Hospital Boosts Medication Barcode Scanning, Post-Opioid Pain Reassessment Rates

A California hospital improved rates for barcode medication administration scanning by 14% and pain reassessments an hour after opioid administration by 50% using tools such as 5-minute huddles, weekly performance dashboards, and plan-do-study-act cycles. Pharmacy team members from Sierra View Medical Center published their report online in BMJ Open Quality. 

“On discovering potentially dangerous gaps in care, the medication safety interdisciplinary team successfully implemented Kotter’s process for creating a major change,” researchers wrote. “The established sense of urgency was conveyed to leaders.” 

The team used huddles, weekly audit results, and other approaches to communicate and reinforce the need for improvement to nursing and pharmacy staff. It also invited staff feedback into obstacles, which the team worked to remove. 

Barcode medication administration scanning rates increased from 81% at baseline to 95% after the medication safety effort, according to the study. Pain reassessments 1 hour after opioid administration rose from 41% to 91%. 

“Improvement was sustained over 17 months postimplementation for both projects,” researchers reported. 

Moreover, the number of adverse drug events related to administration errors dropped 17%, a decrease estimated to save between $120,750 and $239,725 annually. Opioid-related adverse drug events fell 2.6%, a change estimated to save between $72,855 and $80,928 annually. 

“Adopting John Kotter’s model for change, developing performance dashboards, and sustaining engagement among stakeholders on a weekly basis improved bar code medication scanning rates and pain reassessment compliance,” researchers wrote. “The stakeholders created momentum for change in both practice and culture resulting in improved patient safety with a favorable financial impact.”

—Jolynn Tumolo 

Reference 

Ho J, Burger D. Improving medication safety practice at a community hospital: a focus on bar code medication administration scanning and pain reassessment. BMJ Open Qual. 2020;9(3):e000987. doi:10.1136/bmjoq-2020-000987