Mark Heelon RE: Bar Code in the PACU Setting

We are an acute care, academic organization that has successfully
implemented CPOE with over 95% of our orders placed by physicians directly
into our Clinical System. We have Pyxis and Pyxis profile on our inpatient
units also. We have completed Bar Code medication administration
Implementation on our inpatient nursing units. The Inpatient units are over
90% scanning Patient ID’s and over 80% med scanning.

Our PACU has a low medication scanning rate. We discovered this issue was
related to a med practice issue which was not encountered on the inpatient
units. In the PACU many patients have an order placed for Morphine __mgs
every 5 minutes times __doses. Nursing staff will remove 10 mg's of morphine
from the Pyxis machine and use the same syringe to deliver multiple doses.
To save time the nurse will not return the morphine to the Pyxis station.
When the nurse scans the 10mg morphine they receive an error message because
a 2mg morphine order is tied to the 2mg Morphine syringe. Therefore the
nurse manually charts the dose bypassing the safety features built into PPID
(scanning).

Has anyone else encountered this issue and what resolutions have you come
too?

Mark Heelon Pharm.D.
Medication Safety Specialist
Baystate Medical Center
Phone 794-3940
Mark.Heelon@baystatehealth.org