News
Flaws in barcode systems for hospital medicines management
9 July 2008
A study of how hospital nurses use barcoding technology that matches
the right patient with the right dose of the right medication has found
that design and implementation of the technology is flawed and can
increase the probabilities of certain errors.
It also found that the urgencies of care and the ingenuity of nurses
to cope with these shortcomings have the unintended consequences of
creating other medication errors.
These findings appear in the July/August issue of the Journal of
the American Medical Informatics Association (JAMIA). The
study also illustrates how adjustments to workflow and the technology
can dramatically reduce the risk of these errors.
These barcode systems usually consist of handheld devices and
computers that match machine-readable barcodes on patient wristbands and
medications. If they match, and if they are consistent with the ordered
medications, the medications are given. If not, usually a signal goes
off telling the nurse of a discrepancy.
The study, which was led by led by Prof Ross Koppel of The University
of Pennsylvania School of Medicine, was conducted at five hospitals in
the US Midwest and East Coast. Prof Koppel and his colleagues from other
healthcare systems examined nearly half a million instances where nurses
and other staff scanned patients and medications.
The researchers found a remarkably high proportion of scans involved
nurses overriding the technology with workarounds to compensate for
difficulties with the barcode systems. Nurses scanning the barcode on
the medication or the patient’s ID bracelet overrode the technology for
4.2% of patients charted and for 10.3% of medications charted.
In contrast, vendors of barcode medication administration (BCMA)
systems report error rates that are a small fraction of this study’s
numbers; but vendors focus primarily on the ability to physically affix
and read barcodes, not on the totality of the many processes in actual
use.
In addition to examining the half million scans, the researchers
spent years shadowing nurses using the technology, participated in many
BCMA implementation meetings, and conducted scores of interviews with
pharmacists, nurses, and IT leaders.
Hospital patients, on average, are subject to one medication
administration error a day, according to the Institute of Medicine, and
in hospitals, medication administration accounts for 26% to 32% of adult
patient medication errors. Thus, an automated system using barcodes to
reconcile a patient’s medications and orders with the patient’s identity
would be a great advance, helping to ensure the right patient receives
the right dose at the right time.
But the researchers found in the five study hospitals found 31
'causes' of problems that engendered workarounds by the nurses. These
causes included:
- unreadable medication-barcodes (crinkled, smudged, torn,
missing, covered by another label);
- malfunctioning scanners;
- unreadable or missing patient-ID wristbands (chewed, soaked,
missing);
- non-barcoded-medications;
- medications in distant refrigerators;
- lost wireless connectivity;
- problems with patients in contact isolation; and
- emergencies.
In some cases, if the pharmacy sent two 10mg tablets for a 20mg
order, the scanners/computers would not accept the medications. Nurses
devised workarounds to compensate for the awkward and inconvenient
aspects of the barcode technology.
These nonstandard procedures consisted of, for example, affixing
extra copies of patient ID barcodes on desks, scanning machines,
clipboards, supply room, and doorjambs, as well as carrying several
pre-scanned patient’s medications on one tray.
Prof Koppel emphasized that: “It’s not that staff are lazy or
careless, it’s that the system does not work as well as it should. If
the refrigerated medication is two floors and a long hallway away,
you’re not going to wheel your 87 year old patient to the fridge. You
make a copy of her barcode. And while you do that, you help another two
patients who also need refrigerated medications.”
“Barcoding is still under development,” says Koppel. “Administrators
and vendors may expect it to be fool-proof, but users know it’s not.
It’s a very promising technology that still requires constant refining
and careful observation of on-the-floor workflow to get it right.”
The researchers found that in the pressurised, “can-do” culture of
today’s hospital, nurses compensated for the imperfect technology and
workflow by devising 15 types of workarounds. The study also presents
typologies of workarounds, BCMA 'causes', and the kinds of errors
associated with each.
Every day BCMAs save lives and stop errors, says Dr Koppel, and the
published study documents thousands of medication errors avoided via
these systems. In addition, the article also lists many recommendations
for identifying the problems and mitigating workarounds. Four of the
study hospitals reduced the number of overrides dramatically by
following these recommendations.
“The causes of workarounds are neither rare nor secret,” added
Koppel. “They are hidden in plain sight, obscured by, among other
things, a blind faith in technology and the urgent needs of patient
care. Clever as they are, workarounds are the unintended consequence of
a technology in need of continuing and in situ evaluation.”
Professor Koppel’s research on healthcare information technology came
to national prominence a few years ago with a JAMA article on
medication errors associated with computerized physician order entry
systems (CPOE).
But he has published widely on healthcare IT, noting its many
benefits as well as its problems. In the same July/August issue of JAMIA,
in fact, he is also the first author on a paper that presents a way of
using CPOE to detect and prevent medication errors — a decidedly pro-CPOE
piece.
Koppel remarked, “Many vendors and their supporters mistakenly
believe I’m some sort of Luddite. That’s the exact opposite of my
position. I view these technologies as vital; that’s why we must make
them work to help clinicians and patients. Right now, the vendors and
true believers focus on marketing HIT, and attack any criticisms as
anti-technology. That’s the worst way to improve these essential tools.”
This study challenges assumptions of how these increasingly popular
bar-coded medication administration systems are actually used in
hospital practice. “It is not enough to tell the staff to “do it right”,
concludes Koppel, “rather, repeated examinations and corrections of the
technologies in actual use will help optimize their roles in preventing
medication error and enhancing patient safety.”
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