IN 1999, DEATH DUE TO medication errors became the eighth leading cause of mortality in the United States.1 Since then, advances in nursing informatics and technology have brought major changes to the old system of medication administration, improving patient safety.2 The electronic health record (EHR), bar code medication administration (BCMA), and other technologic innovations help nurses deliver safer patient care, efficiently manage patient information, and improve documentation.
The Quality and Safety Education for Nurses (QSEN) initiative has established a set of competencies for nursing informatics including safety, evidence, quality, and team involvement. QSEN defines the role of informatics as the use of information and technology “to communicate, manage knowledge, mitigate error, and support decision making”.3 These competencies relate to the role of the BCMA coordinator and support the main focus of this article, which is the informatics nurse's crucial role in the implementation and management of technology that improves safety during medication administration. This article reviews literature to support validation of practice and technologic solutions to enhance medication administration safety.
The big picture
The first problem regarding patient safety involves medication errors caused by failure to verify the right patient, medication, dose, time, and/or route (the five rights of medication administration). According to the National Coordinating Council for Medication Error Reporting and Prevention, “a medication error is any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional or consumer.”4,5 Preventable medication errors during inpatient stays in U.S. hospitals cost an estimated $16.4 billion annually.6 BCMA technology with an electronic medication administration record (eMAR) improves medication administration safety on a universal level. This technology works in conjunction with the EHR.7
The process begins with computerized order entry by the provider. This step reduces the probability of a transcription error. Next, a pharmacist verifies the order and dispenses the medication. Then, the RN notes the active medication order in the patient's medical record. After verifying receipt of the medication to the unit, a nurse scans the patient's bar coded wristband to assist with positive identification. Finally, the nurse checks the medication order in the eMAR and scans the bar coded medication. An alert will display on the screen if one of the “five rights” isn't followed.5
Some studies have shown that BCMA technology can reduce medication errors by 65% to 86%.8 One study saw a 54% reduction in medication errors 5 days post-BCMA implementation.9 Another study from a Veterans Affairs medical center reviewed medication error reduction at 1 and 5 years post-BCMA implementation and reported medication error reductions of 23% and 66% at 1 year and 5 years, respectively.10
Most of the literature reviewed indicated that the use of BCMA in itself isn't the only solution to medication errors. Even when used properly, BCMA isn't intended to replace clinical judgment.11 A number of workarounds can occur, such as failure to scan the patient wristband or medication, failure to follow alerts and parameters, and failure to follow policy.12 Other problems include temporary barcoding solutions (for example, products that aren't labeled by the manufactured and require manual barcoding by a pharmacy technician before dispensing), system failures, workflow obstructions, and poor implementation.13 Another temporary workflow solution involves placing wireless barcode scanners at nurses' station computers to make up for the lack of a wireless network and/or workstations on wheels. Instead of verifying patient identity and medication accuracy at the bedside, this solution forces documentation do be done away from the point of care and introduces additional steps, time, and distractions to the process.
Personal experiences with error
This author has personal experiences as a BCMA coordinator and as a BCMA end-user, which allows for analysis of systemic problems associated with BCMA. One problem involved nurses making copies of patient wristbands and storing them inside the medication cart. Some nurses who don't understand the safety benefits of point-of-care bar code verification might not take the time to move a medication cart to a patient's bedside. Instead, they may scan the copied wristband in the medication room or hallway, then scan the medications, open them, and deliver them in a cup to a patient's bedside. One small distraction could easily lead to the wrong patient receiving the wrong medications.
To effectively reduce medication administration errors, BCMA must be used at the point of care. BCMA coordinators must continue to reinforce this during new employee orientation classes, daily walking rounds, and e-mail communication.
Another serious workaround occurs when medication bar codes won't scan or aren't recognized by the software as being the “right medication.” Occasionally, nurses call pharmacy to request replacements for these damaged or invalid bar codes. This can lead to an error if the nurse proceeds to administer the medication without scanning while a pharmacist prints and sends a new bar code label without questioning the cause of the scanning failure. When the label arrives, the nurse scans it to document the earlier administration. But the medication that was actually administered may have been another form of the drug or it may have been a sound-alike, look-alike drug.
Errors involving I.V. infusions often occur when a nurse scans the drug label and hangs the solution on the I.V. pole but doesn't verify that the infusion actually occurs. Another nurse may find the uninfused bag still hanging hours later.
It's easy but unproductive to draw conclusions by calling these errors the result of careless or noncompliant end-users. To minimize risks, one must look beyond the face value of these mistakes and examine the most-likely contributing factors within the system's processes. The BCMA coordinator is in the ideal position to analyze problems and propose system changes that enhance patient safety.
Many hats of BCMA coordinators
The complexities of BCMA systems require oversight by an individual with knowledge from all processes involved in BCMA, including order entry, pharmacy verification, medication administration, and bar code interaction with hardware and software. When the BCMA coordinator receives a phone call from a user reporting a scanning problem, troubleshooting often begins with the hardware. If hardware is the problem—whether it's the scanner, computer, or medication cart—the user is walked through the equipment's reset procedure. If resetting and reconnecting equipment isn't successful, the BCMA can promptly provide a replacement or alternative.
To improve efficiency and minimize downtime, a few secondary wireless multipurpose devices should be available on each nursing unit. Tablet computers and personal digital assistants (PDA) with integrated scanners and BCMA software can be used as stopgaps when the primary hardware fails. Tablets and PDAs are also convenient for units with a high incidence of PRN and one-time medication prescriptions.
If a user's issue isn't equipment related, the BCMA coordinator asks for the patient's identifiers and asks the user to read the medication label aloud in order to double check the order against the medication on hand. Because time is critical to both the end-user and to the patient, the BCMA coordinator must have the capability, skill, and access to simultaneously troubleshoot the problem from the prescription, the pharmacy verification, and the eMAR. This determines who will need to be contacted (the provider or the pharmacist) to resolve the immediate issue. It also helps in identifying the need for additional educational offerings aimed at reducing the potential for similar errors. If troubleshooting by phone proves unsuccessful, the BCMA coordinator quickly reaches the point of care to act as a second set of eyes.
Point-of-care findings occasionally indicate pharmacy stocking the wrong form of the drug. For example, a sustained action or extended release drug is prescribed but an immediate release drug is delivered, or vice versa. When the medication nurse pauses to use the available resources after a BCMA alert prompts an invalid drug scan, pharmacy dispensing errors don't reach the patient.
Superusers and educators
Education is another key role of the BCMA coordinator. The BCMA coordinator knows how to use the system as a superuser and teaches other users of all skill levels how to safely use and properly document in the system. At this author's facility, all new nursing employees, students, and temporary staff receive a 4-hour hands-on BCMA course in a relaxed classroom environment before entering the clinical setting. The class begins with an explanation of BCMA's origins and its intended use. Then, each new employee is asked to describe any previous experiences he or she may have had with eMAR technology.
Those who are new to the BCMA concept may be challenged by the notion of documenting medications before administering them. Nurses with no prior BCMA experience are accustomed to administering medications before signing the medication administration record (MAR). BCMA reverses that process. The eMAR is electronically signed and time stamped by the medication nurse as bar codes are scanned.
During this class, the limitations of BCMA are described up front with an emphasis on the concept that BCMA is merely a documentation tool that enhances patient safety by highlighting the five rights verification. Several “what should you do?” scenarios aimed at stimulating critical thinking and clinical reasoning are discussed throughout the class.
New employees are also shown how to look at the prescription details that are necessary for identifying mistakes on the eMAR. The BCMA software will display only information that's been input into the system. Prescribers and pharmacists can make errors in prescribing and dispensing that can reach the patient. In fact, a recent study published by the Pennsylvania Patient Safety Authority found 17.3% of wrong-patient medication errors originated during provider prescribing and pharmacy dispensing.14
BCMA software won't stop those types of errors from reaching the patient. Although scanning a medication does prevent a patient from receiving a different drug than what was prescribed, scanning doesn't prevent errors that should have been caught during the verification/dispensing process in the pharmacy. A patient may have a previously documented medication allergy or adverse drug reaction that the provider and pharmacist should have reviewed. Also, a medication with a critical drug interaction to another medication on the patient's profile may be accidentally dispensed. These types of medication errors are the ones that most often reach the patient despite BCMA scanning. But nurses can protect patients by pausing for a moment to evaluate why their patient is supposed to receive a newly prescribed medication. Whenever possible, the nurse should engage the patient and state, “The healthcare provider has prescribed this medication. Do you know why you're supposed to take it?” A little bit of verbal communication can prevent a sentinel event. The documentation systems aren't designed or intended to replace direct verbal communication.
During orientation at this author's facility, new employees are provided with a brief but practical overview of electronic medication reference guides and other medication safety related tools. These tools are one mouse click away and they can make a significant difference to a patient outcome when they're used in conjunction with nursing judgment. Nurses are also encouraged to save time at the bedside by doing simple things such as running concurrent I.V. infusions whenever the evidence supports the practice. The I.V. compatibility reports from the electronic reference guides are always a favorite feature during the class. Students are also encouraged to role-play with other new hires by trading off between the role of patient and nurse.
On completion of this class, new employees have learned the basic functionality of the software and hardware. The main message reinforced throughout the class is: Despite the inherent safety features of BCMA, you always need to practice with caution and pay attention.
New employees also learn how to contact the BCMA coordinator and other members of the informatics department for any future questions. In a large organization, it's very beneficial to know the resource people.
Following the class, new employees are released back to the general nursing orientation, where they take a written 50-question medication test. Ten of the 50 questions are specifically related to using BCMA and the other electronic references.
After passing the test, the new employees spend a day observing the BCMA process on a busy unit. After observing for at least 1 day, they spend the next day delivering medications with a clinical educator at their side. This establishes their initial competency. New employees are allowed to independently administer medications after their preceptor on the nursing unit checks them off.
To ensure continued program success, the BCMA coordinator must collaborate with pharmacy, nursing, and information technology (IT) support staff on a daily basis. Pharmacists on all shifts must be well versed in troubleshooting the bar code system as nurses frequently notify them regarding scanning problems.15 In fact, nurses are taught to call a pharmacist first when a medication doesn't scan. The pharmacist may be able to fix the problem if it's related to a prescription discrepancy. If the pharmacist can't correct the scanning problem, he or she may be able to verify the medication with the nurse over the phone. In this case, the pharmacist will recommend that a nurse use the five rights and override the software.
At our facility, the BCMA coordinator and the pharmacy systems manager receive an e-mail notification each time the scanning override feature is used. The notifications are compiled and analyzed to identify trends. The resulting data are used daily to target areas for walking rounds.
At our facility, walking rounds are an effective way of solving scanning issues and preventing workarounds. Together with the pharmacy systems manager, the BCMA coordinator identifies scanning failure trends pulled from system alerts and walks to the point of care to investigate. Scanning failures result from five factors: equipment problems, poor practice, bar code issues, provider order/product mismatches, or dispensing discrepancies. (See Five factors in scanning errors.) All five of these issues can be improved or resolved at the point of care. If the bar code scanner fails, the BCMA coordinator reprograms or replaces it.
To minimize downtime for the nurse, the same applies to laptop failures. If a system-wide failure occurs, the BCMA coordinator notifies all areas to initiate the paper contingency plan, available on every unit. The contingency computers receive updated medication orders virtually every second, and the entire system is monitored daily by the BCMA coordinator.
Make room for BCMA coordinators
Nationwide, BCMA systems continue to grow and expand. In 2002, only 5% of 300-399-bed hospitals used BCMA technology, compared with 40.2% in 2007.16 Over the last 5 years, the growth rate hasn't slowed down. The 2013 American Society of Health Systems' Pharmacy Practice survey found 80% of hospitals reporting the use of BCMA systems for medication administration.17
National adoption of BCMA technology may be just over the horizon. The Centers for Medicare and Medicaid Services (CMS) established a 3-stage EHR incentive program that provides financial incentives to providers, hospitals, and clinics for using certified EHR technology to improve patient care.18 In order to progress through the stages of the program, enrollees must meet all the core requirements of each stage plus a few additional requirements of their choice. For stage 2, CMS adopted eMAR technology (in conjunction with assistive devices such as barcode scanners) as one of the 16 core measures.19 As of 2014, early participants in the CMS EHR incentive program (those who enrolled in 2011) began reporting adherence with stage 2 criteria. In order to meet the eMAR core requirement, hospital inpatient areas must have more than 10% of all medication orders trackable from order to administration and documented on an eMAR. This change is expected to accelerate eMAR/BCMA implementation over the next few years.
If the current trend continues, the BCMA coordinator will be a required and integral part of virtually every hospital in the nation.
BCMA coordinators are expected to wear many hats, and the best candidate for the role is a nurse. With a patient safety focus, team-based attitude, critical thinking, advanced informatics skills, and a work ethic devoted to quality and positive patient outcomes, who is better qualified for the job than a nurse? (See BCMA coordinator roles and responsibilities.)
For budgetary reasons, smaller hospitals may choose to combine the BCMA coordinator duties with another position such as informatics support, patient safety manager, or performance improvement coordinator. A dual role may work fine after the system is well established, but isn't recommended during the initial implementation. Facilities should consider funding to have a dedicated coordinator beginning in the preimplementation phase. Nurses and pharmacists who learn how to use the system for the first time will need a great deal of positive feedback and oversight, and any workflow barriers will need to be quickly removed. Otherwise, creative workarounds will continue to compromise patient safety.
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