Page 1 of 10 BRIGHAM AND WOMEN S HOSPITAL DEPARTMENT OF NURSING ELECTRONIC MEDICATION ADMINISTRATION RECORD (EMAR) DOWNTIME POLICY APPROVED FOR: RN LPN PCA GENERAL ICU OTHER PURPOSE: To insure a process that allows the nurse to continue to administer and document medications in the event that any component of the network system does not function and the emar (Electronic Medication Administration Record) is not available for use at the bedside. DEFINITIONS: There are three different scenarios that may occur with a computer system downtime. They are as follows: Section 1: Network Downtime: During this time all of the Information Systems are not working. This includes BICS, Physician Computer Order Entry and Pharmacy/eMAR system. This will be scheduled once a month and may occur unscheduled. Section 2: Pharmacy/eMAR Downtime During this time BICS and Physician Order Entry are working. The Pharmacy/eMAR system is not available so medications cannot be approved by pharmacy nor can the nurse bar code scan or document the medication administration in the emar. This will be unscheduled occurrence. Section 3: Wireless Network Downtime During this time all of the network systems are available including BICS, Physician Order Entry, Pharmacy and emar but only on the desktop computers. The wireless laptop computers and the bar code scanners will not be working. This will be an unscheduled occurrence. POLICIES: In the event of a network shutdown when the emar is not available, the documentation of medication administration will convert to a hand written paper system until the network is restored. Paper medication administration records (MAR) that are to be used will be printed on each patient by the designated fail-safe computer on each pod. Physicians will be required to hand write orders during the computer down time. Paper medication administration records and physician s orders that are used during any network downtime will become a permanent part of the patient s medical record and filed in the chart. Once the emar is available for use, the nurse will update the electronic medication administration record to reflect the medications administered during the network downtime. When the network is restored and emar becomes available, it will be the responsibility of the covering physicians to enter all of the orders written during the downtime into the computer order entry system. This is required to update any medications that are ordered during the network downtime onto the patient s emar. Communications of Network Down Time: Scheduled Network Downtime Regularly schedule network downtime will occur on the third Monday of every month from
Page 2 of 10 2:00am to 4:00am. The notification of this process will continue through e-mail to all BWH employees 3 days prior to the scheduled network downtime. Unscheduled Network Downtime See BWH IS Administrative On call Procedure : Communications Procedure for Major IS System Failures PROCEDURE Section 1 PROCEDURE FOR NETWORK DOWNTIME A. FAILSAFE INSTRUCTIONS Logging on to the fail safe computer to print paper reports and paper Medication Administration Sheets 1. Identify the failsafe computer next to the printer on the pod clearly marked Failsafe Computer. 2. Login as the following: User Name: failsafe Password: failsafe Logon to: Click on arrow in login box to change from Partners to this computer. 3. Click OK through Error, platform unsupported message if it appears. 4. Double click on failsafe or OE emar icon that appears on the screen. 5. Next message will come across An active X control on this page might be unsafe to interact with the other parts of this page. Do you want to allow this interaction? Click YES. 6. Choose your pod in the drop down box in the upper left corner. 7. Click on the patient s name you want to print. 8. Click on Admins for the past 48 hrs. A. The failsafe computer stores information so that when the system shuts down the nurse is able to print a MAR with all of the patient active meds, a report of all the medications administered over the past 48 hours and all of the pending orders that were not taken off prior to shutdown. A failsafe computer is located on each pod and is labeled. 7. You must print the reports and paper MAR individually. The computer does not print the entire pod automatically. 8. Choose this option if you need a report of all of the medications administered to the patient in the past 48 hours. This includes maintenance medications, IV dtpn PRN di i
9. Click on display to see report. 10. Click on the print icon at the top of the page to print. 11. Click on Paper MAR for use @ downtime. 12. Click on display to see MAR. 13. Click on Blank Template. Select the category of med sheets desired and the number of boxes for an entry. 14. If a patient admitted during downtime, user will print blank medication sheet by selecting Blank Patient. 15. Click on the print icon at the top of the page to print. 16. Click on OE Pending Orders. 17. Click on displays to see pending orders. 18. Click on the print icon at the top of the page to print. 19. To escape from failsafe, x out of the screen in upper right hand corner of screen, 20. To logout of failsafe, click on Start button in lower left side of screen and choose Log of Failsafe (clicking yellow lock will not work here). 21. When logon box displays, change the logon to option back to Partners. This is essential for normal computer use. Page 3 of 10 and TPN, PRN medications, chemotherapy and blood. 9. mmm 10. Reports will print on the central printer on the pod. 11. Choose this option to print paper medication sheets that will list all of the patient s current active medications with a designated place for the nurse to document that the meds were given. The paper MAR will also have patient s name and medical record number at the top of the page. 12. mmm 13. Choose this option if you want to print blank medication sheets to transcribe new orders. Since emar is not functioning, no medication will pass to the online record. Everything must be now transcribed onto paper. 14. Blank medication sheets will print with no patient name or medical record number. 15. Paper MAR will print on the central printer of the pod. 16. Choose this option if you want to view any pending orders that were not taken off before the system shutdown. Orders can only be viewed they cannot be taken off electronically. They will need to be transcribed by hand onto paper MAR and any other required places depending on the type of order. 17. mmm 18. mmm 19. mmm 20. mmm 21. When logon box displays change the logon to option back to Partners. This is essential for normal use.
B. Medication Administration During Scheduled or Unscheduled Network Downtime 1. Identify MAR that is printed by the failsafe computer can be used for three days and contains all of the active medications. 2. Locate patient s name, medical record number and allergies in the upper left hand corner of the paper MAR. 3. Identify that medications are listed in the same categories as MAR, X1 s, maintenance medications, IV s and TPN, PRN s blood and chemotherapy. 4. Identify that under each medication can be found: schedule of administrations, time next dose due, time last dose given and the start and the end time of the medication order. 5. Check paper MAR for medications that are due. 6. Obtain medications from the Omni cell. 7. Administer medication to patient. 8. Sign out medications on the paper MAR by writing initials with the time in the appropriate box i.e. ab/8am. 9. Sign signature log at the bottom of the paper MAR. C. Transcribing orders during a scheduled or unscheduled Network Downtime. 1. Identify that during a network shutdown all physician s orders are written on paper order sheets. 2. Identify that paper orders can be found in the failsafe binder on the pod. 3. Identify that when order are written, one copy goes to pharmacy to obtain the drug. 4. Transcribe the new medication order, drug, dose route and frequency onto one of the blank MAR s. 5. Write initials on the line Order Take Off in the medication box where order was transcribed. Page 4 of 10 B. Medication Administration During Scheduled or Unscheduled Network Downtime C. 6. Double check for right drug, dose, route, time and patient. There is no bar code scanning of drugs or patient ID bracelets when the system is down. C. Transcribing orders during a scheduled or unscheduled Network Downtime. When the network is down, the MD will be unable to enter orders into the OE. During a scheduled downtime if the orders are not of an urgent nature, orders are generally written before or after the network is shutdown so they can be entered into the computer. Otherwise, if orders need to be written during the scheduled downtime or any time during the unscheduled downtime, the physician will hand write them on paper. When the order entry system comes back on, the physician must enter the orders into the computer to get them on the patient s emar.
D. Updating the emar when the network returns 1. Click on patient on the pod monitor list. 2. Click on emar key. 3. Click on To Do List. 4. Click on the emar screen tab and in the drop down box click on On Paper. 5. Identify that a list appears of all the overdue administrations. 6. Check that the administrations that are listed are all documented on paper. 7. If the administration has been documented on paper, click on the check box next to the medications. 8. Identify that when a PRN medication is selected, a pop up box will appear asking for the total number of administrations documented on paper. Enter the correct number. 9. Identify that a second pop up box will appear asking to enter the date and time of the last administration of the PRN med documented on paper. 10. Update the time using the 24-hour Page 5 of 10 D. Updating the emar when the network returns While the network is shut down emar continues to schedule administrations. As a result when the nurse opens the To Do List on the emar, there will be several administrations in the Overdue Medications category that have been already given and documented on paper. In emar no current medications will be able to be given until all of the overdue administrations are removed. Nurse can remove these meds from the overdue list by using the On Paper routine. 6. Double check that all of the medications that were due during the time that the network was shut down have been given and documented on the paper MAR. 7. The box should only be checked if the administration is documented during the paper MAR. 8. If the nurse looks up these administrations in the daily or weekly views, the time will be identified with a paper icon next to the time indicating that the official documentation is on a paper MAR found in the patient s medical record. 9. This information is required so that the emar To Do List will accurately reflect when the next dose will be due and the PRN medication will be due. electronic clock. Click along the inner circle (green) to pick the hour, click along the outer circle (tan) to pick the minutes. Identify the correct time at the bottom of the pop up box. 11. Select the AM/PM selector if needed. 12. Pick the correct date by clicking the date in the electronic calendar and the click on OK. 13. After clicking all of the desired boxes, click Sign. 14. Type in BICS password and click OK or scan ID badge.
15. Identify a pop up message that says, Signing these Administrations means that the official medical record is on paper. These will not be documented in the emar application. 16. Compare paper MAR to emar to be sure all of the current meds are listed on the To Do List. Initial the paper MAR next to Confirm Reconciliation when you have validated that the medication has passed to the Electronic Medication Record. 17. Identify that any medications that are not listed in the emar must be written in OE by the covering MD in order for them to pass onto emar. Page 6 of 10 16. Orders may have been written on paper during the downtime so they will not be on the emar To Do List when the emar comes back. These orders must be entered into the OE by covering MD what the system returns. 17. Once the MD enters these orders, be sure to update the schedule of administration to match what was on paper.
Section 2 PROCEDURE FOR emar/pharmacy DOWNTIME See All Procedures in Network Downtime Except Order Transcription A. Failsafe Instructions (see Section 1A) B. Medication Administration During Scheduled or unscheduled Network Downtime (See Section 1b) C. Transcribing Orders During an unscheduled Pharmacy/eMAR Downtime. 1. Identify that during a pharmacy/emar downtime physicians will be able to continue writing orders on OE. 2. Look up orders by going to BICS View screen. 3. To see orders, select Date and Time. 4. Transcribe new medication order, drug, dose, route and frequency onto the blank copies of the paper MAR. 5. Write initials online Order Take Off in the medication box where order was transcribed. D. Updating the emar when the network returns (See section 1D) Page 7 of 10 In this downtime BICS and Physicians computer order entry will continue to be functioning by the pharmacy system and emar will not be available. All of the emar applications will not be available including Web Take Off and the To do list. Physicians will continue to write orders in OE but the nurse will view the orders from the BICS view screens to Web Take Off in emar. The nurse will NOT be able to take off the orders electronically. They will need to be transcribed by hand onto paper until the system comes back up again. 2. The nurse will not be able to electronically take off orders. 3. mmm 4. mmm 5. Initially the box will indicate that the order as transcribed by an RN not a unit coordinator.
Section 3 PROCEDURES FOR WIRELESS NETWORK DOWNTIME A. Failsafe Instructions (no need to print the paper MAR as the emar application is available on the desktop computer). B. Medication Administration During Wireless Network Downtime 1. Select a patient on the web pod monitor from the desktop computer. 2. Select "emar" key. 3. Select Reports key. 4. Select Worksheet short. 5. Prints worksheet by clicking on the printer icon on the upper left hand corner at the top of the report. 6. Identify the number of pages for report in the upper left hand corner with the printer icon. 7. Retrieve the worksheet from the central printer on the pod. 8. Review worksheet for medications that are due. 9. Obtain medications from the Omni cell. Patient drawer of refrigerator. 10. Administer medications to patient. Page 8 of 10 During a wireless network downtime all of the applications are working, BICS, OE and emar but none of the wireless equipment is functioning. This includes the laptops and bar code scanners. The nurse will be unable to scan medications or patient Identification bracelets. Documentation of medications on the Electronic Medication Administration Record is done on the desktop computer on the pods only. B. Wireless laptops will not work. Nurse must use the desktop computers. 4. The worksheet will list all of the patient s active medications. They will be listed in the same manner as the emar: X1 s, Maintenance medications, PRN medications, IV s and TPN, blood and chemotherapy. Worksheet will list all of the administrations given in the past 24 hours and the time that the next administration is due. 10. Double click for the right drug, dose, route, time and patient. There is no bar code scanning of drugs or patient ID bracelets when the system is down. Medications or patient ID bracelets
11. Document medication administration on a desktop computer. 12. Select the patient from the web pod monitor. 13. Select the emar key. 14. Select the medication(s) from the To Do list that was administered. 15. Select Manual Patient Entry at the bottom left hand corner of the screen. 16. A pop up box appears asking why the med was not scanned. Enter Downtime dedication already given. 17. The documentation screen will appear. Confirm that the date, time and dose are correct. 18. If the time/date is incorrect edit. 19. Update the time using the 24-hour electronic clock. Click along the inner circle (green to pick the hour, click along the outer circle (tan) to pick the minute. Identify the correct time at the bottom of the pop up box. 20. Select the AM/PM selector if needed. 21. Pick the correct date by clicking the date in the electronic calendar and then click on OK. 22. Click on given and the OK to confirm the date and time the medication was administered. 23. Confirm that a green check mark will appear next to the medication on the To Do List. 24. Click on Manual Patient Entry. 25. Type in your BICS password and click OK or scan your ID badge. 26. Enter a reason for not scanning the patient s ID bracelet Downtime medication already been given. 27. Identify that the scratchpad appears listing all of the drugs administered. 28. If correct, click sign. 29. Type in your BICS password and click OK or scan your ID badge. Page 9 of 10 cannot be scanned. 29. Highlight and manually enter any other medications that were given. Each
C. Transcribing orders during an unscheduled wireless network downtime (no need to transcribe orders onto paper MAR. Take off orders on Web Take Off in the emar application on the desktop computer). D. Updating the emar when the wireless network returns (no need to update the emar as all medication administration will be entered on the desktop computer). Page 10 of 10 medication must be entered individually. N.C.P.M. emar-00 Electronic Medication Administration Record (emar) Barcode Scanning N.C.P.M. emar-01 Equipment N.C.P.M. emar-02 Functions Performed from the OE Pod Monitor Screen N.C.P.M. emar-03 Functions Performed from the Take Off Screen N.C.P.M. emar-04 Functions Associated with Medication Administration N.C.P.M. emar-05 Functions Associated with Reconcile N.C.P.M. emar-06 Editing Medication Administration N.C.P.M. emar-07 Manual Entry (Unable to scan medication or patient bracelet) N.C.P.M. emar-08 Documentation of Blood Product Administration in emar N.C.P.M. emar-09 Printing Reports N.C.P.M. emar-10 Viewing Medication Administration History N.C.P.M. emar-11 Chemotherapy Orders DOCUMENTATION: Paper MAR, Paper Physician s Order Sheet CCL S: REFERENCES: Partner s Information Systems emar On Line Help Guide For intervening approved/revised/reviewed dates refer to archived copies. DEVELOPED BY: Department of Nursing Professional Development Department, 10/04 REVIEWED/REVISED BY: Clinical Practice Committee, 10/04 APPROVED BY: Clinical Practice Steering Committee, 10/04 Dr. Robert Goldszer, Associate Chief Medical Officer 10/05