# Presentation: 498324

## Class #208Bar Code Medication Administration (BCMA)

- It’s More Than a Good Idea

## Faculty

- Janine Purcell, MSIEOR, Cognitive Engineer
- Bar Code Resource Office
- Toni King, RN, BSN, Informatics/BCMA Coordinator
- Lexington VAMC
- Tom Campbell, IT Specialist
- VHIT, Clinical Product Support, Clinical 1 Team
- Jim Mantia, Senior Attorney
- Office of Regional Counsel, Orlando FL

**Notes:**
Your presenters today are 
Janine Purcell, Cognitive Engineer from the Barcode Resource Office.
Toni King, Register Nurse and BCMA Coordinator from the Lexington VAMC.
Tom  Campbell, IT Specialist from the Office of Information and Technology.  He (I) am part of the Clinical Product Support (formally EVS), the Clinical 1 Team (formally Provider Systems Team).  
 Jim Mantia, JD, Office of Regional Counsel, Orlando Florida

Each of the presenters will give you a bit of history on themselves at the beginning of their part of the presentation.  Each of us will cover one of the four objectives.

## HOUSE KEEPING

- This is a 1.5 Hour Lecture class
- Restrooms are located...
- Cell Phones and pagers,
- Please turn off or change to vibrate
- 	If you must answer a call, please leave the room.

**Notes:**
Before we get started we need to take care of some Housekeeping issues. Restrooms are located..
This is a 1.5 hour class.  Restrooms are located........
Give yourself a 1.5 hour break from you cell phones, blackberry’s, and/or beepers----turn them off or at least set them to vibrate if you feel an anxiety attack coming on if you turn them off!

## HOUSE KEEPING

- Please,
- No questions during the presentation.
- Questions written on the 3X5 card will be answered at the conclusion of the presentation.
- For questions not answered,
- the question and the answer will be available on the web.

**Notes:**
If you have any questions please write them on the 3X5 card provided. If we can’t answer you question at the end of our presentation then  your questions will be posted on the VEHU website. So please check the website when you return home.

## Objectives

- Discuss human factors & patient safety issues related to the patient and nurse.  Janine Purcell
- Review the 6 rights of medication administration.  Toni King
- Share examples of proper and improper documentation.  Tom Campbell
- Discuss the legal aspects of the Medication Administration Record.  Jim Mantia

**Notes:**
The objectives we will be covering for this presentation are:
To demonstrate safety issues related to the patient and nurse.  This will be covered by Janine.
 We will review the 6 rights of medication administration.  This will be covered by Toni.
 We will share examples of proper and improper documentation and show where all this is stored in VistA.  This will be covered by me (Tom).
  We will discuss the legal aspects of the Medication Administration Record.  This will be covered by Jim Mantia.

Janine, the podium is yours.

## Human Factors & Patient Safety Issues

## Human Factors Engineering

- =

- Designing Systems to fit human capabilities and limitations
- AND the tasks that humans perform in or with that system

- User-Centered Design

## Why User Centered Design?

- Safety principles – early detection of potential problems before an adverse event occurs.
- Cost benefits –
- allows for changes in User Interface early in life cycle, _before_ time and resources have been expended.
- increases the chance that the product will better meet end users needs.
- Product effectiveness – an intuitive user interface design will lead to more accurate and efficient product use.

## Human – Systems Model 

**Notes:**
The Human Systems model example:  overview

This illustration has people at the center of the system in which they work.  The elements of the system of the human systems model here are:
culture, environment, tools and tasks. 

Culture – support of nurse managers, pharmacy, environmental services, chief nurse – site figure from collaborative research

Environment – location of your med storage areas that supplement delivery to the med cart drawers.  Carpeting on the floor of a patient room.  Alcoves in the halls with plugs to recharge equipment.
Tools – what pill crusher are you using?  What med carts are you using?  
Tasks – does the shift sort out meds in the patient drawers for the next shift and order missing doses?  Does a nurse use the missed med reports during her med pass to catch new orders or just help her track how many patients she has left in her med pass?  

## Culture

**Notes:**
Culture example from NCPS report on Root Cause Analysis:  Effective Interventions and Implementation Strategies to Reduce Adverse Drug Events in the VA System, VA National Center for Patient Safety, April 2006

Interviewed 119 of 120 patient safety managers whose root cause analyses were used in this work.   
Note that 30% of respondents noted that lack of middle management support was an obstacle to making changes to avert medication errors.  Lack of strong frontline staff and senior leadership support are around 20%. 

## Environment

**Notes:**
Human Systems model – environment component 

Illustration of work flow pattern in a medical ward where a small computerized medication cart in conjunction with centralized med storage/delivery area on the unit can shorten the amount of walking that a nurse is going through.  

Rubbermaid medical had this simulation study done to demonstate how the choice of equipment coupled with tne environment of care can make a difference to workload for users. 

## Tools for BCMA

- BCMA Software
- Medication Carts
- Bar Code Scanners
- PYXIS
- Pill crushers

- Eyes and Ears
- Memory
- Cognition
- Body

**Notes:**
Tools used for BCMA in our Human Systems model example:

Our bodies and its capabilities can be viewed as part of the toolset for using Bar Code Medication Administration.  Our eyes and ears, our memories, capacity for cognition and decision making, and the limits and capabilities of our physical body such as our height, strength, hand size, etc. influence how we interact with the environment and other tools.

Those other tools include the BCMA software, computerized medication carts, bar code scanners, the bar code labels, drugs themselves, drug storage devices such as PYXIS, pill crushers, etc. 

## Tasks

- Nurse on med pass regenerates missed meds report several times during the med pass on the computer and checks it onscreen
- By doing this she updates her “checklist” of remaining patients (“Situational Awareness”)  Acute Psych 23 patients for that med pass

## A Human Factors Framework

- What do people do?
- Sense
**Perceive/assume/interpret/think**
- Store information in memory
- Retrieve information from memory
- Decide how to respond
- Respond

## Slide 15

## MZALB
ZYP
JCEFT
SUWRG
TPJOM
XCIDB
GCUFI
WOPR
BGLDA

**MZALB**
**ZYP**
**JCEFT**
**SUWRG**
**TPJOM**
**XCIDB**
**GCUFI**
**WOPR**
**BGLDA**

**LAALK**
**OEWSI**
**GCUFI**** **
**TPJOM**
**JCEFT**
**SUWRG**
**TPJOM**
**XCIDB**
**JDIEL**

**Notes:**
Preece’s example of the stroop task

## RED

**RED**
**BLUE**
**WHITE**
**GREEN**
**BLUE**
**RED**
**WHITE**
**YELLOW**
**GREEN**** **

**BLUE**
**RED**
**GREEN**
**WHITE**
**BLUE**
**RED**
**YELLOW**
**WHITE**
**YELLOW**** **

**Notes:**
Illustrates the difference between controlled and automatic cognitive processes:

Automatic processes are note affected by the limited capacity of the brain and do no require attention

Controlled processes have limited capacity and require attention and conscious control  (Preece)

## Automatic processes unaffected by memory limits
fast
demand minimal attention
not available to consciousness
Controlled processes require attention and conscious control
Automatic processes difficult to unlearn once they have become automatic themselves
function key assignments, consistent screen locations 

- fast
- demand minimal attention
- not available to consciousness
- Controlled processes require attention and conscious control
- Automatic processes difficult to unlearn once they have become automatic themselves
- function key assignments, consistent screen locations

- Automatic Processing Versus Controlled Processing (Preece, 1994)

## A Human Factors Framework

- What do people do?
- Sense
- Perceive/assume/interpret/think
**Store information in memory**
**Retrieve information from memory**
- Decide how to respond
- Respond

## Sensory store
Specific to sense
vision:  less than a second
hearing: several seconds
Working memory
information actively being worked on
Miller’s Magic Number 7 +/- 2
Permanent long term memory

- Specific to sense
- vision:  less than a second
- hearing: several seconds
- Working memory
- information actively being worked on
- Miller’s Magic Number 7 +/- 2
- Permanent long term memory

- Mind as Tool:  Multi-store Model of Memory (Preece, 1994)

## Working memory is where people
perform calculations
interpret incoming data
juggle information as they solve problems
Sustained attention is required to maintain contents of working memory
Interruptions hasten the degradation of information in working memory, especially as interruptions become more complex

- perform calculations
- interpret incoming data
- juggle information as they solve problems
- Sustained attention is required to maintain contents of working memory
- Interruptions hasten the degradation of information in working memory, especially as interruptions become more complex

- Human Memory ModelWorking Memory (Mayhew, 1992)

## Limited resources are a cognitive reality

**Notes:**
Use checklists in key areas
Avoid requiring users to hold information in their head as they move from one part of the system to another -- replicate information needed at the next step or place it in an omnipresent portion of the screen real estate
Assign calculations of data to the system
Assign translations of information to the system
Use distinct names for operations, especially those that appear within a set of options

## Solutions must come from the nursing team 

- Vest for Med Pass:
- DRUG ROUND IN PROGRESS
- PLEASE DO NOT INTERRUPT AS MISTAKES CAN COST LIVES

**Notes:**
A hospital in the UK used vests for the nurses to wear during their med pass.  It reads:  Drug round in Progress Please do not Interrupt as mistakes can cost lives.  This approach attempts to create an agreement with the fellow staff, visitors and even patients to minimize interruptions that interfere with the nurse’s concentration on her medication administration tasks.  

## A Human Factors Framework

- What do people do?
- Sense
- Perceive/assume/interpret/think
- Store information in memory
- Retrieve information from memory
**Decide how to respond**
- Respond

## Slide 25

**Notes:**
The screen shot shows the newly designed dialog box for PRN, as needed medications.  The new dialog box includes the drug's schedule, a computation since the actual time last given and a mandatory checkbox that states "I have reviweed the schedule and last administration of this medication.  The computation of the time last given appears in red font, and there is also an warning icon in this area of the screen.  These design elements and the introduction of the mandatory action are meant to make the nurse more conscious of this vital information to the correct determination on whether to give requested medication to the patient. 

## The 6 Rights of Medication Administration

## Objective

- Review the 6 rights of Medication Administration
- Right patient
- Right drug
- Right dose
- Right route
- Right time
- Right documentation

**Notes:**
Thanks Janine for getting this Presentation off to a good start by discussing Human factors and cognitive actions which affect the medication administration process. 
For this portion our objectives are to review the 6 rights of Medication Administration. 
As one of the many BCMA coordinator working n VHA I am honored to have available resource staff to work through BCMA issues. Janine is one of the staff working at the BCRO that has helped many of us gain a greater understanding of the important role of cognition, people, computers especially during the medication administration process. Tom supports the files and is always available to answer question and resolve remedy tickets.  The Office of Regional Counsel is also available to answer medical legal questions and to assist staff with depositions and courtroom appearances
Before we get started I want to share a story with you.  This particular story could be anyone's story at anytime in their healthcare career.

## What Went Wrong?

- Brief review of an actual case
- Right patient
- Right procedure
- Right documentation
- It may seem a strange principal to enunciate as the very first
- requirement in a Hospital that it should do the sick no harm
- 	—Florence Nightingale *Notes on Hospitals, 1859*

**Notes:**
Brief review of an actual case involving the Right patient, procedure and documentation
It was a warm summer day when the novice nurse returned from vacation.  What had been a relaxing time away from the daily demands of life were immediately met with tremendous stress. There was a list of calls from senior managers from the hospital.  She had a strange feeling that something was wrong but was uncertain of what. She called the hospital and the Director of Nursing informed her that a lawsuit had been filed and she was named as a defendant.  She had only been practicing nursing for 3 years and could not imagine that she did anything to intentionally harm anyone under her care.  She picked up the local newspaper and read the article that was displayed on the front page.  There it was her name along with the names of several other colleagues being named in this complaint. After reading the article she immediately attempted to replay this patient encounter in her head.  “Everything that was supposed to be done was completed”.  She even tried to replay the video of the documentation surrounding this event, all along hoping that everything in this patients record was proper and that the documentation reflected the care that was delivered at the time it was delivered.  

## Proper documentation is a good thing when past events must be recalled

## Right Patient

- Joint Commission National Patient Safety Goal Standard 1A
- Improve the accuracy of resident identification
- Use at least 2 resident identifiers when providing care, treatment or services
- Implementation Expectations
- When doing the following
- Administering medications or blood products
- Collecting blood samples and other specimens for clinical testing
- Room name and physical location is not used
- Containers used for blood and other specimens are labeled in the presence of the resident

**Notes:**
Medication administration is one of the various  things that we do in healthcare requiring that we validate the right patient.  From the simplest acts to the most complex we should always be vigilant to ensure we have the right patient.  Most people do that everyday. Safe and effective administration of medications can be disrupted due to human factors.  As Janine has shared human factors can at times intercept us and cause problem.  She has shared about user centered design and how important it is that the technology being implemented consider human factors.  Joint Commission generally focuses on issues in healthcare that are not always followed or based on data that shows a need for improvement.  In addition the VA is increasing safety initiatives by expanding bar-coding technology to include laboratory specimen collection, blood and blood product administration and BCMA using hand held point of care technology to decrease wrong patient misadventures.  As Janine has shared interruptions can cause problems for staff and patients.  Session 110 Bar Code Expansion (BCE) Raising the Bar on Patient Safety is a session this week that covered VA’s initiative to move barcode technology to the next level.  Please view this training on the VeHU website  So what’s driving this shift.  

## Right Patient -- Drivers

- In the report *To Err is Human: Building a Safer Health System*, the Institute of Medicine estimated that as many as 98,000 hospitalized Americans die each year—not as a result of their illness or disease but as a result  of errors in their care   (IOM, 2000)

**Notes:**
One of the big drivers was the ground breaking report To Err is Human: building a Safer Health System

## Right Patient -- Drivers (cont.)

- Customer Satisfaction
- Patient Safety
- Joint Commission
*[Only] the right dose differentiates a poison*
* **from a remedy.*
*         **—**Paracelsus (1493-1541),  the father of modern pharmacology*

**Notes:**
In 2002 35 percent of practicing physician and 42 percent of the American public responded to a 2002 national survey.  In this survey 18% of the physicians and 24 percent of the public cited an error that had serious health consequences (Blendon et al., 2002).  I am sure that incomplete or incorrect documentation played a role in many of the errors coupled with poor communication. Having the right patient is vital to safe effective delivery of care.  Imagine being the patient about to receive medications and the nurse refers to you by the wrong name.  We must create an environment that equips and empower our patients with the ability to question actions that relate to their healthcare.  This was recently reinforced at the OI&T conference when Robert Howard, Director said we must create environments of greater vigilance related to our IT environment.  This can be applied to what should occur at the point of care and be non-negotiable.

## Right Drug, Dose, Route and Time

- Prior to and during medication administration perform a mental/visual cross check:
- Medication Reconciliation
- Active order in CPRS
- Allergy checks
- Proper patient ID
- Medication Education with opportunity for the patient to ask questions and share any concerns
- Avoid BCMA circumvention
- Appropriate monitoring and documentation of patients response to therapy
- Documentation of the medication administration

**Notes:**
The right drug, dose route and time are some of the critical steps during the administration process.  In the book Internal Bleeding (2004) authored by Doctors Robert M. Watcher and Kaveh G. Shojania reads on page 87-88 that one analyst found that fifty steps stood between the doctor’s decision to order the medication up to the point of administration.  The book reads even if things go right 99% of the time, the chance that one error  will occur in a 50 step process is equivalent to 39% of the time That being said staff should perform a mental/visual cross check prior to and during medication administration of the following. 

## Are these first 5 rights enough?

- May 2007 Issue of ISMP Nurse Advise Err reported
- Few Excerpts :
- Not the “be all that ends all” but broadly stated goals that offer no procedural guidance on how to attain the goals
-  Human factors and system weaknesses contribute to errors
- 5 rights often cited as a performance deficit
- Nurse and other practitioners cannot be held accountable for achieving the five rights but
- can be held accountable for the procedure that their organization has designed as the best way to verify the 5 rights
- If we hold them accountable we should give them authority to design their own systems.

**Notes:**
The ISMP published a wonderful article in the May 2007 of Nurse Advise-ERR titled The five rights: A destination without a map___________
Since the inception and implementation of BCMA so much has changed.  Huge stake holder involvement goes into new enhancements via the BCMA Health Systems Committee (HSC) that meets weekly via teleconference.  BCMA is one of the VistA applications that has an assigned cognitive engineer.  The other application is Pharmacy Re-engineering.  The cognitive engineer performs usability testing with field based front end users before implementing. This testing gives them a roadmap and a guidance system that can assist with following the VHA process for safe and effective medication administration and documentation 

## Don’t forget the documentation

- Document at the time of administration
- Avoid accepting verbal orders without documentation
- Be vigilant with documentation-use cognitive cues like the missed medication report, check list and other job aids to ensure all medications are documented in a timely manner
- Edit the Med Log to reflect the time medications were administered

**Notes:**
Don’t forget the documentation
Document at the time of administration
Avoid accepting verbal orders without supporting documentation adhering to your sites policies and procedures.
Be vigilant with documentation-use cognitive check list to assist- Don Berwick of the Institute of health Improvement (IHI) shared this story of his wife's experience at a prestigious medical center.  Dr. Berwick said that errors were not rare; they were the norm.  In one instance he shared that his wife was receiving a potent chemotherapy agent.  She was to receive 5 doses.  Dose #3 was labeled #2. for half a day no record could be found that documented that dose #2 had been given even though he watched it drip it.  I tell you from my personal observation, no day passed—not one without a medication error. (Internal Bleeding Chapter 5 Page 97-98)

## Right Documentation

- Roadmap for charting delivery of care
- Used for decision making and patient response to therapy
- Assist as a reference to recall information during handoff
- Used for historical information
- Used for performance improvement
- Staff and patient education
- Joint Commission readiness
- Used for litigation

**Notes:**
The right documentation is important in any setting be it the board room or something as simple as getting  driving directions.  With the increasing cost of petroleum no one wants to drive too far off course.  
In healthcare proper documentation is especially important.   As British psychologist and professor James Reason has shared in the sharp/blunt end dichotomy  
In fast paced health care delivery setting proper and timely documentation can assist other members of the sharp end healthcare team with charting the patients medical history and with future decision making. 
It can also enhance the hand off communication process.  We have all had experiences where we could not located the documentation.  If the person who was involved is not contacted often the team speculates.  Speculation can lead to harm
It can be used to gain historical information
It can also be used for performance improvement
Staff and patient education
Joint Commission Readiness
And yes it can be used for purposes of litigation.  Jim will share in greater detail the important aspects of proper documentation.  One recent example of an error that received a lot of national attention was the case of the Wisconsin nurse Julie Thao.   Julie was the nurse administering care on July 12, 2006 when a 16 year old girl died as the result of a medication error.  The state of Wisconsin on November 6, 2006 acted swiftly by filing a criminal complaint against Julie. I want to share with you a direct quote from Gregory Schuler an investigating office  with the Wisconsin Department of Justice Medicaid Fraud Control Unit “My investigation has revealed that the actions, omissions and unapproved shortcuts of the defendant constituted a gross breech of medical protocol, resulting in the death of this child.”  
Tom Campbell will share with you examples of appropriate and inappropriate documentation.  This information has been pulled from various VistA BCMA files across the country.  Folks proper documentation cannot be overemphasized.
So what was the outcome for my visit to the courtroom.  At the time of the case the hospital was in the process of being bought thus they settled out of court.  The physicians won with trial by jury of which I was called to testify.  My experience as a novice nurse has been a guiding factor in my practice. Do I do it right every time....NO...today I am still human.  I like many of you strive to serve our nations finest and deliver patient centric care with vigilance, passion and commitment.

## Vigilant Nurses

- Intercept 86% of errors
-                                        (Leape et al., 1995)
- Medication administration and documentation may occupy up to 33% of a nurses time
-                                       (A J Health System Pham 1995 15;52(4):390-5)

- Causes of medication errors include miscommunications, miscalculations, workload/staffing problems, interruptions, increases in knowledge and technology demands and incomplete documentation.
*                                                                  **(IOM, 2004b)*

**Notes:**
We have touched what need to be fixed or what is wrong.  I want t touch on what’s right.
According to the Leape and colleagues a 1995 reports says nurses have been responsible of intercepting 86% of errors made by Pharmacist, Physicians and others.  This is quite impressive.  Included with this is that 1/3 of the nurses TOD can be consumed with the medication administration process.

## “We cannot change the human condition but we can change the conditions under which humans work”                       

-                               *Reason (2000:769)*

**Notes:**
We must continue or be vigilant with fixing holes in the Swiss cheese

## Examples of proper and improper documentation

## Who am I and what will I cover?

- Tom Campbell, IT Specialist from Veterans Health Information Technology.
- Enterprise Product Support (formally EVS)
- Clinical 1 Team (formally Provider Systems Team)
- Are you confused yet?

**Notes:**
I am Tom Campbell.  I am an IT Specialist from the Veteran’s Health Information Technology.  I officially work at the Hines Field Office remotely located in Minneapolis.
I have worked for the VA since April of 1972 which if you are real quick with math equates to 35 years.  My first 25 years were spent in Pharmacy as supervisor and ADPAC.  For the past 10 years I have worked for IRM in Minneapolis and VISN 23 as an support person for Pharmacy, BCMA, CPRS and other clinical packages.  I joined the OI&T support 3 years ago.  I am the primary support person for BCMA, the Allergy package, and several of the Pharmacy packages.
I am going to cover our third objective which is Examples of Proper and Improper documentation.  I want to let all of you know that all of my examples are from several Production accounts through-out the VA system.  Nothing is from a TEST account, nothing is doctored or edited, this is all real!

## File 53.79

**This is where everything for medication administration is stored.**
- PATIENT NAME: XXXXXX,XXXX      PATIENT LOCATION: xxxxxx
- PATIENT DIVISION: XXXXXXX HCS         ENTERED DATE/TIME: MAR 02, 2007@09:33:36
- ENTERED BY: XXXXXXXX,XXXXXXX        ACTION DATE/TIME: MAR 02, 2007@09:33:36
- ACTION BY: XXXXXXX,XXXXXX
- ADMINISTRATION MEDICATION: MORPHINE SULFATE
- ACTION STATUS: GIVEN                  PRN REASON FLAG: 0
- ORDER REFERENCE NUMBER: 273U          ORDER SCHEDULE: PRN
- ORDER DOSAGE: 6MG/0.6ML               INJECTION SITE: IV/Lock
- PRN REASON: Pain Level #7
**PRN EFFECTIVENESS: this medication was not given.**
- PRN EFFECTIVENESS ENTERED BY: XXXXXXX,XXXXXX
- PRN EFFECTIVENESS ENTERED AT: MAR 02, 2007@15:13:20
- PRN EFFECTIVENESS MINUTES: 340
***COMMENT: this medication was scan twice, only one morphine dose was given sq***
- ENTERED BY: XXXXXXXX,XXXXXXX        ENTERED DATE/TIME: MAR 02, 2007@15:15:29
- DISPENSE DRUG: MORPHINE SULFATE 10MG/ML INJ 1ML   DOSES ORDERED: 1                      DOSES GIVEN: 1 UNIT OF ADMINISTRATION: 0.6ml
- AUDIT LOG: MAR 02, 2007@15:13:20        USER: XXXXXXXX,XXXXX

**Notes:**
This is an example of an entry in file 53.79.  This file stores the Who (patient), What (medication they got), When (Date/Time), Where (Location). And sometimes the Why, this would be the “comments”.  And of course it stores who administered the medication and it records any other actions taken related to this medication administration.  There is an AUDIT Log which records everything that is done related to this event.
This is also an example of a poor documentation. When I first saw this, I thought is was an example of GOOD documentation.  I will explain in a minute why this is poor documentation.   As it relates to the 6 rights, there are only 2 of the 6  Rights that can be entered incorrectly if BCMA is used properly.  The 2 that could be brought into question are “Correct Dose” or DOSES GIVEN, and “Correct Documentation” or COMMENT(S).
The only time the Correct Dose could be entered wrong or improperly is on something other than a Tablet/Capsule, such as an Oral Liquid or an Injectable.  With an Oral Liquid, the Nurse has to enter the amount they are giving the patient.  Example would be a Docusate Liquid could be documented as 15ml, 1 tablespoons, 100mg, all would be a correct .  
The other example of where a dosage has be to documented is shown in my slide.  This is for an injectable Morphine.  The injectable comes in a 10mg/ml syringe.  The dose is for 6mg and the RN documented they gave 0.6ml.  Also, in this slide I am showing the other example of the 6 rights: the comment is entered and it is a bit confusing.  I states the medication was scanned twice but only 1 dose was given.  Yet in the PRN EFFECTIVENESS comment it states “this medication was not given”, but yet the action Status is GIVEN.  I would guess Jim would have a lot of issues with this because of the comments and because this is a controlled medication!!
In the electronic record, everything you do is stored and can be viewed!  This needs to be stressed during any BCMA training.  This record was eventually straighten out through some diligent work and detailed comments by the sites BCMA Coordinator.

## Examples of questionable comments

- Examples of comments that don’t offer enough information:
_*Quick and easy*_
**COMMENT: ok**
**COMMENT: its ok**
**COMMENT: P**
**COMMENT: .**
_*Just a number*_
**COMMENT: 276**   < Drug IEN
**COMMENT: 0904224461**  <  this is a NDC number
_*The Nurses Initials*_
**COMMENT: awa**
_*A little too obvious*_
**COMMENT: given**
**COMMENT: bcma**

**Notes:**
These are all comments were recorded by a nurse during a medication administration.  What ever action they were taking required a comment to be entered.  This could have been a dosage issue, administration variance, and hopefully not a PRN effectiveness.
The first 4 examples are kind of a quick and easy.  Kind of a “I have to enter a comment so what is the fastest and quickest way to do it”.  Of course these types of comments really offer no clinical significance.
The next 2 examples, the nurse when presented with the comment they have to enter, they re-scan the medication package or the IV label, a number is recorded and they click OK.  Another way this happens that has come to light recently is the RN “double-scans” the package and doesn’t realized they did it so the 2nd scan is added to the Comments field.
The nurses initials example is again a quick way to record a comment, but we already know who is taking the action so this really isn’t what is needed here.
The last 2 examples fall into what I would call the “DUH” category.  We never would have been able to figure out that the medication was “given” or that the nurse used “bcma” to document what they just did.
The COMMENT: field is a “free text” field, that is why this type of documentation can be recorded.

## My Favorite Example!!

**Notes:**
This may be a bit hard to see but please focus on the comment.  This was not an isolated instance.  This was recorded on more that a dozen entries in file 53.79.  This was either done by someone with vampire tendencies, a computer geek, but of course then it would have been “byte” me, or a very unhappy person!
The point of all this is much like CPRS, this is a “PERMANENT” electronic record.  Please stress to your staff and coworkers that the documentation should be appropriate.

Now moving into our next segment, we will discuss what can be done about this type of documentation.

## What happens when you shortcut?

**Notes:**
This is what can happen when a free text field is used improperly.  This alert was issued on 6/18/2007.  When a RN is administering a medication that requires the particular dose to be documented, the Medication package or the IV bag barcode is scanned instead of actually typing in the correct dose administered. 
Once this alert was issued it caused all types of concern and problems at every VA site in the system.
We can discuss and argue that the software should NOT allow this type of improper documentation, but the bottom line is the pop-up window that appears is asking for specific types of information.
We think of BCMA as a nursing tool.  I would like you to think outside the “box” for a minute and think of BCMA as a “vehicle”.  Much like a car, BMCA is designed to be used a certain way.  You can go to the grocery store in your car.  When you get your groceries and are ready to go home, your car has a trunk or a space to put those groceries in.  Of course you can put those groceries on top of the car and drive home but that might not work real good!  
So as you can see with this issue, the software is designed to be used a certain way, but that doesn’t mean the USER will use it or drive it correctly.

## What can nursing do about documentation

- Reports
-    Nothing at this time dealing with this type of issue.
- Training
-    This is where most of the effort belongs.
- What can be edited in BCMA
-    BCMA Med Log Edit in the GUI

**Notes:**
For Nurse Managers/Administrators, there is no report at this time that will just print the comment field for review.  The comments will appear on the Medical Administration History report and the Medication Log Report.  Also, there is no report as it relates to the Dose administered because there is no way to determine if what was entered is or isn’t appropriate because these are what are called “Free Text” fields.  I would hope that if a report did exist that show’s this, it would be used as a training tool only.
Proper training is where this type of thing needs to be stressed.  I know many of the things I have shown are examples of a very quick way to get on to the next task.   In most cases the comments are fairly innocent, but as shown in the example of the Morphine dose, this could come back to haunt you.
Can any of this be edited or changed so it is more appropriate?  In the BCMA GUI, there is an option called Edit Med Log.  Either the nurse that gave the original dose or a nurse with the PSB MANAGER key can edit certain fields in the medication log.  Comments are not one of the fields that can be changed that is why it is so important to be appropriate the first time.  The next slide shows what can be edited.

## BCMA Edit Med Log

**Notes:**
Anytime one of these fields are edited it is required that a comment be entered before the “OK” button becomes active and can be clicked on to finish the documentation.

## What your IRM can do for you

- Integrity of the Database
-    Should IRM do anything with improper documentation?
- Reporting issues to National Support
-     Remedy (this isn’t an evil word!)

**Notes:**
Can your local IRM do anything about improper documentation?  They can do a file search and look for this type of thing but they really should not change it.  This is a part of a patients clinical data and there is a Database Integrity issue and a USER Integrity issue here.  Nothing should be deleted from this file.  This isn’t something your IRM department should be actively looking for.  This is something that has to be dealt an issue arises.
What your IRM department can do about this is determined by what the USER might have entered, what they meant to enter, or is there a possible issue with the software.  If your IRM department, BCMA Coordinator, CAC, or Pharmacist needs help beyond what can be done at your site, then a Remedy ticket should be submitted.  
E-mail is used frequently and might be a way to get information, it may not be totally accurate.  Your colleagues at other sites are great sources of information, but they could steer you in the wrong direction—not intentionally.

## What National Support can do for you.

- Use of Remedy
-  Veterans Administration Service Desk (VASD)  888-596-4357
- Determining where the problem is based
-     1.  USER issue
-      2.  Software problem
- Who fixes the problem?

**Notes:**
I don’t want to get into all the issues of who has access or who can enter a Remedy ticket at your site.  I know all sites have issues with this, but the bottom line is to engage the help of National Support, a remedy ticket has to be filed.  If you don’t have Remedy access, you can call the VA Service Desk at 888-596-4357.  If you use this, please give them as much information as possible about your issue.  This will help them to determine where the Remedy ticket is to be assigned and who should work on it.
Once that happens, if the ticket is related to our subject today, there are 4 people with Enterprise Product Support that could work on the ticket.  It is up to us to review the problem and determine what can be done about it.
An example of where the software caused at serious documentation problem was reported in January of this year (see slide 42) .  After a couple of hours work, it was determine the software was the issue.  The site asked me to get rid of the incorrect documentation because of the problems it might cause.  I could not do that (data integrity) but offered suggestions for some correct and detailed comments. The sites BCMA coordinator did an excellent job adding comments so there would be no question as to what happened with the particular medication administration. The ticket was referred to the VistA Maintenance Project (VMP) and a patch PSB*3.0*39 was released by me and has fixed the problem.
If it is discovered that a USER at the site caused the problem, then that can be taken care of by the site.
This product, BCMA, is being worked on continuously to be made better for the sake of the nurse and most important the Patient.
I would now like to turn this over to Jim to discuss some of the legal aspects of documentation.

## Legal Aspects of the Medication Administration Record

**Notes:**
Hello My name is Jim Mantia.  Today I will discuss the legal aspects of medication administration and documentation

## The Medical Record

- “Friend
-           or
-                 Foe”
-      *A SHORT STORY*

**Notes:**
This portion of the power point presentation was created primarily by Ruth Dowling, CRNP, JD from our Bay Pines Office.  A few adjustments have been made for today.           

Actually, the title should be “Best Friend or Most Fearsome Foe” – but remember you are the ones who create it.

This portion of the presentation puts the spotlight on bad practices.  However, don’t forget that only a few cases go to trial and result in an adverse judgment, because good practice is the “rule” not the exception.

## Slide 51

**Notes:**
Health care providers who have access to an electronic medical record no longer have to struggle with the perils of legibility. Here are a few examples.

## Slide 52

**Notes:**
If you are cryptic or vague in creating your notes, the result can be nearly as bad.

## COMMUNICATE

- COMPASSION
- “MEDICALESE”
- FLOW SHEETS

**Notes:**
Communication is the reason for any written or data entry task – keep it simple and accurate.

## Slide 54

**Notes:**
“Taquicarbia”  meant to be “tachycardia” –Spelling counts, use english.

## APPEARANCES COUNT

- Personal Comments
- Legibility
- Neatness

**Notes:**
Whenever tempted to insert personal comments, DON’T, DON”T, DON’T.  Avoid the temptation at all times.

## Slide 56

**Notes:**
As inconsequential and useless as this note first appears to be, there is a very tragic story behind it, which makes very damaging.  

The female patient mentioned had experienced a very serious injury shortly before this date.  She allegedly was raped in the hospital room by the male patient whose record this note contains.  As a result, the entry seems to mock the situation, even if the provider had no knowledge of the allegation of the female patient.  If he/she did, then how much worse would this be? 

## Slide 57

**Notes:**
Whatever is that?

## Slide 58

## Personal Comment?

**Notes:**
“Bite me” is certainly a “NO”. As are all of the following bad examples.

## Slide 60

**Notes:**
It probably wasn’t funny anyway.

## SAY WHAT YOU MEAN

- Vocabulary
- Syntax

**Notes:**
You are the one who will have defend what you create.  So be certain that you know what you are entering is correct and understood by you- and hopefully all subsequent readers.

## Slide 62

**Notes:**
I am certain that this provider would like to take back his/her written words.  

Text on the photo says:  Exploratory laparatomy was performed on 12-15-71.  however no heroic measure was done.  As a result of septicemia and hepatic dysfunction the patient was killed on 12-30-71.

## Slide 63

**Notes:**
Too much said for no good purpose, and raises the suspicion of a a problem at the very onset.

## Slide 64

**Notes:**
This is the start of an unnecessary dialogue between two providers.

## File 53.79

**This is where everything for medication administration is stored.**
- PATIENT NAME: XXXXXX,XXXX      PATIENT LOCATION: xxxxxx
- PATIENT DIVISION: XXXXXXX HCS         ENTERED DATE/TIME: MAR 02, 2007@09:33:36
- ENTERED BY: XXXXXXXX,XXXXXXX        ACTION DATE/TIME: MAR 02, 2007@09:33:36
- ACTION BY: XXXXXXX,XXXXXX
- ADMINISTRATION MEDICATION: MORPHINE SULFATE
- ACTION STATUS: GIVEN                  PRN REASON FLAG: 0
- ORDER REFERENCE NUMBER: 273U          ORDER SCHEDULE: PRN
- ORDER DOSAGE: 6MG/0.6ML               INJECTION SITE: IV/Lock
- PRN REASON: Pain Level #7
**PRN EFFECTIVENESS: this medication was not given.**
- PRN EFFECTIVENESS ENTERED BY: XXXXXXX,XXXXXX
- PRN EFFECTIVENESS ENTERED AT: MAR 02, 2007@15:13:20
- PRN EFFECTIVENESS MINUTES: 340
***COMMENT: this medication was scan twice, only one morphine dose was given sq***
- ENTERED BY: XXXXXXXX,XXXXXXX        ENTERED DATE/TIME: MAR 02, 2007@15:15:29
- DISPENSE DRUG: MORPHINE SULFATE 10MG/ML INJ 1ML   DOSES ORDERED: 1                      DOSES GIVEN: 1 UNIT OF ADMINISTRATION: 0.6ml
- AUDIT LOG: MAR 02, 2007@15:13:20        USER: XXXXXXXX,XXXXX

**Notes:**
This is an example is from Tom’s discussion of File  53.79.  An attorney will request all available files during the discovery phase of any litigation .  This file stores the Who (patient), What (medication they got), When (Date/Time), Where (Location). This is the type of information a prudent attorney will pursue. This AUDIT Log is the type of file that an attorney would enjoy having a subject matter experts such as Tom to interpret the original intent and the what was actually documentation.
As Tom as already pointed out this an example of a poor documentation. The 2 that could be brought into question are “DOSES GIVEN”, and “Documentation” or what I will call Comments.
 Yet in the PRN EFFECTIVENESS comment it states “this medication was not given”, but yet the action Status is GIVEN. 
In the electronic record, everything you do is stored and can be viewed!  The best time to do this is during the initial documentation entry.  During a deposition in the court room is not the time to explain.

## CHART FOLLOWUP

- Impression Counts

**Notes:**
Loose/ careless words, like “loose lips” (WW II caveat) can sink ships – or make any case likely to have a bad outcome. 

## Slide 67

**Notes:**
Nothing needs to said here.

## DO NOT FIGHT

- Inappropriate
- Use in Court

**Notes:**
Any court case in which two managers, care providers, administrators, etc. are seen to be engaging in a bitter disagreement is what every Plaintiff’s attorney longs to discover.  

## Slide 69

**Notes:**
 know my record says the surgeon is a knife-happy maniac, but I didn’t really mean it exactly the way it sounds.  

The caption to the cartoon says:  Risk Prevention Skills. 

## Slide 70

**Notes:**
Logically follows the last cartoon – but its not funny.

## Slide 71

**Notes:**
More of the same.

## Slide 72

## Medical RecordAs Comic Relief

## Slide 74

**Notes:**
We know what he was thinking, but he didn’t need to say it.

## Slide 75

**Notes:**
Even those with an anatomy to be proud of, should not brag about it in the medical record.

## Thank you  for sending me a copy of your book.  I’ll waste no time reading it.   

**Moses Hadas (1900-1966)**

- Jim Mantia, Senior Attorney
- Office of Regional Counsel

- for attending this learning session

**Notes:**
Janine, Tom, Toni and I would like to take this time to thank you for attending this learning session. 

## Questions

**Notes:**
We are now ready to field your questions.