Name of student: Matriculation number: Personal Tutor: Dr Anne Whittaker Title of study Does Bar-Code Technology in Medication Administration and Dispensing Reduce Medication Errors in Healthcare Setting: A Systematic Review SCQF Level 11 (Masters) No of credit points: 60 Rationale In 2000, the Institute of Medicine (IoM) presented a report – To Err is Human: Building a Safer Health System, and brought to attention the preeminent issues of patient safety and preventable medical errors in the health care system (Institute of Medicine, 2000). It was reported that medical errors could be the leading cause of death and injury and an astonished estimate of 44,000 to 98,000 patients died in hospitals each year due to medical errors; of which medication errors represented the largest single cause, accounting for more than 7000 deaths annually (Institute of Medicine, 2000). Following the release of the report, the emphasis had been placed on the prevention of medical errors, particularly medication errors. To combat the potential risks and causes of medication errors, there had been a proliferation of preventive measures and strategies. Traditionally, methods such as the use of independent double-checking system (Grissinger, 2006), visual alerts, improvising the labelling such as highlighting, colouring, boldfacing, or using “tall-man” lettering; and physical separation of look-alike, sound-alike (LASA) medications were employed (Berman, 2004). In the last decade, the trend had been towards the leverage on information technology in clinical applications to tackle medication errors, such as the use of computerised physician order entry (CPOE) with clinical decision support systems, robots for filling prescriptions, bar-coded systems for medication dispensing and administration, and automated dispensing devices (Ackroyd, Hartnell and MacKinnon, 2005; Agrawal, 2009; Bates, 2000; Kaushal and Bates, 2002; Lafleur, 2004). Many of the healthcare institutions had reportedly benefited from the use of technology in tackling medication errors (Carlson, 2004; Foote and Coleman, 2008; Kester, 2004; Sublett, 2002). Bar-code technology, applied in clinical areas such as medication administration and dispensing, had been identified as a potential strategy to reduce medication errors and improve patient safety. In 2003, with the principal aim of reducing medication errors, the US Food and Drug Administration (FDA) proposed mandatory bar-coding of all drugs and biological products (Food and Drug Administration, 2004). Similarly in 2004, the National Health Services (NHS) in United Kingdom embarked on its strategy to reduce the risks of medication errors through the use of information technology and bar-coding (Department of Health, 2004). FDA estimated that the bar-code rule, when fully implemented, will help to prevent 500,000 adverse events and bring about an economic benefit of $93 billion over a 20-year period (Food and Drug Administration, 2004). In 2007, further reinforcing the drive towards medication safety, the Institute of Medicine (IoM) released the publication– Preventing Medication Errors: Quality Chasm Series, and bar-coding technology was one of the recommendations for the prevention of medication errors in hospital care (Institute of Medicine, 2007). Despite the fact that the benefits of bar-code technology in medication safety may be promising, the implementation of medications bar-coding in clinical applications proves complex as it involves consensus among drug manufacturers regarding a common approach, the collaboration between the healthcare regulator, healthcare institutions and drug manufacturers, the need for multiple systems to interface to allow the databases to communicate; and requires huge financial investments (Kaushal and Bates, 2002; Ragan et al., 2005). Furthermore, the use of bar-code technology in medication administration and dispensing is not error-proof. The utilization of these advances, if not properly planned and applied, can result in limitations and workarounds which potentially can facilitate new medication errors too (Grissinger and Globus, 2004; Koppel et al., 2008). In the context of the Singapore healthcare system, though we actively adopted most of the strategies in the prevention of medication errors, for example double-checking system, improvised labelling, and the use of CPOE; the use of bar-code technology in medication administration and dispensing is slow to evolve. It was only recently did the Singapore healthcare system witness the transformation of integrating bar-code technology into medication administration and dispensing (JCInsight, 2011; Lee, 2008). This slow evolution may be due to the presence of multiple barriers, limited and empiric data to support the efficacy of bar-code technology in the reduction of medication errors to justify the huge financial investments; and a lack of strong government directives. Furthermore, Singapore being a small market, does not present compelling incentives for drug manufacturers to adopt bar-codes on their medications or unit-dose packaging to cater for our local use. With the strong advocacy by the Western counterparts on the clinical use of bar-code technology in medication management, and the eagerness of the other local public healthcare institutions to jump on the bar-code technology bandwagon, it is of great interest to determine the true value of the contributions of bar-code technology in medication safety, in relation to the reduction of medication errors and adverse events prevention. Through the preliminary literature review, it was found that most published literature on the effect of bar-code technology in medication errors reduction and adverse events prevention presented with the limitations of being small scale, cohort studies conducted in single centre, or single unit setting, which are difficult to extrapolate the findings to a wider context. A systematic review, which considers the entirety of available evidence, would be useful to present with a more reliable and precise estimate on the effectiveness of bar-code technology in medication safety. However, a search conducted in the NHS Centre for Reviews and Dissemination (CRD) databases and Cochrane Database of Systematic Reviews (CDSR) yielded only two relevant reviews conducted to date (NHS Centre for Reviews and Dissemination, 2011; The Cochrane Library, 2010). The first one was conducted by Oren, Shaffer and Guglielmo (2003) but the research was completed before FDA and NHS issued directives on the use of bar-code technology in medication administration and dispensing. The second study was conducted by Perras et al. (2009) and the authors had only included studies conducted in hospitals with data collection ended in 2008. It was, hence, identified that there is a need to conduct an updated and complete systematic review, to evaluate the effectiveness of bar-code technology in medication management. There had also been reports of medication errors resulting from the application of bar-code medication administration systems (Pennsylvania Patient Safety Advisory, 2008). The limitations, pitfalls, and new opportunities for errors with the adoption of the bar-code technology would also be taken into consideration, so that the true value of the technology can be evaluated. (1031 words) References: Ackroyd, S., Hartnell, N., MacKinnon, N.J., (2005). Approached to Improving the Safety of the Medication Use System. Healthcare Quarterly. 8, pp. 59- 64 Agrawal, A., (2009). Medication Errors: Prevention Using Information Technology Systems. British Journal of Clinical Pharmacology. 67(6), pp. 681-686 Bates, D.W., (2000). Using Information Technology to Reduce Rates of Medication Errors in Hospital. British Medical Journal. 320, pp. 788-791 Berman, A., (2004). Reducing Medication Errors Through Naming, Labeling and Packaging. Journal of Medical Systems. 28(1), pp. 9-29 Carlson, R., (2004). Setting Safe Standards: Homegrown Bar Coding Medication Administration System Helps VA Hospitals Minimize Mistakes at Point of Care. Health Management Technology. 25(4), pp 30-33 Department of Health, (2004). Building a Safer NHS for Patients - Improving Medication Safety. Available from: http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_4084961.pdf [Accessed 19th July 2011] Food and Drug Administration, (2004). HSS Announces New Requirements for Bar Codes on Drugs and Blood to Reduce Risks of Medication Errors. Available from: http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/2004/ucm108250.htm [Accessed 19th July 2011] Foote, S.O., Coleman, J.R., (2008). Medication Administration: The Implementation Process of Bar-coding for Medication Administration to Enhance Medication Safety. Nursing Economics. 26(3), pp. 207- 210 Grissinger, M., (2006). The Virtues of Independent Double-Checks: They Really Are Worth Your Time! Pharmacy & Therapeutics Journal. 31(9), pp. 492 Grissinger, M., Globus, N.J., (2004). How Technology Affects Your Risk of Medication Errors. Nursing. 34(1), pp. 36- 41 Grissinger, M., (2006). The Virtues of Independent Double-Checks: They Really Are Worth Your Time! Pharmacy & Therapeutics Journal. 31(9), pp. 492 Institute of Medicine, (2000). To Err is Human – Building a Safer Health System. The National Academies Press. Available from: http://www.nap.edu/openbook.php?record_id=9728&page=R1 [Accessed 15th July 2011] Institute of Medicine, (2007). Preventing Medication Errors: Quality Chasm Series. The National Academies Press. Available from: http://www.nap.edu/openbook.php?record_id=11623&page=R1 [Accessed 5th October 2011] JCInsight, (2011). National University Hospital, Tan Tock Seng Hospital Win 2010 National Award - Closed Loop Medication Management System is Honoured for Innovative Use of Technology. JCInsight. Available from: http://www.jointcommissioninternational.org/JCInsight/National-University-Hospital-Tan-Tock-Seng-Hospital-Win-2010-National-Award-Closed-Loop-Medication-Management-System-Is-Honored-for-Innovative-Use-of-Technology/ [Accessed 8th October 2011] Kaushal, R., Bates, D.W., (2002). Information Technology and Medication Safety: What is the Benefit? Quality & Safety in Health Care. 11, pp. 261-265 Kester, M., (2004). Bar Coding at the Bedside. Health Management Technology. 25(5), pp. 42-44 Koppel, R., Wetterneck, T., Telles, J.L., Karsh B.T., (2008). Workarounds to Barcode Medication Administration Systems: Their Occurrence, Causes and Threats to Patient Safety. Journal of American Medical Informatics Association. 15, pp. 408-423 Lafleur, K.J., (2004). Tackling Med Errors with Technology. RN. 67(5), pp. 29-34 Lee, H.C., (2008). Robots to Pack Drugs at Hospitals. The Straits Times. 26th November 2008. Available from: http://www.sgh.com.sg/about-us/newsroom/News-Articles-Reports/2008/Pages/Robots-to-pack-drugs-at-hospitals-The-Straits-Times,-Wed,-pg-B2--20081126.aspx [Accessed 11th October 2011] NHS Centre for Reviews and Dissemination (2011). CRD Databases. Available from: http://www.crd.york.ac.uk/CMS2Web/HomePage.asp [Accessed 21st July 2011] Oren, E., Shaffer, E.R., Guglielmo, B.J., (2003). Impact of Emerging Technologies on Medication Errors and Adverse Drug Events. American Journal of Health-System Pharmacy. 60, pp. 1447-1458 Pennsylvania Patient Safety Advisory, (2008). Medication Errors Occurring with the Use of Bar-code Administration Technology. Pennsylvania Patient Safety Advisory. 5(4), pp. 122-126 Perras, C., Jacobs., P., Boucher, M., Murphy, G., Hope, J., Lefevre, P., McGill, S., Morrison, A., (2009). Technologies to Reduce Errors in Dispensing and Administration in Hospitals: Clinical and Economic Analyses. Technology Report Number 121. Ottawa: Canadian Agency for Drug and Technologies in Health. Available from: http://www.cadth.ca/media/pdf/H0472_med-errors_tr_e.pdf [Accessed 21st July 2011] Ragan, R., Bond, J., Major, K., Kingsford, T., Eidem, L., Garrelts, J.C., (2005). Improved Control of Medication Use with an Integrated Bar-Code-Packaging and Distribution System. American Journal of Health-System Pharmacy. 62, pp. 1075-1079 Sublett, P., (2002). Technology’s Impact on Reducing Medication Errors. Health Management Technology. 23(11), pp. 24-26 The Cochrane Library, (2010). Available from: http://www.thecochranelibrary.com/view/0/index.html [Accessed 21st July 2011] Aim The aims of this study are: 1. To gain a better understanding on bar-code technology and its applications in medication safety, such as its use in bar-code assisted medication administration systems and bar-code assisted medication dispensing systems 2. To display mastery in conducting a systematic review to address the research question of interest 3. To evaluate the effect of using bar-code technology in medication administration and dispensing on medication errors reduction and adverse events prevention through conducting a literature review 4. To determine the extent of the effect (if any), as compared to non bar-assisted medication administration and dispensing methods 5. To identify the limitations and workarounds with the use of bar-code technology in medication administration and dispensing (118 words) Learning outcomes (write time-line if appropriate) 1) Critically explore how bar-code technology had been employed clinically to promote medication safety in areas of medication administration and dispensing, 2) Evaluate the effectiveness of bar-code technology used in medication administration and dispensing in the reduction of medication errors and prevention of adverse drug events through conducting a literature review, 3) Critically appraise the value of bar-code technology in medication safety through the examination of its pitfalls, limitations and potential for creations of new errors. 4) Draw conclusions on the effectiveness of bar-code technology in medication errors reduction and to recommend guidelines for successful implementation of bar-code technology in medication management systems I think these are ok, but 2 and 3 are quite similar, so you may wish to combine them. See how you get on when you start writing up the report, you can always amend this later, it is really just a guide. (107 words) Pattern of activity 1. Develop research proposal 2. Develop Learning Agreement 3. Conduct literature reviews and sourcing for relevant information 4. Retrieval of articles for identified studies 5. Critically analyse and evaluate the information retrieved 6. Collate and synthesise data 7. Submission of formative reports for feedback from project supervisor 8. Develop final project report for submission 9. Perform a reflective exercise on the processes of conducting the project and to develop a reflective commentary (72 words) Sources of information 1. Edinburg Napier University On-line Library (NUINlink) 2. E-Resources - National Library Board, Singapore 3. National University Of Singapore Library 4. WebCT Module Resources 5. Librarian 6. Databases – EBSCO CINAHL, Entrez Pubmed, Medline, JSTOR 7. Internet Search Engines – Google Scholar, Google and Yahoo (43 words) Assessment • Draft for Formative Feedback The drafts shall be submitted for formative feedback by: 1) Learning Agreement – 25th October 2011 2) Project Report – 1st April 2012 3) Reflective Commentary – 22nd April 2012 (27 words) Date due The summative assessment is to be submitted in 3 parts: 1) Learning Agreement – 11th November 2011 2) Project Report – 22nd April 2012 3) Reflective Commentary – 6th May 2012 (28 words) • Nature and length of final assessment Abstract – 250 words Introduction – 1500 words Methodology and data collection (inclusion and exclusion criteria): 1500 words Literature Review/Results – 7000 words Discussion: 1500 words Date of final submission 11th November 2011 Signed (student) Date Signed (tutor) Date Approximately 1468 words