White Papers

---

Preparing for EHR Downtime and System Failures

by Kelly Bilodeau

A rapidly increasing percentage of health care providers and hospitals are now using electronic health records to manage patient information. As of 2013, more than 80 percent of hospitals were using EHRs. [1] In addition, some 70 percent of office- based physicians were using EHR or electronic medical record systems EMR as of 2012. [2]

While electronic systems can bring many advantages, such as increased efficiency, reduced costs and improvements in both accuracy and care coordination, they have a big downside — system failures. [3]

When the system goes down, it can paralyze an organization.

Consider the case of Boulder Community Hospital. In March 2012, the EHR system at this Boulder, Colo., hospital was brought down by a major malfunction that not only affected its main server, but also a backup server. The system was offline for days, which caused major upheaval for patients who faced long wait times and sluggish staff response. [4][5]

Be prepared

Planning ahead is critical to help mitigate potential electronic health record downtime problems. This means ensuring, among other things, easy access to printed documents and labels, and training staff members on manual documentation procedures. Preparing for EHR downtime, whether it is planned or unplanned, also requires the development of clear protocols.

In order to ensure an organized process, organizations should consider forming a team to take on the task. Drawing team members from a number of different departments will help to ensure that the planning process is thorough and doesn’t overlook any important elements. For example, your team should have members from not only IT, but also physicians, nurses and pharmacists, among others. This team should meet on a regular basis not only during the formation of an organization’s downtime plan, but also on an ongoing basis after that to review and update it regularly. [8]

Under federal law, specifically the HIPAA Security Rule, organizations must ensure data security in the event of a system failure. [5] In addition, organizations need to develop policies and procedures that focus on other areas, such as how the staff members should respond to EHR system failures, policies and procedures for bringing the system back online, and how to add information collected during an EHR system outage back into the system. [5]

A swift staff response to an EHR system problem can minimize disruptions in service and problems for patients.

Staff members can't respond appropriately to an EHR system failure, however, if they aren't informed about the problem. Designating a person within the organization, for example, an internal information technology professional, to notify staff members quickly of a system failure can help prepare them to act quickly. Using a communication form or template can help ensure that this process is standardized and that pertinent information is not accidentally omitted. [6]

Train up

Staff training in electronic health record downtime response should ideally begin during initial system training and continue on an ongoing basis. [6]

The creation of written reference materials and tools can also provide staff members with additional support. When electronic systems are down, staff members will need to rely on paper records and forms to continue providing service.

The creation of an electronic medical record downtime kit for each unit in the hospital provides staff members with the tools they need to maintain continuity of care. This kit should ideally include enough blank versions of all forms in the medical record to make it through 96 hours of system downtime. [7]

The kit should also include other information. Some items to consider are daily printouts of critical laboratory results, the patient census for each unit and medication administration records. [7] Each day a staff member should replace the previous day's printout with the current version. [7] Labels should also be included in the kit, so staff members and physicians can use them to flag important information that should not be overlooked. When building kits, take into consideration what each department would be missing if the electronic health system was down. Consider the needs of both newly admitted as well as existing patients. Include labels to highlight important information such as allergy, fall and DNR alerts, things that might be flagged automatically by an electronic system. In addition, also think about preparing preprinted backups of any labels that would normally be printed by the electronic system, such as medication added labels, specimen labels and consecutively numbered labels.

Also prepare an alternative system for printed wristbands that are given to newly admitted patients. For example, include bands that can accept handwriting or labels printed offline.

If downtime is planned, staff members should print daily appointment schedules the day before. If not, paper sign-in forms should stand in for the electronic record. Staff members should also have blank encounter forms and charge slips on hand. [5] Other paper documents to prepare include medication forms that list allergy information and information about any recent procedures the patient may have had.

Often, younger staff members aren't experienced using paper charts, so training them in written documentation is critical. [7]

Protocols should also be put in place to handle laboratory and pharmacy communications.

One item to consider is establishing alternative practices for delivering orders to the pharmacy or for laboratory tests, whether by fax machine, phone call or hand delivery. [5] Organizations should consider making a list of services or tests that can be safely postponed and decide whether there should be limits on the number of certain tests performed during downtime. [5] [6]

When it comes to radiology and laboratory results, these can also be printed ahead of time if system downtime is planned. [6] If unplanned, forms and labels can serve as a method to manually record and communicate test results.

Have a plan

Organizations should also establish protocols for how to distribute these test results; for example, urgent results may warrant fax or telephone notification. Less urgent matters can be held until the system is back up and running. [6]

Organizations using e-prescribing systems should also ensure that paper prescription pads and/or security paper are available and that these items meet pharmacy guidelines. Most pharmacies specify tamper-proof pads and/or security paper based on their state regulations. [6]

In addition to ensuring operations run smoothly, another focus should be on planning for an organized response to bring the EHR system back online. Developing a protocol can help this process run smoothly, by spelling out which areas should receive attention first. For example, IT might opt to bring registration and scheduling systems back first before focusing on other areas. [6]

Designating a staff member to enter clinical information collected during the downtime can avoid missing information and gaps in the medical record. [5] Another staff member could be assigned to follow up with patients who were seen during the outage and to make sure that all documentation, such as encounter forms, billing information and clinical information, is up to date. [5] Creating a downtime recovery report can assist in recovery by listing all the information verified and gathered during the downtime.

Paper documents and labels used during system downtime should be stored in a secure location to ensure that this information is readily available to be included in the medical record once the system is back up and running. [6]

Organizations can help ensure that they are prepared and have the proper systems in place by running downtime drills. Simulating an outage can help staff members understand what resources will no longer be available and what tasks they will need to modify. [5] Running routine drills can not only train staff members, but it may also detect potential planning gaps that require additional thought or training. [5]

Testing employee knowledge through drills and practice runs is another way to ensure the organization is prepared. [6]

Sources

• U.S. Department of Health and Human Services, "Doctors' and hospitals' use of health IT more than doubles since 2012," https://www.hhs.gov
• Centers for Disease Control and Prevention, "Use and Characteristics of Electronic Health Record Systems Among Office-Based Physician Practices: United States, 2001-2012," https://www.cdc.gov
• HealthIT.gov, "Benefits of Electronic Health Records (EHRs)," https://www.healthit.gov
• EHR Intelligence, "Boulder community back online after lengthy EHR outage," https://ehrintelligence.com
• EHR Intelligence, "EHR downtime: What to do when an IT disaster strikes," https://ehrintelligence.com
• American Health Information Management Association, "Plan B: A Practical Approach to Downtime Planning in Medical Practices,"

Maintenance and Compliance for Life-Safety Medical Equipment

By Deborah C. Bauers, M.A., D.C.C

The average individual goes about his or her daily routines with little conscious thought about whether his or her day could be interrupted by a life-threatening emergency. For a majority of people, health-safety concerns focus on the home environment and involve activities like salting icy walkways and picking up toys that someone could trip on. Safety measures in the hospital setting, however, are of a much bigger magnitude and often mean the difference between life and death. For most families, critical safety issues do not surface until an illness, accidental injury or trauma require a trip to the emergency room where life support and monitoring systems are an essential part of saving a life.

In the hospital setting, safety issues are multidimensional and involve everything from computer systems to maintenance of lifesaving equipment. Professionals who are tasked with the oversight, maintenance and execution of mandated safety measures must also document and be able to demonstrate the efficacy of their compliance with state and federal regulations. Lifesaving equipment must be maintained and careful records kept to ensure readiness and reliability. As technicians work behind the scenes, the smallest label is often a critical component of saving a life. The information it records assures doctors, nurses and technicians that durable equipment is ready at exactly the moment it is needed.

The hospital is a setting where people receive essential treatment for disease and injury. It is a place where the hoped-for outcome is recovery. In cases of serious injury or sickness, the National Institutes of Health’s MedlinePlus defines “critical care” as “close, constant attention by a team of specially trained health professionals.” Whether a critical patient lives or dies depends upon multiple factors. The hands-on care of doctors, nurses and diagnostic technicians plays an up-front and very visible role in patient outcomes and recovery. Behind the scenes, however, there are other professionals who play an equally vital role in maintaining lifesaving equipment that is used to resuscitate, provide life support, monitor vitals and perform diagnostic imaging that is essential for proper treatment. Maintenance and documentation are the keys to making certain that critical care equipment such as defibrillators and hemodialysis machines are accessible and regularly tested to provide optimal life support. Failure to comply with life-safety protocol can result in injury or death of a patient.

Inventory and maintenance of lifesaving equipment is mandated by both federal and state regulatory boards. Hospitals are required to differentiate between critical and noncritical equipment. This means that critical care equipment is subject to more stringent regulation and oversight.

HHS has issued mandates to ensure that lifesaving equipment and all new apparatuses are tested, inspected and maintained according to specified manufacturer’s guidelines. In the absence of specific guidelines, hospitals should follow the manufacturer’s recommended schedule for maintenance services. Noncritical equipment may be maintained less frequently with appropriate risk outcome data that supports and justifies changes made. According to the most recently revised CMS Regulations 482.41(c)(2), governing acceptable levels of safety and quality of medical facility equipment, “Equipment that is critical to patient health and safety is not a candidate for an alternative less frequent maintenance activity schedule.” This means that upkeep of critical care equipment must either meet or exceed the manufacturer’s guidelines.

Maintenance does not end when a technician has completed necessary repairs or performed a routine test to determine that equipment is in working order. Biomedical personnel and/or contracted individuals must maintain compliance with safety regulations through careful documentation of equipment maintenance. This is most effectively accomplished by concise notations affixed to each piece of vital equipment that document preventive, predictive, reactive and reliability types of maintenance. Such documentation ensures that medical staff will have timely access to the quality of hospital equipment needed to save lives.

Labeling equipment is an efficient and recommended practice that provides ready access to accurate and essential information about equipment maintenance schedules. Labels commonly include an assigned identification number that codifies each specific piece of equipment and assures that maintenance records and equipment are correctly matched. Labels also note the dates of scheduled testing as well as brief records of technical maintenance and the initials and/or name of the technician or service provider who performs the activity. Documentation in the form of labels provides clinicians with the assurance that the equipment is in good operating order and safe to utilize. Technicians use this information to determine when reactive maintenance has been performed as well as when mandated preventive forms of maintenance should be executed. In general, labels that are manufactured for hospital use include space for notation of preventive maintenance, inspection, testing and usage status.

Labels come in assorted sizes and are tailored to provide necessary documentation for virtually every biomedical application. Hospital labels generally include appropriate spaces for notations of preventive and reactive maintenance as well as periodic inspection, testing and calibration. Labels used in the hospital setting should meet the ISO requirements for providing necessary information to maintain quality assurance. Additional tamper proof features and a wide variety of face stocks are available that include metallics and synthetics that are made to resist smudging from cleaning agents, alcohol and blood. Some labels provide self-contained protective coverings, while others require an additional application to ensure preservation of recorded information. They are routinely made of paper or vinyl and often come without protective coverings. Without protection, however, they are subject to degradation from normal wear and tear on the equipment and exposure to harsh chemicals commonly used to clean and minimize the presence of bacteria. For this reason, a top coat of a synthetic nature is recommended to preserve critical data. Separate labels are available that form a protective coating and can be affixed on top of the original label. Such labels are not customized and must be trimmed to fit.

Perhaps the most effective labels are those that are self-laminating. Rather than having two individual labels, they come with an integrated, made-to-fit adhesive shield that seals and preserves the underlying label after maintenance, testing and calibration is done. A self-laminating label is convenient, comprehensive and time-saving.

In the world where CMS and Life Safety Code requirements strictly regulate biomedical and clinical engineering systems, careful documentation and preservation of critical maintenance data is a closely monitored system of checks and balances. Yet when it comes to preservation of essential data, a label can make all the difference in helping to maintain life saving equipment. Labels come in an assortment of sizes, colors and materials and can be customized to meet the needs of each hospital department. What is essential, however, is that the integrity of recorded vital information on labels be protected in order to demonstrate the readiness and reliability of equipment that is critical to positive patient outcomes.

References

CMS Office of Clinical Standards and Quality/Survey & Certification Group, Ref: S&C 12/07/2011-Hospital.

Comparison of CMS Preventive Maintenance Regulations. State Operations Manual, Appendix A, Survey Protocol, Regulations and Interpretive Guidelines for Hospitals, 482.41(c)(2) and 482.41(c)(2).

John J. Dougan, Associate Director/Field Services. Life Safety in the Hospital Setting. Antillean Adventist Hospital, 02/02/2009.

National Institutes of Health. MedlinePlus: Critical Care.

United Ad Label. RR Donnelley. 1998-2012.

World Health Organization. Medical Equipment Maintenance Programme Overview. 2011.

Barcoded Wristbands Help Ensure Accurate Patient Identification

In 2003 the United States Joint Commission cited the misidentification of hospital patients as a major cause of medical error and made improved patient identification a top safety goal within the scope of hospital accreditation standards [1] The commission took concerted steps to bring the need for improved safety practices to the forefront of the medical profession by admitting the unfortunate reality of too many historical instances of patient harm due to negligent healthcare practices.

One year later, the Presidential Administration created a new position within the Department of Health and Human Services to address improved patient care outcomes. The White House appointed the first National Coordinator for Health Information Technology to oversee a developmental plan that would eventually result in every American having a transferable electronic medical record (EMR) by the year 2014.[2] The President believed that the creation of a scannable health record would help to appreciably decrease medical error and improve patient services outcomes in the healthcare sector.

The President’s Healthcare Initiative has continued to prioritize the need for quality assurance in medical care practices. Through the Health Information Technology for Economic and Clinical Health Act, the government has promised incentives of close to $100,000 to clinicians who will participate in the creation and use of electronic health records. It has also offered additional funding to help subsidize clinics in purchasing equipment necessary to implement an EMR system.[3]

But without the use of the electronically scanned wristband, electronic medical records still lack the necessary checks and balances to guarantee appropriate patient identification and ensure that accurate medical services are administered in a timely manner. Scannable wristbands are an essential link between the patient’s record that contains physician’s orders, and the onsite locations for point of care.

Although wristbands have been used in the hospital setting for several decades, their efficacy has been limited by human error. Use of color-coding to designate patient alerts and end-of- life directives has too frequently resulted in confusion due to lack of a regional or national protocol calling for standardized colors for specific designations. This confusion has compromised patient safety and even resulted in death. A number of states are now moving toward the use of three primary colors to code wristbands. These will be used to identify patients who are at risk of falling, have allergies, or have “do not resuscitate.” directives.

The further edition of electronically scannable wristbands can significantly decrease patient risk due to medication errors and performance of incorrect procedures. The use of barcodes provides an effective system of cross-checking patient identification with medical records prior to administration of medical and laboratory services.

In case studies done, medical errors connected to the use of existing manual wristband protocols have highlighted several areas of vulnerability. These include mistaken identity through use of the wrong wristband, illegible writing on wristbands and incomplete data due to lack of uniformity in regulations regarding the information that is required.

Bar-coding of patient wristbands reduces the risk of patient error and provides for a comprehensive system of checks and balances. Electronically scanned patient data improves communication between the patient, his medical record and the healthcare service providers and technicians that execute a physician’s orders. Electronic scanning by means of bar- coding standardizes data and helps to prevent human error due to manual transcription of the incorrect information on a patient’s wristband. The patient’s wristband can then serve as both an entry and exit point in checking to be certain that the same five rights associated with medication administration apply to the administration of other healthcare services.[4]

As a part of The Joint Commission’s safety initiatives, it has recommended that two pieces of identification be used on each wristband to reduce the risk of medical error. Its primary safety goal is twofold; The Commission seeks to ensure that each patient is correctly identified and that he/she receives the correct treatment.[5]

The use of wristbands in home healthcare and outpatient settings has become equally important due to the larger volume of services that are rendered to patients in settings other than the hospital. Many outpatient laboratories are now demanding wristbands as a means of identification prior to drawing blood or performing other diagnostic services. An equal number of home health services are beginning to consider requiring that patients receiving care at home on an ongoing basis be fitted with wristbands as a requirement before blood draws or home urinalysis may be done. It is important to realize that The Joint Commission’s safety initiative focuses on both inpatient and outpatient services.

Bar-coded wristbands are available in several styles to accommodate specific needs of patients. Snap closure wristbands are tamper-proof and cannot be removed without destroying their integrity. Foam wristbands are available for patients who have allergies to nylon and latex as well as for elderly and preemies or newborns whose skin is susceptible to breakdown due to chaffing. Wristbands are also available that have adhesive closures that can be adjusted to fit a variety of wrist sizes. Thermal barcode wristbands are made to retain their integrity in the presence of moisture, alcohol, and wear and tear due to rubbing during patient movement.

Patient wristbands are an essential part of the delivery of quality healthcare. Bar coding offers the opportunity for healthcare professionals to further partner with their patients to provide the most reliable healthcare practices while minimizing risk of medical error due to lack of quality assurance in patient identification and delivery of services. The Federal Drug Administration currently requires that all bedside prescriptive medications be bar-coded. Acting now to incorporate bar-coded wristbands into your health services protocol will likely prepare you for future regulations that may well require wristband bar-coding.

1. https://www.ccforpatientsafety.org [2]
2. https://www.healthcareitnews.com
3. https://www.nejm.org
4. https://dora.colorado.gov
5. https://www.endonurse.com

Central Sterile Processing

In every hospital around the country, routine and emergency surgeries take place on a daily basis. Quite often, the coordination and appearance of the operating team, patient, and surgical supplies is seamless and uneventful. But sometimes surgeons can arrive only to find that necessary equipment and/or instruments are missing. This can result in a waste of valuable time and negatively impact the surgeon, surgical team, and even the tightly run surgical schedule. It sometimes results in a longer hospital stay for the patient. Surgical outcomes like these are preventable with the behind-the-scenes implementation of tools designed to identify and track medical supplies. With the help of color coding, asset tagging, and barcodes, surgical instruments can leave Central Sterile and arrive at the appropriate surgical suite on time and with peak efficiency.

The culture of a 21st-century hospital should include technological advances that can enhance departmental efficiency while continuously seeking ways to improve continuity of patient care. Communication between doctors and support medical staff is critical to comprehensive delivery of services. Patient safety must be systematically monitored and its outcomes measured. Risk prevention concerns top the list in most hospitals when it comes to preventing unnecessary contamination or failing to provide adequate medical care. When the latter is due to lack of departmental coordination or improper identification and organization of medical supplies and instruments, this deficiency must be mitigated.

The Biomedical Department of a hospital seeks to provide innovative yet cost- effective ways to integrate cutting-edge technology with continuity and intentionality in patient care. Its job is to assess the medical needs of the facility and then find solutions through research and consultation. It is perhaps the most critical area in the hospital because it must assume responsibility for services, supplies, and tech personnel. No other department has a greater need for a system of checks and balances with respect to its delivery of both goods and services.

The Biomedical and Central Sterile departments should be able to efficiently interface in order to provide necessary equipment for surgery. Technicians, surgeons and sterile supplies must all be coordinated in order to bring together resources and manpower for a specific patient who is scheduled for a designated surgical procedure. This process begins when biomedical staff does the research and then procures programs and tools to inventory, track, and ensure delivery of the exact surgical equipment and supplies needed at the time of a specific surgery.

The coordination that occurs between Biomedical and Central Sterile departments and designated surgeons does not happen because surgical staff posts the necessary information on a whiteboard at the nurse’s station. The coordination efforts needed to successfully treat one specific patient before, during, and after surgery depend upon procedures that go on largely behind the scenes. These procedures do everything from ensuring delivery of the right surgical instruments to the correct operating room, to successfully tracking supplies from the time they leave Central Sterile inventory until they arrive within the surgical field. This is best accomplished with color coding, appropriate asset tagging and bar codes.

In most medical facilities where surgeries are performed, the Biomedical and/or Central Sterile departments may be housed in distinctly separate parts of the hospital, making communication challenging. Technicians must rely on methods of labeling and tagging equipment to ensure that appropriate surgical instruments are autoclaved, bundled, and sent to the correct operating suite. Sterile surgical technicians must be able to stay ahead of the demand for surgical supplies so that surgeons do not arrive in their operating rooms only to find that surgical trays are incomplete or missing.

Many hospitals use a system of barcodes to scan instruments, drapes, and portable pieces of equipment into a master list of surgical supplies that becomes the inventory from which to draw upon as needed. As inventory is used to stock surgical trays or is assigned to a specific operating room, the same bar code may be scanned, designating that the items have been removed from stock and are in transport for a specific upcoming surgery and/or surgeon. Bar coding allows Central Sterile and Central Supply to keep an accurate accounting of inventory on hand and supplies that need to be ordered.

The Chief of Surgery or Faculty Surgeon often favors specific instruments and will have a standing request for their inclusion in his assigned surgical tray. Bar coding allows Central Sterile the specificity to assign instruments through computer scan, guaranteeing their availability at a moment’s notice, even for a specific user.

The use of bar codes is a quick and efficient way to track medical supplies and instruments as they travel to and from various departments, whether from Central Sterile to the operating room or from surgery to be washed, wrapped, and autoclaved for re-sterilization.

The efficacy of bar coding is dependent upon both electronic and computer functionality. In the event that either fails, color coding on asset tagging continues to ensure continuity and safety of procedures that govern communication between Biomedical and Central Sterile departments.

Asset tags are labels that are affixed to supplies and instruments to provide identification and tracking throughout the hospital setting. They may be constructed of paper, vinyl, or a synthetic material. A variety of top coatings can be applied to protect them from harmful effects associated with cleaning chemicals. Some are composed of a foil-type product that is available in silver and gold. Labels may be permanent or removable to meet the need for change-outs and relabeling due to track servicing. Tamper-evident tags are also available that shed when removal is attempted. Asset tags may be coded only by color and a numerical system or also equipped with a barcode for scanning and tracking. They are either directly applied to surgical drapes and larger pieces of equipment or affixed to the exteriors of opaque plastic that is used to wrap instruments before sterilizing.

Color coding on asset tags is often a less expensive alternative for smaller hospitals and outpatient surgical clinics for which software programs using barcodes are not cost effective. However, bar codes do provide superior tracking capability. A surgical nurse or medical technician anywhere in the hospital can locate a missing surgical tray or find a smaller piece of medical equipment by imputing the assigned barcode into the station’s computer.

Although labels may be one of the smallest items used in the daily operation of the Biomedical and Central Sterile departments in a hospital, they are of primary importance. Hospital management seeking to improve patient care, mitigate risk factors, and better coordinate activities between departments should consider implementing the use of color coding, asset tags, and barcodes.

Direct Thermal Printer Labels in Today’s Healthcare Environment

Labeling is necessary in many aspects of the medical and healthcare industries. Healthcare providers are required to have labeling systems in place for patient identification with wristbands, containers of specimens and samples sent for diagnostic lab work, and pharmaceutical directions and dosages for bedside therapies and treatment. In 2001 the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) issued patient requirements that included instituting technology to control patient medication administration and identify patients in a manner that reduces medical errors. Bar-coding was determined to be a suitable choice to accommodate these requirements [2].

Many hospitals in the United States have implemented new bar code systems to address medical errors in response to a 2000 federal report and president’s directive [7]. Thermal printing technologies have been implemented as a way to obtain crisp, clear, and consistent barcodes in a manner that reduces and avoids medical errors upon scanning. One such technology is direct thermal printing, which does not require ink. The image is created by the direct contact of pins in the thermal print head with a heat-sensitive coating on the label material.

A 2005 case study of Beloit Memorial Hospital in Beloit, Wisconsin, found that medication administration errors were reduced 67 percent in the first four months after introducing a bedside bar code system in 2003, which was further reduced by an average of 82 percent upon program expansion. The bar code system also increased nurses’ job satisfaction, improved patient satisfaction, and generated positive public relations without increasing nurse staffing time as the system was expanded to additional clinical units [10]. The bar- coding systems used with medication administration have also improved inventory systems and billing accuracy [2]. Similarly, laboratory samples are often labeled with bar codes at the patient’s bedside or prior to staining to avoid errors in labeling and attribution to the specific patient. Direct thermal labels have cut sample identification errors and increased efficiency at the labs of Massachusetts General Hospital, which handles roughly 400,000 samples a year [6].

Compared to traditional ink and paper printing, direct thermal printing offers more flexibility at the bedside, more reliable barcodes, and a better financial and time investment for institutions that are investing in barcode labeling systems. However, the heat coating on direct thermal labels can be sensitive to chemicals, such as alcohol. The reaction between alcohol and the paper's thermal coating fades the printed information or darkens the paper, which can interrupt efficient bar code scanning, increasing the time and effort needed to ensure proper labeling and decreasing the accuracy aimed for with the implementation of the printing system.

Hand washing with soap and water still only has an adherence rate of approximately 40 percent in some healthcare settings [9]. Hygiene practices and cleansing the hands with antimicrobial washes and sanitizers have been encouraged as part of an initiative to increase patient safety [1]. Alcohol-based sanitizers are recommended and used in medical settings as a low-cost method of reducing the incidence of infection, and the availability of these waterless cleansers has resulted in boosting general adherence to good hygiene practices [9]. Generally, medical quality sanitizers contain 60 percent to 95 percent ethanol or isopropanol [8] to be effective.

The Centers for Disease Control and Prevention (CDC) recommends the use of alcohol-based sanitizing gel by health care workers whenever soap and water are not available for washing their hands. A small amount of the product is added to the palm of the hand and then rubbed all over the hand and fingers. Though the guidelines recommend rubbing until the hands are dry [3] (and it only takes an average of 15 to 30 seconds for the sanitizer to evaporate [4]), different types of sanitizer and alcohol concentrations dry at different speeds [5], and some individuals may use more than recommended. The presence of the alcohol on hands immediately before handling bar code labels may not be conducive to obtaining the clear images desired with direct thermal printing, as the material fades or turns black.

Companies like United Ad Label (UAL) are coming up with unique solutions to the problems caused by alcohol-based sanitizer use. UAL has secured a material that protects the bar code against chemical vulnerabilities. Our new direct thermal label has a heat-sensitive coating with reduced susceptibility to alcohol, which will further increase the reliability and efficiency of the thermal printing systems implemented in many health care settings. The introduction of this product for use as labels in healthcare settings would greatly improve upon the advancements already made in the field of bedside barcode technology. This new label will solve the problems created by healthcare workers touching the labels with alcohol on their hands. Labels will no longer be at risk of fading or discoloration when alcohol-based sanitizers are used.

Direct thermal printing is a cost-effective and relatively flexible technology for printing bar- code labels in healthcare settings. Though great strides have been made in introducing bedside bar-code scanning, the prevalence of alcohol-based sanitizers sometimes interferes with their efficient use. The introduction of UAL’s improved label material for use in direct thermal printing would solve the issues of mixing alcohol-based hand sanitizers with direct thermal labels while maintaining advances in the reduction of medical errors and increased patient safety.

References

Agency for Healthcare Research and Quality. Patient Safety Practices Rated by Strength of Evidence. Addendum to Summary. July 2001. AHRQ Publication No. 01-E057b. Available at: https://www.ahrq.gov Accessed July 22, 2010. American Hospital Association, Health Research & Educational Trust, and the Institute for Safe Medication Practices. “Assessing bedside bar-coding readiness.” Pathways for Medication Safety, 2002.

Available at: https://www.ismp.org Centers for Disease Control & Prevention. Clean hands save lives! Germ-X. Hand Sanitizer. Available at:https://www.germx.com. Accessed July 22, 2010. Lincoln County, Nevada. Hand Sanitizer Safety. Available at:https://lincolncountynv.org. Accessed July 22, 2010. Moher, Ralph and Wilson, Kevin. Labeling and tracking prevents errors in the lab. Patient Safety and Quality Healthcare. 2005. Available at: , 2010. Quality Interagency Coordination Task Force. Doing what counts for patient safety: Federal actions to reduce medical errors and their impact. February 2000. Accessed July 22, 2010. Reynolds S, Levy F, Walker E. Hand Sanitizer Alert. Emerging Infectious Diseases. 12(3), 2006. Schnirring, Lisa. CDC joins WHO push for better hand hygiene in healthcare. Center for Infectious Disease Research & Policy, University of Minnesota. 4 May 2010. Available at:

https://www.cidrap.umn.edu. Accessed July 22,2010.

Work, Mitch. Improving medication safety with a wireless, mobile barcode system in a community hospital. Patient Safety & Quality Healthcare, May/June 2005.

Using Effective Communication Tools to Help Reduce Hospital Acquired Infections

In the last few years, MRSA (methicillin-resistant Staphylococcus aureus), CDI and even the Swine Flu have become household words, due to infection outbreaks and heavy media coverage. Unfortunately, MRSA, CDI and the Swine Flu may soon share the spotlight with another drug-resistant infection, Acinetobacter. This bacterium causes severe pneumonias or bloodstream infections, some of which are resistant to imipenem, an antibiotic reserved for last-line treatment.

Acinetobacter is common in water and soil and can be found on the skin of healthy people, especially healthcare workers, and can colonize in patients with open wounds. While posing little threat to healthy people, diabetics, those with weakened immune systems, and chronic lung disease sufferers are more susceptible to developing serious infections. A 2009 study published in the journal Infection Control and Hospital Epidemiology found a three-fold-plus increase in the proportion of Acinetobacter cases resistant to imipenem from 1999-2006 (Medical News Today, 2009).

Despite the publicity and the increased awareness to institute new processes to prevent the spread of these infections, problems still persist. According to the World Health Organization, on any given day, more than 1.4 million patients are affected by a healthcare-associated infection (HAI). In the U.S., HAIs are associated with an estimated 99,000 deaths and incur $30 to 40 billion in excess healthcare costs annually.

The Joint Commission accredits hospitals who meet or exceed standards-based performance criteria in a number of areas. For hospitals, one of the most important standards is infection prevention and control. The National Patient Safety Goals (NPSGs) are a group of guidelines developed by The Joint Commission to address patient safety in every aspect of the patient’s care during a hospital stay.

Goal 7 of the NPSGs is to reduce the risk of healthcare-associated infections. In order to be certified by the Joint Commission, hospitals must demonstrate compliance with either the World Health Organization (WHO) or CDC hand hygiene guidelines. Goal compliance is evaluated by the presence of a hand hygiene policy, improving compliance by fostering a culture of hand hygiene and monitoring compliance. Other sections address strategies for cleaning and disinfecting patient care equipment and the patient’s environment. Transmission-based precautions for patients with certain multidrug-resistant organisms are also addressed. These guidelines help target areas in which infection control is particularly important. Clinical staff training and improved Environmental Services processes have helped mitigate the spread of these infections. However, continuing efforts are required to keep them in check and prevent the spread of new infections, like Acinetobacter, that may surface.

A study by Extending the Cure and published in The Archives of Internal Medicine said pneumonia and sepsis, which can be caused by drug-resistant microbes such as MRSA, increased U.S. healthcare costs by $8.1 billion that year due to protracted hospital stays and treatment.

Anthony Sanzo, a former health system CEO commenting on this study stated, "Inadvertent exposure" results when hospitals fail to alert environmental and transport personnel in advance about isolation rooms holding infected patients. This can significantly increase the possibility of wider contamination because the workers continue about their business without knowing they've been exposed, using equipment that has not been properly sanitized.”

"Isolation is ineffective if all workers are not alerted to the room's status," Sanzo said. "Yet, though housekeepers and transporters are among the most widely-traveled hospital personnel, they are being overlooked and under-protected." Communicating to all constituents is crucial. Whether it’s the clinical staff, ancillary services, patients, patient’s family and visitors or vendors, it’s important that appropriate communication devices are used to inform people of the risks and how to effectively avoid them.

One solution is a comprehensive program of infection control signage, posters and labels. Information alerting visitors about infection concerns should be placed on hospital websites, in lobby and general seating areas and throughout patient rooms. It is important to remember that non-medical staff such as housekeeping, food service and visitors enter patient rooms. They do not have medical training, yet they need to be aware of possible high-risk exposure and how to reduce their own risk of infection. Ideally, signage is bilingual and uses primarily pictures with little text. This avoids discriminating against those who are illiterate or cannot speak English. It also serves as an important prompt to children to wash their hands, since children tend to imitate the behavior of others (University of Iowa, 2004).

One of the most important and frequently used components of infection control signage is transmission-based precaution signs on patients' doors. These signs specify which type of precautions are in place (droplet, contact, or airborne) and show pictures of PPE (personal protective equipment) needed before entering, such as gowns, masks, and gloves. They convey vital information without violating HIPPA privacy laws. Chart labels alert physicians, pharmacists, and nurses of the need to use precautions before entering the room, saving time.

Used in conjunction with signage, infection control carts placed outside patient rooms provide the appropriate PPE needed. They serve as a strong visual reminder of the importance of infection control while providing the signs and equipment needed to do so. Labels can be placed on the carts showing the recommended PPE needed for different types of transmission-based precautions.

Many facilities place signs reminding everyone to cover their mouths if they sneeze or cough, or to ask their caregivers if they have washed their hands. During flu season, many facilities place signs at entrances reminding those with a cold, fever or possible flu to not visit the facility. Signage helps bring awareness to the importance of reducing the risk of infection. Tracking the incidence of hospital-acquired infections measured against the average out-of-pocket cost for the facility to treat these infections can highlight areas in which more signage may be needed, or need to be replaced

References

2010 National Patient Safety Goals (NPSGs), 2010. The Joint Commission. Retrieved from https://www.jointcommission.org .

Blodgett, T. (2009). Reminder systems to reduce the duration of indwelling urinary catheters: a narrative review. Urologic Nursing, 29, 369-379. Retrieved from https://library.uab.edu

Centers for Disease Control and Prevention. (2005). Device-associated module. Retrieved from https://www.cdc.gov.

Facts about hospital accreditation (2010). The Joint Commission. Retrieved from https://www.jointcommission.org .

New strain of drug-resistant bacteria emerging in U.S. hospitals (2009). Medical News Today. Retrieved from https://www.medicalnewstoday.com.

University of Iowa Health Care (2004). Hand washing is a simple, easy way to prevent the spread of disease.

Wyeth. (2010).

Improving Patient Safety with Unit Dosing

The role of the hospital pharmacy in inpatient care is broader in scope and more complex than that of the average neighborhood pharmacy. Inpatients are generally sicker and frequently require more serious kinds of medications to treat their illnesses. Diagnosis and intervention strategies must sometimes be modified rapidly to accommodate the diverse and emergent needs of unstable patients whose diagnostic changes necessitate treatment protocols that require a different medication.

According to studies done by the American Psychological Association, deaths due to medication mismanagement have historically been viewed as unfortunate instances of collateral damage in the hospital inpatient setting.[1] Within the last few years, however, a much greater emphasis has been placed on monitoring of hospital pharmacy unit dosing to produce improved outcomes. Quality assurance measures in the pharmacy setting have become the focus of raising the standards of inpatient care. With the help of agencies like The Institute for Safe Medication Practices, in cooperation with the FDA, practitioners are learning how to improve pharmaceutical protocols and safety measures with respect to the packaging, labeling, and administering of bedside medications.

In 1999 the Institute of Medicine released findings that suggested that errors in medication management could be responsible for as many as 7,000 deaths per year in the hospital setting. [2] Studies like these have highlighted the need for raising the standard of medication management of inpatient care. According to the Food and Drug Administration, the use of bar-codes on unit dose medication has decreased pharmaceutically-related hospital errors by as much as 85% in some cases.[3] In light of growing trends toward improving procedures to greatly reduce medication errors, pharmacy unit dosing is emerging as a leading technological advance in preventing unnecessary accidents and deaths related to lax pharmaceutical practices in the healthcare setting. Manufacturers of healthcare technology like Cerner, McKesson and Omnicell offer fully automated systems that provide the means to inventory, store, barcode, and deliver secure point- of-care patient medication services.

Pharmacy unit dosing provides a system of checks and balances for tracking prescription medications from the time of documentation in a patient’s chart until the moment they are administered. Standardized protocols for labeling and bar-coding help to ensure that proper dosing occurs in a timely manner for every patient. When medications arrive at the bedside they are carefully checked against patient wristbands to confirm that the dispensed drug is given to the correct patient. This is accomplished by checking the full name and birth date on the wristband against the patient’s medical record.

A single dose of medication in pill or capsule form is usually dispensed in a bubble or blister pack. Liquid medication is prepackaged according to a specified volume for each dosing unit. The Federal Food and Drug Administration mandates that certain information must be clearly labeled including the patient’s name, the name and dosing amount of each medication, the expiration date, its lot or control number, and any specific instructions needed to assure that the medication remains stable and does not lose its efficacy prior to being administered.[4]

The FDA also requires that all manufacturers provide bar-coding on unit dosing medications. This means that before a medication is administered at the bedside, its packaging is equipped with a computer readable strip that is scanned to verify the patient’s identity and to ensure that the unit dose matches prescribed orders contained in his medical record.

In the hospital setting, some pharmacies repackage and label their own unit doses from medications that have been shipped in bulk from manufacturers. To do this, they must have computerized equipment that is capable of packaging and applying scannable labels. Smaller pharmacies often outsource production of bar-code labels that meet FDA standards. Hospitals that do not currently have in-house bar-code label printers can opt for new technology such as the thermal printer that interfaces with already existing pieces of equipment to produce bar-coded labels.

When a patient enters the hospital he is given a scannable identification wristband that connects him to his medical record. When a physician writes a drug prescription, a national drug code assigned to that specific medication is scanned onto the unit dose through the use of bar-coding. Prior to bedside administration, the label on the medication is also scanned and compared to the patient’s identification wristband to confirm proper patient and dosage. The medication label is then cross-checked to be certain that the dosing unit is identical to the written prescription. Any inconsistency must be identified and resolved before the medication can be administered.

In more progressive hospital facilities, the latest technology is being used to ensure that medication errors are reduced and patient care delivered in keeping with the “Five Rights Check.” Before administering a medication to a patient, his wristband is checked to make certain that it is the right medication, right dosage, right patient, right method of dispensing, and right time. This is possible because of the use of bar-coding that allows for all necessary documentation to be scanned, connecting patient to patient record.

The use of bar-codes and labels in the hospital pharmacy is not restricted to processes related directly to patient care. Pharmacy technicians use scanner technology to track the inventory of all medications that have either been prepackaged by the manufacturer or repackaged in the pharmacy to meet unit dosing requirements. While some smaller pharmacies may prefer to outsource production of bar-codes and labels, many inpatient pharmacies are moving toward the use of automated systems that will perform cart fills, first doses, and bar-code scanning with only minimal technician and/or hands-on involvement.

Whether outsourced or produced inside the hospital pharmacy, preparation, labeling, and bar- coding of unit doses is the emerging standard of care necessary to meet FDA guidelines and to substantially decrease medication error. In the future, this method should standardize and vastly improve reporting data used to measure quality assurance in the hospital setting as well as reduce the need for ancillary reporting of medication error by hospital administrations.

1. Cohen, Michael Richard, medication Errors, APA, 2006
2. https://www.fda.gov
3. https://www.fda.gov
4. FDA (CPG Section 430.100 Unit Dose labeling for Solid and Liquid Oral Dose Forms).