Voshall, Barbara DNP, RN; Piscotty, Ronald PhD, RN-BC; Lawrence, Jeanette DNP, CRNA; Targosz, Mary DNP, CPNP
Accurate medication administration is necessary to improve quality and ensure patient safety.1 Thirty-four percent of all medication errors in hospitals occur in the administration phase of the medication use process, and less than 2% of these errors are intercepted before execution.1 A consensus report validated the presence of medication errors in hospitals when systems to reduce medication errors were not in place.2 The development of policies and procedures delineating workflow to prevent medication errors is not a new phenomenon.3 Technologies supporting barcode medication administration (BCMA) have been developed as a system to help prevent these errors and create an additional level of safety for patients. Many organizations are integrating BCMA and electronic health records to achieve an automated closed-loop process, further ensuring patient safety.3 Even in the presence of policies and technology, work-arounds developed by nurses circumvent safety stops and cause errors.4 This article presents the nurse leader with an overview of the literature regarding BCMA systems and best practices and suggests actions for nurse leaders to decrease work-arounds in the process.
Errors in the Medication Administration Process
The purpose of this review was to conduct a systematic literature review on BCMA work- arounds to determine types of these processes occurring with BCMA. The administration of medication is a major component of hospital nursing practice.5 Estimates suggest that nurses spend 25% of a typical shift in some phase of the medication administration process.1 The administration phase is where 34% of errors occur.1 Barcode administration was developed to decrease the number of errors that occur in the administrative phase.1 Barcode administration of medications was initiated as a secondary development following the implementation of electronic order entry and pharmacy automation constituting a closed loop for the process of medication administration.3 Work-arounds are noted when the nurse administering medications using a BCMA system deviates from the defined workflow.4 In 1999, the Institute of Medicine (IOM)2 called attention to preventable medication errors as a significant patient safety issue. It is estimated that preventable medication errors result in more than 7 000 deaths per year2,6 and 400 000 preventable medication errors occur in hospitals each year.7 Errors are commonly attributed to faulty systems that are unable to prevent errors.2 Faulty systems then lead to processes and work conditions that contribute to providers making medication errors. The IOM noted that even though automated systems were available, hospitals were not using them.2 The implementation of BCMA technology, along with significant changes in nursing workflow, can potentially interfere with the delivery of patient care and may not be supported by staff at the bedside.7 The purpose of this study was to review peer-reviewed publications to determine the presence and nature of work-arounds in BCMA to inform nurse executives.
Barcode medication administration has reduced medication errors and adverse drug events (ADEs); however, this technology has led to unintended consequences of work-arounds by nurses at the point of service. In general, to administer medications using a BCMA system, the nurse scans the patient’s wristband barcode and then the medication barcode. If the medication does not match the patient identification, a warning appears in the system.8 The nurse may encounter potential problems with using barcode technology, including poor quality of print on the label or wristband, lack of barcodes on some medications,9 malfunctioning scanners, or providing care in an emergency situation when the time for BCMA is deemed an unnecessary delay.4 These problems may lead to the nurse bypassing the technology or using a work-around to administer the patient’s medication. The consequence of using work-arounds is the facilitation of medication errors by skipping safeguards of the automated system.4
The literature was searched using medical reference from in a university library system. CINAHL was searched using the key words barcode and workarounds. Empirical studies were selected that reported various benefits and consequences of BCMA implementation in the healthcare delivery system.4,5,10 These studies will be explored in the subsequent sections of this manuscript. The time frame used to restrict the results of the search was 2000-2010 because the BCMA system was 1st introduced in 2000.9 The articles were organized chronologically from the oldest to the most recent by year of publication and topics and were summarized in a review matrix. The review matrix was used to systematically organize, analyze, and synthesize the selected studies (see Table, Supplemental Digital Content 1, http://links.lww.com/JONA/A251).
Medication error rates before and after BCMA implementation were compared in a retrospective, comparative, descriptive study by Low and Belcher.11 All medication errors on 2 medical-surgical units in a Midwestern government hospital were included for a 12-month period before BCMA implementation and 12 months after implementation. No statistical significance was found between preimplementation and postimplementation medication error rates. In addition, the authors reported an 18% increase in error rate per 1000 doses after BCMA implementation that was not statistically significant. The authors attributed this to an increase in the number of medication errors reported by the new system, which may not have been detected in a manual reporting system and not an actual increase in the number of medication errors.11
Franklin et al12 completed a preobservational and postobservational study to determine the influence of a closed-loop electronic prescribing and administration system on the presence of medication errors. Franklin and colleagues12 examined the influence of closed loop on (1) prescribing errors, (2) administration errors, (3) medical medication prescribing time, and (4) nurses’ nonintravenous (IV) medication administration time. Results indicated that (1) prescribing errors decreased from 3.8% before implementation to 2.0% after implementation; (2) medication administration on non-IV drugs dropped from 7.0% to 4.3%; (3) the incidence of patient identification not being checked before medication administration dropped from 82.6% to 18.9%; (4) medical staff prescription time increased from 15 to 39 seconds; (5) drug administration turnaround time decreased from 50 to 40 minutes; and (6) nursing time on medication tasks other than drug administration rounds increased from 21.1% to 28.7%, which was statistically significant (P = .006). Although there were changes in a positive direction, they were not statistically significant for 5 of the 6 items examined.12
Nurse Work-Around Strategies
In a prospective ethnographic study, Patterson et al13 used targeted observations to identify the types and extent of work-around strategies of nurses who used the BCMA system in acute care and long-term care wards of 3 Veteran’s Administration (VA) hospitals. The findings included the following: (1) noncompliance with recommended practices on all wards at all facilities; (2) a larger proportion of acute care nurses scanned patient wristbands for identification, compared with long-term care nurses (53% vs 8%; P = .016); and (3) a larger proportion of acute care nurses administered the medication immediately after wristband scanning, compared with long-term care nurses (93% vs 23%; P < .001).13
Nurses’ use of BCMA technology was studied from a human factors viewpoint by Carayon and colleagues14 in a 472-bed Midwestern academic hospital. Structured observations and interviews allowed the authors to identify 18 different sequences of the BCMA process, with some of the steps being potentially unsafe. Various working conditions that hinder the BCMA process and patient factors that made BCMA challenging were identified.14 The conditions identified include (1) technology design of hardware devices, including a small screen; (2) implementation of technology, which included medications that do not have a barcode; and (3) use of the technology, including interruptions of the providers who are administering the medication.
Patterson et al15 described the negative, unintended consequences that resulted from implementation of a BCMA system that may lead to ADEs in a cross-sectional, observational study using field observations. Sixty-seven nurse BCMA interactions in acute care units and nursing home wards at 3 VA hospitals were observed. Observational data analysis revealed 5 negative, unanticipated consequences after BCMA system implementation that could potentially lead to ADEs. They include the following: (1) nurses may be unsure of how to use an automated system for medication removal; (2) lessened coordination between healthcare providers; (3) workflow interruptions for nurses; (4) nurses prioritizing monitored activities over other patient care activities; and (5) deviation from routine care for patients.15
Nurses’ Perceptions of BCMA
Nurses’ satisfaction with medication administration point-of-care technology was examined by Hurley and colleagues16 in a descriptive study. The authors used the Medication Administration System-Nurses Assessment of Satisfaction Scale16 before and after BCMA technology implementation. The results of the study indicated a high level of nurse satisfaction with the barcode/medication administration record technology. The nurses’ scores increased on all of the subscales of efficacy, safety, and access. The changes from before and after implementation were statistically significant (P < .001). The nurses agreed that extra time was wisely spent to ensure patient and medication verification.16
Using the Modified Gladstone Questionnaire, Ulamino et al16 examined nurses’ perceptions of medication error causes and barriers to reporting in a descriptive study using a convenience sample of 61 nurses at a VA center.17 The study also elicited nurses’ perceptions of the effect of physician order entry (POE) and BCMA on medication errors. The outcomes of the study revealed that the number 1 cause of medication errors was failure to check patients’ name band, and the 2nd cause of medication errors was a tired or exhausted nurse. Sixty percent of nurses believed that some medication errors were not reported because of fear of the reaction they would receive from the nurse manager, and 40% did not report because of fear of reaction from their peers. All nurses agreed that medication errors have decreased since implementation of the POE and BCMA systems.17
Costs and Benefits of BCMA
Maviglia and colleagues18 studied the costs and benefits of the BCMA system in a tertiary hospital pharmacy and determined the return on investment. The results of their study found that during 5 years, total costs were $2.24 million ($1.31 million in 1-time costs during the 1st 3.5 years, followed by $342,000 annually in recurring costs). A decrease in 517 ADEs annually from dispensing errors led to a yearly savings of $2.20 million. The net benefit for 5 years was $3.49 million, and the hospital’s breakeven point for return on investment occurred during the 1st year of operation.18
Poon and colleagues19 studied the impact of BCMA technology on how nurses spend their time providing patient care. The study used a comparative time motion study with direct observations before and after the implementation of a BCMA system on the intensive care, medical, surgical, and medical-surgical units of a large tertiary hospital. A total of 232 two-hour observations were equally split between before and after implementation. The results of their study revealed that the percentage of time nurses spent on medication administration activities was unchanged (before BCMA, 26.9%; after BCMA, 24.9%; P = .16), the percentage of time nurses spent providing direct patient care increased from 26.1% before BCMA to 29.9% after BCMA (P = .03), and the percentage of time nurses spent on inefficient activities decreased from 10.8% before BCMA to 7.3% after BCMA (P < .001).19
Koppel et al4 observed and shadowed nurses using BCMA at 2 hospitals, interviewed hospital leaders and staff at 5 hospitals, and participated in staff meetings regarding BCMA to develop a typology of nurses’ work-arounds when using the BCMA system. The authors identified 15 types of work-arounds and 31 types of work-around causes. They found that nurses overrode 10.3% of all documented medication administrations and 4.2% of patients’ medication administrations. The evaluation of their results led to their demonstration of the relationship between work-arounds, their possible causes, and potential medication errors related to each work-around.4
Morriss and colleagues20 conducted a prospective, observational, cohort study in the neonatal intensive care unit at the University of Iowa Hospitals and Clinics to determine if BCMA technology would reduce preventable ADEs by 45% based on the number of medications administered. After observing 92 398 medication doses administered to 958 subjects, the authors’ analysis of the data found that the BCMA system reduced the risk of preventable ADEs by 47%.20
Fowler and colleagues5 studied the impact of a BCMA system on nurse satisfaction and medication errors in a descriptive, longitudinal design using the Medication Administration System-Nurses Assessment of Satisfaction Scale,16 incident reports, and MEDMARX Medication Data Entry form.5 Overall, the nurses reported the most satisfaction with the safety aspects of BCMA and were the least satisfied with stat order turnaround times.5
Poon and colleagues8 examined the effect of barcode technology on the safety of medication administration in a prospective, before-and-after quasi-experimental study. After observing 14041 medication administrations and reviewing 3082 order transcriptions, 776 nontiming errors in medication administration were found on units that did not use the BCMA technology (11.5% error rate) versus 495 errors on units that did use it (6.8% error rate) (P < .001). The rate of nontiming errors fell from 3.1% to 1.6% (P < .001) and the incidence of timing errors from medications administered too early or too late fell from 16.7% to 12.2% (P < .001).8
Discussion and Implications for the Nurse Leader
Prevalence of BCMA in Care Settings
The use of BCMA is becoming more common in acute and ambulatory care to assist nurses and other healthcare professionals improve the safety and accuracy of the medication administration process. An evaluation of relevant literature revealed that BCMA systems have both benefits and challenges. Benefits include a decrease in medication errors and ADEs, thereby improving quality and patient safety. The use of BCMA provides nurses an added sense of safety, as they no longer rely solely upon manual checks. This is beneficial because nurses are frequently the last defense against medication errors because of their position at the point of service and their role in the administration process. The implementation of BCMA technology is reported as cost-effective owing to the enhancements in patient safety.5,16
Although BCMA is beneficial, it does present challenges. Refer to Table 1 for the suggested steps of BCMA. Barcode medication administration is not a perfect solution to prevent every medication error. Shortcomings in BCMA design, implementation, and workflow can lead to work-arounds, thereby facilitating medication errors rather than eliminating them completely.4 Work-arounds negate the benefits of BCMA, diminish staff trust, and disrupt workflow.21 Thirty-one causes for work-arounds were identified by Koppel et al,4 such as (1) unreadable barcodes, (2) malfunctioning scanners, (3) failing batteries, (4) unreadable or missing patient identification wristbands, (5) emergencies, (6) patient refusal, (7) medication kept at sites other than bedside, (8) different dose available than dose ordered, and (9) user not well trained.
Implications for Nurse Leaders
Nurse leaders in healthcare organizations have the opportunity to ensure that BCMA and other technologies are being appropriately used for patient safety. To ensure safe use, nurse leaders must be involved in the selection, design, implementation, and maintenance of these systems. Improved vendor relationships are essential for the successful implementation of any clinical system.22 The role of the nurse leader is in a prime position to ensure that the vendors are meeting the organizational needs of the institution. Vendors of BCMA systems must obtain and be open to feedback from end-users (bedside nurses). Vendors should subsequently review system characteristics and modify them according to feedback, when possible avoiding customization requests that may impede report capabilities.22 This process ensures continued success of the BCMA and reduces work-arounds.
Nurse executives need to be aware of and articulate about the advantages of BCMA regarding the cost-effectiveness in reducing ADEs and ensuring patient safety. The project leader must be aware of baseline statistics regarding ADEs and near-miss events in their institution and of the cost to patient welfare both from their own organizations and from the literature. These data should be monitored as part of an annual review identifying the cost and benefit of the expense of the initial and ongoing system.
Nurse executives should put systems in place to ensure that nursing staff are using the technology correctly and according to organizational policies and guidelines. This ongoing monitoring will identify improvements that must be made to update or improve the technology, education for the staff, or changes to processes and systems.
Barcode medication administration systems have been evaluated and found to decrease medication errors and prevent ADEs, thereby improving the safety of the medication administration process. The return on investment can be realized by improving patient care while reducing costs.23 Results of studies have demonstrated overall nurse satisfaction with BCMA systems. However, nursing work-around strategies may reduce the effectiveness of the BCMA. Work-arounds have implications; they may facilitate new medication administration hazards.4 An important lesson learned from this review is that healthcare technology, including the BCMA system, should be user friendly while mitigating the risk of committing preventable medication errors.24 Ensuring that point-of-care staff are aware of the benefits of new systems and processes will increase the likelihood of adoption of new technology.25 The incidence of medication errors will be decreased by avoiding reported work-arounds in the implementation and use of automated systems for BCMA.
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