an evaluation process for an e l e c t ronic bar code medication … · 2013-02-01 · 356 urologic...

UROLOGIC NURSING / September-October 2009 / Volume 29 Number 5 355

The purpose of this case study is to present an evaluation pro c e s sand recommendations for addressing the gaps found with the imple -mentation of a new bar code medication administration (BCMA) tech -nology in a busy acute care hospital unit. The case study analy ze swo r k f l ow procedures associated with administration of medicationsin an inpatient labor and delivery care unit before and one year afterimplementation of BCMA tech n o l o g y. The comparison reveals a two -fold increase in wo r k f l ow procedures for nu rsing staff because of then ew tech n o l o g y. System gaps are identified from a nu rsing user’sp e rs p e c t i v e, and recommendations are offered to close those gaps.

© 2009 Society of Urologic Nurses and AssociatesU rologic Nurs i n g, p p . 3 5 5 - 3 6 8 , 3 9 1 .

An Evaluation Process for anE l e c t ronic Bar Code MedicationAdministration Information SystemIn an Acute Care UnitMichelle Barg re nD e r-Fa Lu

T he use of bar code med-ication administration(BCMA) technology al-ters the flow of pro c e-

d u res to administer medications.This case study presents findingsof an analysis of workflow pro c e-d u res associated with administra-tion of medications on an inpa-tient labor and delivery care unitb e f o re and one year after imple-mentation of BCMA technology.Results revealed a two-foldi n c rease in workflow for nursings t a ff because of the new technolo-g y. The introduction of new tech-nology can create gaps in safec a re. Several gaps, the result of amismatch between the intendedfunction of a BCMA system, andthe real-life demands on healthc a re workers were identified fro m

O b j e c t i v e s1 . Explain the importance of bar code medication administration

(BCMA) system technology.2 . Discuss the implications of workarounds in medication admin-

istration workflow.3. Describe the implementation of the BCMA workflow as it

relates to this labor and delivery unit.

M i chelle Barg r e n , M S N , R N , is anI n fo rmatics Support Nurse, University ofI owa Hospitals and Clinics, Iowa City, IA.She also continues to wo rk part-time in theLabor and Delive ry Unit, University of IowaHospitals and Clinics, Iowa City, IA.

D e r- Fa Lu, P h D, R N , is an AssistantP r o fe s s o r, College of Nursing, University ofI owa, Iowa City, IA.

Statement of Discl o s u r e : The authorsr e p o rted no actual or potential conflict ofinterest in relation to this continuing nu r s i n geducation art i c l e.

N o t e : O b j e c t i ves and CNE Evaluation Fo rmappear on page 368.

Key Wo rd s : Bar code medication administration (BCMA), wo r k f l ow

p ro c e d u r e s , medication administration, m e d i c a t i o n

e r ro rs , wo r k a ro u n d s , wo r k f l ow bl o ck s , t e ch n o l o g y,

Interactive Sociotechnical Analysis (ISTA ) .

a nursing perspective. Recom-mendations for closing those gapsa re off e re d .

The organization was transi-tioning from a stand-alone BCMAsystem to an electronic medicalre c o rd (EMR) that incorporatescomputer physician/provider ord e re n t ry (CPOE) technology with the

integrated BCMA module of thatsystem. The recommendations pre-sented are based on a post-imple-mentation evaluation and can serv eas possible guidelines for the pre -implementation process of theBCMA component of the new EMRs y s t e m .

356 UROLOGIC NURSING / September-October 2009 / Volume 29 Number 5

B a c k g r o u n d

An Institute of Medicine(IOM) report attributed 7,000deaths annually to medicatione rrors (Kohn, Corrigan, &Donaldson, 1999). The magnitudeof these errors was pre v i o u s l yunknown, and the findings galva-nized an enormous reaction fro mboth government and health carere p resentatives (Bates et al., 2001).The IOM re p o rt prompted ani n c rease in exploration of technol-ogy to support safer care. Lisingand Kennedy (2005) concludedthat the traditional paper re c o rd isno longer satisfactory due to con-c e rns re g a rding the accessibilityand legibility of paper chart s .Additionally, the informationcontained in paper re c o rds mayresult in either postponed deci-sions or decisions based onincomplete inform a t i o n .

Bar code medication admin-istration (BCMA) systems aretechnologies developed to de-c rease the frequency of medica-tion administration errors. Thegoal is to provide a standard i z e dp rocess for medication adminis-tration. “Tr a d i t i o n a l l y, the vigi-lance of nurses has been the pre-dominant protection against med-ication administration errors,without any systematic safeguardto ensure that the ‘five rights’(right patient, right drug, rightdose, right route, and right time)a re achieved for billions of med-ication doses each year” (Cescon& Etchells, 2008, p. 2200). BCMAs o f t w a re provides electronic ver-ification of the five rights andeasy access to a decision supporttool for drug information andinteraction checking at the pointof delivery.

No system is foolproof, andtechnologies such as BCMA,implemented to decrease erro r s ,have been associated with news o u rces of error when not used asintended, raising critical implica-tions for patient safety (Ash, Berg ,& Coiera, 2004; Bates et al., 2001;Cescon & Etchells, 2008; Harr i s o n ,Koppel, & Bar- L e v, 2007; Koppel,

We t t e rneck, Telles, & Karsh, 2008;O ren, Shaff e r, & Guglielmo, 2003;Patterson, Cook, & Render, 2002).A reas of safety concern include afalse sense of security andreliance on technology to catch alle rrors (Ash et al., 2004; Harr i s o net al., 2007); desensitization fro mover -utilization of warnings(Cescon & Etchells, 2008; Douglas& Larrabee, 2003); improper usef rom placing the wrong ID bandon a patient or applying thew rong bar code label to a medica-tion (Cescon & Etchells, 2008);and degradation of coord i n a t i o nand communication betweennurses and physicians (Harr i s o net al., 2007; Patterson et al., 2002).Even the best-designed systemwill fail in an environment inwhich dysfunctional practicesu n d e rmine the proper use of thesystem (Oren et al., 2003).

Technological Safety Net Medication administration

in the acute care setting is a com-plex process requiring coord i n a-tion among clinicians who ord e rmedications, pharmacists whoverify and dispense medications,and nursing staff who administermedications (Patterson et al.,2002). Research implies that 39%of medication errors occur dur-ing the prescribing phase, where-as 38% of those errors occur dur-ing administration of medica-tions (Leape et al., 1995). Nearlyhalf of medication errors origi-nating from a pre s c r i b e r’s ord e r sa re intercepted before they re a c hthe patient (86% of them by nurs-es and 12% by pharm a c i s t s ) ;h o w e v e r, only 2% of nursingmedication administration erro r sa re intercepted (Leape et al.,1995). These data emphasize thatno human safety net exists tocatch errors for nurses whenadministering medication as itdoes for clinicians when pre-scribing. A BCMA system canp rovide a technological safetynet for nurses at this step of thep rocess. However, to be of opti-mal value, these systems must bereliable, have a rapid re s p o n s e

time, re q u i re little downtime, beeasily accessible, and have inter-faces that are easy to understandand navigate (Ash et al., 2004).

Closing the MedicationAdministration Loop

Ideally, BCMA technologywill be part of a suite of integratedclinical systems, including CPOE,to provide health care pro v i d e r smany lines of defense in all stepsof the medication delivery p ro c e s s(Ash et al., 2004, Franklin,O ’ G r a d y, Donyai, Jacklin, & Barber,2007; Guchelaar, Colen, Kalmeijer,Hudson, & Te e p e - Twiss, 2005;Newell & Christensen, 2003).CPOE technology enables clini-cians to enter orders electro n i c a l-ly directly into the patient re c o rdand integrates important clinicaldata about a patient, such as aller-gies, age, weight, and laboratoryresults into the medication ord e rp rocess (McCart n e y, 2006).

Bar code medication admin-istration systems, designed tos e rve primarily as a safety toolfor nurses, are directed at re d u c-ing the number of errors at thepoint of administration. CPOEtechnology is clinician-focusedand designed to decrease theo c c u rrence of transcription ando rdering errors (Newell &Christensen, 2003). Each tech-nology has a specific focus toi m p rove upon a segment of themedication delivery pro c e s s .H o w e v e r, to close the medicationadministration loop and achievethe ultimate clinical and finan-cial benefits, integration of thetwo technologies is cru c i a l( K u p e rman & Gibson, 2003;Newell & Christensen, 2003).

Medication AdministrationWorkflow and Wo r k a rounds

BCMA systems facilitatee rror reduction by intro d u c i n gworkflow blocks (such as com-puterized alerts or warnings) thatcompel users to stop and re c o n-sider a potentially unsafe step in the process (Vo g e l s m e i e r,Halbesleben & Scott-Cawiezell,2008). BCMA systems intention-


ally introduce work pro c e s sblocks that impede workflow(Halbesleben, Wakefield, &Wakefield, 2008). In some cases,the intentional stop in the med-ication administration pro c e s ss e rves its purpose well, and ane rror is averted. Workflow blocks,whether intentional or uninten-tional, are quite common and dis-ruptive to nursing staff. Con-s e q u e n t l y, workflow blocks tendto distract staff from patient careissues and can result in erro r s(Halbesleben et al., 2008;Vogelsmeier et al., 2008).

R e s e a rch suggests that in ane ff o rt to save time and curtail thefrequency of interruptions tow o r k f l o w, workflow blocks maybe circumvented by engaging inw o r k a rounds. “Given the extraor-d i n a ry demands placed on healthc a re professionals, it should serv eas little surprise that when addi-tional demands are put into place,they seek innovative ways to min-imize the impact of thosedemands on their pro d u c t i v i t y ”(Halbesleben et al., 2008, p. 7).

Wo r k a rounds are a pro b l e m -solving behavior involving usersadapting their routine and substitut-ing alternative, informally desig n e d ,and inconsistently applied workp rocesses (Halbesleben et al., 2008;Vogelsmeier et al., 2008). Often thesolutions, or workarounds, de-vised to address a block involvebypassing important safety fea-t u res in medical technology. Forexample, in an attempt to savetime, a user may neglect to verifythe new or updated medicationo rders displayed in the BCMAsystem before administering amedication, and as a result, maygive a medication that has beendiscontinued. Such workaro u n d smay reduce reliability of theintended work processes, possi-bly resulting in reduced patientc a re quality and safety (Cescon &Etchells, 2008; Halbesleben et al.,2008; Harrison et al., 2007;Koppel et al., 2008; Patterson,Rogers, Chapman, & Render,2006). In extreme cases, usersmay resist using the BCMA sys-

tem entire l y, negating the safetybenefits intended with use ofBCMA technology. Bar codecompliance re p o rts withinBCMA software allow org a n i z a-tions to monitor users’ scan ratesand approach staff members witha low scan rate who are bypass-ing the safety feature intendedwith BCMA technology.

P o s t - I m p l e m e n t a t i o nMonitoring

Despite the best of inten-tions, information systems oftendo not fully meet the objectivesfor which the system wasdesigned (Ash et al., 2004; Bateset al., 2001). Post-implementa-tion evaluation and monitoringof clinical technology can identi-fy modifications that will opti-mize a system’s eff i c i e n c y, im-p rove safety, and in the case ofBCMA, attempt to maintain theclinical relevancy of alert se n c o u n t e red by users in diff e re n tnursing care units (Cescon &Etchells, 2008; Guchelaar et al.,2005; Koppel et al., 2008;Patterson et al., 2002). By moni-toring the BCMA-generated alert snurses routinely encounter,health care organizations cangauge both the relevance and per-tinence of these warnings for spe-cific patient populations. Ad e c rease in the number of unnec-e s s a ry alerts triggered by a BCMAsystem can help ensure the work-flow blocks nurses encounter areclinically significant and justi-fied (Guchelaar et al., 2005).

Interactive SociotechnicalAnalysis ConceptualFramework

The Interactive Sociotechni-cal Analysis (ISTA) conceptualmodel offers a framework to aidunderstanding of the unintendedand undesired consequences ofhealth care information tech-nologies (HIT). Many undesir-able outcomes of HIT implemen-tation emanate from sociotechni-cal interactions, the interplaybetween new HIT and existingsocial and technical systems

within an organization (Harr i s o net al., 2007). The ISTA frame-work stresses the importance ofrelationships among the newH I T, workflow, clinicians, org a n-izations, and their potential forp roducing unintended conse-quences (Harrison et al., 2007). Inaddition, ISTA places a specialemphasis on recursive pro c e s s e s ,such as feedback loops that alterthe newly introduced HIT( H a rrison et al., 2007).

Method

A case study was used todescribe the extent of change innursing workflow related to med-ication administration on aninpatient care unit after imple-mentation of a stand-aloneBCMA system.

Setting The study site was a 12-bed,

high-risk labor and delivery unitwithin a 700-bed academic tert i-a ry care center. In November2005, BCMA technology andp rocesses were implemented inthe labor and delivery unit. Wi t hthe exception of the two operat-ing rooms located within thelabor and delivery unit, comput-er monitors, central pro c e s s i n gunits (CPUs), and tethered barcode scanners were installed ineach patient room on a desktopa rea a few steps from thep a t i e n t ’s bed. All health care per-sonnel attended training ses-sions. Clinical application sup-p o rt staff were available for users u p p o rt 24 hours a day on theunit during the first weeks of ini-tiation, and they continue to pro-vide round the clock support in-h o u s e .

CPOE was not concurre n t l yinstalled, and there f o re, hand-written or paper orders were stillsent to pharmacy via a pneumat-ic tube system. In March 2007,desktop image scanners wereinstalled at the nurse’s station toallow electronic transmission ofhandwritten or paper medicationo rders to pharm a c y. This change


Ta ble 1.Steps to Administer Medication Pre and Po s t - B C M A

Steps to Administer Medication Before BCMA Steps to Administer Medication After BCMA

“0 steps could signify a continuing order or no wa rning t riggered, etc.”

“0 steps could signify a continuing order or no wa rning t riggered, etc.”

Order sheet stamped with patient name/location/date (0 to 1 step)

Order sheet stamped with patient’s name, location, and date(0 to 1 step)

P hysician writes order/nurse writes verbal order (0 to 1 step) P hysician writes order or nurse writes verbal order (0 to 1 Step)

A ny special requests/instructions (STAT, non-standard timedue) noted (0 to 1 step)

A ny special requests/instructions (STAT, nonstandard timedue) noted on orders (0 to 1 step)

Order sheet torn from orders (0 to 1 step) Log into in-house system to scan medication orders to phar-m a c y ; select correct nursing unit, patient’s name; s c a no r d e r s ; select status (routine, one hour, stat) (0 to 4 steps)

Order sent to pharmacy (via pneumatic tube system whenava i l a bl e, or wa l ked by unit clerk / nurse to pharmacy) (0 to 1 step)

Stamp order sheet “ S c a n n e d ” and write in date, time, anduser name/initials (0 to 2 steps)

P h a rmacy inputs order into Pyxis (electronic medical stora g ebins) (0 to 1 step)

P h a rmacy inputs order into BCMA and/or Pyxis (electronicmedical storage bins) (0 to 1 step)

P h a rmacy dispenses medication to unit (tube, pharmacy technician delive r s, or pick up by RN/unit clerk (1 step)

P h a rmacy dispenses barcode labeled medication to unit(via tube, pharmacy technician delive r s, or pick up byRN/unit clerk (1 step)

N ew medication order tra n s c ribed onto paper medication administration record (MAR) by RN (0 to 1 step)

RN obtains drug through Pyxis, patient medication drawe ron unit, or medication refri g e rator on unit (1 step)

RN obtains drug through Pyxis, patient’s medication drawer onunit, or medication refri g e rator on unit (1 step)

RN obtains supplies to administer medication – medicinec u p, wa t e r, syri n g e, IV tubing (1 step)

RN obtains supplies to administer medication – medicine cup,wa t e r, syri n g e, IV tubing (1 step)

RN signs in to BCMA on computer terminal located in roombut usually 3 to 7 feet from bedside (1 step)

Ve rify patient identification using two patient identifiers (patienta rmband and paper MAR) (1 step)

Tra n s p o rt scanner device to bedside (1 step)

Ve rify 5 rights of medication administration against paper MAR– right medication, dose, route, time (1 step)

Manipulate ID band on patient wrist to enable RN to scanbarcode (1 step)

Prepare medication for administration (1 step minimu m)1 ) Dispense tabl e t s, pills into medicine cup (0 to 1 step)2 ) Hang IV medications (0 to 3 steps)

a . Mix IV medicine powder vial with attached solutionb. P rime tubingc . Enter correct rate into IV pump

3 ) D raw up liquid medications into syringe (0 to 1 step)

Scan patient barcode on ID band (1 step)1 ) If any of the fo l l owing occur, RN must return to

computer terminal and use mouse to: (0 to 1 step)a . C o n f i rm new orders on BCMA (0 to 1 step)b. C o n f i rm DC’d orders on BCMA (0 to 1 step)c . Select correct admission, link medication administra-

tion if 2 admissions same day (0 to 1 step)d . Ve rify documentation of allergy info rmation (0 to 1

s t e p)e. Document why scheduled medication doses we r e

not given on prior shift (patient off floor for X-ray,etc.) (0 to 1 step)


Ta ble 1. ( c o n t i nu e d )Steps to Administer Medication Pre and Po s t - B C M A

Steps to Administer Medication Before BCMA Steps to Administer Medication After BCMA

Administer medication (1 step) If no wa rnings triggered when ID band is scanned, thenscan medication (1 step)1 ) If scan of medication barcode successful/readabl e :

a . If medication triggers wa rn i n g / a l e rt (no order in system, sound alike/look alike med, etc.) RN mu s tuse mouse to ack n owledge wa rning (0 to 1 step)

b. For certain wa rn i n g s, selection from drop-dow nm e nu required for documentation regarding wa rn i n g / a l e rt (e.g., why medication is being give nlate or early) (0 to 1 step)

c . If no order exists in BCMA for the med, RN mu s tinput dose, ra t e, route, and location of the medica-tion manually into BCMA (0 to 3 to 4 steps)

d . Option exists to input free text note (pain ra t i n g ,location for pain medication being administered) (0 to 1 step)

2 ) If medications scan unreadable by BCMA or if wrongbarcode on medication scanned:a . Re-scan medication (0 to 1 step)b. If unsuccessful, must search for medication by

typing in medication name, then manually selectingcorrect drug fo rm/dosage with mouse from d r o p - d own menus in “Floor Stock ” or “ Fo rmu l a ry ”areas in BCMA system (0 to 3 steps)

Document administrations on paper MAR (1 step) Upon ve rifying that all info rmation for medication a d m i n i s t ration is correct on BCMA screen, RN must usemouse to select “ F i n i s h ” on the computer terminal (1 step)

B l a ck line order sheet (0 to 1 step) Use mouse to select “Document All” (1 step)

Use mouse to select “Log Out” (1 step)

Replace scanner to housing (1 step)

Prepare drug for administration (1 step minimu m)1) Dispense liquid/pills to medication cup (0 to 1 step)2) Hang IV medications (0 to 3 steps)

a . Mix powder in vial with attached solutionb. P rime tubingc . Enter correct rate into IV pump

3) D raw up liquid medications into syringe (0 to 1 step)

Walk from terminal to patient bedside (1 step)

Administer medication (1 step)

B l a ck line order sheet after confirming new orders on BCMA(0 to 1 step)

M i n i mum number of steps to administer medicationb e fore BCMA = 8 steps

M a x i mum number of steps to administer medicationb e fore BCMA = 20 steps

M i n i mum number of steps to administer medicationusing BCMA = 15 steps

M a x i mum number of potential steps to administer medication using BCMA (if new ord e r, “No order in s y s t e m ,” multiple warnings, medication barc o d eu n r e a d a ble) = 48 steps


accelerated the speed of deliveryand entry of medication ord e r sby pharmacists into those sys-tems involved in the medicationadministration pro c e s s .

Data Collection and GapAnalysis

BCMA processes were exam-ined using a mixed approach thatincluded direct staff observ a t i o n ,p rocess mapping, and inform a lg roup discussions. The contentof the pre and post-workflow dia-grams and process maps werevalidated by members of thenursing staff on the labor andd e l i v e ry unit using inform a lg roup discussion and direct staffo b s e rvation of the workflowsteps. Feedback was integratedand consensus obtained.

A process map (see Table 1)detailing the medication admin-istration process for the labor andd e l i v e ry unit captures a system-atic account of the process bothb e f o re the implementation ofBCMA technology and again oneyear later. The step-by-stepb reakdown facilitates easy com-parison of the medication admin-istration workflow pre and post-BCMA implementation.

A workflow diagram (seeF i g u re 1) illustrates user roles andthe diff e rent information systemsassociated with the medicationadministration process after im-plementation of BCMA. Gaps inthe flow of medication adminis-tration were identified andlabeled sequentially thro u g ho u tthe workflow diagram at varioussteps of the process. The majorityof identified gaps were BCMA ort e c h n o l o g y - related. Recommen-dations for resolution of the gapsa re displayed where applicablet h roughout the workflow dia-gram as well. Details of the gapsa re included below in the re s u l t ss e c t i o n .

R e s u l t sThe user workflow steps to

administer medication adminis-tration after implementation ofthe BCMA technology are signifi-

cantly greater in number thanb e f o re on the labor and deliveryunit (see Table 1). The minimumnumber of steps increases from 8to 15 with the introduction ofBCMA. The maximum number ofuser steps could potentially dou-ble when increasing from 22( p re-BCMA) to 48 (post-BCMA).The number of steps for each sce-nario could fluctuate based onc e rtain variables. For example,the number of steps will incre a s ewith a new medication order incontrast to an ongoing medica-tion ord e r, when a patient and/ormedication bar code is missing,and when encountering warn-ings or alerts during medicationa d m i n i s t r a t i o n .

The labor and delivery work-flow diagram (see Figure 1) por-trays the nurse’s workflow formedication administration fro madmitting a patient on the laborand delivery unit to administra-tion of a medication. The 13p rocess steps are labeled sequen-tially with the numerals “1t h rough 13” and are shown inF i g u re 1. These steps were asso-ciated with one or more gaptypes. Of those 13 steps, 4 stepshave a second gap that may occurat that same juncture in thep rocess. This brought the totalnumber of identified gaps to 17.

Table 2 is an inventory ofeach gap. Column 1 describes theg a p ’s source within the step ofthe medication process, whilecolumn 2 provides the conse-quence or reason for the gap inmedication administration pro-cess. Column 3 categorizes eachgap into at least 1 of 3 classifica-tion of gap types: technical gaps,human interaction gaps, and/orcontent workflow gaps d e f i n e db e l o w.

Technical gap. The “techni-cal” type gaps describe issuesresulting from technology, suchas computer capacity (Harr i s o net al., 2007), downtime for hard-w a re and software that altersw o r k f l o w, or the inability of tech-nology to capture completelycomplex care processes, such as

medication management. Human interaction gap.

“Human interaction” type gapsdescribe issues that result fro mhuman mistakes and ineff i c i e n-cies. One example was place-ment of an ID band with thei n c o rrect bar code on a patient.Another example was failure tonote on the paper medicationo rder sent to pharmacy that thedue time for a medication variedf rom the institution’s standarddosing schedule. This failurecaused the scheduled due timese n t e red into the BCMA system byp h a rmacy to be incorrect andgenerated late or early dosew a rn i n g s .

Content workflow gap. “ C o n-tent workflow” type gaps describeissues related to a need for infor-mation or to the addition of stepsto the medication administrationp rocess with BCMA functions.For example, the administrationof a late dose of medication willtrigger a BCMA “late dose” alertthe user must then acknowledgeby selecting the reason for thedelay via the drop-down menu(this was not a process stepbefore, but is essential withBCMA for safe care ) .

When the 17 gaps were cate-gorized into more than one clas-sification, 27 gaps were identi-fied. There were 14 technicalissues, 3 human interactionissues, and 11 content workflowissues among the 17 gaps notedin the diagramed workflow.F i g u re 1 illustrates and Table 2explains the gap to workflowre l a t i o n s h i p .

A review of the BCMA sys-t e m ’s software bar code compli-ance re p o rt (“actually scanned”vs. “potentially scanned”) wascompleted for users in the laborand delivery unit. The scan ratep rovided insight into users’acceptance (or perceived burd e n )of the technology. Furt h e rm o re ,the bar code compliance ratedocumented the patient safetybenefit derived from consistentuse of the system as intended.BCMA implementation in labor


R e c o m m e n d a t i o n

S O L NR e c o m m e n d a t i o n

Figure 1.Wo r k f l ow Diagram After BCMA

C l e r k

Pt visit entered into ADT system

R N / U s e r

Pt ID band applied afterverified by Pt. information

is correct

Verbal order written

P h y s i c i a n

Order written

P h a r m a c y

ADT system

Custom In-House CIS

B C M A

Pharmacy InformationS y s t e m

Order taken from printer

Order entered into p h a r m a c y ’s information

system by technician

Order checked by pharmacist for accuracythen released to BCMA

Medication dispensed to unit

Note any special actions(eg., time med due if varies

from standard dosing time).

Scan orders and select status from drop-down

box in CIS (Routine, Stat, one hour)

Medication retrieved frommed room or tube station

Orders stamped/noted“scanned” on paper orders.

Date, time, and initials ofsender documented

Obtain supplies to administer drug (syringe,

IV tubing, med cup)

Transport wired handset/scanner to Pt bed

Manipulate Pt ID band inorder to position for scan

Scan Pt ID b a n d

Enter user name and password into BCMA

Enter/verify pt allergy infointo stand-alone clinical

information system (CIS)

- Log onto CIS &- Select patient/Unit

Pt ID b a rcode label generated

Paper orders imprintedwith medical record #,

Pt name, date and unit location

BCMA ordersverified withp a p e r / c h a r torders and

confirmed onBCMA system.

S o f t w a r emodification to

BCMA system toallow RN tochange timemeds due

1 2

5

6

8

3

4

7

ADT

continued on next page


Figure 1. ( c o n t i nu e d )Wo r k f l ow Diagram After BCMA

ADT system

Custom In-House CIS

B C M A


If the following actionsneeded the

RN needs to walk back to terminal and use mouse/keyboard to:

If no warning triggeredduring ID band scan:

If barcode scans u c c e s s f u l

M e d i c a t i o ntriggers a warning

eg. “No order in systems”“Sound alike/look alike

If barc o d eu n s u c c e s s f u l /

u n r e a d a b l e

If scan remains u n s u c c e s s f u l :

R N / U s e r

Scan

M e d i c a t i o n

R e s c a nm e d i c a t i o n

R N must use computer mouseto acknowledge

the warning

RN has option oftyping a free text note (e.g. Pain

rating and/or location

If “No Order”warning triggered and

R N wants to cont.administration of

medication RN will needto input the dose, rate,

route, and possibly location in cases of IM

meds, into BCMA m a n u a l l y

For certain warningsselection from

drop-down menue also needed for docu-mentation regarding

the warning/alert (e.g. why medication is being given late)

Use mouse to select“Finish” on computer

screen after verifying allinformation for med

administration correctin BCMA

RN willl need tos e a rch for medicationby manally selectingcorrect medicationform/dosage withmouse from drop-

down menus in “FloorStock” or “Formulary ”

tabs in B C M A

RN has option of typing a free text

note (e.g., pain ratingand/or location)

Confirm new and/orDC’d orders on BCMA

Respond to warning that p t ’s allergy info needs to be

entered into CIS

Unsigned medication fromprior sign-on/session

Select correct admission to link medadmin to if pt has one or more admission

episodes present for last few days

R e c o m m e n d a t i o n

Remove prioradmission data

from screen view

9

10

11

12 13



Figure 1. ( c o n t i nu e d )Wo r k f l ow Diagram After BCMA

Use mouse to select “Document All”

on computer s c r e e n

Use mouse to select “Log Out”

Replace scannerto housing

Prepare medication for a d m i n i s t r a t i o n :

Draw up liquidmedication into

s y r i n g e

Walk fromcomputer terminalto patient bedside

A d m i n i s t e rmedication to

p a t i e n t

Black line paper order sheet after confirming neworder on BCMA

Dispense tablets, pills into med cup

Hang IVm e d i c a t i o n

Mix IV medicationpowder in vial withattached solution

Enter correct rateinto IV p u m p

Prime tubing

RN User P h y s i c i a n

Physician may view MedicationAdministration Record on CIS

ADT system

Custom In-House CIS

B C M A



Ta ble 2.Gap Inv e n t o ry Analy s i s

Gap Sourc e Gap ConsequenceGap Ty p e

H u m a n ,Te ch n i c a l , Wo r k f l ow

1. ADT system downtime, pharmacytech must enter patient name,medical record number (MRN)manually into pharmacy systems

1. No visit generated; patient datadoes not flow to other clinicalsystems

1. Technical

2. Incorrect ID band inadvertentlyput on patient

2. Violates five rights “wrong patient” 2. Human – Increased risk asBCMA may decrease diligence ofstaff to verify patient ID with twoidentifiers

3. Verbal order may never getwritten by either RN or physician

3a. Order not received by pharmacyfor entry into system.

3b. Unable to verify five rights withBCMA

3a. Technical – Creates false positiveerror with generation of “no order”warning in BCMA

3b. Workflow – Increases the # ofsteps to complete administration

3c. Human – Failure to write order

4. Information system used toscan med orders to pharmacyexperiences downtime

4a. Unable to scan new order(s),resulting in “No Order” BCMAwarning

4b. Unable to generate patient barcode/MRN for patient

4a. Technical – Creates new error(false positive)

4b. Workflow – Increased steps

5a. User fails to send (scan or tube)orders to pharmacy.

5b. Order written in error for wrongpatient and/or transposition erroroccurs, wrong patient selectedwithin the unit census.

5a. No order entered by pharmacyinto system; results in “No Order”warning

5b. Violates five rights “wrong patient“and/or “wrong drug”

5a. Technical – Creates new error bygenerating “no order” BCMAwarning (false positive)

5b. Technical/human error by forcingmanual selection of patient fromunit census list.

5c. Workflow, increased steps

6a. BCMA system downtime6b. User log-in ID not functioning

6a. Unable to electronically verify fiverights with bar codes.

6b. Must locate another RN toadminister med and documentelectronically.

6a. Technical6b. Technical and work flow

7. Electronic due time for medicationentered incorrectly or follows apreexisting dose times in BCMAsystem set by pharmacy

7. BCMA system incorrectly gener-ates early/late dose warnings

7a. Technical – Software modificationallows RNs to access/change duetimes rather than wait for pharmacy

7b. Workflow issue – RN must con-tact pharmacy to request duetimes on BCMA be changed

8a. Baby ID bands often difficult toscan due to size/curvature.

8b. ID band difficult to access or donot wish to awaken patient toscan ID band.

8a1. Must generate and replace band,or

8a2. Place second unsecured band indrawer of bassinet to scan.

8b1. Scan barcode not affixed topatient’s ID band.

8a. Technical8b. Workflow

9. BCMA-generated alert displayedin current BMCA system for multi-ple admissions same week.

9. Must associate correct admissionw/med administration (transposi-tion error possible).

9a. Technical – Software modification/HCIS could remove prior admis-sion from screen

9b. Workflow

10. Medication bar code cannot bescanned

10. Unable to verify five rights elec-tronically via bar codes

10a. Technical10b. Work flow



and delivery occurred on Nov-ember 28, 2005. The software didnot generate requested data priorto August 2007, so scan rates wereobtained for two time periods.The scan rate for users in laborand delivery was as follows: as c o re of 96% from August 1, 2007,to December 1, 2007; and a scoreof 97% for the period December 1,2007, to December 1, 2008. Theconsistently high scan ratesi m p l y, at the very least, accept-ance of the BCMA system by usersin the labor and delivery unit.

Discussion The ISTA conceptual model

for gap identification stresses thei m p o rtance of assessing a c t u a luses of HIT, rather than uses thatw e re planned or envisioned, andthe impact of that HIT on itsphysical and technical enviro n-ment (Harrison et al., 2007). Thepost-BCMA evaluation examinesthe influence of BCMA technolo-gy on the medication administra-tion workflow patterns of usersin the labor and delivery unit. Inaddition, the ISTA model empha-sizes the importance of re c u r s i v e

p rocesses, such as feedbackloops that alter the newly intro-duced HIT (Harrison et al., 2007).The recommendations identifiedduring the post-BCMA imple-mentation may serve as an addeds o u rce of knowledge to guidemodifications during the pre -EMR implementation phase.F i g u re 2 demonstrates the ISTAmodel as it applies to the laborand delivery unit and BCMAevaluations for this study.

Recommendations for GapResolution

I m p rovements to inform a-tion systems come from varieds o u rces. Perhaps from somethingas simple as re i n f o rcement ofusers’ educational training tosomething more involved, suchas a software change or upgradeby the vendor. Such is the casefor the recommendations pro-posed here upon completion ofthe pre and post-BCMA imple-mentation evaluations and itsutilization on the labor andd e l i v e ry unit. The goals of thesuggested recommendations aret o :

• Fill the identified gaps andreduce the false positivee rrors generated.

• D e c rease the number of clin-ically insignificant warn i n g s .

• Remove unneeded data ortechnical steps from the com-puter scre e n .The basis of these re c o m-

mendations is the belief that acommittee or team should bef o rmed to review not only thec redence of the re c o m m e n d a-tions but to provide staff mem-bers with a way to submit theirsuggestions for changes they feeld e s e rve consideration. Customiz-ing HIT in the clinical setting isan important step in maintainingpatient safety and increasing thee ffectiveness of such technology(Bates et al., 2001). To permit cus-tomization, recommendations toconsider include:• F o rmation of an interd i s c i-

p l i n a ry committee to elicitand review user suggestionsthat may in turn guide sys-tem optimization and cus-tomization of HIT. The com-mittee should include a mixof members from nursing

Ta ble 2. ( c o n t i nu e d )Gap Inv e n t o ry Analy s i s

Gap Sourc e Gap ConsequenceGap Ty p e

H u m a n ,Te ch n i c a l , Wo r k f l ow

11. Manually select correct medica-tion/concentration from“Formulary” or “Floor Stock” inBCMA system if medication barcode does not scan or is absent

11a. Unable to verify five rights elec-tronically via bar codes

11b. Transposition error possible ifincorrect medication selected

11a. Technical – Creates new errorpotential; possible transpositionerror during manual drugselection

11b. Workflow

12a. Select (dropdown menu) reasonmedication given early/late

12b. Early dose warning if given evenone minute early

12a. Workflow issue – Addition of stepto administration of meds

12b. Error and/or warning generated

12a. Workflow12b. Technical – New error (false/

positive) for error generated forgiving medication one minuteearly

13. “No order” warning encounteredroutinely as no CPOE systemcurrently in place and new ordersare often not received bypharmacy to be entered intoBCMA system beforeadministration of medications.

13. Invalid “no order” warnings gener-ated. “No order” in system wouldappear as serious error and a“right drug” violation. A valid orderexists but has not yet beenentered into the system. Result isa workflow issue, as a “No order”warning means nurse must man-ually input correct dose, route,and in case of IM medications,location of the injection.

13a. Technical –No closed loop systemfor medication administration dueto lack of integrated CPOEtechnology

13b. Workflow


i n f o rmatics, hospital com-puter information systems,and pharmacy depart m e n t s ;as well as clinicians andsuper users for applications.The inclusion of clinical staffp rovides a perspective of usein their workspace to assistin the identification and re s-olution of gaps to customizethe system for each clinicala rea, when possible, toi n c rease efficiency and eff e c-tiveness. Harrison and col-leagues (2007) point out thatthe unintended consequen-ces of IT often emerge afterimplementation; thus, man-agers, designers, clinicians,and re s e a rchers need to trackH I T-in-use carefully thro u g hcontinuous or repeated eval-u a t i o n s .

• Develop an issue-trackingp rocess for the committeep roposed above to ensure fol-low up and pro g ress towardresolution of issues withinthe issue-tracking database.Feedback should be elicitedf rom diff e rent patient careunits seeking identificationof warn i n g s / a l e rts that usersfeel are clinically insignifi-cant to their specific patientpopulation. Upon comple-tion of a judicial review andprioritization process, re-moval of clinically unneces-s a ry warnings can decre a s ethe risk for desensitization ofusers to meaningful alert s .An issue-tracking pro c e s sp rovides a formal means ofconveying and compilingissues for impro v e m e n t .

• D e t e rmine the process forhandling each issue. Theissue-tracking process re-q u i res a team to meet at re g u-lar intervals, such as everytwo weeks, to triage gaps andrecommend resolutions. Thefollowing is an example ofissue resolution through cus-tomization of the system.After implementation of thec u rrent BCMA system, thehospital initiated changes in

the time constraints of the“Late Dose” warning. A “LateDose” warning is now gener-ated if a medication is notgiven within a one-hour win-dow of its due time. Thischange in hospital-definedBCMA dose schedule, from a30-minute to a 60-minutew i n d o w, greatly decreases thenumber of “Late Dose” warn-ings generated, yet pre s e n t sno harm to patient safety.This modification also re-duced the “noise” withine rror re p o rts. Of note, the hos-p i t a l ’s policy of a 30-minutewindow for medication dos-ing did not change, only thew a rning timeframe within theBCMA software .

• Continue to identify contentworkflow gaps and the feasi-bility for continuously im-p roving workflow. For exam-ple, recommend continuationof the current practice of col-lecting medication packagingthat either has no bar codea ffixed or triggers an unre a d-able bar code warning by theBCMA system.

• R e i n f o rce previous trainingof users by alerting them tovarious risks inherent withuse of information systems.The use of BCMA, as well asmany other HIT systems,changes how health care isd e l i v e red. As with anychange, attention must bepaid to ensure that users arec o m f o rtable and using thetechnology as intended.R e s e a rch has shown thate rrors may actually be cre a t-ed by a BCMA system if it isnot used properly or usersexhibit decreased diligenceas a result of the availabletechnology and do not re l yon their own clinical judg-ment (Sakowski et al., 2005).The team should encourageusers to repeat training tore i n f o rce best practices andto identify and re p o rt issuesthat need to be re s o l v e dt h rough a tracking system.

• D e t e rmine which stakehold-ers control the workflowp rocess steps that give nursesaccess to input certain datainto BCMA systems, such asscheduled dosing times with-in the medication administra-tion re c o rd (MAR). The phar-macist sets a medication’sdosing schedule during entryof the order into the BCMAsystem. The pharmacist willinput the standardized dosingtimes, per hospital policy,unless the person sending theo rder to the pharmacy hasnoted specific start times onthe ord e r. In the past, a re g i s-t e red nurse was re s p o n s i b l efor scheduling the due timesof medications on the papermedication administrationre c o rds. BCMA accountabili-ty has transferred that re s p o n-sibility to pharm a c y. By trans-ferring that responsibilityback to the members of thehealth care team closest to thepatient and those actuallyadministering the medica-tions, many false-positivee rrors can be avoided. Wo r k-flow will also be impro v e dbecause of a decrease in thenumber of late and early dosew a rnings received in erro rand the need to then docu-ment a reason within BCMAfor the variance in adminis-tration time.

Conclusion

This case study found that thenumber of steps to administermedication after implementationof a BCMA system on this inpa-tient unit nearly doubled. Wi t hthis addition of steps and time tonursing staff workflow, it is cru c i a lthat health care organizations cus-tomize HIT in an attempt tod e c rease the prevalence ofw o r k a rounds employed by staffmembers. Recommendations havebeen made to fill the identifiedgaps of the current BCMA pro c e s sand improve workflow by re m o v-ing unneeded data and steps fro m


the process. Recommendationscan also be incorporated into theo rg a n i z a t i o n ’s conversion to anEMR and use of its integratedBCMA and CPOE technology.

Post-implementation eval-uation and monitoring of clini-cal technology will optimize as y s t e m ’s efficiency and im-p rove safety. In the case ofBCMA, the team can work toresolve gaps, attempt to de-c rease workarounds, and main-tain the clinical relevancy ofa l e rts encountered by users ind i ff e rent nursing care units.Wo r k a rounds defeat the over-all purpose of BCMA, which isto decrease errors and incre a s epatient safety around the med-ication administration pro c e s s .Limitations of this case studyinclude the narrow scope ofthe population studied andmay be restricted to the specif-ic systems evaluated.

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Figure 2.Interactive Sociotechnical Analysis Conceptual Framework for BCMA

Post-BCMA Evaluation (Spring 2006)

Wo rk f l ow assessment (examine actual useand impact of HIT use of technical andp hysical settings):

Pre and post-BCMA medication a d m i n i s t ration step analysis

D i a gram post-BCMA medicationa d m i n i s t ration wo rk f l ow in labor andd e l i ve ry unit

Gap analysis

Adapt innovations pre-implementationphase (HIT-in-use changes social system):

Committee fo rm a t i o n

Identify process for tra cking issues

D e t e rmine process to handle each iden-tified issue

C o n t i nue to monitor systems, wo rk f l ow,g a p s

R e i n force staff education/tra i n i n g

Pre-EMR Implementation (Spring 2009)

I n n ovations related to intera c t i o n

of social system and HIT

U rologic Nursing Editorial Board Statements of Discl o s u r e

In accordance with ANCC-COA gove rning rules Urologic Nursing E d i t o rial Board state-ments of disclosure are published with each CNE offe ri n g .The statements of disclosure fo rthis offe ring are published below.

K aye K. G a i n e s , M S , A R N P, C U N P, disclosed that she is on the Speake r s ’ Bureau fo rP f i ze r, Inc., and Nova rtis Oncology.

Susanne A. Q u a l l i ch , A N P - B C , N P - C , C U N P, disclosed that she is on the Consultants’Bureau for Coloplast.

All other U rologic Nurs i n g E d i t o rial Board members reported no actual or potential con-flict of interest in relation to this continuing nursing education art i c l e.

continued on page 391


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Vo g e l s m e i e r, A.A., Halbesleben, J.R.B., & Scott-Cawiezell, J.R.(2008). Technology implementation and workarounds in thenursing home. J o u rnal of the American Medical Inform a t i c sAssociation, 15, 114-119.

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