Evaluation of Medication Incidents in a Long-term Care Facility Using Electronic Medication Administration Records and Barcode Technology

Objective To describe the frequency, type, and severity of reported medication incidents that occurred at a long-term care facility (LTCF) despite electronic medication administration record and barcode-assisted medication administration (eMAR-BCMA) use. The study also contains analysis for the contribution of staff workarounds to reported medication administration errors (MAEs) using an established typology for BCMA workarounds, characterize if the eMAR-BCMA technology contributed to MAEs, and explore characteristics influencing incident severity. Design Retrospective incident report review. Setting A 239-bed LTCF in Alberta, Canada, that implemented eMAR-BCMA in 2013. Participants 270 paper-based, medication incident reports submitted voluntarily between June 2015 and October 2017. Interventions None. Results Most of the 264 resident-specific medication incidents occurred during the administration (71.9%, 190/264) or dispensing (28.4%, 75/264) phases, and 2.3% (6/264) resulted in temporary harm. Medication omission (43.7%, 83/190) and incorrect time (22.6%, 43/190) were the most common type of MAE. Workarounds occurred in 41.1% (78/190) of MAEs, most commonly documenting administration before the medication was administered (44.9%, 35/78). Of the non-workaround MAEs, 52.7% (59/112) were notassociated with the eMAR-BCMA technology, while 26.8% (30/112) involved system design shortcomings, most notably lack of a requirement to scan each medication pouch during administration. MAEs involving workarounds were less likely to reach the resident (74.4 vs 88.8%; relative risk = 0.84, 95% CI 0.72-0.97). Conclusion Administration and dispensing errors were the most reported medication incidents. eMAR-BCMA workarounds, and design shortcomings were involved in a large proportion of reported MAEs. Attention to optimal eMAR-BCMA use and design are required to facilitate medication safety in LTCFs.

The impact of introducing automated dispensing cabinets, barcode medication administration, and closed-loop electronic medication management systems on work processes and safety of controlled medications in hospitals: A systematic review

BACKGROUND

Technology in the form of Automated Dispensing Cabinets (ADCs), Barcode Medication Administration (BCMA), and closed-loop Electronic Medication Management Systems (EMMS) are implemented in hospitals to assist with the supply, use and monitoring of medications. Although there is evidence to suggest that these technologies can reduce errors and improve monitoring of medications in general, little is known about their impact on controlled medications such as opioids.

OBJECTIVES

This review aimed to fill this knowledge gap by synthesising literature to determine the impact of ADCs, BCMA and closed-loop EMMS on clinical work processes, medication safety, and drug diversion associated with controlled medications in the inpatient setting.

METHODS

Eight databases (Medline, Pubmed, Embase, Scopus, Web of Science, PsycINFO, CINAHL, and ScienceDirect) were searched for relevant papers published between January 2000 and May 2019. Qualitative, quantitative, and mixed-methods empirical studies published in English that reported findings on the impact of ADCs, BCMA and/or closed-loop EMMS on controlled medications in the inpatient setting were included.

RESULTS

In total, 16 papers met the inclusion criteria. Eleven studies reported on ADCs, four on BCMA, and only one on closed-loop EMMS. Only four studies focused on controlled medications, with the remainder reporting only incidental findings. Studies reported the elimination of manual end-of-shift counts of controlled medications after ADC implementation but cases of drug diversion were reported despite introducing ADCs. Three quantitative studies reported reductions in medication errors after implementing BCMA, but medications labelled with wrong barcodes and unreadable barcodes led to confusion and administration errors.

CONCLUSIONS

More quality, targeted research is needed to provide evidence on the benefits and also risks of implementing technology to safeguard against inappropriate use of controlled medications in the inpatient setting. Processes need to be in place to supplement technological capabilities, and resources should be made available for post-implementation evaluations and interventions.

Nurse workarounds in the electronic health record: An integrative review

OBJECTIVE

The study sought to synthesize published literature on direct care nurses' use of workarounds related to the electronic health record.

MATERIALS AND METHODS

We conducted an integrative review of qualitative and quantitative peer-reviewed research through a structured search of Academic Search Complete, EBSCO Cumulative Index of Nursing and Allied Health Literature (CINAHL), Embase, Engineering Village, Ovid Medline, Scopus, and Web of Science. We systematically applied exclusion rules at the title, abstract, and full article stages and extracted and synthesized their research methods, workaround classifications, and probable causes from articles meeting inclusion criteria.

RESULTS

Our search yielded 5221 results. After removing duplicates and applying rules, 33 results met inclusion criteria. A total of 22 articles used qualitative approaches, 10 used mixed methods, and 1 used quantitative methods. While researchers may classify workarounds differently, they generally fit 1 of 3 broad categories: omission of process steps, steps performed out of sequence, and unauthorized process steps. Each study identified probable causes, which included technology, task, organizational, patient, environmental, and usability factors.

CONCLUSIONS

Extensive study of nurse workarounds in acute settings highlights the gap in ambulatory care research. Despite decades of electronic health record development, poor usability remains a key concern for nurses and other members of care team. The widespread use of workarounds by the largest group of healthcare providers subverts quality health care at every level of the healthcare system. Research is needed to explore the gaps in our understanding of and identify strategies to reduce workaround behaviors.

Factors associated with workarounds in barcode-assisted medication administration in hospitals

Aims and objectives

To identify that workarounds (defined as “informal temporary practices for handling exceptions to normal procedures or workflow”) by nurses using information technology potentially compromise medication safety. Therefore, we aimed to identify potential risk factors associated with workarounds performed by nurses in Barcode‐assisted Medication Administration in hospitals.

Background

Medication errors occur during the prescribing, distribution and administration of medication. Errors could harm patients and be a tragedy for both nurses and medical doctors involved. Interventions to prevent errors have been developed, including those based on information technology. To cope with shortcomings in information technology‐based interventions as Barcode‐assisted Medication Administration, nurses perform workarounds. Identification of workarounds in information technology is essential to implement better‐designed software and processes which fit the nurse workflow.

Design

We used the data from our previous prospective observational study, performed in four general hospitals in the Netherlands using Barcode techniques, to administer medication to inpatients.

Methods

Data were collected from 2014–2016. The disguised observation was used to gather information on potential risk factors and workarounds. The outcome was a medication administration with one or more workarounds. Logistic mixed models were used to determine the association between potential risk factors and workarounds. The STROBE checklist was used for reporting our data.

Results

We included 5,793 medication administrations among 1,230 patients given by 272 nurses. In 3,633 (62.7%) of the administrations, one or more workarounds were observed. In the multivariate analysis, factors significantly associated with workarounds were the medication round at 02 p.m.–06 p.m. (adjusted odds ratio [OR]: 1.60, 95% CI: 1.05–2.45) and 06 p.m.–10 p.m. (adjusted OR: 3.60, 95% CI: 2.11–6.14) versus the morning shift 06 a.m.–10 a.m., the workdays Monday (adjusted OR: 2.59, 95% CI: 1.51–4.44), Wednesday (adjusted OR: 1.92, 95% CI: 1.2–3.07) and Saturday (adjusted OR: 2.24, 95% CI: 1.31–3.84) versus Sunday, the route of medication, nonoral (adjusted OR: 1.28, 95% CI: 1.05–1.57) versus the oral route of drug administration, the Anatomic Therapeutic Chemical classification‐coded medication “other” (consisting of the irregularly used Anatomic Therapeutic Chemical classes [D, G, H, L, P, V, Y, Z]) (adjusted OR: 1.49, 95% CI: 1.05–2.11) versus Anatomic Therapeutic Chemical class A (alimentary tract and metabolism), and the patient–nurse ratio ≥6–1 (adjusted OR: 5.61, 95% CI: 2.9–10.83) versus ≤5–1.

Conclusions

We identified several potential risk factors associated with workarounds performed by nurses that could be used to target future improvement efforts in Barcode‐assisted Medication Administration.

Relevance to clinical practice

Nurses administering medication in hospitals using Barcode‐assisted Medication Administration frequently perform workarounds, which may compromise medication safety. In particular, nurse workload and the patient–nurse ratio could be the focus for improvement measures as these are the most clearly modifiable factors identified in this study.

Understanding Mental Health Nurses' Perceptions of Barcode Medication Administration: A Qualitative Descriptive Study

Barcode medication administration (BCMA) technology has been challenging for mental health nurses to incorporate into their clinical practice despite the potentially positive benefits of using the technology for improving patient safety. A review of the literature identified a number of practices that nurses can use to improve adoption of the technology, however, these practices have been primarily used in non-mental health contexts. Therefore, the purpose of this study was to understand mental health nurses' perceptions of practices identified from the literature to improve BCMA adoption in a mental health inpatient setting. Using a qualitative descriptive approach, ten (n = 10) interviews were conducted with direct care mental health nurses working at a mental health and addiction academic teaching hospital in Canada. Data analysis consisted of a conventional content analysis of the interview transcripts by two independent coders. The following five themes emerged from the transcripts: 1) safety, 2) clinical workflow, 3) education, 4) accountability, and 5) strategies. Sub-themes were also identified within the themes of safety and clinical workflow. Insights gleaned from this study warrant acknowledgement and consideration when implementing strategies to increase BCMA compliance within mental health contexts.

Medication management strategies used by older adults with heart failure: A systems-based analysis

BACKGROUND

Older adults with heart failure use strategies to cope with the constraining barriers impeding medication management. Strategies are behavioral adaptations that allow goal achievement despite these constraining conditions. When strategies do not exist, are ineffective or maladaptive, medication performance and health outcomes are at risk. While constraints to medication adherence are described in literature, strategies used by patients to manage medications are less well-described or understood.

AIM

Guided by cognitive engineering concepts, the aim of this study was to describe and analyze the strategies used by older adults with heart failure to achieve their medication management goals.

METHODS

This mixed methods study employed an empirical strategies analysis method to elicit medication management strategies used by older adults with heart failure. Observation and interview data collected from 61 older adults with heart failure and 31 caregivers were analyzed using qualitative content analysis to derive categories, patterns and themes within and across cases.

RESULTS

Data derived thematic sub-categories described planned and ad hoc methods of strategic adaptations. Stable strategies proactively adjusted the medication management process, environment, or the patients themselves. Patients applied situational strategies (planned or ad hoc) to irregular or unexpected situations. Medication non-adherence was a strategy employed when life goals conflicted with medication adherence. The health system was a source of constraints without providing commensurate strategies.

CONCLUSIONS

Patients strived to control their medication system and achieve goals using adaptive strategies. Future patient self-mangement research can benefit from methods and theories used to study professional work, such as strategies analysis.

Analysis of the technology acceptance model in examining hospital nurses' behavioral intentions toward the use of bar code medication administration

Serious medication errors continue to exist in hospitals, even though there is technology that could potentially eliminate them such as bar code medication administration. Little is known about the degree to which the culture of patient safety is associated with behavioral intention to use bar code medication administration. Based on the Technology Acceptance Model, this study evaluated the relationships among patient safety culture and perceived usefulness and perceived ease of use, and behavioral intention to use bar code medication administration technology among nurses in hospitals. Cross-sectional surveys with a convenience sample of 163 nurses using bar code medication administration were conducted. Feedback and communication about errors had a positive impact in predicting perceived usefulness (β=.26, P<.01) and perceived ease of use (β=.22, P<.05). In a multiple regression model predicting for behavioral intention, age had a negative impact (β=-.17, P<.05); however, teamwork within hospital units (β=.20, P<.05) and perceived usefulness (β=.35, P<.01) both had a positive impact on behavioral intention. The overall bar code medication administration behavioral intention model explained 24% (P<.001) of the variance. Identified factors influencing bar code medication administration behavioral intention can help inform hospitals to develop tailored interventions for RNs to reduce medication administration errors and increase patient safety by using this technology.

Implementing a bar-code assisted medication administration system: effects on the dispensing process and user perceptions

PURPOSE

We assessed the effects of a bar-code assisted medication administration system used without the support of computerised prescribing (stand-alone BCMA), on the dispensing process and its users.

METHODS

The stand-alone BCMA system was implemented in one ward of a teaching hospital. The number of dispensing steps, dispensing time and potential dispensing errors (PDEs) were directly observed one month before and eight months after the intervention. Attitudes of pharmacy and nursing staff were assessed using a questionnaire (Likert scale) and interviews.

RESULTS

Among 1291 and 471 drug items observed before and after the introduction of the technology respectively, the number of dispensing steps increased from five to eight and time (standard deviation) to dispense one drug item by one staff personnel increased from 0.8 (0.09) to 1.5 (0.12) min. Among 2828 and 471 drug items observed before and after the intervention respectively, the number of PDEs increased significantly (P<0.001). 'Procedural errors' and 'missing drug items' were the frequently observed PDEs in the after study. 'Perceived usefulness' and 'job relevance' of the technology decreased significantly (P=0.003 and P=0.004 respectively) among users who participated in the before (N=16) and after (N=16) questionnaires surveys. Among the interviewees, pharmacy staff felt that the system offered less benefit to the dispensing process (9/16). Nursing staff perceived the system as useful in improving the accuracy of drug administration (7/10).

CONCLUSION

Implementing a stand-alone BCMA system may slow down and complicate the dispensing process. Nursing staff believe the stand-alone BCMA system could improve the drug administration process but pharmacy staff believes the technology would be more helpful if supported by computerised prescribing. However, periodical assessments are needed to identify weaknesses in the process after implementation, and all users should be educated on the benefits of using this technology.

Automation and adaptation: Nurses' problem-solving behavior following the implementation of bar coded medication administration technology

The most common change facing nurses today is new technology, particularly bar coded medication administration technology (BCMA). However, there is a dearth of knowledge on how BCMA alters nursing work. This study investigated how BCMA technology affected nursing work, particularly nurses' operational problem-solving behavior. Cognitive systems engineering observations and interviews were conducted after the implementation of BCMA in three nursing units of a freestanding pediatric hospital. Problem-solving behavior, associated problems, and goals, were specifically defined and extracted from observed episodes of care. Three broad themes regarding BCMA's impact on problem solving were identified. First, BCMA allowed nurses to invent new problem-solving behavior to deal with pre-existing problems. Second, BCMA made it difficult or impossible to apply some problem-solving behaviors that were commonly used pre-BCMA, often requiring nurses to use potentially risky workarounds to achieve their goals. Third, BCMA created new problems that nurses were either able to solve using familiar or novel problem-solving behaviors, or unable to solve effectively. Results from this study shed light on hidden hazards and suggest three critical design needs: (1) ecologically valid design; (2) anticipatory control; and (3) basic usability. Principled studies of the actual nature of clinicians' work, including problem solving, are necessary to uncover hidden hazards and to inform health information technology design and redesign.

Nurses' workarounds in acute healthcare settings: a scoping review

BACKGROUND

Workarounds circumvent or temporarily 'fix' perceived workflow hindrances to meet a goal or to achieve it more readily. Behaviours fitting the definition of workarounds often include violations, deviations, problem solving, improvisations, procedural failures and shortcuts. Clinicians implement workarounds in response to the complexity of delivering patient care. One imperative to understand workarounds lies in their influence on patient safety. This paper assesses the peer reviewed empirical evidence available on the use, proliferation, conceptualisation, rationalisation and perceived impact of nurses' use of workarounds in acute care settings.

METHODS

A literature assessment was undertaken in 2011-2012. Snowballing technique, reference tracking, and a systematic search of twelve academic databases were conducted to identify peer reviewed published studies in acute care settings examining nurses' workarounds. Selection criteria were applied across three phases. 58 studies were included in the final analysis and synthesis. Using an analytic frame, these studies were interrogated for: workarounds implemented in acute care settings by nurses; factors contributing to the development and proliferation of workarounds; the perceived impact of workarounds; and empirical evidence of nurses' conceptualisation and rationalisation of workarounds.

RESULTS

The majority of studies examining nurses' workarounds have been published since 2008, predominantly in the United States. Studies conducted across a variety of acute care settings use diverse data collection methods. Nurses' workarounds, primarily perceived negatively, are both individually and collectively enacted. Organisational, work process, patient-related, individual, social and professional factors contribute to the proliferation of workarounds. Group norms, local and organisational culture, 'being competent', and collegiality influence the implementation of workarounds.

CONCLUSION

Workarounds enable, yet potentially compromise, the execution of patient care. In some contexts such improvisations may be deemed necessary to the successful implementation of quality care, in others they are counterproductive. Workarounds have individual and cooperative characteristics. Few studies examine nurses' individual and collective conceptualisation and rationalisation of workarounds or measure their impact. The importance of displaying competency (image management), collegiality and organisational and cultural norms play a role in nurses' use of workarounds.

Comparing portable computers with bedside computers when administering medications using bedside medication verification

This research examined bedside medication verification administration in 2 adult critical care units, using portable computers and permanent bedside computers. There were no differences in the number of near-miss errors, the time to administer the medications, or nurse perception of ease of medication administration, care of patients, or reliability of technology. The percentage of medications scanned was significantly higher with the use of permanent bedside computers, and nurses using permanent bedside computers were more likely to agree that the computer was always available.

Study of nurse workarounds in a hospital using bar code medication administration system

This study analyzed registered nurse workarounds in an academic medical center using bar code medication administration technology. Nurse focus groups and a survey were used to determine the frequency and potential causes of workarounds. More than half of the nurses surveyed indicated that they administered medications without scanning the patient or medications during the last shift worked. Benefits of this study include considerations when implementing bar code medication administration technology that may minimize the development of these workarounds in practice.

Scanning for safety: an integrated approach to improved bar-code medication administration

This is a review of lessons learned in the postimplementation evaluation of a bar-code medication administration technology implemented at a major tertiary-care hospital in 2001. In 2006, with a bar-code medication administration scan compliance rate of 82%, a near-miss sentinel event prompted review of this technology as part of an institutional recommitment to a "culture of safety." Multifaceted problems with bar-code medication administration created an environment of circumventing safeguards as demonstrated by an increase in manual overrides to ensure timely medication administration. A multiprofessional team composed of nursing, pharmacy, human resources, quality, and technical services formalized. Each step in the bar-code medication administration process was reviewed. Technology, process, and educational solutions were identified and implemented systematically. Overall compliance with bar-code medication administration rose from 82% to 97%, which resulted in a calculated cost avoidance of more than $2.8 million during this time frame of the project.

Health information technology: fallacies and sober realities

Current research suggests that the rate of adoption of health information technology (HIT) is low, and that HIT may not have the touted beneficial effects on quality of care or costs. The twin issues of the failure of HIT adoption and of HIT efficacy stem primarily from a series of fallacies about HIT. We discuss 12 HIT fallacies and their implications for design and implementation. These fallacies must be understood and addressed for HIT to yield better results. Foundational cognitive and human factors engineering research and development are essential to better inform HIT development, deployment, and use.

Hospital information technology systems' impact on nurses and nursing care

OBJECTIVE

We conducted a review of the literature to determine the impact of health information technologies (HITs) on nurses and nursing care.

BACKGROUND

Nurses' effective use of HIT has the potential to produce a positive impact on nursing-sensitive patient outcomes, patient safety, and quality of care.

METHODS

A review of the literature produced 564 unique references of which 74 were selected for review.

RESULTS

Findings suggest that (1) HIT improves the quality of nursing documentation; (2) HIT reduces medication administration errors; (3) nurses are generally satisfied with HIT and have positive attitudes about it; and (4) nurse involvement in all stages of HIT design and implementation, and effective leadership throughout these processes, can improve HIT.

CONCLUSION

HIT has had positive influences on nurse satisfaction and patient care. Effective nursing leadership can positively influence the effective development, dissemination, and use of HIT.

Value of human factors to medication and patient safety in the intensive care unit

Conventional wisdom suggests that the "human factor" in critical care environments is reason for inadequate medication and patient safety. "Human factors" (or human factors engineering) is also a scientific discipline and practice of improving human performance. Using decades of human factors research, this paper evaluates a range of common beliefs about patient safety through a human factors lens. This evaluation demonstrates that human factors provides a framework for understanding safety failures in critical care settings, offers insights into how to improve medication and patient safety, and reminds us that the "human factor" in critical care units is what allows these time-pressured, information-intense, mentally challenging, interruption-laden, and life-or-death environments to function so safely so much of the time.

Smart medical environment at the point of care: auto-tracking clinical interventions at the bed side using RFID technology

We developed a wireless auto-tracking system for tracking clinical intervention such as drug administrations and blood tests at the patient bedside. The system can not only authenticate patients and nurses, but also confirm medications and provide relevant information, depending on the clinical situation and personnel location. We conducted a feasibility experiment and examined whether or not the system could work as a patient safety measure in terms of reducing misidentifications of patients and medical errors including wrong medication type, dose, time, and route. Also, the duration of clinical interventions in the system were measured to compare with the BCMA system. Moreover, we conducted a qualitative evaluation with nurses and received feedback clarifying their perceptions of the system. The results showed that the system correctly recognized medical staff, patient ID, and medication data in real time. With regards to workflow time, a significant reduction of time of clinical interventions was observed, when compared to a bar-coding system. In addition, on the nurses' evaluation, we received mostly positive comments although they also clarified some issues to consider with regards to operability and privacy issues. We concluded that the system had great potential for reducing medical errors and nurse workload with high efficiency.

Medication errors: problems and recommendations from a consensus meeting

Here we discuss 15 recommendations for reducing the risks of medication errors: 1. Provision of sufficient undergraduate learning opportunities to make medical students safe prescribers. 2. Provision of opportunities for students to practise skills that help to reduce errors. 3. Education of students about common types of medication errors and how to avoid them. 4. Education of prescribers in taking accurate drug histories. 5. Assessment in medical schools of prescribing knowledge and skills and demonstration that newly qualified doctors are safe prescribers. 6. European harmonization of prescribing and safety recommendations and regulatory measures, with regular feedback about rational drug use. 7. Comprehensive assessment of elderly patients for declining function. 8. Exploration of low-dose regimens for elderly patients and preparation of special formulations as required. 9. Training for all health-care professionals in drug use, adverse effects, and medication errors in elderly people. 10. More involvement of pharmacists in clinical practice. 11. Introduction of integrated prescription forms and national implementation in individual countries. 12. Development of better monitoring systems for detecting medication errors, based on classification and analysis of spontaneous reports of previous reactions, and for investigating the possible role of medication errors when patients die. 13. Use of IT systems, when available, to provide methods of avoiding medication errors; standardization, proper evaluation, and certification of clinical information systems. 14. Nonjudgmental communication with patients about their concerns and elicitation of symptoms that they perceive to be adverse drug reactions. 15. Avoidance of defensive reactions if patients mention symptoms resulting from medication errors.

An Automated Drug Delivery Tracking Device Utilizing RFID Technology

Medication errors are one of the most common types of medical errors involving a substantial number of individuals and accounting for a sizable increase in healthcare costs (Institute of Medicine, 2000, To Err Is Human: Building a Safer Health System, National Academies, Washington, DC). These errors are also potentially injurious or fatal (2008, “National Study on the Frequency, Types, Causes and Consequences of Voluntarily Reported Emergency Department Medication Errors,” J. Emerg. Med., in press). Currently, particularly in time critical tasks, such as during the treatment of a cardiac arrest, drugs may not be properly documented. This leads to an increased likelihood of subsequent medication errors with the patient. In order to efficiently and accurately record the time a drug is delivered, a device is needed that (1) records information with little or no intervention by the healthcare professional, so that they are free to focus on their primary task (of particular relevance in time critical tasks), (2) provides a precise time mark, and (3) is reliable for proper documentation. The prototype device proposed here for marking the time of drug delivery involves the use of radio frequency identification (RFID) technology. Each drug dose (i.e., the typically used preloaded syringes or packages) is labeled by a RFID tag mounted on it in terms of the type of drug and its dosage. Both the drug and the tag are enclosed in a radio frequency shielded sleeve to prevent the tag from being read prematurely by the time marking system. The time marking system itself consists of a RFID reader and a software or hardware based internal clock. When a drug is administered to a patient, the sleeve is opened, the drug is removed, and the RFID tag transmits encoded information to the reader, which then records the time of an internal clock. This setup results in the proposed time marking system providing a hands-free documentation of the time at which a specific drug is administered. The device requires little or no training on its use, is fast and efficient, can be easily integrated with current medical technology, and can be adapted to the various constraints of a healthcare setting. Requiring no time from healthcare professionals to mark the time of drug administration, the proposed time marking system will help alleviate error in documenting drug delivery.