Computerized charting and point-of-care testing came together in December 2007 on our nursing unit. When E-charting was implemented, results from glucometer readings went into cyberspace if the medical record numbers (MRNs) were not entered correctly. Consequently, managers spent valuable time correcting the daily logs of glucometer entry data, finding it very difficult to track the data that previous paper charting saved. Nurses spent time trying to track glucose results before giving insulin to the patients.
The Project
The lost time and data created a problem that was immune to solutions such as teaching, counseling, corrective e-mails, and signing contracts that included reviewing written instructions. Misentry of data affected all the staff who entered the MRNs, nurses and nursing assistants (NAs) alike, high and low performers. Each mistaken entry came with a reasonable excuse: loss of concentration, slip of the finger, or distraction. Correcting human data entry error seemed an insurmountable problem. A quality improvement effort was initiated to find a means to accurately and inexpensively enter the MRNs into the glucometer and electronic medical record.
Lean Processes
The leadership team of the unit brainstormed using articles from their journal club, including those on Virginia Mason Medical Center's lean management efforts1 and Transforming Care at the Bedside.2 We realized that a system that would prevent human error was needed. One team member had experience with bar coding in a furniture factory that used lean management to assure tracking quality of finished goods; the idea seemed appropriate for healthcare use. We found articles on how bar coding improved patient identification accuracy when used for medication administration and laboratory blood draws and thus decided to buy a bar code scanner to generate MRN labels. However, after searching the Web, a free Internet site with code generator seemed to provide an efficient and cost-effective answer to the rapid improvement process. The site provided a template on which to place the MRN and then made a bar code, which was printed and taped to the patient's armband. The staff put together a simple procedure for assuring the right MRN so unit secretaries and NAs could quickly and safely carry out the process. The staff tested the process over a weekend to see if it would work.
Methods
The staff suggested the following procedure:
1. On admission to the unit, the unit clerk generates a bar code from the Web at http://www.barcodesinc.com/generator/index.php.
a. Type in the patient's full MRN without the dash (-) but with the number after the dash in the last line of the Web site generator. For example, 0112345-6 would be put in as 01123456.
b. Press "print."
c. Cut out the rectangle with the bar code in it, give to the nurse or NA.
2. The nurse verifies the bar code and MRN then tapes it to the back of the armband with clear tape.
3. To do an Accucheck, scan the patient's bar code when the machine prompts for patient number.
4. Verify that the number is the same on the armband and in the machine.
5. If it does not work, put the number in manually and let the charge nurse know!
Immediately, the managers saw positive results. They were very pleasantly surprised when the first quality report from the laboratory came back with no errors after bar coding started. With 3 weeks of zero-error reports, the managers and staff declared the effort a unit success. As the procedure is adopted by more units, the results continue to show complete accuracy if the proper checks and procedures are followed. For the cost of a sheet of paper, the unit's glucose MRN entry problem was solved.
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