EMR barcode scanning eliminates breast milk misadministration

February 19, 2018  //  FOUND IN: Michigan Medicine News

C&W has had no breast milk misadministrations since a new barcode scanning initiative took effect. Photo by Leisa Thompson.

C.S. Mott Children’s Hospital and Von Voigtlander Women’s Hospital is home to the first 24/7 formula and breast milk preparation room in a pediatric hospital nationwide. Opened in 2011, the Milk Room stores, prepares, and delivers mixed formulas and breast milk to inpatients.

“We service 50-60 percent of C&W inpatients on daily basis — a majority of whom are in the NICU,” said Sara Tutor, R.D.N., CNSC, CLC, manager of the Milk Room. “When we initially opened, we saw a decrease in misadministration — the wrong baby getting the wrong breast milk. Having one centralized operation resulted in fewer mix-ups.”

While misadministration was rare, it did still occur. That’s why an interdisciplinary team of nurses and support staff was brought together, including the MiChart electronic medical record team.

“We wanted allergy alerting on our orders so providers would receive a notification if they entered an order that was contradictory to a patient’s allergies,” said Matthew Enell, clinical informatics pharmacist with Health Information Technology & Services. “As we moved forward, we decided the best solution was to mimic other successful workflows commonly used for medication and food allergies. Barcoding meant that instead of relying on a manual double-check, nurses could scan a patient’s wristband and the breast milk. If they match, they administer the milk.”

Enell created new breast milk and formula orders, set up scanning for breast milk and created new labels. The new process went live in August 2016 and the results speak for themselves: MiChart barcoding has prevented any misadministrations.

“I worked on this for more than a year with lots of different people and all of the hard work paid off,” Enell said. “There’s a great sense of accomplishment and pride to see that it’s working and doing what it’s supposed to do.”

Tutor credits the Milk Room’s recent 365 Days of Safety Award to the engagement of a variety of people across the health system.

“We’ve always had a positive experience working with the MiChart team. Matt did a great job learning about our workflow and he’s continued to support our operation,” Tutor said. “To be recognized by C&W leadership and administration for our work is very meaningful. It gives us a goal to strive for every year.”