Solution Title: Scanning for Accuracy: Validation of NDC Safety Check

Transcription

1 Organization: University of Maryland Medical Center Solution Title: Scanning for Accuracy: Validation of NDC Safety Check Program/Project Description/Goals: With the advancing evolution of technology, the expectation when implementing an information system is that it is not only effective but also safe. The current method to assess the safety of the process in relation to error reporting relies on the human element. Dispensing errors rage from 0-3.6%, with the highest error rates documented in studies involving direct observation. 1 At the University of Maryland Medical Center (UMMC) the pharmacy department dispenses over five million doses annually with a reported error rate of approximately 0.01%. While the dispensing error rate is quite low, due to the high volume of dispensed doses it is estimated that more than 100 undetected dispensing errors may occur daily and only about a third of these errors are caught by nursing. 2 The most frequently reported dispensing errors at our institution are wrong drug and wrong dose. The challenge in dispensing error reporting is the reliance on self-reporting by patient care staff. It is suspected that the true dispensing error rate is under reported in our institution. In the autumn of 2013 the Aethon Inc. requested the beta testing of their new module National Drug Code (NDC) Safety Check system. This system is an expansion of the previously implemented MedEx system used for tracking medication deliveries via the TUG robots and pneumatic tube system. The NDC Safety Check system utilizes a barcode scanning system which matches the pharmacy medication label barcode and the product NDC barcode. This system aims to improve technician and pharmacist filling accuracy. The purpose of this study is to utilize the new technology to determine the true dispensing error rate at our institution. Process: We implemented the NDC Safety Check system pilot program in March 2014 in a 700 bed tertiary academic medical center s one of two 24-hour critical care pharmacy satellites. The satellite dispenses an average of 630 doses per day with an average reported dispensing error of 3 errors per fiscal quarter. The data was collected over a 17 day time period with an aim to attain at minimum 2,500 doses. Implementation: In November February 2014 the system acquisition, software updates, and work flow design took place in order to accommodate the new technology. In March 2014 the NDC Safety Check system was implemented and technicians and pharmacists were trained in the utilization

2 and application of the module. A run-in time period took place March 19, 2014 April 7, 2014, during which system analysis of system limitations and resolution took place as well as the provision of additional supplemental training. Outcomes: The primary objective of the study was to utilize the NDC Safety Check system to measure the first dose dispensing error rate. The secondary outcome was to identify the NDC Safety Check system flaws. NDC Safety Check system is supported by Aethon Inc. which utilizes data collection software via the MedEx system that records the user name, drug scanned, and the outcomes of the scan (Table 1). A total of 14,593 doses were dispensed from a single critical care pharmacy satellite out of which 27% (n=3883) were scanned via the NDC Safety Check system (Figure 1). Out of the scanned doses 87 % (n=3365) were scanned and passed on first attempt, 1% (n = 25) passed on second attempt, 11% (n=438) were false fails, < 1 % (n=12) were skips, and 1% (n=43) were fails (Figure 2). Out of the 43 fails the errors fell into three categories of wrong strength (n=19), wrong drug (n=22), and wrong formulation (n=2) (Figure 3). The encountered system limitations included the utilization of a single source NDC database which is supported by an organization outside of Aethon Inc. and is updated once a month. Another limitation was the legibility of NDC barcodes on the packages of the medications. For such products as inhalers and products in clear plastic bags the barcodes were either not easily accessible or unreadable by the system. Repackaged products by outsource companies provided a challenge in that those companies create unique NDC barcodes for their products that would not be included in any NDC databank. Lastly, the system is limited to a single line item and is unable to account to multiple components of an order such as intravenous preparations and multidose drug orders (i.e., Metoprolol Tartrate 75 mg requires a 25 mg tablet and a 50 mg table to make the order). Table 1: Definitions of Scan Outcomes Outcome Definition Passed Medication label barcode matched NDC barcode on first attempt Second Pass Medication label barcode matched NDC barcode on second attempt False Fail No NDC information available* Fail Medication label barcode did not match NDC barcode on first attempt Skipped NDC scanning skipped** * False fails were due to the system s inability to recognize the scanned barcode ** Reason unknown

3 Figure 1: Scanned vs. Estimated Dispensed Doses Doses Scanned 27% Estimated doses dispensed 73% Estimated doses dispensed were obtained from institutional EMR system, Cerner. Doses scanned was obtained from the MedEx system. Figure 2: System Utilization by Scan Type Fails, 1% (43) False Second Pass, 1% (25) Fails, 11% (438) Skips, <1% (12) Passed, 87% (3365) Data was obtained from the MedEx system database.

4 Number of Doses Figure 3: Dispensing Error Types Data was analyzed based on the detected failure rates. 22 Wrong Strength Wrong Drug Wrong Formulation The reported dispensing error rate for the fiscal year 2013 in our institution was %, the NDC Safety Check detected a dispensing error rate of 1.1%. Historically the most frequently seen dispensing errors involved wrong drug and wrong dose, in addition the system detected wrong formulations. Sustainability: The challenges faced with the system was the maintenance of the NDC database. Currently Aethon Inc. utilizes as single source for its NDC database reference which is updated once a month. With the current drug shortages and ever changing generic drug availability from various manufacturers such commercially available databases are unable to keep up with the most current NDCs. The alternative is to maintain the NDC database in-house and utilize the commercially available databases as a reference point. The other hurdle that this system faces is repackaging of products into unit doses which results in unique NDC s assigned to the repackaged product. Currently we are working with Aethon Inc. to develop a barcode scanning algorithm that would be able to detect changes in the repackaged NDC barcodes in order to streamline the barcode recognition by the system with minimal manual maintenance. Therefore the sustainability and the expansion of this project highly dependent on the ease of barcode recognition by the system. Role of Collaboration and Leadership: This was an internal effort within the pharmacy department to reduce dispensing errors. The implementation and sustainability was highly reliant on the participation of the pharmacy technicians, clinical pharmacists, Critical Care Pharmacy Manager, Pharmacy IT department, 2

5 and Pharmacy Leadership. Pharmacy leadership provided authorization for funds to purchase necessary equipment as well as provided support of the vision to decrease dispensing errors. Innovation: What makes this solution innovative is that while barcode scanning is utilized in various aspects of drug dispensing it has not been utilized in the dispensing of first doses from the inpatient pharmacy. Currently first dose dispensing is highly reliant on the accuracy of the technician filling and pharmacist checking. The NDC Safety Check provides a source of error detection and prevention by automating the fill process. This system also provides insight into the true dispensing error rate which opens up for opportunities of improvement that may not have otherwise been detected.