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SAF 20-049 – HSR Study

SAF 20-049
Creating Safety and Reducing Medical Error with Bar Coding
Marta L Render, MD
Cincinnati VA Medical Center, Cincinnati, OH
Cincinnati, OH
Funding Period: July 2001 - June 2003
Adverse drug events are the most common cause of injury to patients in the hospital. The VA implemented Bar Code Medication Administration (BCMA) across the VA in 2000 in order to reduce adverse drug events. The introduction of a new technology into a complex setting nearly always has unanticipated side effects on how work is performed that create new potential paths to adverse events. We examined this natural experiment for new sources of error related to changes in work processes and different settings.

The objective of this study is to identify new routes to medication error with BCMA through observation of nurses and interviews about near-misses, examine how setting impacts on software use and develop "Best Practices" to avoid these failures.

Two cross-sectional ethnographic observational studies at three different VA medical centers on acute care and nursing home units, combined with critical decision method interviews of observed "near misses" and administration errors. We solicited input in best practices through a web-based questionnaire informed by the findings from observations and completed by 16 VA hospitals, and validated those results through focus groups of a variety of stakeholders.

We identified five negative side effects following BCMA implementation: 1) nurses confused by automated removal of medications by BCMA; 2) degraded coordination between nurses and physicians; 3) nurses dropping activities to reduce workload during busy periods; 4) increased prioritization of monitored activities during goal conflicts; and 5) decreased ability to deviate from routine sequences. We found statistically significant (p £ 0.05) differences in practice among nurses administering medications in the acute care compared to long-term care. Acute care ward nurses: 1) used more detailed printed reports to plan medication passes and detect errors in ordering and dispensing; 2) scanned barcoded wristbands more frequently (53% vs. 8%); and 3) administered medications immediately after scanning and opening medication packets more frequently (93% vs. 23%). Using a novel format that describes the rationale as well as the context most relevant to the best practices, we described 14 best practices that address implementation/continuous improvement strategies, training, troubleshooting, contingency planning, equipment maintenance, medication administration, and wristband maintenance.

This project demonstrates how established human factors concepts and methods can be applied in healthcare to conduct innovative research that has immediate and long-term practical impacts. It is expected that medication errors will be reduced within the VA based on BCMA redesign and application of "best practices." In addition, impacts go beyond the VA, as private hospitals are already using the results to improve their bar code-based software prior to implementation (>30 requests for JAMIA preprint).

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None at this time.

DRA: Health Systems
DRE: Prevention, Technology Development and Assessment
Keywords: Adverse events, Nursing, Safety
MeSH Terms: none

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