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Grailey K, Brazier A, Franklin BD, McCrudden C, Fernandez Crespo R, Brown H, Bird J, Acharya A, Gregory A, Darzi A, Huf S. Raising the barcode: improving medication safety behaviours through a behavioural science-informed feedback intervention. A quality improvement project and difference-in-difference analysis. BMJ Qual Saf 2024:bmjqs-2023-016868. [PMID: 38902018 DOI: 10.1136/bmjqs-2023-016868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 05/13/2024] [Indexed: 06/22/2024]
Abstract
Barcode medication administration (BCMA) technology can improve patient safety by using scanning technology to ensure the right drug and dose are given to the right patient. Implementation can be challenging, requiring adoption of different workflows by nursing staff. In one London National Health Service trust scanning rates were lower than desired at around 0-20% of doses per ward. Our objective was to encourage patient safety behaviours in the form of medication scanning through implementation of a feedback intervention. This was informed by behavioural science, codesigned with nurses and informed by known barriers to use. Five wards were selected to trial the intervention over an 18-week period beginning August 2021. The remaining 14 hospital wards acted as controls. Intervention wards had varying uptake of BCMA at baseline and represented a range of specialties. A bespoke feedback intervention comprising three behavioural science constructs (gamification, the messenger effect and framing) was delivered to each intervention ward each week. A linear difference-in-difference analysis was used to evaluate the impact of our intervention on scan rates, both for the overall 18-week period and at two weekly intervals within this timeframe. We identified a 23.1 percentage point increase in medication scan rates (from an average baseline of 15.0% to 38.1%) on the intervention wards compared with control (p<0.001) following implementation of the intervention. Feedback had most impact in the first 6 weeks, with an initial percentage point increase of 26.3 (p<0.001), which subsequently plateaued. Neither clinical specialty nor number of beds on each ward were significant factors in our models. Our study demonstrated that a feedback intervention, codesigned with end users and incorporating behavioural science constructs, can lead to a significant increase in the adoption of BCMA scanning.
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Affiliation(s)
- Kate Grailey
- Centre for Health Policy, Imperial College London Institute of Global Health Innovation, London, UK
| | | | - Bryony Dean Franklin
- Centre for Medication Safety and Service Quality, Imperial College Healthcare NHS Trust, London, UK
- Department of Practice and Policy, UCL School of Pharmacy, London, UK
| | - Clare McCrudden
- Helix Centre, Imperial College London Institute of Global Health Innovation, London, UK
| | - Roberto Fernandez Crespo
- Centre for Health Policy, Imperial College London Institute of Global Health Innovation, London, UK
| | | | - James Bird
- Imperial College Healthcare NHS Trust, London, UK
| | - Amish Acharya
- Centre for Health Policy, Imperial College London Institute of Global Health Innovation, London, UK
| | - Alice Gregory
- Helix Centre, Imperial College London Institute of Global Health Innovation, London, UK
| | - Ara Darzi
- Department of Surgery and Cancer, Imperial College London, London, UK
- Imperial College London Institute of Global Health Innovation, London, UK
| | - Sarah Huf
- Imperial College London Institute of Global Health Innovation, London, UK
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Taft T, Rudd EA, Thraen I, Kazi S, Pruitt ZM, Bonk CW, Busog DN, Franklin E, Hettinger AZ, Ratwani RM, Weir CR. "Are we there yet?" Ten persistent hazards and inefficiencies with the use of medication administration technology from the perspective of practicing nurses. J Am Med Inform Assoc 2023; 30:809-818. [PMID: 36888889 PMCID: PMC10114056 DOI: 10.1093/jamia/ocad031] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 02/09/2023] [Accepted: 02/20/2023] [Indexed: 03/10/2023] Open
Abstract
OBJECTIVES (1) Characterize persistent hazards and inefficiencies in inpatient medication administration; (2) Explore cognitive attributes of medication administration tasks; and (3) Discuss strategies to reduce medication administration technology-related hazards. MATERIALS AND METHODS Interviews were conducted with 32 nurses practicing at 2 urban, eastern and western US health systems. Qualitative analysis using inductive and deductive coding included consensus discussion, iterative review, and coding structure revision. We abstracted hazards and inefficiencies through the lens of risks to patient safety and the cognitive perception-action cycle (PAC). RESULTS Persistent safety hazards and inefficiencies related to MAT organized around the PAC cycle included: (1) Compatibility constraints create information silos; (2) Missing action cues; (3) Intermittent communication flow between safety monitoring systems and nurses; (4) Occlusion of important alerts by other, less helpful alerts; (5) Dispersed information: Information required for tasks is not collocated; (6) Inconsistent data organization: Mismatch of the display and the user's mental model; (7) Hidden medication administration technologies (MAT) limitations: Inaccurate beliefs about MAT functionality contribute to overreliance on the technology; (8) Software rigidity causes workarounds; (9) Cumbersome dependencies between technology and the physical environment; and (10) Technology breakdowns require adaptive actions. DISCUSSION Errors might persist in medication administration despite successful Bar Code Medication Administration and Electronic Medication Administration Record deployment for reducing errors. Opportunities to improve MAT require a deeper understanding of high-level reasoning in medication administration, including control over the information space, collaboration tools, and decision support. CONCLUSION Future medication administration technology should consider a deeper understanding of nursing knowledge work for medication administration.
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Affiliation(s)
- Teresa Taft
- Department of Biomedical Informatics, University of Utah, Salt Lake City, Utah, USA
| | - Elizabeth Anne Rudd
- Department of Biomedical Informatics, University of Utah, Salt Lake City, Utah, USA
| | - Iona Thraen
- Department of Biomedical Informatics, University of Utah, Salt Lake City, Utah, USA
| | - Sadaf Kazi
- National Center for Human Factors in Healthcare, MedStar Health Research Institute, Washington, District of Columbia, USA
- Department of Emergency Medicine, Georgetown University School of Medicine, Washington, District of Columbia, USA
| | - Zoe M Pruitt
- National Center for Human Factors in Healthcare, MedStar Health Research Institute, Washington, District of Columbia, USA
| | - Christopher W Bonk
- National Center for Human Factors in Healthcare, MedStar Health Research Institute, Washington, District of Columbia, USA
| | - Deanna-Nicole Busog
- National Center for Human Factors in Healthcare, MedStar Health Research Institute, Washington, District of Columbia, USA
| | - Ella Franklin
- National Center for Human Factors in Healthcare, MedStar Health Research Institute, Washington, District of Columbia, USA
| | - Aaron Z Hettinger
- National Center for Human Factors in Healthcare, MedStar Health Research Institute, Washington, District of Columbia, USA
- Department of Emergency Medicine, Georgetown University School of Medicine, Washington, District of Columbia, USA
| | - Raj M Ratwani
- National Center for Human Factors in Healthcare, MedStar Health Research Institute, Washington, District of Columbia, USA
- Department of Emergency Medicine, Georgetown University School of Medicine, Washington, District of Columbia, USA
| | - Charlene R Weir
- Department of Biomedical Informatics, University of Utah, Salt Lake City, Utah, USA
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HOW BAR CODED MEDICATION ADMINISTRATION TECHNOLOGY AFFECTS THE NURSE-PATIENT RELATIONSHIPS: AN ETHNOGRAPHIC STUDY. Int J Technol Assess Health Care 2018; 34:507-513. [PMID: 30362444 DOI: 10.1017/s0266462318000582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVES This study aims to assess how care is mediated through technology by analyzing the interaction between nurses, patients, and a Bar Coded Medication Administration (BCMA) system. The objective is to explore how patients experience care through medication technology, with the main focus of our observations and interviews on nurses rather than patients. METHODS A qualitative ethnographic study was conducted in an orthopedic ward of a Dutch general hospital. RESULTS After analyses, the following two themes were discerned: (i) the use of bar code medication technology organizes double institutionalization, and (ii) nurses frequently need to work around the BCMA, as the system is not always supportive of patient needs. CONCLUSIONS The results of this study indicate that BCMA is not merely a neutral tool, but an active component within the nurse-patient relationship, as it influences medication administration and profoundly affects patient participation in the care process.
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Boonen M, Rankin J, Vosman F, Niemeijer A. Nurses' knowledge and deliberations crucial to Barcoded Medication Administration technology in a Dutch hospital: Discovering nurses' agency inside ruling. Health (London) 2018; 24:279-298. [PMID: 30230356 DOI: 10.1177/1363459318800155] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
This article shows how Barcoded Medication Administration technology institutionally organizes and rules the daily actions of nurses. Although it is widely assumed that Barcoded Medication Administration technology improves quality and safety by reducing the risk of human error, little research has been done on how this technology alters the work of nurses. Drawing on empirical and conceptual strategies of analysis, this qualitative study used certain tools of institutional ethnography to provide a view of how nurses negotiate Barcoded Medication Administration technology. The approach also uses elements from practice theory in order to discern how technology operates as a player on the field instead of being viewed as a 'mere' tool. A literature review preceded participant observation, whereby 17 nurses were followed and data on an orthopaedic ward were collected over a period of 9 months in 2011 and 2012. Barcoded Medication Administration technology relies on nurses' knowledge to mediate between the embedded logics of its design and the unpredictable needs of patients. Nurses negotiate their own professional logic of care in the form of moment-to-moment deliberations which subvert the ruling frame of the barcoded system and its objectified model of patient safety. The logic of Barcoded Medication Administration technology differs from the logic of nursing care, as this technology presumes medication distribution to be linear, even though nurses follow another line of actor-bound safety practices that we characterize as 'deliberations'.
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Boonen MJMH, Vosman FJH, Niemeijer AR. Tinker, tailor, deliberate. An ethnographic inquiry into the institutionalized practice of bar-coded medication administration technology by nurses. Appl Nurs Res 2017; 33:30-35. [PMID: 28096019 DOI: 10.1016/j.apnr.2016.10.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2016] [Revised: 09/15/2016] [Accepted: 10/10/2016] [Indexed: 11/28/2022]
Abstract
AIM Explore the practice of nurses working with bar-coded medication administration technology, to gain insight in the impact it has on their work. BACKGROUND The widespread presumption of using Barcoded Medication Administration Technology (BCMA) is that it will effectively reduce the number of errors in the dispensing of medication to patients. However, it remains unclear whether this is the case in actual practice. METHOD Two distinct but overlapping research methodologies of Institutional Ethnography and Praxeology were combined as a means to uncover the highly complex practice of BCMA by nurses. RESULTS The implementation of BCMA creates a series of problems leading to nurses constantly tinkering with the technology. At the same time they are continuously deliberating the best ways of tailoring the BCMA to each of their patients. CONCLUSION Although working with BCMA is often misconstrued as being mindless and automatic, conforming to the technology, this tinkering with BCMA in fact always entails thorough deliberation by nurses.
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Affiliation(s)
- M J M H Boonen
- Elisabeth-Tweesteden Hospital, Hilvarenbeekseweg 60, 5022, GC, Tilburg, The Netherlands.
| | - Frans J H Vosman
- University of Humanistic Studies, Kromme Nieuwegracht 29, 3512, HD, Utrecht, The Netherlands
| | - Alistair R Niemeijer
- University of Humanistic Studies, Kromme Nieuwegracht 29, 3512, HD, Utrecht, The Netherlands
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