Workarounds to Barcode Medication Administration Systems: Their Occurrences, Causes, and Threats to Patient Safety

Abstract

The authors develop a typology of clinicians' workarounds when using barcoded medication administration (BCMA) systems. Authors then identify the causes and possible consequences of each workaround. The BCMAs usually consist of handheld devices for scanning machine-readable barcodes on patients and medications. They also interface with electronic medication administration records. Ideally, BCMAs help confirm the five "rights" of medication administration: right patient, drug, dose, route, and time. While BCMAs are reported to reduce medication administration errors--the least likely medication error to be intercepted--these claims have not been clearly demonstrated. The authors studied BCMA use at five hospitals by: (1) observing and shadowing nurses using BCMAs at two hospitals, (2) interviewing staff and hospital leaders at five hospitals, (3) participating in BCMA staff meetings, (4) participating in one hospital's failure-mode-and-effects analyses, (5) analyzing BCMA override log data. The authors identified 15 types of workarounds, including, for example, affixing patient identification barcodes to computer carts, scanners, doorjambs, or nurses' belt rings; carrying several patients' prescanned medications on carts. The authors identified 31 types of causes of workarounds, such as unreadable medication barcodes (crinkled, smudged, torn, missing, covered by another label); malfunctioning scanners; unreadable or missing patient identification wristbands (chewed, soaked, missing); nonbarcoded medications; failing batteries; uncertain wireless connectivity; emergencies. The authors found nurses overrode BCMA alerts for 4.2% of patients charted and for 10.3% of medications charted. Possible consequences of the workarounds include wrong administration of medications, wrong doses, wrong times, and wrong formulations. Shortcomings in BCMAs' design, implementation, and workflow integration encourage workarounds. Integrating BCMAs within real-world clinical workflows requires attention to in situ use to ensure safety features' correct use.

Medical Devices and Patient Safety

“…13 For example, devices used during medical transport or at extremes of temperature, humidity, or altitude must be appropriately designed for those environments. A nurse scans a whole tablet but then forgets to split it before administration; packaging medications in the dose of administration can reduce this risk 25 Failing batteries on scanners or computers produce slow performance, alter workflow, and encourage unsafe work-arounds 25 The inability to physically bring the scanner/computer setup to the patient bedside reduces safety 25 An unsafe modification of endoscope tubing resulted in backflow of body fluids into a tubing and potentially exposed multiple patients to bloodborne pathogens 27…”

“…Less obvious are the automated dispensing cabinets, computerized charting systems, medical gas systems, and the additional complex equipment in the laboratory, pharmacy, and other support areas. Additional details about specific device errors and recommendations for improving safety [18][19][20][21][22][23][24][25][26][27][28][29][30][31][32][33][34][35][36] are presented in Table 1. Manufacturer-related errors occur during design or production of a medical device.…”

Exploring the Translational Impact of a Home Telemonitoring Intervention Using Time-Motion Study

“…The implementation of new technology into clinical workflow can trigger positive and negative unintended consequences, [14][15][16] encourage workarounds, 17 and potentially increase worker frustration 18 and opportunities for new errors. 19 Prior time-motion studies have quantified the impact of technology interventions on clinician workflow, 11,20,21 but to the best of our knowledge, the methodology…”

Bags, batteries and boxes: A qualitative interview study to understand how syringe drivers are adapted and used by healthcare staff

“…In the homecare environment this could involve customising the device to make it look discreet (O'Kane et al, 2015). In the hospital context equipment could be modified beyond the original design intent, as per accounts relating to barcoding systems (Koppel et al, 2008), alarm settings (Watson et al, 2004), physiological monitors (Cook and Woods, 1996) infusion pumps (Obradovich and Woods, 1996) and glucometers (Furniss et al, 2015).…”