Introducing Bar-Coding of Medications Into Clinical Practice: Research Based Protocol for Practice, Article Critique Example

Introduction

Medication errors cause 7000 deaths and cost 2 billion dollars yearly and are the leading cause for error-related inpatient deaths (Sakowski, Newman & Dozier, 2008). Williams (2007) defines medical “any error in the prescribing, dispensing, or administration of a drug, irrespective of whether such error leads to adverse consequences or not”. No hospital unit is protected from medical errors; they happen everywhere and anytime, as to err is human. Errors can happen at any stage of the medication-use process (Skibinski et al, 2007), but errors made during the prescribing and administering stages are the most frequent, constituting an estimated 26-34% of all preventable medication errors (Koppel et al., 2008). Cescon & Etchells (2008) add that errors during the medication administration process are far more likely to reach the patient than errors that occur at any other stage.

Fowler, Sohler & Zarillo, (2009) state that medication administration process takes up to 40% of the nurses’ time and includes several stages: verifying the prescription, preparing the doze of the medication, administering medication to the patient in accordance with prescription, and recording the administration into the patient’s personal record. Approximately 1-2% of all administrations are erroneous for some reason (Sakowski, Newman & Dozier, 2008). The study by Peggy Hewitt (2010) categorizes the nurses’ perception of the reasons of medication errors during the administration process. These are: distraction, fatigue, poor physician handwriting, confusion of drugs with similar names or packaging, failure to follow protocol and five rights of medication administration, confusion regarding infusion devices, miscalculations daytime sleepiness, prolonged shifts and events in the unit requiring higher priority.

BCMA systems have shown their high efficiency for preventing medication errors. According to Sakowski, Newman and Dozier (2008), the implementation of bar-coding into hospital practice leads to a 50% reduction of medication administering errors, while Fowler, Sohler and Zarillo (2009) state this rate is 55%. According to their research, the effectiveness of using a BCMA system in a chain of twenty seven hospitals in northern California showed that medication errors were prevented in 1.1% of all medication administrations (Fowler, Sohler & Zarillo, 2009). Helmons, Wargel, and Daniels (2009), who compared medication error rates before introducing BCMA system, when the non-electronic patient identification systems were used, and after BCMA implementation, state that the overall errors reduction rate was 58% after the implementation of BCMA system. Moreover, the implementation of BCMA systems increases job satisfaction levels of the nurses, who work with it (Fowler, Sohler and Zarillo, 2009; Morris et al, 2009).

Introducing BCMA systems into the hospital practice increases patient safety and allows to comply medication administration process to the five rules: are the right patient, right drug, right dose, right route, and the right time (Cescon & Etchells, 2008). At the same time, various workarounds and problems are possible when using BCMA systems (Koppel et al., 2008).

Purpose

Medication errors are one of the leading causes of death in the U.S hospitals. Introducing bar-coding into clinical practice has shown to reduce the medication error rates considerably. The purpose of this paper is to develop a research-based protocol for introducing the Bar-Code Medication Administration (BCMA) system into the healthcare practice in a single hospital unit.

Background

The BCMA system, for which the protocol is developed in this paper, is similar to the one described by Wideman, Whittler, and Anderson (2005). It contains an interactive electronic client/server database system, where all the patients’ records are kept. Medication administration process starts when physician makes an entry that detail’s patient orders. The orders appear in the system, so that pharmacists can see, edit and verify them. When the orders are verified, they appear on nursing staff’s point-of-care BCMA. After orders are verified by a registered nurse, medications can be administered. Scanning patient’s wristband and medication before administering it to the patient allows to record the time of administering the medication. The software also contains “Missing Dose Request” function, which allows the nurse to request missing medications for specific patient directly from the pharmacist.

Methods

This protocol was created as a result of the analysis of the article by Wideman, Whittler, and Anderson (2005) about introducing the BCMA system in the acute care and long-term care sections of a 118-bed Veterans Administration hospital, and Koppel’s et al (2009) article about workarounds connected to using BCMA system.

Findings

Summarizing all the research analyzed, BCMA system usage protocol for nurses should be the following:

1. Nurses should check BCMA point-of-care before preparing medications for administration, in order to check for updates from physicians and pharmacists. Nurses should check the information about the doze and route of administering medications, even if this information takes more than one screen, as there maybe critical updates from physicians or pharmacists there (Koppel et al., 2008).
2. Nurses should perform double-confirmation before preparing to administer high-risk medications.
3. Nurses should take medications for one patient at a time’ in case the nurse takes medications for more than one patient a time, they should be carried in separate containers (drawers in medication cart etc) (Wideman, Whittler, & Anderson 2005).
4. Scanning of the medications and patient’s wristbands should be performed at the patient’s location. It is forbidden to scan medications before reaching the patient, removing the patient’s wristbands to scan them separately, or creating copies of the wristbands to scan them in nursing room or elsewhere (Koppel et al., 2008).
5. Nurse should perform visual examination of the medication list, name, and dose before preparing medication for administration (Koppel et al., 2008).
6. The administering process should begin with scanning the patient’s wristband and checking his medications list. Then the nurse should scan the label of the doze of medication she is going to administer (Koppel et al., 2008).
7. In case the patient’s wristband is missing or damaged, nurse should order another wristband, and administer medication after it is delivered. This guideline can be omitted in cases when administration is urgent (Wideman, Whittler, & Anderson 2005).
8. In case the bar-code on medication is missing or damaged, the nurse should take another doze of the medication. Medications should not be administered without scanning them beforehand (Wideman, Whittler, & Anderson, 2005).
9. Administration of medication should be recorded after the patient got the doze, and nurse made sure he took it. Recording administration before the actual administration is not allowed (Koppel et al., 2008).
10. In case some medications are missing from the cart, nurses should use “Missing Dose Request” function, and wait for the medications to be delivered (Wideman, Whittler, & Anderson, 2005).
11. Nurses should report problems with the software or hardware components of BCMA system as soon as the problem becomes evident (Wideman, Whittler, & Anderson, 2005).

Conclusion

BCMA systems are capable of reducing medication error rates by 50-58% (Sakowski, Newman & Dozier, 2008; Helmons, Wargel, and Daniels (2009). Nevertheless, BCMA systems often create various workarounds (Koppel et al., 2008). At the same time, their effectiveness is so high that the benefits of introducing it outweigh its costs and risks. Developing an effective research-based practice protocol is one of the keys to successful implementation of BCMA system in a hospital unit. Nurses should be educated about the process of working with BCMA system, and informed about rules and possible problems associated with using this system in order to reduce the rate of errors and workarounds connected with BCMA system.

References

Cescon, D. W. & Etchells, E. (2008). Barcoded medication administration: A last line of defense. Journal of the American Medical Association, 299, 2200-2202.

Fowler, S. B., Sohler, P., & Zarillo, D. F. (2009). Bar-code technology for medication administration: Medication errors and nurse satisfaction. Medsurg Nursing, 18, 103-109.

Helmons, P.J., Wargel, L.N., Daniels, C.E. (2009). Effect of bar-code-assisted medication administration on medication administration errors and accuracy in multiple patient care areas. American Journal of Health-System Pharmacy, 66 (13), 1202-1210.

Hewitt, P. (2010). Nurses’ perceptions of the causes of medication errors: an integrative literature review. Medsurg Nursing, 19 (3), 159-167.

Koppel, R., Wetterneck, T., Telles, J. L., & Karsh, B. (2008). Workarounds to barcode medication administration systems: Their occurrence, causes, and threats to patient safety. Journal of the American Medical Association, 15 (4), 408-423.

Sakowski, J., Newman, J. M., & Dozier, K. (2008). Severity of medication administration errors detected by a bar-code medication administration system. American Journal of Health-System Pharmacy, 65, 1661-1666.

Skibinski, K., White, B., I-Kuel Lin, L., Dong, Y., and Wenting, W.(2007). Effects of technological interventions on the safety of a medication-use system. American Journal of Health-System Pharmacy, 64 (1), 90-96.

Wideman, M.V., Whittler, M.E., & Anderson, M.A. (2005). Barcode Medication Administration: Lessons Learned from an Intensive Care Unit Implementation. In K. Henriksen, J. Battles, E. Marks, and D. Lewin (Eds.) Advances in Patient Safety: From Research to Implementation. Vol. 3: Concepts and methodology. Rockville, MD: Agency for Healthcare Research and Quality.

Williams, D.J. (2007). Medication errors. The Journal of the Royal College of Physicians of Edinburg, 37, 343–346. Retrieved from http://www.rcpe.ac.uk/journal/issue/journal_37_4/W