Barcode medication administration
Barcode Medication Administration (BCMA) systems are designed to reduce the potential for adverse drug events (ADEs) by reducing the cognitive load placed on nursing staff during the medication administration process.
Bernard Silver and Norman Woodland, inventor of barcode, were granted the first commercial patent in 1952 (Barcode History Timeline - Birchwood Enterprise) Barcoding was initiall used and operated in the food and commercial industries. With the advent of technology, barcodes were introduced in the healthcare care industry. Today, the goal of barcoding is to be utilized in almost every hospital in the United States of America (USA). Although barcoding has been a mature technology in the food and drug administration (FDA), its practical application in regard of patient safety has just become common to healthcare. Though barcode introduction to Health Information Technology (HIT) was believed to improved safety, it has not yet reached it goals. According to the Institute of Medicine (2012) "HIT safety is contingent on how the technology is designed, implemented, used and fits into clinical workflow, requiring the cooperationof both vendores and users."==
Barcode History Timeline - Birchwood Enterprise
Two systesm, one at a Pontiac, MI General, Motors plant and one at General Trading. Company in Carlstadt, NJ. The GM systems was used to identitfy car axels on. Retrieved from http://wwww.birchwoodenterprises.com/a2bnews/A2B_Barcode-TimelineHiRes_withlinks.pdf Institute of Medicine. Health IT and Patient Safety: Building Safer Systems for Better Care. Washington, D.C.: The National Academies Press, 2012. (PP. 29)
The Veterans Health Administration (VHA) uses the information system called VistA an acronym for Veterans Health Information Systems and Technology Architecture. In 2002, VistA contained 99 applications. One of these applications was BCMA. This application is used by nurses at the patient bedside to validate administration of the right medication to the right patient using wireless scanners or laptops to cross reference with the patient's computerized medication administration record (MAR). The nurse will scan patient information on the wristband, medication bar code and employee ID which is electronically send to the MAR. BCMA will immediately alert the nurse to medication error.
Brown,S.H.,Lincoln,M.J.,Groen,P.J., Kolodner,M. (2003). International Journal of Medical Informatics. VistA-U.S. Department of Veterans Affairs national-scale HIS,69,135-156.
BCMA systems maximize the cognitive load in the medication administration process by electronically verifying the accuracy of the “5 rights” of right patient, drug, dose, time and pathway. To achieve this level of functionality BCMA systems as highly dependent on a user interface culture where safe-use protocols are consistently adhered too. In such cases the benefits are real. In a 2010 quasi-experimental study Poon, et al., report that barcode medication administration systems have been associated with a 41% reduction in non-timing administration errors and a 51% reduction in potential adverse drug events from these errors, carrying the potential to prevent 95,000 possible ADEs (2010).
Medication administration errors have the potential to induce that can potentially cause serious harm to patients.
Workarounds consist of processes that allow for the task to be complete but do not necessarily follow the desired workflow, designed to achieve specific quality and safety outcomes. In developing workarounds, providers deviate from required safe-use protocols, thereby limiting BCMA benefits, effectively creating new pathways to adverse drug events at the time of medication administration (Koppel, et al., 2008).
BCMA systems are complex and involve the efforts of multiple systems to coordinate the work of providers over time and space. Implementation of BCMA systems is often disruptive. Accordingly, the majority of workarounds are developed to cope with the disruptions that occur to workflows that had previously coordinated medication administration tasks across shifts and between departments and units (Novak & Lorenzi, 2008).
A typology of workarounds has been posited by Koppel, et al., in a 2008 article titled Workarounds to Barcode Medication Administration Systems: Their Occurrences, Causes, and Threats to Patient Safety. The authors conducted a mixed-method study of BCMA use over a three-year period between 2003 and 2006 at a 470 bed Midwestern hospital and a 929 bed East Coast health system. Results of the study identified omitted steps (i.e. failure to scan wristband), incorrect sequence (i.e. prospective medication documentation) and unauthorized steps (i.e. disabling device alert safety features) as the most commonly observed workarounds. The study concluded that workarounds could be associated with technology, task, organization, patient and environmental causes. Workaround triggers range from software or hardware failure to the need to save time to patient circumstances (i.e. sleeping or vomiting).
- Koppel, R. P., Wetterneck, T. M., Telles, J. L., & Karsh, B.-T. (2008). Workarounds to Barcode Medication Administration Systems: Their Occurances, Causes, and Threats to Patient Safety Journal of the America Medical Informatics Association , 408-421.
- Novak, L. L., & Lorenzi, N. M. (2008). Barcode Medication Administration Administration: Supporting Transitions in Articulation Work. AMIA 2008 Symposium Proceedings, (p. 515).
- Poon, E. G., Keohane, C. A., Yoon, C. S., Ditmore, M. B., Bane, A. R., Levtzion-Korach, O. M., et al. (2010). Effect of Bar-Code Technology on the Safety of Medication Administration. New England Journal of Medicine , 362 (18), 1698-1707.
Adverse drug events (ADEs) not only threaten patient safety but are also costly due to prolonged patient stays, increased monitoring and complexity of care, and litigation. The 1999 Institute of Medicine report estimated that between 44,000 and 98,000 patients die annually due to medical errors, with medication error being a major source. An IOM update report in 2006 estimated between 380,000 and 450,000 hospital drug errors each year and nearly 800,000 people suffered in long-term care facilities due to drug mistakes .
Medication error can come from any of the four stages in the process: ordering, transcribing, dispensing and delivering, and administrating. In a study by Bates et al. , it was estimated that errors resulting in preventable ADEs occurred most often at the stages of ordering (56%) and administration (34%); transcription (6%) and dispensing errors (4%) were less common. While computerized physician order entry (CPOE) targets at resolving ordering errors, there is another system designed to reduce errors in medication adminstration.
Barcode medication administration (BCMA) system was developed to reduce medication errors during administration and help ensure the “five rights” of medication administration: right patient with the right drug and right dose at the right time with the right route. The use of BCMA systems to improve patient safety has been recommended by many organizations, including the Institute of Medicine, the National Patient Safety Foundation, the American Society of Health-System Pharmacists, and the National Alliance for Health Information Technology . FDA has also mandated barcode labels on all human medications and biological products by 2006 in an attempt to reduce medication errors. FDA has predicted that the ruling will prevent nearly 500,000 adverse drug events and transfusion errors over the 20 years that follow, at a cost savings of $93 billion .
BCMA systems features
While the specific features and user interfaces of various BCMA systems differ, the basic functionalities are all largely the same. When administrating drugs to patient, clinicians scan barcodes on patients (often in the form of patient wristbands), drugs labels (encodes the National Drug Code (NDC), which includes the drug company labeling the package for sale, the name of the drug and its dose, and the type of packaging ), and their own staff barcode (often on staff badge). The software then verifies the five rights, and if any of it is violated, warnings and/or errors will be issued. The software also automatically documents the actual administration of the medication as part of patient’s record. Often, systems also allows data to be stored, so reports can be generated to review omitted or late medications, investigate errors during the administration process, and resolve reported discrepancies.
The biggest benefit of BCMA is patient safety. BCMA is generally believed to be effective in preventing medication administration errors [3, 7, 8]. In addition, BCMA systems automatically capture and time-stamp drug administration steps for workflow analysis and accurate documentation. BCMA also allows multiple users to access administration information and decrease potential for missing medications to be administered . Furthermore, when BCMA is interfaced to CPOE and Pharmacy system, the integrated system enhance communications among the care team and share information on the ordering, dispensing, verifying, and administrating steps, and further help reduce the chance for medication error.
Cochran et al.  analyzed reports of errors submitted to MEDMARX, a national database of voluntarily reported medication errors, and discussed the frequent BCMA-related challenges and errors. Mislabeling was found to be the most frequently reported problem, with 27% of these errors reaching the patient. The second most frequently reported problem is medications without barcodes (e.g., such as IV, partial doses, multi-dose containers, and inhalers). Other reported problems included smearing or fading of barcodes on medications or patient wristbands and differences in equipment used (e.g., pens vs. hand-held devices).
There are also human factor challenges with nursing resistant to change and fear of tracking errors generated from the system. BCMA is often perceived to increase nursing workflow because nurses need extra steps to scan in several barcodes during the administration stage, so nursing often found “workarounds” to the barcode scanning. Some nursing bypass barcode scanning in the system due to fear of punitive actions resulted from error tracking. To overcome this human factor challenge, good selection of equipment, proper training and education, and proactive pharmacy involvement to ensure barcodes on medication packages are scannable are all important.
Impact on Nursing Workflow
A well planned and executed BCMA implementation project at a large academic medical center found that BCMA was not associated with an increase in the amount of time spent on medication administration-related activities. There was a nonsignificant drop in the proportion of time nurses spent on a activities related to medication administration 26.9% to 24.9%.
A UK hospital that implemented BCMA in 2003 for non-IV drug medication rounds found that medication administration rounds were quicker, on average 50 minutes pre-intervention and 40 min post-intervention. Although medication rounds were quicker, a higher percentage of time was spent on medication-related tasks in between drug rounds.
Impacts on nurse efficiency may occur in the short-term while nurses learn the new system, but AHRQ grantee hospitals reported no long-term impacts. Though BCMA does not appear to increase workload, realistic expectation should be set with nursing staff that it is not a time-saving technology.
A survey of nurses from a unit implementing BCMA found the elements they were most satisfied with were the BCMA process was safer and it was easy to check “five rights.” Elements nurses were most dissatisfied with were turn around time for stat medications, drug interaction messages, and more time with patients.
Two years after a BCMA implementation on a neonatal intensive care unit (NICU,) nurses reported they were comfortable using the system within two weeks of implementation and the new process was perceived as taking more time to administer medications. Workarounds were initially related to faulty equipment and technical problems limited the effectiveness of the BCMA system such as barcodes not scanning and unreliable computer equipment. Over half of the nurses felt the new system improved job satisfaction and increased professionalism.
- Woolston C. Ills and Conditions: Hospital medication errors. Caremark.
- Wideman MV, Whittler ME, Anderson TM. Barcode Medication Adminsitration: Lessons learned from an intensive care unit implementation. Advances in Patient Safety: Vol 3.
- Sakowski J, Leonard, T, Colburn S, Michaelsen B, Schiro T, Schneider J, Newman JM. Using a Bar-Coded Medication Administration System to Prevent Medication Errors. Am J Health Syst Pharm. 2005 Dec 15;62(24):2619-25
- Grotting J.B., et al.: The Effect of Barcode-Enabled Point-of-Care Technology on Patient Safety: Literature Review by Bridge Medical, Inc., October 2002.
- Bar Code Medication Administration. Pharmacy Health Care Solutions. Volume 1, issue 5.
- Patterson ES, Rogers ML, Render ML. Fifteen Best Practice Recommendations for Bar-Code Medication Administration in the Veterans Health Administration. Joint Commission Journal on Quality and Safety. July 2004 30(7): 355-365
- David W Bates. Using information technology to reduce rates of medication errors in hospitals. BMJ. 2000 March 18; 320(7237): 788–791
- Johnson CL, Carlson RA, Tucker CL, Wilette C. Using BCMA software to improve patient safety in Veterans Administration Medical Centers J HealthcInft Manag. 2002 Winter; 16(1) : 46-51
- Bates DW, Cullen DJ, Laird N, Petersen LA, Small SD, Servi D, Laffel G, Sweitzer BJ, Shea BF, Hallisey R. Incidence of adverse drug events and potential adverse drug events. JAMA. 274(1):29-34
- Poon EG, et al. Impact of barcode medication administration technology on how nurses spend their time providing patient care. J Nurs Adm. 2008 Dec; 38(12): 541-549.
- Franklin BD, O'Grady K, Donyai P, Jacklin A, Barber, N. The impact of a closed-loop electronic prescribing and administration system on prescribing errors, administration errors and staff time: a before-and-after study. Qual Saf Health Care. 2007;16:279-284.
- Hook JM, Pearlstein J, Samarth A, Cusak, C. Using barcode medication administration to improve quality and safety. AHRQ. 2008 Dec. AHRQ Publication No. 09-0023-EF.
- Fowler, SB, Sohler P, Zarillo, DF. Bar-code technology for medication administration: medication errors and nurse satisfaction. Medsurg Nurs. 2009 Mar-Apr;18(2):103-9.
- Morriss FH, Abramowitz, PW, Lee C. Wallis AB. "Nurses don't hate change" survey of nurses in a neonatal intensive care unit regarding the implementation, use and effectiveness of a bar code medication administration system. Healthcare Quarterly. 2009; 12: 135-140.