An Interview: Success with Barcode Scanning to Enhance Perioperative Medication Safety

A few months ago, ISMP interviewed Dustin Carneal, PharmD, from the Crystal Clinic Orthopaedic Center in Akron, Ohio, about the implementation of barcode scanning technology in their perioperative and procedural settings. The Crystal Clinic Orthopaedic Center is a physician-owned hospital system that has 22 operating rooms in two locations, which accommodate a volume of approximately 17,000 medical and/or surgical procedures each year. Total knee, hip, and shoulder replacements, as well as spinal fusions, are some of the more frequent procedures performed there. In 2021, the health system completed its transition to a Cerner electronic health record (EHR) and has adopted barcode scanning technology in all perioperative and procedural settings prior to medication administration. The ISMP Medication Safety Self Assessment for Perioperative Settings, which included barcode scanning technology as a best practice, served as motivation and assisted Dustin in discussions with leadership to adopt the technology.

We are publishing our interview with Dustin because newsletter readers told us in our 2022 readership survey that, in future newsletters, they wanted to see how other organizations have implemented the 2022-2023 ISMP Targeted Medication Safety Best Practices for Hospitals, including Best Practice #18 associated with expanding the use of barcode scanning technology to short- and limited-stay locations such as perioperative and procedural areas. 

ISMP: Which patients and products are required to be scanned for verification before medication administration in the perioperative setting?

Dustin: In the perioperative setting, leaders expect the barcode on every patient’s identification bracelet and the medications they receive to be scanned prior to administration. This means that perioperative medications, including plain hydrating infusions and irrigation fluids, require barcode scanning before administration; the barcode on all patients’ identification bracelets is also scanned to verify both the patient and the product. We had to decide up front which perioperative products were “drugs” that required scanning. For example, we decided that skin preparations like ChloraPrep were “drugs” that we wanted to barcode and scan. We currently require some anesthesia-provider medications to be scanned and documented on the medication administration record (MAR), including antibiotics, tranexamic acid, and certain anesthetics. Cerner has yet to release barcode medication administration (BCMA) within their anesthesia module, but we hear it is coming soon!

The barcodes on all patients’ identification bracelets and most medications are scanned in the traditional perioperative setting, such as the preoperative holding areas, operating rooms (ORs), procedure rooms, and post-anesthesia care units (PACUs), as well as non-traditional perioperative settings such as outpatient units that perform procedures, and radiology. We are currently scanning all contrast media, radiopharmaceuticals, medications, and flushes administered in radiology, including during interventional radiology and pain management procedures.   

ISMP: What was your workflow associated with medication administration in perioperative settings before and after implementing barcode scanning technology?

Dustin: Before implementing barcode scanning technology, we used preference cards submitted by surgeons to retrieve medications from non-profiled automated dispensing cabinets (ADCs) before each procedure. There were few actual orders for the medications used perioperatively, and they were infrequently verified by a pharmacist prior to administration. Staff historically administered the medication and documented it in the patient’s medical record.

Now, surgeons enter intraoperative orders, planned mostly during the preoperative clinic visits. The orders are initiated upon the patient’s arrival for surgery, and a pharmacist verifies the medication orders prior to surgery. The medications are then removed when needed by the perioperative staff from profiled ADCs. The barcode on the patient’s identification band is scanned, as well as the barcode on the medication, intravenous (IV) solution, or irrigation solution using a non-tethered scanner, and the medications are administered and automatically documented in the EHR. 

ISMP: Implementing barcode scanning technology in the perioperative setting is a complex task. Where and how did you start?

Dustin: This was a 2-year journey for us. We started by identifying interdisciplinary champions and involving them from the start. This included pharmacy staff, anesthesia providers, and other perioperative practitioners.

While it was no easy task, pharmacy champions began by gathering all the preference cards for procedures and creating orders and order sets for each procedure based on the preference cards. We also created kits for the shorter procedures, such as spinal injections and hand surgery. Each week, we met with specific surgeons, one-on-one, to ensure the accuracy of the kits and preference cards. These kits (physical and virtual) were stocked in profiled ADCs in the preoperative holding area, operating and procedure rooms, and PACU. The kits are only removed after a pharmacist has verified the medication orders. The kits (and the medications) are not available via ADC override.

At the same time, the circulating nurses began to standardize all the procedural order sets and build master order sets. Again, they used the preference cards to build in surgeon “favorites” with alternatives (for times of shortages or allergies), and appropriate clinical decision support was built into the prescribing system. If the physician saved a “favorite” with a specific dose, the clinical decision support was overridden. The standard order sets and physician “favorites” greatly improved appropriate prophylactic antibiotic selection, and proper medication dosing increased from 53% in 2020 to 92% in 2021. When we met weekly with specific surgeons to ensure the accuracy of the orders and kits, circulating nurses and information technology (IT) staff were also present to ensure the accuracy and acceptance of the standard order sets and to capture the physicians’ “favorites.”

We identified a standard change management process and then described the new workflow for select cases. We then tested the standard order sets and kits for ADC efficiency, and simulated the more complex cases to make sure unnecessary time was not added to the case due to barcode scanning, and to ensure fast room turn-around time. We also worked with nurse champions to identify MAR documentation limitations and adjusted the orders and MAR settings for efficient workflow and intraoperative flexibility.

ISMP: How did you handle patient identification and scanning the barcode on an identification band that might be hidden under sterile drapes intraoperatively?

Dustin: Perioperative and admission staff received a list of patients and their procedures the day prior. Depending on the surgical or procedural site, we applied patient identification bands on limbs that could be accessed during the procedure. For example, we put an identification bracelet on the ankle if we knew both arms could be covered by surgical drapes, or we put an identification bracelet on the left or right wrist on the opposite side of the surgical procedure. In some cases, we applied two identification bands on the patient if we were not certain the identification bracelet barcode could be reached during surgery. Additionally, a workflow was implemented to ensure the proper chart was open upon patient entry to the operating room. The patient’s identification band barcode is scanned upon entering the operating or procedure room. So, if the identification band barcode can not be scanned during the procedure, the staff have already verified the patient, which is also confirmed during the surgical “time out.” Also, they have already ensured that one chart, the proper chart, is open.

ISMP: What were some of the other significant barriers to implementing the technology in perioperative settings, and how did you overcome those barriers?

Dustin: First, not all products used in the perioperative setting have a barcode. We had to first decide which products would be considered a “drug” and make sure each had a functional barcode. It took a lot of manpower to identify all the products utilized, test all the barcodes up front, and build a uniform workflow for similar items such as irrigation solutions. There were also items with two barcodes, one with the NDC (national drug code) number and one with the expiration date and lot number. So, we developed and provided education around which barcode to scan.

We also had to reduce the number of nuisance alerts practitioners would receive. For example, pharmacists (and to some degree prescribers) received a lot of duplicate therapy alerts for any product that contained sodium chloride (5,000+ alerts/day initially). It took 10 months of working with IT staff and Cerner representatives to reduce the non-meaningful alerts, but now we have only meaningful alerts that fire.

Also, we needed to ensure that nurses could modify the MAR to document what had actually been administered to a patient. There were a lot of EHR limitations for perioperative medication orders that we needed to work through.

ISMP: Did you have to increase pharmacy staffing to implement barcode scanning technology in perioperative settings?

Dustin: For the EHR build and maintenance, there was an increase in staff to ensure the safety of our patients. However, with all perioperative orders being entered electronically, pharmacists now had the capability to verify orders anywhere in the hospital. We found the best place to have these pharmacists was at the point of patient care. So our pharmacists transitioned to decentralized clinical roles, working in perioperative locations to verify medication orders and to assist in patient care. This also allowed pharmacists to resolve any questions about allergies, answer questions about medications, and review drug interactions. Having pharmacists verify orders in preoperative locations also prevented a delay in accessibility to medications in the profiled ADCs once the procedure started.

ISMP: What was the barcode scanning compliance rate in the perioperative setting at the start of implementation and what is it today?

Dustin: Although we had an entirely new EHR workflow in the perioperative setting, we achieved a scanning compliance rate of 84.5% (scanning medications prior to administration) and 87.6% (scanning patient identifiers) in operating and procedure rooms, preoperative holding areas, and PACUs during the first month of implementation in 2021. Our most recent measurement in June 2022 showed 93.5% compliance for the entire organization. That’s including all personnel (including new and locum staff), medications without barcodes, and two EHR downtimes. If we exclude the few products without barcodes, our perioperative compliance rate for the entire organization is 96.2% for June (2022).

ISMP: Were there any unanticipated advantages to implementing barcode scanning technology in the perioperative setting?

Dustin: Yes, many. Besides capturing multiple close calls that would have otherwise reached the patient, we found that we had an increase in capturing charges in the perioperative setting, as medication charges now occurred upon administration. We also had better data and a grasp on what was actually being administered, for example, specific doses and volumes of medications. This enabled us to manage medication shortages and medication costs more effectively.

With the processes and conversion to a new EHR, there was a significant increase in the order volume entered for each patient. We found that standardizing the order sets resulted in more appropriate weight-based dosing of medications. There has also been a three-fold increase in perioperative order verification by pharmacists, as well as a significant reduction in perioperative ADC overrides. 

Furthermore, implementing perioperative barcoding has presented us with a unique opportunity to collaborate with both surgeons as well as the internal medicine service physicians who provide a history and physical for perioperative patients and who may manage them postoperatively if they are admitted to the hospital. We established a general practice agreement with our orthopedic surgeons that allows for expansion of the collaboration.

Also, during preadmission testing visits, our pharmacists take the time to review all home medications and to speak with the patient regarding any discrepancies. Having an accurate medication history is important for many reasons, but for our organization, it is important especially for patients who will be admitted to the hospital postoperatively. On admission and in the PACU, medication reconciliation is planned by a pharmacist, mitigating potential problems with nonformulary items, proper conversion to an automatic therapeutic interchange, and avoiding duplicate or inappropriate therapy. Then the medication reconciliation is initiated by the internal medicine service physicians.

This admission medication reconciliation process was very successful, and the internal medicine service physicians requested that the service be continued at discharge, which has been accomplished. At discharge, a pharmacist conducts a medication reconciliation process, adding documentation for written prescriptions, monitoring, and hold parameters for patients, and providing discharge education so patients are prepared for a safe transition home. The internal medicine service physicians then review the plan and complete a final sign-off at discharge. Currently, pharmacists are looking to expand their general practice agreement to include anticoagulation bridging, pain management, insulin management, and hypertension management. 

If you would like more information from Dustin Carneal about implementing barcode scanning technology in the perioperative setting, you can email ISMP with your questions ([email protected]), and we will forward your email to Dustin. For additional information on perioperative barcode scanning, please visit our new ISMP Guidelines for Safe Medication Use in Perioperative and Procedural Settings.

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