DESIGNED AND USED CORRECTLY, bar code medication administration (BCMA) technologies can improve patient safety by reducing errors. But they offer this benefit only if clinicians use them properly. Taking shortcuts or creating workarounds to save time or “fix” frustrating glitches in the system isn't only unsafe for patients, but may also expose you to serious legal consequences. In this article, I'll explain key elements of the BCMA process and discuss how you can avoid patient harm and legal pitfalls that could threaten your career.
Step by step
When the BCMA process works properly, several steps occur (with some variations according to differences in software and facility policies). These steps are divided into two categories: those that don't have to be performed at the bedside, and those that do.
Steps that don't have to be performed at the bedside include:
- visual verification by the nurse of the accuracy of new orders by comparing each element of the order in the patient's medical record against each element of the order on the electronic medication administration record (eMAR)
- procurement of medications from a pharmacy-managed storage source, such as an automated dispensing cabinet
- an initial visual five rights check against the eMAR while removing the ordered medication from the storage source.
Steps that occur at the bedside include:
- identification of the patient according to the facility's policy
- visual five rights check of the selected medications against the eMAR
- a final, electronic five rights check performed by scanning both the bar code on the packaging for each unopened medication and the bar code on the ID band on the patient's wrist
- confirmation of bar code matching by the software system
- response by the nurse to cues or alarms from the system, such as a patient/order mismatch, allergy alerts, dosage warnings, required double checks, and administration parameters
- preparation (opening, pouring, measuring) of the medication in the packaging that was just scanned
- prompt administration of the medication
- immediate electronic documentation of the medications administered.
Avoid hazardous workarounds
Workarounds are omitted or unauthorized steps in a process that enable staff to bypass systems problems, such as those related to training, equipment, policies, or workload. Over a dozen such workarounds in the BCMA system have been identified.1 These include:
- scanning medications without first performing any visual five rights checks. Problem: You're relying solely on electronic equipment to confirm correctness.
- scanning medication bar codes after removing the medication from the packaging. Problem: Medications out of their packaging with no labeling attached are unlabeled medications. This workaround usually happens when nurses perform steps of the bedside BCMA process somewhere other than at the bedside.
- scanning a patient bar code other than the one that's on his ID wristband. Problem: This doesn't meet the criteria for patient ID. This workaround also occurs when nurses perform bedside steps of the BCMA process somewhere other than at the bedside.
If you're taking shortcuts to get your work done, you may not realize you've fallen into unsafe behavior. Safe behavior (for example, following all the steps carefully) may provoke criticism from supervisors and nursing colleagues because it takes more time, while at-risk behavior may invoke rewards because tasks are getting done faster.2 When workarounds become the status quo, the perception of risk to both patients and staff fades.
Of course, you'd be horrified if a patient suffered harm as a result of a medication error you made. It would be especially tragic if that error could have been prevented if you'd used the BCMA system correctly.
According to the New York State Department of Health, fraud is “conduct intended to deceive”; one example of fraud is falsifying documentation.3 Scanning is a form of documentation, because it transfers information into the patient's medical record. If you're required to scan the bar code on the patient's ID wristband but you scan something else, you're practicing a form of deception: You didn't scan the patient's ID band, but you made it look like you did. When you scan a medication bar code after you've already removed the medication from its packaging, you're also deceiving the system. You didn't scan the medication before you opened it, but you made it look like you did.
If something happens that leads to an investigation, your facility's legal staff could decide these actions constitute professional misconduct and require a report to your state's board of nursing. If a patient is harmed as a result of your actions, you could be further subjected to a civil suit. Criminal charges could be brought if your negligence resulted in a patient's permanent injury or death.
Finally, nurses can and have lost their jobs for this kind of practice, which employers consider dishonest. Facilities have policies that specify disciplinary actions to be taken in response to procedure violations. If you're terminated, your ability to secure a new job elsewhere could be threatened if the facility tells prospective employers why you were terminated when called for a routine background check.
You can protect both your patients and yourself by using your BCMA system properly. Read your facility's policies and procedures—and ask questions! Report any hardware and software problems that create slowdowns and frustration, as well as hassles and concerns associated with the process. Insist on education that includes a focus on responsibilities, risks, and consequences. Use organizational resources and channels, such as staff development nurses and medication committees, to make sure questions and concerns are addressed as quickly as possible.
If your facility is getting ready to implement a BCMA system, volunteer for an associated committee. (See An action plan for safe technology use for ideas on implementing a plan to improve processes.) Be sure it's multidisciplinary, with representation from nursing, pharmacy, and information technology, as well as appropriate leadership staff. Visit other facilities for insight into implementation options, strategies for success, and lessons learned. Initiate a serious discussion about how the use of the electronic system will impact workload and how that might affect patient safety, nursing risk, and nurse satisfaction. (For more on possible drawbacks to electronic technology, see “Medication Safety: Clinicians Override Electronic Alerts,” Drug News, page 14 of this issue.)
As a prelude to BCMA implementation, directly observe nurses preparing and administering medications and openly discuss what's wrong with current manual processes–don't assume that computers and scanners will eliminate unsafe practices. Select equipment with input from many nurses from different practice settings; there's probably no single solution that'll work for every department. Ensure that both during the testing phase and early during the live implementation, bedside nurses verify that each step in the BCMA system is relatively intuitive, simple, works well for them, and doesn't create work slowdowns that can't be minimized with repetition and familiarity.
Ask your facility's legal staff to include information about documentation fraud in annual corporate compliance training; after all, corporate compliance isn't only about financial integrity. Ask your staff education department to arrange for speakers on the topic of professional misconduct and other legal topics in nursing.
Play it safe
To be successful, a BCMA system requires careful planning, major resources, and ongoing commitment from administration. But nurses have the final duty—to patients, to employers, and to themselves and the loved ones who rely on them—to use that system correctly. The public trusts us. Let's keep it that way.
An action plan for safe technology use
So how can you, and your facility, ensure you're using electronic medication verification and administration technology properly? To improve this process, your facility may put an action plan into place that includes, among other things, a weekly review of:
- statistical reports that show the percentage of patients and medications scanned by each nurse, with nursing department leaders expected to counsel low performers
- results of walking rounds by pharmacy and nurse leaders for direct observation of the BCMA process
- progress of the facility-wide, computer classroom-based staff development nurse retraining program, featuring a multidisciplinary faculty and a curriculum designed to take nurses through various common BCMA challenges
- hardware problems reported by nurses during the previous week, follow-up actions taken, and the status of purchase orders for new equipment.
1. Koppel R, Wetterneck T, Telles JL, Karsh BT. Workarounds to barcode medication administration systems: their occurrences, causes and threats to patient safety. J Am Med Inf Assoc
. 2008; 15(4):408–423.
2. Institute for Safe Medication Practices. Our long journey towards a safety-minded Just Culture. ISMP Medication Safety Alert!
3. New York State Department of Health. Fraud in.