Bar code medication administration technology: characterization of high-alert medication triggers and clinician workaroundsAHRQ Patient Safety Network

Bar code medication administration technology: characterization of high-alert medication triggers and clinician workarounds.

Miller DF, Fortier CR, Garrison KL. Ann Pharmacother. 2011;45:162-168.
Bar coding medication administration (BCMA) technology is being widely implemented as a means of preventing medication administration errors, but like many innovations, early experience has yielded both success stories and unintended consequences. This analysis of BCMA implementation at an academic medical center found that potential administration errors were identified by the system, particularly for high-alert medications. However, nurses and pharmacists both engaged in a variety of workarounds that may have compromised the effectiveness of the system. The problem of workarounds has been discussed in prior studies and in an AHRQ WebM&M commentary.

full-text:
AHRQ Patient Safety Network

Ann Pharmacother. 2011 Feb 1. [Epub ahead of print]

Bar Code Medication Administration Technology: Characterization of High-Alert Medication Triggers and Clinician Workarounds (February).
Miller DF, Fortier CR, Garrison KL.

PGY-1 Health-System Pharmacy Administration Resident, Medical University of South Carolina, Charleston, SC.


Abstract
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.

PMID: 21285409 [PubMed - as supplied by publisher]
Bar Code Medication Administration Technology: Cha... [Ann Pharmacother. 2011] - PubMed result