is a discrepancy in any of the Five Rights that nurses use for medication administration, then a warning sign comes up on the handheld's screen. It will ask the nurse if he or she wants to continue to give this medication. "An example would be 'This medication isn't due for 4 hours. Do you want to continue to give it?'" says Mulder. "There are times when a nurse is acting quicker than the pharmacy can catch up with things, so it doesn't stop you from giving a medication, but if the nurse did want to give the medication at that time, to get through that screen she would have to enter why, such as a physician's order change, or patient's blood pressure dropped, or whatever the reason might be."

While there might seem to be obvious benefits from barcoded wristbands in medication management, there are still problems with them. One is that they might not be there when needed.

Edith Nourse Rogers Memorial Veterans Hospital, Bedford, Mass., is a long-term care facility with wards devoted to Alzheimer's patients, patients with dementia, long-term rehab, psychiatric units and substance abuse. This population presents a challenge for a patient identification — up to 90% of the population was not regularly wearing their wristbands. This wasn't because the staff didn't put them on the patients, but because patients can easily remove the bands.

The facility reviewed products on the market and chose the SecuriCuff from Endur ID. Once implemented, the new barcoded wristbands were found to reverse the previous number with up to 90% of the patients wearing the band at all times. It is thought that moving the bands to the ankle for more difficult patients will improve that figure.

The SecuriCuff has also demonstrated an improved barcode scan rate over a longer period of time. It lasts an average of 3 to 6 weeks, depending on the patient. "It is important to note that in most cases, the band is replaced, not because it is not scanning effectively or has become illegible, but because it is worn or has become stained," claims Chadwick, the president of Endur ID.

In addition, there have been other benefits: an increase in staff satisfaction and an overall increase in patient safety due to the higher patient compliance rate. In regards to patient safety, they have found that the addition of a color photo to the wristband and color-coded allergy, wander, and choke risk warnings also enhance care at the bedside. "In one recent case, a wandering patient was found in much less time because the patient's photo was immediately available to the staff and security," says Chadwick.

The future is looking better for the application of barcodes. Ben-Chitrit at The St. John Companies, notes, "I think it's going to increase, and increase fairly quickly. The idea is, the FDA is requiring pharmaceutical companies to barcode the medications sold to hospitals and many of those would be unit dose medications. Therefore, you avoid the 'chicken and egg thing' of, 'Well, I can't do point of care barcoding for medication administration because there are no medication packages that are barcoded.' Now you lose that."

From a medication administration perspective, you can't implement the system unless your medications all have barcodes on them at the unit dose level. So every eye drop and every pill needs to have a barcode on it. That's expensive for hospitals to implement on their own but because of the FDA ruling, hospitals that were buying their pharmaceutical products in pre-packaged unit dose anyway, are now getting those packages with the barcode on them.

Another improvement that will help implementation is the increased use of 2D barcodes that contain much more information than the traditional multilines-on-a-label version. These high-density barcodes are starting to be noticed. Ben-Chitrit explains, "We have a new system that, when you scan a 2D barcode on the patient wristband, a small portable printer spits out a label with the information that's being gathered from the barcode. The barcode contains a number of different data elements so one barcode can have the patient's name, date of birth, account number, medical record number, etc. JCAHCO requires two identifiers be used and they be evaluated when you're labeling the sample collection container. Our system allows you to scan the patient and print out a label then and there."

There are other applications for barcodes and one of those is charges. Hospitals have a lot of kits and supplies they use in barcoded packages. If those are scanned along with the patient wristband at the time they're used, it's a lot easier to charge back to that patient's account what's been used. "We had somebody ask us if our system could be used for radiology to make sure the orders placed for a patient in the radiology department could be tracked using the wristband," recalls Ben-Chitrit. "Absolutely they can. In our system we can print out a second label that can be put in the chart so the nurse doesn't have to write all the details again. It saves personnel time."

Barcodes can't save lives by themselves but their use, with checks and reviews, can help medical personnel save lives. As Chadwick points out, "Within 5 years, hospital use of barcodes will be at 80 to 90% . Hospitals are starting to see the value, that's the number one reason, but I believe that JCAHO will put out a mandate to do so. They suggested doing one a while ago with a completion date of 2007. Hospitals thought that it was a little to aggressive a schedule and they've backed off for now. They haven't really established a date, but I'm sure that mandate is going to be coming down soon."