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.

Knowledge, Attitude and Practice Survey Regarding High Alert Medication among Resident Doctors in a Tertiary Care Teaching Hospital in Eastern India

BACKGROUND

Medication errors are a reality in all settings where medicines are prescribed, dispensed and used. High Alert Medications (HAM) are those that bear a heightened risk of causing significant harm to the patient, if used erroneously. Though mishaps with HAM may not be more common than with other drugs, the consequences of error with them can be especially serious. We conducted a survey on knowledge, attitude and practice, among residents working in a teaching hospital, to assess the ground situation regarding HAM awareness and handling.

METHODS

We approached 492 residents among the approximately 600 residents currently working through purposive sampling. Residents in all disciplines (clinical, paraclinical and preclinical) were targeted. A structured questionnaire with 54 questions, pilot-tested on 20 volunteer residents, was used for data collection. The questionnaire was administered to residents through face-to-face interview, by two raters, while they were on duty, but not during rush hours.

RESULTS

Of the total 261 responses received, 32.33% respondents correctly defined or explained the meaning of the term 'medication error'. Knowledge regarding difference between medication error and adverse event did not get reflected in 68.38% of the participants, and only 16.86% were able to name relevant group of medicines as HAM. Regarding attitude in dealing with HAM, majority believed that taking the history of drug allergy and reconciling all prescription and over the counter (OTC) drugs already being used before prescribing or using a medicine, is important. In practice, most respondents followed protocols, but not routinely. Several potential errors in practice were identified.

CONCLUSION

The current situation requires corrective action. There is an urgent need for improving awareness regarding HAM for the sake of patient safety. The pharmacology department can take the lead in designing awareness campaign with support from the hospital administration.

High-Alert Medication Stratification Tool-Revised: An Exploratory Study of an Objective, Standardized Medication Safety Tool

OBJECTIVE

To develop an objective tool designed to standardize the identification of high-alert medications (HAMs) according to patient safety risk.

METHODS

Medications were evaluated using the High-Alert Medication Stratification Tool (HAMST). Tool revision occurred through assessing medications on an organization-approved HAM list and comparing scores with control medications not included on the list. Because of variations in HAMST interpretation by end users in interdisciplinary committees, a revision of the scoring tool was completed to create the High-Alert Medication Stratification Tool-Revised (HAMST-R), and the assessment was repeated. Both tools range from 0 to 10, with 10 describing agents with highest risk.

RESULTS

The median (interquartile range [IQR]) initial HAM (n = 44) score using HAMST was 6 (5-7). The median (IQR) control (n = 45) score was 1 (0-2). Using the modified tool, HAMST-R, the median (IQR) HAM score was 4 (4-6) versus 1 (0-1) for controls. Scores for HAMs were significantly higher than controls using both tools (P < 0.001). A HAMST-R score of 4 or higher defines medications as high alert, as this score includes 75% of HAMs and no controls.

CONCLUSIONS

Through this exploratory study, clarification of the tool was required to increase its concurrent validity, interrater reliability, and implementation among other health systems. The revised tool, HAMST-R, is a newly developed, objective tool for standardized identification of HAMs. The tool may also be used for prospective identification of medications as high risk to patient safety during formulary review.

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.

Association between workarounds and medication administration errors in bar-code-assisted medication administration in hospitals

Objective

To study the association of workarounds with medication administration errors using barcode-assisted medication administration (BCMA), and to determine the frequency and types of workarounds and medication administration errors.

Materials and Methods

A prospective observational study in Dutch hospitals using BCMA to administer medication. Direct observation was used to collect data. Primary outcome measure was the proportion of medication administrations with one or more medication administration errors. Secondary outcome was the frequency and types of workarounds and medication administration errors. Univariate and multivariate multilevel logistic regression analysis were used to assess the association between workarounds and medication administration errors. Descriptive statistics were used for the secondary outcomes.

Results

We included 5793 medication administrations for 1230 inpatients. Workarounds were associated with medication administration errors (adjusted odds ratio 3.06 [95% CI: 2.49-3.78]). Most commonly, procedural workarounds were observed, such as not scanning at all (36%), not scanning patients because they did not wear a wristband (28%), incorrect medication scanning, multiple medication scanning, and ignoring alert signals (11%). Common types of medication administration errors were omissions (78%), administration of non-ordered drugs (8.0%), and wrong doses given (6.0%).

Discussion

Workarounds are associated with medication administration errors in hospitals using BCMA. These data suggest that BCMA needs more post-implementation evaluation if it is to achieve the intended benefits for medication safety.

Conclusion

In hospitals using barcode-assisted medication administration, workarounds occurred in 66% of medication administrations and were associated with large numbers of medication administration errors.

Tinker, tailor, deliberate. An ethnographic inquiry into the institutionalized practice of bar-coded medication administration technology by nurses

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.

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.

Bar Code Medication Administration Technology: Characterization of High-Alert Medication Triggers and Clinician Workarounds

BACKGROUND

Bar code medication administration (BCMA) technology is gaining acceptance for its ability to prevent medication administration errors. However, studies suggest that improper use of BCMA technology can yield unsatisfactory error prevention and introduction of new potential medication errors.

OBJECTIVE

To evaluate the incidence of high-alert medication BCMA triggers and alert types and discuss the type of nursing and pharmacy workarounds occurring with the use of BCMA technology and the electronic medication administration record (eMAR).

METHODS

Medication scanning and override reports from January 1, 2008, through November 30, 2008, for all adult medical/surgical units were retrospectively evaluated for high-alert medication system triggers, alert types, and override reason documentation. An observational study of nursing workarounds on an adult medicine step-down unit was performed and an analysis of potential pharmacy workarounds affecting BCMA and the eMAR was also conducted.

RESULTS

Seventeen percent of scanned medications triggered an error alert of which 55% were for high-alert medications. Insulin aspart, NPH insulin, hydromorphone, potassium chloride, and morphine were the top 5 high-alert medications that generated alert messages. Clinician override reasons for alerts were documented in only 23% of administrations. Observational studies assessing for nursing workarounds revealed a median of 3 clinician workarounds per administration. Specific nursing workarounds included a failure to scan medications/patient armband and scanning the bar code once the dosage has been removed from the unit-dose packaging. Analysis of pharmacy order entry process workarounds revealed the potential for missed doses, duplicate doses, and doses being scheduled at the wrong time.

CONCLUSIONS

BCMA has the potential to prevent high-alert medication errors by alerting clinicians through alert messages. Nursing and pharmacy workarounds can limit the recognition of optimal safety outcomes and therefore workflow processes must be continually analyzed and restructured to yield the intended full benefits of BCMA technology.

A safe practice standard for barcode technology

OBJECTIVE

Safety advocates have identified barcode verification technology as an important tool to improve health-care practices.

METHODS

We evaluated the evidence for the role of barcode technology in improving a wide range of medication safety outcomes across a broad range of settings. Important implementation issues were highlighted to guide standards for the safe adoption of barcode technology.

RESULTS

Adverse drug events are common, occurring frequently in both inpatient and outpatient settings. Although approximately half of all preventable adverse drug events in inpatients result from medication errors arising from transcription, dispensing, and administration, these errors are far less likely to be caught than in any of the earlier stages of the medication use process and are therefore most amenable to improvement. When integrated with electronic medication administration records, barcode systems are associated with complete elimination of transcription errors. Furthermore, barcode-assisted dispensing systems are associated with 93% to 96% reductions in dispensing errors, and 85% reductions in potential adverse drug events in dispensing. Most studies have reported large and significant reductions in administration errors by up to 80% after implementation of barcode medication administration systems. Although most studies of barcode technology have been conducted in the adult inpatient setting, the limited data available also support their benefit in pediatric and outpatient settings.

CONCLUSIONS

There is growing evidence for the efficacy of barcode solutions in improving overall medication safety. Standards for the implementation of barcode technology are proposed.

The unique effects of general and specific support in health care technology: An empirical examination of the principle of compatibility

BACKGROUND

The principle of compatibility suggests that specific attitudes should target specific behaviors. The attitude-behavior relationship is contingent upon the consistency between the two.

PURPOSE

This aim of this study was to examine the strength of relationships involving general versus specific support perceptions and attitudes regarding smart pump technology in hospitals. Specifically, we hypothesized that organizational support perceptions would be more strongly related to general positive work attitudes than it would to smart pump satisfaction. We also hypothesized that smart pump-specific support would be more strongly related to smart pump satisfaction than it would to general positive work attitudes.

METHODOLOGY

Data were collected in a cross-sectional field study via online surveys at two large, public hospital systems in the Midwestern United States, one in Iowa (n = 311 nurses) and one in Wisconsin (n = 346 nurses). Because nurses in one system had more experience with smart pump technology than nurses in the other system, analyses were run separately to compare results across the two sites.

FINDINGS

Consistent with the principle of compatibility, hierarchical regression revealed across both sites that smart pump support had a stronger relationship with smart pump satisfaction whereas general organizational support perceptions had a stronger relationship with general positive work attitudes. In addition, moderation effects were present in one sample where high levels of the noncompatible support (e.g., smart pump-specific support on positive workplace attitudes) buffered low levels of compatible support.

PRACTICE IMPLICATIONS

Our findings highlight the contextual importance of support in regard to the growing technological transformations that health care systems currently experience. When specific forms of support are provided for specific technologies, end-users will generally respond more favorably compared to when general support is the only available resource.

Use of failure mode, effect and criticality analysis to improve safety in the medication administration process

RATIONALE, AIMS AND OBJECTIVES

To critically evaluate the causes of preventable adverse drug events during the nurse medication administration process in inpatient units with computerized prescription order entry and profiled automated dispensing cabinets in order to prioritize interventions that need to be implemented and to evaluate the impact of specific interventions on the criticality index.

METHODS

This is a failure mode, effects and criticality analysis (FMECA) study. A multidisciplinary consensus committee composed of pharmacists, nurses and doctors evaluated the process of administering medications in a hospital setting in Spain. By analysing the process, all failure modes were identified and criticality was determined by rating severity, frequency and likelihood of failure detection on a scale of 1 to 10, using adapted versions of already published scales. Safety strategies were identified and prioritized.

RESULTS

Through consensus, the committee identified eight processes and 40 failure modes, of which 20 were classified as high risk. The sum of the criticality indices was 5254. For the potential high-risk failure modes, 21 different potential causes were found resulting in 24 recommendations. Thirteen recommendations were prioritized and developed over a 24-month period, reducing total criticality from 5254 to 3572 (a 32.0% reduction). The recommendations with a greater impact on criticality were the development of an electronic medication administration record (-582) and the standardization of intravenous drug compounding in the unit (-168). Other improvements, such as barcode medication administration technology (-1033), were scheduled for a longer period of time because of lower feasibility.

CONCLUSION

FMECA is a useful approach that can improve the medication administration process.

Analysis of high alert medication knowledge of medical staff in Tianjin: A convenient sampling survey in China

The current situation of medical staff's awareness about high alert medication was investigated in order to promote safe medication and standardized management of the high alert medication in China. Twenty questions were designed concerning elementary knowledge of high alert medications, storage management, medication issues and risks. In order to understand the knowledge level and education status of high alert medication, a convenient survey was conducted among 300 medical staffs in Tianjin. Medical staff's average score of high alert medication knowledge was 12.43±0.27, and the average scores of elementary knowledge of high alert medication, storage management, medication issues and risks were 3.38±0.11, 2.46±0.14, 3.17±0.11 and 3.41±0.12 respectively. Occupation (F=4.86, P=0.003), education background (F=5.57, P=0.019) and professional titles (F=13.44, P≤0.001) contributed to the high alert medications knowledge scores. Currently, the most important channel to obtain high alert medication knowledge was hospital files or administrative rules, and clinical pharmacist seminars were the most popular education form. It was suggested that the high alert medication knowledge level of the medical staff needs to increase, and it might benefit from targeted, systematic and diverse training to the medical staff working in the different circulation nodes of the medications. Further research to develop and validate the instrument is needed.

Impact of implementing smart infusion pumps in a pediatric intensive care unit

PURPOSE

The impact of smart infusion pumps on the interception of errors in the programming of i.v. drug administrations on a pediatric intensive care unit (PICU) is investigated.

METHODS

A prospective observational intervention study was conducted in the PICU of a hospital in Madrid, Spain, to estimate the patient safety benefits resulting from the implementation of smart pump technology (Alaris System, CareFusion, San Diego, CA). A systematic analysis of data stored by the devices during the designated study period (January 2010-June 2011) was conducted using the system software (Guardrails CQI Event Reporter, CareFusion). The severity of intercepted errors was independently classified by a group of four clinical pharmacists and a group of four intensive care pediatricians; analyses of intragroup and intergroup agreement in perceptions of severity were performed.

RESULTS

During the 17-month study period, the overall rate of user compliance with the safety software was 78%. The use of smart pump technology resulted in the interception of 92 programming errors, 84% of which involved analgesics, antiinfectives, inotropes, and sedatives. About 97% of the errors resulted from user programming of doses or infusion rates above the hard limits defined in the smart pump drug library. The potential consequences of the intercepted errors were considered to be of moderate, serious, or catastrophic severity in 49% of cases.

CONCLUSION

The use of smart pumps in a PICU improved patient safety by enabling the interception of infusion programming errors that posed the potential for severe injury to pediatric patients.

Evaluation of the personalized bar-code identification card to verify high-risk, high-alert medications

An effective intervention to decrease medication errors related to high-risk, high-alert medications is to implement double checks and second verification using the five rights of medication administration. To evaluate the effectiveness and use of the Personalized Bar-Code Identification card in verifying high-risk, high-alert medications, the High-Risk, High-Alert Medication Verification Audit Tool was used to collect data from the medical records of patients who received high-risk, high-alert medications in four ICUs. Data were collected for administered high-risk, high-alert medication, primary registered nurses who administered the high-risk, high-alert medication, and secondary registered nurses who verified the medication. The percentage of medications that were "not verified," "Personalized Bar-Code Identification verified," and "verified" using a method other than the Personalized Bar-Code Identification was calculated and compared using Z tests for two proportions. The percentage of Personalized Bar-Code Identification-verified medications (83.5%) was significantly higher than the percentage of medications that were not verified (10.9%) (Z = 38.43, P < .05). Also, the difference between the proportion of the Personalized Bar-Code Identification-verified medications and those that were verified using another method (5.6%) was significant (Z = 41.42, P < .05). The results show that nurses generally tend to follow the standardized procedure for verifying high-risk, high-alert medications in the four ICUs.

Effect of barcode-assisted medication administration on emergency department medication errors

OBJECTIVES

Barcode-assisted medication administration (BCMA) is technology with demonstrated benefit in reducing medication administration errors in hospitalized patients; however, it is not routinely used in emergency departments (EDs). EDs may benefit from BCMA, because ED medication administration is complex and error-prone.

METHODS

A naïve observational study was conducted at an academic medical center implementing BCMA in the ED. The rate of medication administration errors was measured before and after implementing an integrated electronic medical record (EMR) with BCMA capacity. Errors were classified as wrong drug, wrong dose, wrong route of administration, or a medication administration with no physician order. The error type, severity of error, and medications associated with errors were also quantified.

RESULTS

A total of 1,978 medication administrations were observed (996 pre-BCMA and 982 post-BCMA). The baseline medication administration error rate was 6.3%, with wrong dose errors representing 66.7% of observed errors. BCMA was associated with a reduction in the medication administration error rate to 1.2%, a relative rate reduction of 80.7% (p < 0.0001). Wrong dose errors decreased by 90.4% (p < 0.0001), and medication administrations with no physician order decreased by 72.4% (p = 0.057). Most errors discovered were of minor severity. Antihistamine medications were associated with the highest error rate.

CONCLUSIONS

Implementing BCMA in the ED was associated with significant reductions in the medication administration error rate and specifically wrong dose errors. The results of this study suggest a benefit of BCMA on reducing medication administration errors in the ED.

Modeling nurses' acceptance of bar coded medication administration technology at a pediatric hospital

OBJECTIVE

To identify predictors of nurses' acceptance of bar coded medication administration (BCMA).

DESIGN

Cross-sectional survey of registered nurses (N=83) at an academic pediatric hospital that recently implemented BCMA.

METHODS

Surveys assessed seven BCMA-related perceptions: ease of use; usefulness for the job; social influence from non-specific others to use BCMA; training; technical support; usefulness for patient care; and social influence from patients/families. An all possible subset regression procedure with five goodness-of-fit indicators was used to identify which set of perceptions best predicted BCMA acceptance (intention to use, satisfaction).

RESULTS

Nurses reported a moderate perceived ease of use and low perceived usefulness of BCMA. Nurses perceived moderate-or-higher social influence to use BCMA and had moderately positive perceptions of BCMA-related training and technical support. Behavioral intention to use BCMA was high, but satisfaction was low. Behavioral intention to use was best predicted by perceived ease of use, perceived social influence from non-specific others, and perceived usefulness for patient care (56% of variance explained). Satisfaction was best predicted by perceived ease of use, perceived usefulness for patient care, and perceived social influence from patients/families (76% of variance explained).

DISCUSSION

Variation in and low scores on ease of use and usefulness are concerning, especially as these variables often correlate with acceptance, as found in this study. Predicting acceptance benefited from using a broad set of perceptions and adapting variables to the healthcare context.

CONCLUSION

Success with BCMA and other technologies can benefit from assessing end-user acceptance and elucidating the factors promoting acceptance and use.

Prevalence of medication administration errors in two medical units with automated prescription and dispensing

OBJECTIVE

To identify the frequency of medication administration errors and their potential risk factors in units using a computerized prescription order entry program and profiled automated dispensing cabinets.

DESIGN

Prospective observational study conducted within two clinical units of the Gastroenterology Department in a 1537-bed tertiary teaching hospital in Madrid (Spain).

MEASUREMENTS

Medication errors were measured using the disguised observation technique. Types of medication errors and their potential severity were described. The correlation between potential risk factors and medication errors was studied to identify potential causes.

RESULTS

In total, 2314 medication administrations to 73 patients were observed: 509 errors were recorded (22.0%)-68 (13.4%) in preparation and 441 (86.6%) in administration. The most frequent errors were use of wrong administration techniques (especially concerning food intake (13.9%)), wrong reconstitution/dilution (1.7%), omission (1.4%), and wrong infusion speed (1.2%). Errors were classified as no damage (95.7%), no damage but monitoring required (2.3%), and temporary damage (0.4%). Potential clinical severity could not be assessed in 1.6% of cases. The potential risk factors morning shift, evening shift, Anatomical Therapeutic Chemical medication class antacids, prokinetics, antibiotics and immunosuppressants, oral administration, and intravenous administration were associated with a higher risk of administration errors. No association was found with variables related to understaffing or nurse's experience.

CONCLUSIONS

Medication administration errors persist in units with automated prescription and dispensing. We identified a need to improve nurses' working procedures and to implement a Clinical Decision Support tool that generates recommendations about scheduling according to dietary restrictions, preparation of medication before parenteral administration, and adequate infusion rates.

Medication-error alerts for warfarin orders detected by a bar-code-assisted medication administration system

PURPOSE

Medication-error alerts for warfarin orders detected by a bar-code-assisted medication administration (BCMA) system were evaluated.

METHODS

All patients receiving warfarin who were admitted to a university medical center between July 1, 2008, and February 6, 2009, in inpatient units with BCMA systems were candidates for inclusion in this study. Medication-error alerts displayed to the nurse administering the warfarin were reviewed to determine whether a true potential error was detected. Each alert was converted to a scenario, and its potential to require treatment or cause patient harm was rated using a validated severity scale of 0-10, where a score of 0 indicated no probable effect on the patient and 10 indicated that the error would likely result in patient death. A severity score was obtained by averaging the scores of four pharmacist reviewers.

RESULTS

Of the 18,393 warfarin doses ordered during the study period for 2,404 patients, error alerts associated with only 99 warfarin doses were found to be clinically meaningful. The mean ± S.D. severity rating of these alerts was low (2.93 ± 1.42), with a standardized Cronbach's coefficient alpha of 0.845. The mean ± S.D. warfarin dose attempted when the nurse received an alert was 4.10 ± 2.48 mg. The majority of doses with alerts (70%) were for patients who had an active order for warfarin.

CONCLUSION

Of the large number of medication-error alerts generated through a BCMA system, only a small proportion were considered clinically significant. This indicated that the rate of false-positive alerts was unexpectedly high, increasing the risk of alert fatigue.

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.

A network collaboration implementing technology to improve medication dispensing and administration in critical access hospitals

We report how seven independent critical access hospitals collaborated with a rural referral hospital to standardize workflow policies and procedures while jointly implementing the same health information technologies (HITs) to enhance medication care processes. The study hospitals implemented the same electronic health record, computerized provider order entry, pharmacy information systems, automated dispensing cabinets (ADC), and barcode medication administration systems. We conducted interviews and examined project documents to explore factors underlying the successful implementation of ADC and barcode medication administration across the network hospitals. These included a shared culture of collaboration; strategic sequencing of HIT component implementation; interface among HIT components; strategic placement of ADCs; disciplined use and sharing of workflow analyses linked with HIT applications; planning for workflow efficiencies; acquisition of adequate supply of HIT-related devices; and establishing metrics to monitor HIT use and outcomes.

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.

Bar coding: what's your role?

As many as 32% of medication errors occur during administration, so there's good reason to find effective methods to minimize these error opportunities.

Effect of bar-code-assisted medication administration on medication error rates in an adult medical intensive care unit

PURPOSE

The effect of bar-code-assisted medication administration (BCMA) on the rate of medication errors in adult patients in a medical intensive care unit (ICU) was studied.

METHODS

Medication errors were identified in a community teaching hospital medical ICU using a direct observation technique whereby nurses were observed administering medications. Observations occurred for four consecutive 24-hour periods one month before and four months after the implementation of BCMA. Errors in the following categories were recorded: wrong drug, wrong administration time, wrong route, wrong dose, omission, administration of a drug with no order, and documentation error. Two evaluators reviewed all errors for accuracy. Medication error rates were calculated and compared by determining the number of medication errors identified per number of medications administered (observed) preimplementation and postimplementation of BCMA. Statistical analyses were conducted to determine significance.

RESULTS

A total of 1465 medication administrations were observed (775 preimplementation and 690 postimplementation) for 92 patients (45 preimplementation and 47 postimplementation). The medication error rate was reduced by 56% after the implementation of BCMA (19.7% versus 8.7% , p < 0.001). This benefit was related to a reduction associated with errors of wrong administration time. Wrong administration time errors decreased from 18.8% during preimplementation to 7.5% postimplementation (p < 0.001). There were no significant differences in other error types.

CONCLUSION

The implementation of BCMA significantly reduced the number of wrong administration time errors in an adult medical ICU.

Recent Publications on Medications and Pharmacy

Hospital Pharmacy presents this feature to keep pharmacists abreast of new publications in the medical/pharmacy literature. Articles of interest regarding a broad scope of topics are abstracted monthly.