Bar Code Medication Administration BCMA Pharmacy Troubleshooting

1. VEHU 215 August 22, 2007 1 Bar Code Medication Administration (BCMA) � Pharmacy Troubleshooting Ron Schneider, R.Ph. Daphen Shum, R.Ph. Good afternoon, I�m Ron Schneider, Pharmacist Consultant with the Bar Code Resource office. My co presenter is Daphen Shum, pharmacy ADPAC and BCMA C from Perry Point Maryland. Our presentation is �A Fistful of Bar codes�Good afternoon, I�m Ron Schneider, Pharmacist Consultant with the Bar Code Resource office. My co presenter is Daphen Shum, pharmacy ADPAC and BCMA C from Perry Point Maryland. Our presentation is �A Fistful of Bar codes�

2. VEHU 215 August 22, 2007 2 Objectives Bar Code Program Office update Discuss Equipment Purchasing Directive 2006-069 To understand the purpose of the Bar Code Quality Directive To review enterprise results of the Bar Code Quality Directive

3. VEHU 215 August 22, 2007 3 Objectives To learn helpful hints for trouble shooting BCMA issues (pharmacy and nursing) To understand the Closed Loop Verification Program Discuss results of the Closed Loop Verification Program

4. VEHU 215 August 22, 2007 4 BCMA Program Office nowThe Bar Code Resource Office(BCRO) Why change the name? In my introduction, I stated that I was from the Bar Code Resource Office (BCRO) not the BCMA Program Office as so many of you knew us. Why did we change the name of something so familiar to everyone?In my introduction, I stated that I was from the Bar Code Resource Office (BCRO) not the BCMA Program Office as so many of you knew us. Why did we change the name of something so familiar to everyone?

5. VEHU 215 August 22, 2007 5 Bar Code Resource Office (BCRO) BCP (formerly BCE) added Experts on bar codes for the VA Standardization of products that read, print or have bar codes on them Liaison with suppliers, GS1 and FDA for product improvements First we have become the surrogate business owners for the Bar Code Project which is the new name for the Bar Code Expansion Project. The first 3 applications WMA, CareVue and CareAssist are currently being deployed to 16 sites this year. All the applications utilize a PDA device. The BCRO has been designated as the experts on bar code products within the VA The BCRO is working to standardize the products that utilize BCMA for all VA medical Centers. Finally the BCRO has become the liaison with suppliers of pharmaceuticals, Global Standards 1(an international bar code quality group) and the FDAFirst we have become the surrogate business owners for the Bar Code Project which is the new name for the Bar Code Expansion Project. The first 3 applications WMA, CareVue and CareAssist are currently being deployed to 16 sites this year. All the applications utilize a PDA device. The BCRO has been designated as the experts on bar code products within the VA The BCRO is working to standardize the products that utilize BCMA for all VA medical Centers. Finally the BCRO has become the liaison with suppliers of pharmaceuticals, Global Standards 1(an international bar code quality group) and the FDA

6. VEHU 215 August 22, 2007 6 VHA Directive 2006-069 Purchasing Bar Code Scanners, Wristband Printers and Wristband Media Standardize products Requires facilities to purchase only BCRO approved equipment Replacement equipment only Directive located on BCRO website http://vaww1.va.gov/bcmapmo/ I am going to spend several minutes discussing VA Directive 2006-069. This is the first attempt to standardize BCMA equipment. It deals with scanners, printers and wristband media. When we first started BCMA, there were no guidelines for purchasing equipment or how to compare equipment specifications. Those days are over! Our office has spent a lot of time developing criteria to analyze and grade the products used in BCMA. All products are compared in the same way against the same criteria. In this way the sites do not have to spend the time or their resources to test equipment. This Directive applies when ever you replace your equipment. You must select from our approved list. We are constantly evaluating new products.I am going to spend several minutes discussing VA Directive 2006-069. This is the first attempt to standardize BCMA equipment. It deals with scanners, printers and wristband media. When we first started BCMA, there were no guidelines for purchasing equipment or how to compare equipment specifications. Those days are over! Our office has spent a lot of time developing criteria to analyze and grade the products used in BCMA. All products are compared in the same way against the same criteria. In this way the sites do not have to spend the time or their resources to test equipment. This Directive applies when ever you replace your equipment. You must select from our approved list. We are constantly evaluating new products.

7. VEHU 215 August 22, 2007 7 Approved BCMA Equipment Scanners HHP 4600 wired SF HHP 4620 VA wireless Wristband printers Blaster Advantage 242003 Intermec Easy Coder� 3400 Zebra TLP 28442 Wristband media PDC Compuband� PDC Sentry� 5080 Endur ID� Laser Band� LB2 Adult L3 Laser Band�LB2 Adult LTC

8. VEHU 215 August 22, 2007 8 Bar Code Quality Directive for Unit Dose Packaging and Bar Code Labeling Developed in 2005 February 9, 2006- Approved by Dr Perlin Baseline data requested from all sites by March 31, 2006 This required observing the scanning of 200 doses within six monitors. One hundred (100) doses will be observed in Pharmacy; the remaining 100 doses will be observed at the point-of-care. First quarterly reporting period- April 1-June 30 2006 The Bar Code Quality Directive is a favorite topic of mine. That�s because I helped design it and I get to tabulate the data every quarter. It was designed by 8 pharmacists and a representative from NCPS. It was approved in Feb 2006 by then Under Secretary for Health Jon Perlin. Since we had no idea where we stood as an enterprise, he asked for a Baseline data collection period. No one else had tried anything like this so we did not know what to expect. We asked for 200 scans, 100 from each of the pharmacy monitors which I will discuss shortly and 100 direct observations of the nurses.The Bar Code Quality Directive is a favorite topic of mine. That�s because I helped design it and I get to tabulate the data every quarter. It was designed by 8 pharmacists and a representative from NCPS. It was approved in Feb 2006 by then Under Secretary for Health Jon Perlin. Since we had no idea where we stood as an enterprise, he asked for a Baseline data collection period. No one else had tried anything like this so we did not know what to expect. We asked for 200 scans, 100 from each of the pharmacy monitors which I will discuss shortly and 100 direct observations of the nurses.

9. VEHU 215 August 22, 2007 9 Bar Code Quality Directive Objectives: Ensure that all products from Pharmacy are in the VistA drug synonym file Establish a procedure to identify and correct problem bar codes in Pharmacy before they reach the point-of-care Reduce scanning circumvention at the point-of-care Improve BCMA system reliability and user confidence 95% compliance rate What were the objectives for this Directive. First we wanted to make sure that a process was in place to add products to the VistA drug file. We knew the FDA regulation would require bar codes on increased products and we did not want to have products fall through the cracks. A procedure was needed to identify products that would not scan and correct them before they got to the end user. It was hoped that these measures would increase the reliability in using BCMA and reduce the circumvention of scanning. A 95% acceptance rate was established as the target goal for each monitor.What were the objectives for this Directive. First we wanted to make sure that a process was in place to add products to the VistA drug file. We knew the FDA regulation would require bar codes on increased products and we did not want to have products fall through the cracks. A procedure was needed to identify products that would not scan and correct them before they got to the end user. It was hoped that these measures would increase the reliability in using BCMA and reduce the circumvention of scanning. A 95% acceptance rate was established as the target goal for each monitor.

10. VEHU 215 August 22, 2007 10 Pharmacy Quality Control Monitors Verifies the machine readability of bar code labels on pharmacy- dispensed medications Two Monitors for Manufacturer Packaging Pharmacy Controlled Substance Monitor Manufacturer�s Bar Code Monitor There are 2 pharmacy monitors for products that come into pharmacy with a bar code. The first is the Controlled Substances Monitor and the second is the Manufacturers monitor. I am often asked why the 2 monitors are separate and not combined since most CS are manufacturers products. There are 2 reasons, first is that the CS products are high risk so we did not want them to be missed when a sample of products is scanned. Second is that since the products are in the vault, we do not want them transported elsewhere in the pharmacy to be scanned.There are 2 pharmacy monitors for products that come into pharmacy with a bar code. The first is the Controlled Substances Monitor and the second is the Manufacturers monitor. I am often asked why the 2 monitors are separate and not combined since most CS are manufacturers products. There are 2 reasons, first is that the CS products are high risk so we did not want them to be missed when a sample of products is scanned. Second is that since the products are in the vault, we do not want them transported elsewhere in the pharmacy to be scanned.

11. VEHU 215 August 22, 2007 11 Three Monitors for Pharmacy Labeled Packaging 1. Intravenous (IV) Labeling Monitor 2. Automated Unit Dose Packaging Monitor 3. Pharmacy Relabeled Monitor The Directive has 3 other pharmacy monitors. We have a monitor for IV label testing, testing the print quality of the ATC machines and testing the print quality of other products that pharmacy may re-label.The Directive has 3 other pharmacy monitors. We have a monitor for IV label testing, testing the print quality of the ATC machines and testing the print quality of other products that pharmacy may re-label.

12. VEHU 215 August 22, 2007 12 End User Quality Monitor BCMA Coordinator or designee validates the scanning process at the point-of-care Observes scanning of representative sample sizes for each of the Pharmacy Quality Control Monitors The last monitor is direct observation of the scanning of products by the nurse at the point of care. It validates all the hard work that pharmacy is doing for the Directive. The end user observation should be a representative sample across all the pharmacy monitors.The last monitor is direct observation of the scanning of products by the nurse at the point of care. It validates all the hard work that pharmacy is doing for the Directive. The end user observation should be a representative sample across all the pharmacy monitors.

13. VEHU 215 August 22, 2007 13 Testing Recommendations Pharmacy Controlled Substance Monitor �There is no set number of items scanned for the denominator. Manufacturer Barcode Monitor - 30 items per 5-day work week x 4wks/mo x 3mo/qtr = 360 items per quarter IV Labeling Monitor �3 items per 5-day work week x 4wks/mo x 3mo/qtr = 180 items per quarter Automated Unit-Dose Packaging Monitor - 3 items per 5-day work week x 4 wks/mo x 3mo/qtr = 180 items per quarter Pharmacy Re-labeling Monitor � �30 items per 5-day work week x 4wks/mo x 3mo/qtr = 360 items per quarter End User Monitor � 20 items per quarter x each of the 5 types of packaging listed above = 100 items per quarter This slide lists the BCRO recommendations for the number of scans to report each quarter. You can read them so I will not repeat them to save time. We realize that due to staff shortages, vacations, etc you may not reach these numbers each quarter. The exact numbers that you report are not set in stone. The process of monitoring and having a quality management program is the key to reducing circumvention. is the most important feature of the Directive.This slide lists the BCRO recommendations for the number of scans to report each quarter. You can read them so I will not repeat them to save time. We realize that due to staff shortages, vacations, etc you may not reach these numbers each quarter. The exact numbers that you report are not set in stone. The process of monitoring and having a quality management program is the key to reducing circumvention. is the most important feature of the Directive.

14. VEHU 215 August 22, 2007 14 Baseline CS 91% Manufacturer 91% IV Label 98% ATC 99% Re-label 97% End User 93% Overall Success 95% 3rd Quarter FY 2007 CS 99% Manufacturer 98% IV Label 100% ATC 100% Re-labeled 100% End User 98% Overall Success 99% Directive Result Percentage Success So how have we done? This slide compares the Directive results from the Baseline Period with the 3rd quarter FY 2007. We had 3 monitors that caused problems during the Baseline collection period. The CS, the manufacturer and the end user monitors all fell below the 95% compliance goal. Look at the changes by the 3rd quarter FY 2007. We have really made great improvements. Notice that the same 3 monitors still lag behind the other monitors success rate.So how have we done? This slide compares the Directive results from the Baseline Period with the 3rd quarter FY 2007. We had 3 monitors that caused problems during the Baseline collection period. The CS, the manufacturer and the end user monitors all fell below the 95% compliance goal. Look at the changes by the 3rd quarter FY 2007. We have really made great improvements. Notice that the same 3 monitors still lag behind the other monitors success rate.

15. VEHU 215 August 22, 2007 15 Comparison Results Sometimes a graph of the information shows the improvement even more dramatically then just seeing the numbers.Sometimes a graph of the information shows the improvement even more dramatically then just seeing the numbers.

16. VEHU 215 August 22, 2007 16 Interpretation of Results 600,000 medications administered per day While 24,600 more products consistently scan there are 15,600 (2.6%) that remain problematic each day

17. VEHU 215 August 22, 2007 17 Facilities Achieving 95% Threshold Baseline CS 57% Manufacturer 51% IV Label 80% ATC 86% Re-label 83% End User 56% Overall Success 77% 3rd Quarter FY 2007 CS 74% Manufacturer 74% IV Label 88% ATC 88% Re-labeled 89% End User 81% Overall Success 91% This is the most important slide in this portion of my talk. It shows the % of facilities that met the 95% compliance rate in each monitor. In the beginning, a little over � of the facilities scored 95% or greater in the CS, manufacturer and end user monitors. Look at the increase for the 3rd quarter fy 2007. It is increasing but we still have a long way to go. This is only one of the reasons that we most continue our efforts with the Directive.This is the most important slide in this portion of my talk. It shows the % of facilities that met the 95% compliance rate in each monitor. In the beginning, a little over � of the facilities scored 95% or greater in the CS, manufacturer and end user monitors. Look at the increase for the 3rd quarter fy 2007. It is increasing but we still have a long way to go. This is only one of the reasons that we most continue our efforts with the Directive.

18. VEHU 215 August 22, 2007 18 Facilities Achieving 95 % ThresholdProblem Monitors Sometimes a graph of the information shows the improvement even more dramatically then just seeing the numbers.Sometimes a graph of the information shows the improvement even more dramatically then just seeing the numbers.

19. VEHU 215 August 22, 2007 19 BCMA Problem Solving / Troubleshooting Pharmacist�s Impact on BCMA When a Nurse Calls � what is a pharmacist to do? Best Practices Let�s look at BCMA from the view of the Pharmacy We�ll take a look at troubleshooting � if a nurse calls Pharmacy with a problem, what can the pharmacist do to determine where the problem is We�ll also consider some best practices�.. Let�s look at BCMA from the view of the Pharmacy We�ll take a look at troubleshooting � if a nurse calls Pharmacy with a problem, what can the pharmacist do to determine where the problem is We�ll also consider some best practices�..

20. VEHU 215 August 22, 2007 20 Pharmacist�s Impact Medication orders are basis of BCMA Order does not appear on BCMA until finished by Pharmacy How the order is finished affects what the Nurse sees in BCMA How does the pharmacist impact BCMA? JCAHO requires that a pharmacist reviews ALL medication orders prior to administration to a patient (except in emergent situations) How does the pharmacist impact BCMA? JCAHO requires that a pharmacist reviews ALL medication orders prior to administration to a patient (except in emergent situations)

21. VEHU 215 August 22, 2007 21 Pharmacist�s Impact Order affects what is available from automated dispensing cabinets (Pyxis, Omnicell, etc) Start / Stop date / times Admin Time How an order is finished � affects what is available at the automated dispensing cabinets What is stocked � controlled subs only, prn / starter doses? How is stock identified to the finishing pharmacists? Consider what dosages are stocked � affect the �# of units� of dispense drug on the order Start / Stop date / times; Admin times all affect when the order appears in BCMA�..How an order is finished � affects what is available at the automated dispensing cabinets What is stocked � controlled subs only, prn / starter doses? How is stock identified to the finishing pharmacists? Consider what dosages are stocked � affect the �# of units� of dispense drug on the order Start / Stop date / times; Admin times all affect when the order appears in BCMA�..

22. VEHU 215 August 22, 2007 22 Let�s take a look at the start times --- The start date / time determine when the order is first available on the VDL REQUESTED start is when the calculated start date/time. For a DAILY order with an Admin time of 9AM, the calculated start will be 9AM on the same day, if the order was entered before 9AM. If the order was entered AFTER 9AM, the calculated start will be at 9AM on the next day�� Let�s take a look at the start times --- The start date / time determine when the order is first available on the VDL REQUESTED start is when the calculated start date/time. For a DAILY order with an Admin time of 9AM, the calculated start will be 9AM on the same day, if the order was entered before 9AM. If the order was entered AFTER 9AM, the calculated start will be at 9AM on the next day��

23. VEHU 215 August 22, 2007 23 BCMA VDL (GUI) viewStart Date / Time This is the BCMA view you can see that the Aspirin order is not available for administration on 7/11 This is the BCMA view you can see that the Aspirin order is not available for administration on 7/11

24. VEHU 215 August 22, 2007 24 BCMA VDL (GUI) viewStart Date / Time Aspirin is on the VDL on 7/12.Aspirin is on the VDL on 7/12.

25. VEHU 215 August 22, 2007 25 Looking at an �odd� schedule - Q3D (with a standard Admin Time of 9AM) � you can see that the calculated start will be available +3days @ 9AM if entered after 9AM. This may or may not be the intention of the provider entering the order. While entering the order via CPRS, the provider is notified of the date / time of the �expected first dose�, however, we�re not sure how many providers actually read that�� Looking at an �odd� schedule - Q3D (with a standard Admin Time of 9AM) � you can see that the calculated start will be available +3days @ 9AM if entered after 9AM. This may or may not be the intention of the provider entering the order. While entering the order via CPRS, the provider is notified of the date / time of the �expected first dose�, however, we�re not sure how many providers actually read that��

26. VEHU 215 August 22, 2007 26 If it is to start the next morning, the Start date/ time must be edited Entering a start TIME at or before 9AM will make the order available on the date specified. If the start TIME is 9AM, it will not be available on BCMA until 8AM (1 hour early) � assuming that the BCMA site parameter is set up to allow administration of meds 60 minutes before the Admin Time. Using an earlier �start� time will allow the nurse to view the order earlier than med pass time The REQUESTED start does NOT change��. If it is to start the next morning, the Start date/ time must be edited Entering a start TIME at or before 9AM will make the order available on the date specified. If the start TIME is 9AM, it will not be available on BCMA until 8AM (1 hour early) � assuming that the BCMA site parameter is set up to allow administration of meds 60 minutes before the Admin Time. Using an earlier �start� time will allow the nurse to view the order earlier than med pass time The REQUESTED start does NOT change��.

27. VEHU 215 August 22, 2007 27 The Dispense drug & Units dispense affect what the nurse is asked to scan. What is dispensed must be what the order states � if pharmacy is OOS on a particular strength & an alternate needs to be dispensed, the order MUST be adjusted accordingly. In this case, if clonidine 0.1mg tabs were to be dispensed, the Dispense Drug must be changed. If not changed, scanning the 0.1mg will give an error of �drug not found� & if the nurse decides to administer it based on the package & order information available, that is technically a workaround - NOT good. Note � JCAHO is now requiring the dispensing of the dose as ordered, so Pharmacy will have to split & repackage tablets soon. Also, some states do not allow nursing to split tabs��.. . The Dispense drug & Units dispense affect what the nurse is asked to scan. What is dispensed must be what the order states � if pharmacy is OOS on a particular strength & an alternate needs to be dispensed, the order MUST be adjusted accordingly. In this case, if clonidine 0.1mg tabs were to be dispensed, the Dispense Drug must be changed. If not changed, scanning the 0.1mg will give an error of �drug not found� & if the nurse decides to administer it based on the package & order information available, that is technically a workaround - NOT good. Note � JCAHO is now requiring the dispensing of the dose as ordered, so Pharmacy will have to split & repackage tablets soon. Also, some states do not allow nursing to split tabs��.. .

28. VEHU 215 August 22, 2007 28 On the BCMA view, DU of 0.5 or � tab � generates a Fractional Dose pop-up to remind the nurse of the need to split the tab for the doseOn the BCMA view, DU of 0.5 or � tab � generates a Fractional Dose pop-up to remind the nurse of the need to split the tab for the dose

29. VEHU 215 August 22, 2007 29 Multiple dispense drugs may be dispensed to make up the required dose � example - dose of simvastatin 15mg � may dispense 1.5x10mg tabs or 1x5mg & 1x10mg or 3x5mg Consider � minimum number of units for administration, cost, easier for nurse admin? Again, What is dispensed MUST be what the order states�..Multiple dispense drugs may be dispensed to make up the required dose � example - dose of simvastatin 15mg � may dispense 1.5x10mg tabs or 1x5mg & 1x10mg or 3x5mg Consider � minimum number of units for administration, cost, easier for nurse admin? Again, What is dispensed MUST be what the order states�..

30. VEHU 215 August 22, 2007 30 Multiple dispense drug � also generates a Multiple Dose pop-up box You can see that the 5mg is already checked as given, and it is prompting for the 10mg tabMultiple dispense drug � also generates a Multiple Dose pop-up box You can see that the 5mg is already checked as given, and it is prompting for the 10mg tab

31. VEHU 215 August 22, 2007 31 Pharmacist�s ImpactDay of the week schedule Day of week schedule � if a schedule such as �weekly� is used, a comment noting the day of the week is necessary along with the adjustment of the appropriate Start date to make it clear when the patch is due. Day of week schedule � if a schedule such as �weekly� is used, a comment noting the day of the week is necessary along with the adjustment of the appropriate Start date to make it clear when the patch is due.

32. VEHU 215 August 22, 2007 32 Pharmacist�s ImpactDay of the week schedule An alternative � best practice to use MON@0900 rather than WEEKLY. No ambiguity. Software will calculate the start date.An alternative � best practice to use MON@0900 rather than WEEKLY. No ambiguity. Software will calculate the start date.

33. VEHU 215 August 22, 2007 33 Pharmacist�s ImpactProvider comments / Special Instructions Back to Provider comments � they may be copied into Special instructions Special instructions appear in RED in BCMA for the nurse. -- ! Or not? � pop-up box? Flagging appears on BCMA as a pop-up box to remind the nurse of he special instruction. It is up to pharmacist�s judgment what should be flagged. Reminder � pharmacist MUST READ the comments � the provider may enter comments to the pharmacist / nurse providing further instructions, for example adjustments in the standard Admin Time Special instruction may also be used by the pharmacists to give directions to the nurse. - Sliding scale details, IV titration, check pulse? Take with food? etc Back to Provider comments � they may be copied into Special instructions Special instructions appear in RED in BCMA for the nurse. -- ! Or not? � pop-up box? Flagging appears on BCMA as a pop-up box to remind the nurse of he special instruction. It is up to pharmacist�s judgment what should be flagged. Reminder � pharmacist MUST READ the comments � the provider may enter comments to the pharmacist / nurse providing further instructions, for example adjustments in the standard Admin Time Special instruction may also be used by the pharmacists to give directions to the nurse. - Sliding scale details, IV titration, check pulse? Take with food? etc

34. VEHU 215 August 22, 2007 34 Pharmacist�s ImpactComplex Orders Complex orders � changes allowed only before verification. After verification, if any changes are needed, even if only the Admin Time, the whole series of orders will need to be to re-entered. Exception - special instruction Complex orders � changes allowed only before verification. After verification, if any changes are needed, even if only the Admin Time, the whole series of orders will need to be to re-entered. Exception - special instruction

35. VEHU 215 August 22, 2007 35 Pharmacist�s ImpactComplex Orders Complex prednisone titration order � software calculates the start / stop date & time for each component of the titrationComplex prednisone titration order � software calculates the start / stop date & time for each component of the titration

36. VEHU 215 August 22, 2007 36 Pharmacist�s ImpactComplex Orders The provider comments are available to be placed on all components of the order, however, it may not be appropriate for this particular order component, So I would not include it.The provider comments are available to be placed on all components of the order, however, it may not be appropriate for this particular order component, So I would not include it.

37. VEHU 215 August 22, 2007 37 Pharmacist�s ImpactComplex Orders You can see the start / stop date / time calculation. They may be edited at this point.You can see the start / stop date / time calculation. They may be edited at this point.

38. VEHU 215 August 22, 2007 38 Pharmacist�s ImpactComplex Orders Special instruction appropriate for the last order component.Special instruction appropriate for the last order component.

39. VEHU 215 August 22, 2007 39 Pharmacist�s ImpactComplex Orders 3 orders are generated, with the appropriate dates.3 orders are generated, with the appropriate dates.

40. VEHU 215 August 22, 2007 40 Pharmacist�s ImpactComplex Orders You are able to edit the special instructionsYou are able to edit the special instructions

41. VEHU 215 August 22, 2007 41 Pharmacist�s ImpactComplex Orders Admin Time may NOT be edited. Start/Stop date/times may NOT be editedAdmin Time may NOT be edited. Start/Stop date/times may NOT be edited

42. VEHU 215 August 22, 2007 42 When a Nurse calls Bar code won�t scan Order is not in BCMA Administered med on Missed Med report Order doesn�t make sense After scanning, pt refused, cannot find order to �unmark� If a nurse calls with a problem, what is the pharmacist to do. Some potential problems:If a nurse calls with a problem, what is the pharmacist to do. Some potential problems:

43. VEHU 215 August 22, 2007 43 Identify drug / package Check stock in the Pharmacy for the same Check scannability Check scanner � fully charged, wireless scanner matched to right base, recalibration needed? Problematic location � particular area on ward / �dead� zone? Bar code won�t scan When a nurse calls and say that Bar code doesn�t scan- If it scans in pharmacy � check scanner on the ward When a nurse calls and say that Bar code doesn�t scan- If it scans in pharmacy � check scanner on the ward

44. VEHU 215 August 22, 2007 44 Bar code won�t scan Manufacturer bar code Bar code type � linear vs stacked Is bar code in the Drug File? Is bar code in Drug File on more than 1 drug? Replacement with mandated scanners Enter bar code Remove bar code from incorrect drug Nurse can scan the bar code into an e-mail, send to pharmacy ADPAC (even if the bar code is not linear) Can check for bar code prefixesNurse can scan the bar code into an e-mail, send to pharmacy ADPAC (even if the bar code is not linear) Can check for bar code prefixes

45. VEHU 215 August 22, 2007 45 Bar code won�t scan Pharmacy automated / manually bar coded packages Check for obvious defects in bar code Pharmacy relabeled � ophthalmic products, insulin, topical products Bar code around curve? Bar code folded or wrinkled? Bar code worn? Automated packaging machines � ATC, OS-PAC, FDS, Automed, etcAutomated packaging machines � ATC, OS-PAC, FDS, Automed, etc

46. VEHU 215 August 22, 2007 46 Bar code won�t scan IV labels Valid order �Available� bag � label must be printed �Available� bag on ward not listed Baxter IV solutions � white on clear background Did someone else already hang it? BCMA VDL vs VISTA??? Ron can discuss what is being done about Baxter bar codes And the other manufacturer bar codes that are not scannable.Did someone else already hang it? BCMA VDL vs VISTA??? Ron can discuss what is being done about Baxter bar codes And the other manufacturer bar codes that are not scannable.

47. VEHU 215 August 22, 2007 47 Available bags

48. VEHU 215 August 22, 2007 48 Bar code won�t scan Bar code scan, but error message �Drug Not Found� Check Med order, dispense drug, strength of med dispensed � wrong drug dispensed? Repackaged drug � label is correct � wrong IEN / bar code? If order correct & manufacturer bar code, check that the bar code is in the synonym field � Drug File Inquiry Check they synonym field to assure that only one line item has that bar code � Synonym Enter/Edit [PSS SYNONYM EDIT]

49. VEHU 215 August 22, 2007 49 Order is not in BCMA / VDL Check med order � pending vs finished Check start date / time Check administration time / VDL window time Schedule type check on VDL (One-time order / On-call orders) Med location � UD / IVPush / IV Text orders

50. VEHU 215 August 22, 2007 50

51. VEHU 215 August 22, 2007 51 Administered MedAppearing on �Missed Med� Report Med may appear on the MISSED MED report Due to Admin Time change on an active order Patches PSB*3*30 AND PSB*3*39 to correct this problem Current solution � pharmacist need to change the start date/time, discontinue original order Nurses may be required to run a Missed Med Report after each med pass & periodically for monitoring � they may call to question why a med order may be on the �missed med� report when they had already administered it. Though Admin Time is not a Starred field, a change in the Admin Time on an active order may make the med appear on the MISSED MED Report for previous days, for every day back to the original start date as having been �missed� though previous doses were administered as the previous Admin Time. The patches correcting this is not available yet. To prevent the problem, when the admin time needs to be changed, copy to a new order & adjust the admin time on the new order. Discontinue the original order.Nurses may be required to run a Missed Med Report after each med pass & periodically for monitoring � they may call to question why a med order may be on the �missed med� report when they had already administered it. Though Admin Time is not a Starred field, a change in the Admin Time on an active order may make the med appear on the MISSED MED Report for previous days, for every day back to the original start date as having been �missed� though previous doses were administered as the previous Admin Time. The patches correcting this is not available yet. To prevent the problem, when the admin time needs to be changed, copy to a new order & adjust the admin time on the new order. Discontinue the original order.

52. VEHU 215 August 22, 2007 52 Order doesn�t make sense You can see the ��� at the end of the line (active med column) - Widen the �active medication� column to get see the full order / detailsYou can see the ��� at the end of the line (active med column) - Widen the �active medication� column to get see the full order / details

53. VEHU 215 August 22, 2007 53 Order doesn�t make sense

54. VEHU 215 August 22, 2007 54 Order doesn�t make senseWhen was the last action? Widen columns to readWiden columns to read

55. VEHU 215 August 22, 2007 55 Order doesn�t make sense When was the last action?

56. VEHU 215 August 22, 2007 56 After scanning, pt refuses, cannot find order to �unmark� May only be edited by the nurse who �administered� May only be edited by the nurse who �administered�

57. VEHU 215 August 22, 2007 57 After scanning, pt refuses, cannot find order to �unmark� On BCMA / VDL File \ Edit Med Log May only be edited by the nurse who �administered� Or someone with the PSB Manager key.May only be edited by the nurse who �administered� Or someone with the PSB Manager key.

58. VEHU 215 August 22, 2007 58 After scanning, pt refuses, cannot find order to �unmark� After selecting order � mark Undo or refused.After selecting order � mark Undo or refused.

59. VEHU 215 August 22, 2007 59 Unknown Action Subj: BCMA - Admin 15836497 Problem [#40582435] 06/19/07@11:18 12 lines From: VEHU NURSE, TWO In 'IN' basket. Page 1 ------------------------------------------------------------------------------- The following administration was NOT displayed on the Virtual Due List Order Number....: 467U Orderable Item..: LORAZEPAM INJ Patient.........: VeHu Patient, One (0051) Ward/Bed........: BCMA Reason..........: admin's ACTION STATUS is "UNKNOWN". Schedule........: Q4H PRN Action Dt/Tm....: JUN 07, 2007@22:11:51 BCMA Med Log IEN: 15836497 User............: ( # 0001 ) VENU NURSE, ONE Email generated when the documentation of an med administration is interrupted. Often it is due to the nurse using Manual Medication Entry in VISTA, but the system times out before the task is completed. The email will generate any time a nurse enters the patient�s BCMA record. It must be corrected by the nurse initially involved but Edit Med Log. If it cannot be resolved, IRM intervention is required (fileman fix)Email generated when the documentation of an med administration is interrupted. Often it is due to the nurse using Manual Medication Entry in VISTA, but the system times out before the task is completed. The email will generate any time a nurse enters the patient�s BCMA record. It must be corrected by the nurse initially involved but Edit Med Log. If it cannot be resolved, IRM intervention is required (fileman fix)

60. VEHU 215 August 22, 2007 60 Best Practice BCMA GUI should be available within Pharmacy Communication Pharmacist must READ / review the entire order before verification Provider comments Having BCMA available w/in the Pharmacy allows the pharmacist to see what the nurse is saying s/he is seeing, especially helpful if the explanation of the problem is not clear. Communication � encourage nurses to report problems, whether it is by phone or email � we can�t fix what we don�t know about, - - for example a new manufacturer bar code, not entered in Drug file � the nurse keeps typing in the IEN, once s/he verifies that the drug is correct; in the meantime comments (�complains�) to his/her fellow nurses that scanning doesn�t work, but never contacts pharmacy, so it will not get corrected. Listen to the nurse � you may think it is the �usual� problem, but in the end � it may be different enough to required different action (???) Provider comments / special instructions � comments may be for the benefit for the nurses or for pharmacy also - changes in admin time is a common request � eg. Change in sliding scale admin times Having BCMA available w/in the Pharmacy allows the pharmacist to see what the nurse is saying s/he is seeing, especially helpful if the explanation of the problem is not clear. Communication � encourage nurses to report problems, whether it is by phone or email � we can�t fix what we don�t know about, - - for example a new manufacturer bar code, not entered in Drug file � the nurse keeps typing in the IEN, once s/he verifies that the drug is correct; in the meantime comments (�complains�) to his/her fellow nurses that scanning doesn�t work, but never contacts pharmacy, so it will not get corrected. Listen to the nurse � you may think it is the �usual� problem, but in the end � it may be different enough to required different action (???) Provider comments / special instructions � comments may be for the benefit for the nurses or for pharmacy also - changes in admin time is a common request � eg. Change in sliding scale admin times

61. VEHU 215 August 22, 2007 61 Best Practice All meds must be bar coded Enter manufacturer bar codes of new items on order check-in Check bar codes on repackaging Bar code �scannability� Scannable bar codes Not around curve (ophthal / insulin vials) Do not send up visibly defective bar codes - smudges / missing lines / extra blanks Check bar codes � Drug File Inquiry � If the response is �???� the bar code is not recognized Scannable bar codes Not around curve (ophthal / insulin vials) Do not send up visibly defective bar codes - smudges / missing lines / extra blanks Check bar codes � Drug File Inquiry � If the response is �???� the bar code is not recognized

62. VEHU 215 August 22, 2007 62 Best Practice Insulin sliding scale � Cont vs PRN �NOW� orders � too close to next schedule dose? Dosage should be specific - NOT by unit (tab, patch, etc) Training / Competencies Continuous order prompts to check FS; prn doesn�t require documentation if not administered If NOW dose is too close to next dose, contact provider / flag order or adjust the start time of the order Specific dose, separate OI for combo, e.g. sinemet, patches Training / competencies � VISN 5 BCMA committee considering developing a tool for troubleshooting, will make available thru BCRO when completed Training info � lBCMA websites listed at the endContinuous order prompts to check FS; prn doesn�t require documentation if not administered If NOW dose is too close to next dose, contact provider / flag order or adjust the start time of the order Specific dose, separate OI for combo, e.g. sinemet, patches Training / competencies � VISN 5 BCMA committee considering developing a tool for troubleshooting, will make available thru BCRO when completed Training info � lBCMA websites listed at the end

63. VEHU 215 August 22, 2007 63 BCMA Reports Missing Dose Medication Log Med Admin History (MAH) CPRS order detail Fileman Missing Dose Report � nurse requesting �missing� meds � print on selected printer in Pharmacy Medication Log � list of administered meds MAH � resembles the paper Med Admin Record (MAR) CPRS order � detail identify all doses administered for that Orderable Item for period allow by set up � typically 30-180 days. Fileman reports � specifically generated reports, by sorts / searches example recent FM report on BCMA Medication Log file to identify inappropriate dose documentation due to scanning errorsMissing Dose Report � nurse requesting �missing� meds � print on selected printer in Pharmacy Medication Log � list of administered meds MAH � resembles the paper Med Admin Record (MAR) CPRS order � detail identify all doses administered for that Orderable Item for period allow by set up � typically 30-180 days. Fileman reports � specifically generated reports, by sorts / searches example recent FM report on BCMA Medication Log file to identify inappropriate dose documentation due to scanning errors

64. VEHU 215 August 22, 2007 64 Missing Dose Report Subj: BCMA - Missing Dose Request [#40729810] 07/05/07@17:23 17 lines From: VEHU NURSE, ONE In 'MISSING DOSES' basket. ------------------------------------------------------------------------------- REQUEST NUMBER:.............MD-20070705-172350 DATE/TIME ENTERED:..........JUL 05, 2007@17:23:50 ENTERED BY:.................VEHU NURSE, ONE DIVISION:...................PERRY POINT SENT TO MAILGROUP:..........BCMA MISSING DOSES PRINTED ON DEVICE:..........BAL_PG73$PRT PATIENT:....................VEHU PATIENT, ONE SSN (LAST 4 NUMBERS):.......0051 WARD LOCATION:.............. BCMA ROOM/BED:...................8-J DRUG REQUESTED:.............CLONIDINE 0.2MG DOSE NEEDED:................0.1MG SCHEDULE:................... BID REASON NEEDED:..............NOT AVAILABLE ADMINISTRATION DATE/TIME:... NEEDED BY DATE/TIME:........JUL 05, 2007@21:00 Basically a request for replacement from PharmacyBasically a request for replacement from Pharmacy

65. VEHU 215 August 22, 2007 65 Med History / Log Found in CPRS / Order detail, based on Orderable item Also in BCMA Report & CPRS Reports Found in CPRS / Order detail, based on Orderable item Also in BCMA Report & CPRS Reports

66. VEHU 215 August 22, 2007 66 MAH CPRS / Reports Can use to check when doses were administered or calculated to be dueCPRS / Reports Can use to check when doses were administered or calculated to be due

67. VEHU 215 August 22, 2007 67 Fileman Reports Missed Dose report (Martinsburg) Search created by Martinsburg VAMC IRM, turned into a menu option. Reviewed monthly for trends & have been able to detect deviation. Can be sorted by ward / IEN, you can see how frequently a ward submitted a missing dose request for the same drug. Recently used to identify inappropriate scanning (nationally).Search created by Martinsburg VAMC IRM, turned into a menu option. Reviewed monthly for trends & have been able to detect deviation. Can be sorted by ward / IEN, you can see how frequently a ward submitted a missing dose request for the same drug. Recently used to identify inappropriate scanning (nationally).

68. VEHU 215 August 22, 2007 68 Fileman Reports Patient safety alert � scanning IEN instead of typing in dosage of med Fileman was used to identify entries inappropriate entries found in the BCMA Medication Log file

69. VEHU 215 August 22, 2007 69 Scanner fails to read the bar code Already did trouble shooting on your end What are you going to do? Who are you going to call? DO NOT PANIC!

70. VEHU 215 August 22, 2007 70

71. VEHU 215 August 22, 2007 71 Call the Bar Code Snoops

72. VEHU 215 August 22, 2007 72 Closed Loop Verification Program Problematic bar codes sent to BCRO Verification Labs in DC and Topeka Ron Schneider 7525 Greenway Center Drive Suite T 4 Greenbelt, Maryland 20770 Russ Carlson 2200 Gage Blvd Bldg 3 Room C239 Topeka, Kansas 66622 Bar codes grade (A-F) Grade C or better acceptable Let�s discuss our Closed Loop Verification Program. For those of you in the audience that have not heard of this program before, we ask that any problem bar code product that you are having problems scanning be sent to one of our 2 verification labs. We will then verify and grade the bar code. Bar codes have 9 internationally accepted parameters that grade A-F or pass/fail. A bar code that grades C or better is accepted as an industry standard and it is the accepted the VA standard.Let�s discuss our Closed Loop Verification Program. For those of you in the audience that have not heard of this program before, we ask that any problem bar code product that you are having problems scanning be sent to one of our 2 verification labs. We will then verify and grade the bar code. Bar codes have 9 internationally accepted parameters that grade A-F or pass/fail. A bar code that grades C or better is accepted as an industry standard and it is the accepted the VA standard.

73. VEHU 215 August 22, 2007 73 VA produced product Give recommendations to solve issue IV labels, Zebra labels, wristbands, ATC Supplier product grade D or F Send letter to supplier Send letter to GS1, NAC, PBM and FDA Send Med Watcher report to FDA (if patient safety issue) Closed Loop Verification Program If you send us a VA produced product (wristband, iv label,etc) we will give you recommendations to correct the problem. If you send us a supplier product that grades D or F, we take several actions to hopefully get the problem corrected. We send a letter to the supplier telling them what parameters failed and asking for corrective action. We send an electronic copy of the letter to GS1, the National Acquisition Board, Pharmacy Benefits Management and now the FDA. New contracting language on all products on the national purchasing commitments state the bar codes will be scannable in our system. I have sent several patient safety problems to the FDA MedWatcher program.If you send us a VA produced product (wristband, iv label,etc) we will give you recommendations to correct the problem. If you send us a supplier product that grades D or F, we take several actions to hopefully get the problem corrected. We send a letter to the supplier telling them what parameters failed and asking for corrective action. We send an electronic copy of the letter to GS1, the National Acquisition Board, Pharmacy Benefits Management and now the FDA. New contracting language on all products on the national purchasing commitments state the bar codes will be scannable in our system. I have sent several patient safety problems to the FDA MedWatcher program.

74. VEHU 215 August 22, 2007 74 Closed Loop Verification Program FY 2004 Started to collect data FY 2005 Formalized letter to supplier Contact sites with suggestions for improvement FY 2006 64 facilities submitting barcodes 356 bar code products submitted for verification analysis 57 letters sent to suppliers In 2004 the BCRO started to tabulate the data from the products that you sent in. Not much was done with that information until 2005. In 2005, we formalized our letter to suppliers and started to develop a list of corrective actions to help sites with problems. In FY 2006, we had 64 facilities send products to the verification labs; we tested 356 different products and sent 57 letters to suppliers.In 2004 the BCRO started to tabulate the data from the products that you sent in. Not much was done with that information until 2005. In 2005, we formalized our letter to suppliers and started to develop a list of corrective actions to help sites with problems. In FY 2006, we had 64 facilities send products to the verification labs; we tested 356 different products and sent 57 letters to suppliers.

75. VEHU 215 August 22, 2007 75 This is a copy of the letter that we send the supplier about their product. We include lot number, expiration date and a sample of the product sent to us..This is a copy of the letter that we send the supplier about their product. We include lot number, expiration date and a sample of the product sent to us..

76. VEHU 215 August 22, 2007 76 This pie chart shows the breakdown of products submitted in FY 2006. Notice that wristbands and manufacturer products were almost equal for the number of problem products submitted. The wristband is the first scan point for BCMA. If that fails, it is more than likely that the nurse will continue to utilize work arounds in the process.This pie chart shows the breakdown of products submitted in FY 2006. Notice that wristbands and manufacturer products were almost equal for the number of problem products submitted. The wristband is the first scan point for BCMA. If that fails, it is more than likely that the nurse will continue to utilize work arounds in the process.

77. VEHU 215 August 22, 2007 77 Closed Loop Verification Program FY 2007 10 additional facilities submitting bar codes 77 bar code products submitted for verification analysis 16 letters sent to suppliers So far in FY 2007, we have an additional 10 sites submit problem bar coded products. We have tested 77 products and sent 16 letters to suppliers asking for corrective action.So far in FY 2007, we have an additional 10 sites submit problem bar coded products. We have tested 77 products and sent 16 letters to suppliers asking for corrective action.

78. VEHU 215 August 22, 2007 78 This is a pie chart showing the breakdown of products so far for FY 2007. Notice that manufacturer products now account for 92% of the products submitted to the BCRO. Hopefully, we have solved the wristband problems as an enterprise and can focus our attention on the supplier products.This is a pie chart showing the breakdown of products so far for FY 2007. Notice that manufacturer products now account for 92% of the products submitted to the BCRO. Hopefully, we have solved the wristband problems as an enterprise and can focus our attention on the supplier products.

79. VEHU 215 August 22, 2007 79 Results IV solutions BCRO staff added to GS1 international standards workgroup FDA Involvement GS1 Dimpled Foil Backgrounds Unit dose liquids Percocet� Small vials So what do we have to show for our efforts. Russ Carlson and I have been invited to join the international standards workgroup for IV products. We now have the FDA involved in looking at bar code quality on products. Russ and I gave them many products last month, to show them the problems they we are having. They were amazed and are going to help us resolve problems. Many of us remember the dimpled foil warps on the unit dose liquids and Percocet. They have been changed due to your complaints. Remember the small vials that had the bar code curving around the label so it could not be scanned. They do not exist anymore do to your complaints.So what do we have to show for our efforts. Russ Carlson and I have been invited to join the international standards workgroup for IV products. We now have the FDA involved in looking at bar code quality on products. Russ and I gave them many products last month, to show them the problems they we are having. They were amazed and are going to help us resolve problems. Many of us remember the dimpled foil warps on the unit dose liquids and Percocet. They have been changed due to your complaints. Remember the small vials that had the bar code curving around the label so it could not be scanned. They do not exist anymore do to your complaints.

80. VEHU 215 August 22, 2007 80 Bar code resources Bar Code Resource Office http://vaww1.va.gov/bcmapmo/ BCMA Training Web materials http://vaww.vistau.med.va.gov/vistau/barcode/default.htm

81. VEHU 215 August 22, 2007 81 Questions ?