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The Cost of Implementing Inpatient Bar Code Medication Administration
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The Cost of Implementing Inpatient Bar Code Medication Administration

Julie Ann Sakowski, PhD; and Alana Ketchel, MPP, MPH
Bar code medication administration can be an effective and potentially cost-saving solution to prevent harmful medication administration errors in the community hospital setting.
How the system is used and the effectiveness of the bCMa system in preventing medication errors could have a pronounced effect on the cost-effectiveness estimate. The effectiveness of bCMa at preventing medication errors is a function of 1) the opportunity to prevent errors that may cause harm, which depends on the number and type of medication doses administered and the potential for harm if an error does occur, and 2) clinical work processes and users’ reactions to the warnings generated by the bCMa system (ie, how do they change what they are doing based on receiving a BCMA warning). The cost per error prevented may be even more favorable if BCMA is implemented in settings where the risk of adverse events from medication errors is highest and the processes are optimized to ensure appropriate use of BCMA. For example, 1 study reported an adverse drug event rate of 1.6% in an academic medical center’s units with BCMA, compared with 3.2% in units without BCMA, a relative reduction of 50%.23 Those findings are higher than what we observed or even considered in our sensitivity analysis. Experiencing error prevention rates similar to that would significantly reduce our estimate of cost per error prevented. It should be noted that several studies have suggested that errors may be introduced into the medication use process by the technology itself and presented evidence of “workarounds” created by end users of HIT to bypass certain features of the technology.37,38 Any errors introduced by the system or reduced efficiency from not using the system as intended would reduce the beneficial impact of BCMA on preventing errors, thus increasing the cost per ADE prevented. This reinforces the need for ongoing monitoring efforts to ensure the system is being used properly and operating as intended.

Limitations and opportunities for further research. There are some limitations of our study that need to be taken into account when attempting to generalize our results to other settings. The study sites included in our evaluation are part of a large community hospital network. Network resources were used for the implementation and to support ongoing BCMA operations. We made every effort to capture the value of these network resources, but it is reasonable to assume that savings may be gained by leveraging knowledge from successive implementations. This may potentially understate the costs incurred. The extent of this understatement is unknown, but we do not anticipate it would produce a material impact on our cost or cost-per-prevented-ADE estimates. Our cost estimates are based on the actual costs incurred and include the retail, non-discounted prices for initial BCMA software licensing and hardware purchases at the start of the implementation process: 2002 to 2003. Any major changes in the relative market prices for those goods since that time may alter our overall cost estimates.

At all of the study sites we deployed computers on wheels that users moved from room to room, rather than installing individual computers in the patient rooms. Hardware implementation and upgrade costs may differ for the option of permanently installing computers in the patient room. Although this may impact our estimate for the implementation cost per bed, we expect it would have an immaterial impact on the cost-effectiveness estimate.

There are numerous opportunities for future work that can strengthen and expand on the findings presented in this paper. The evidence on the effectiveness of BCMA will be strengthened by more rigorous data on the incidence and description of medication errors and the adverse drug events that occur with and without BCMA that can be collected using observation methodologies, clinical record abstractions, electronic trigger tools, etc. The BCMA system we evaluated was used as a stand-alone application; evaluating the costeffectiveness of including BCMA as part of a comprehensive medication management system which also includes CPOE and automated dispensing or as a module within a comprehensive EHR system is unknown and warrants further study. Lastly, evaluating the cost-effectiveness of BCMA for different operating time horizon assumptions, such as 2 years and 10 years, will provide insight into the feasibility and business case of implementing a stand-alone BCMA system as a solution within alternative strategic plans.

CONCLUSIONS

Over a 5-year operating horizon, utilizing a bar-code medication administration system for inpatient medication administrations cost $2000 per moderate or severe medication error prevented, less than published estimates of the additional costs of hospital care resulting from preventable adverse drug events. BCMA can be an effective and potentially cost-saving tool for preventing the morbidity and mortality associated with preventable medication errors in the community hospital setting.

Acknowledgments
This study could not have been completed without the assistance and input provided by Mark Riley, Tom Leonard, Denise Crase, Phil Ohlson, and Tim Schiro. We thank them all for generously sharing their expertise and their invaluable contributions. Preliminary versions of this paper were presented at the 2009 AcademyHealth Annual Research Meeting in Chicago, IL, and the 2009 Annual Meeting of the Western Economic Association in Vancouver, BC.

Author Affiliations: From Sutter Health, Institute for Research and Education (JAS, AK), San Francisco, CA.

Funding Source: None.

Author Disclosures: The authors (JAS, AK) report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (JAS, AK); acquisition of data (JAS, AK); analysis and interpretation of data (JAS, AK); drafting of the manuscript (JAS, AK); critical revision of the manuscript for important intellectual content (JAS, AK); statistical analysis (JAS); administrative, technical, or logistic support (AK); and supervision (JAS).

Address correspondence to: Julie Ann Sakowski, PhD, University of California, San Francisco, 3333 California St, Ste 420, Box 0613, San Francisco, CA 94143-0613. E-mail: sakowskij@pharmacy.ucsf.edu.
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