Closing the loop on medication errors

Barcodes were supposed to prevent problems, but instead, staff developed workarounds to speed care. Ferret out the problems before fatalities occur.

At its start, the introduction of barcode technology in hospitals promised to send medication administration error numbers plummeting. But the technology has not entirely lived up to expectations, according to Ross Koppel, PhD, a sociology professor at the University of Pennsylvania, a researcher at Penn's School of Medicine, and the lead author of a recent study in the Journal of the American Medical Informatics Association.


Dr. Koppel's study of five hospitals identified 15 types of “workarounds”— instances of staff working around approved protocols or rules for barcode medication administration (BCMA). Those included affixing patient identification barcodes to doorjambs and carrying several patients' pre-scanned medications on carts. He is careful to point out that, while staff may sidestep protocols, there is often a technological or systemic problem that triggers their actions. Unreadable or missing medication or patient wristband barcodes, malfunctioning equipment, and emergencies were among 31 causes of workarounds identified in the study.

“Yes, there are some lazy or sloppy users, but 99% of the issue is with a faulty system or technology,” said Dr. Koppel. “Most commonly, it's the integration of the system, the linkage between the pharmacy, work processes—[for example] the medication refrigerator is four floors down—and the technology. This study is not an indictment of these technologies, but a means to help perfect them.”

Can't do it alone

Barcoding systems were designed to enhance patient safety by combining with electronic medication administration records to ensure the five rights of medication administration—the right patient, drug, dose, route, and time. Ideally, they work in concert with computerized provider order entry systems (CPOE).

In a perfect world, when a patient is admitted to a hospital, the physician enters medication orders into the CPOE system, explained Robert M. Wachter, FACP, chief of medical service at University of California, San Francisco. The orders then go to the pharmacy, where they are double-checked, and medications are barcoded before going to the floor. Then, prior to administering the medication, the nurse scans the barcodes on both the medication and the patient's wristband to confirm the five rights.

“With such a closed loop, there's little opportunity for mistake. But not many places have that complete a closed loop,” said Dr. Wachter, who estimates that about 20% of hospitals across the country have physician order entry, and 20% have barcoding. “But they're not the same 20%,” he said. “My guess is that the number of places that have fully integrated CPOE and BCMA seamlessly linked together is about 5%. It's sort of the Holy Grail.”

Dr. Wachter cited the 747-bed Brigham and Women's Hospital in Boston as having one of the most advanced systems. Brigham's CPOE was created in-house in 1993 and the hospital has had a BCMA since about 2005, according to William W. Churchill, RPh, executive director of pharmacy services.

Before barcode technology, the pharmacy—which dispenses almost 6 million doses of medication annually—had a 99.25% accuracy rate dispensing medications, already an impressive record. “But the 0.75% error rate had the potential of over 45,000 medication errors annually,” said Mr. Churchill. With the implementation of barcode technology in the pharmacy department, that number was reduced by 85%.

Records showed that the Brigham's BCMA also resulted in 7,000 hard stops, or computer alerts signaling a potential error, per month at bedside, averting 85,000 potential administration errors a year.

Logging problems

Of course, when workarounds (like those highlighted in Dr. Koppel's study) happen, it raises the potential for medication errors that would otherwise be caught by the computerized systems to slip through. One way to ferret out these problems is by keeping track of overrides. Record-keeping built into the bar coding software can be analyzed to determine where and how errors were made, if overrides were improper workarounds, and how to tweak the technology and/or instruct staff to help close the loop.

“Each month, we look at all reports to find the total meds given and the number of near-misses, then categorize near-misses to determine where our biggest vulnerability is,” said Annette Ayers, RN, vice president of patient services and chief nursing officer at Providence Health Center in Waco, Texas.

“We also run reports on a weekly basis to see how many meds a particular person gave in the week, and how many times the bar code bedside technology was used or not, to determine the overall [protocol] compliance rate.” When an inappropriate override is discovered, the user first receives a friendly reminder about the importance of following protocol. A second offense results in counseling and additional education explaining how and why the protocol is in place.

Not all workarounds are bad, noted Ms. Ayers. “For example, a physician needs to give a medication stat, before having a chance to enter the order or a newborn needs a medication within the first few minutes after delivery, before the baby has been registered as a patient in the hospital.” In either of these instances, the nurse would need to override an “order not found” error displayed when the administered medication is entered into the system.

But when there does turn out to be a problem, and it is with the protocol, rather than the user, more widespread discussion is required. At the University of Wisconsin (UW) Hospital and Clinics, scheduled weekly and monthly staff, council, and safety committee meetings offer the opportunity for BCMA oversight by sharing and solving workaround-related problems. Input of problems and suggestions by staff can also be shared via computer by many systems.

Feedback logged by clinicians at the Brigham is reviewed every day by a designated team of nursing, pharmacy and information systems staff. “We used to get 50 or more a day, but now we see only two or three a day,” said Anne Bane, RN, manager of clinical systems innovations. “And we carry out technology rounds on a weekly basis, when a nursing and pharmacy team speak with clinicians during rounds about any [technology] issues.”

Sometimes the solution to a workaround problem is technological. At UW, fixes included the purchase of additional devices so hardware isn't a barrier to adherence to standard practice, and the addition of laboratory and drug information lookup capability on handheld devices, said Mark Kirschbaum, PhD, senior vice president of quality and information. At Providence, additional scanners have also been placed in convenient areas for use when a nurse's personal scanner is not available.

The causes and solutions of workaround problems may not directly involve hospitalists, but the potential consequences for patient care are significant enough that hospitalists should be keeping an eye out and speaking up when they see a problem.

“Although nurses interface with BCMA most, hospitalists have a role in oversight of the systems, and hospitalist representation should be on any task force,” said Christopher Roy, MD, associate director of the hospitalist service at Brigham. “We're the boots on the ground in terms of seeing how these systems are implemented or executed; we're another set of eyes in terms of workarounds.”