Nurses' satisfaction with medication administration point-of-care technology

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Hurley, Ann C., Bane, Anne, Fotakis, Sofronia, Duffy, Mary E., Sevigny, Amanda, Poon, Eric, Gandhi, Tejal. Nurses’ Satisfaction With Medication Administration Point-of-Care Technology. Journal of Nursing Administration. 2007 July/August; 37 (7/8): 343-349.

Although widely recognized as one of several mechanisms in place to help reduce the potential for medication errors at the bedside, a significant potential also exists for these types of technologies to be misused or to generate a number of unanticipated side effects. If the technology implemented fails to support nursing workflow at the bedside, nurses will often intentionally circumvent hospital protocols or procedures with a goal of expediting delivery of the medication to the patient in a more timely manner.

Nurses are frequently recognized as the “last line of defense” in the prevention of medication errors that may have actually been set in motion earlier in the order-entry and/or order verification processes. A large percentage of inpatient adverse drug events (ADEs) are during order entry by the physician, and a smaller but still significant number of those errors fail to be intercepted by pharmacists during order verification. Once the medication order has progressed beyond those two safeguards, the nurse provides the final check prior to the patient receiving the medication in error.

In an ongoing effort to reduce the potential for these errors to be overlooked, point-of-care technologies designed to integrate nurse scanning of bar-coded medications with the patient’s electronic medication administration record (eMAR) provide an electronic safety check during the actual administration process. But regardless of the safety improvements ingrained in automating medication administration processes, actual or perceived inefficiencies may lead to nurses developing workaround solutions or who may refuse to use the system altogether. This article outlined an onsite review of the use of technology-enabled medication administration processes, their impact on the nursing workflow, and the level of satisfaction of nursing staff who had been utilizing a system of this type over the course of several months.

It is widely recognized that the features of an electronic medication administration system must be accepted by nurses in order to support them in their day-to-day processes. If nurses are satisfied with the functions provided by a system of this nature, they are much less likely to develop workaround solutions and much more likely to spend their efforts focusing on the professional aspects of medication administration. Previous studies have confirmed that the majority of nurses who have used point-of-care technology have generally agreed that this strategy does help decrease the risk for errors, and that overall satisfaction and acceptance has been favorable. But in many other reports, nurses have complained that use of barcode technologies have reduced communication between nurses and physicians, have interrupted the timeliness of their medication administrations, or have interfered with their ability to provide non-routine medications due to a perceived lack of system flexibility.

Methods: Data for this study were collected at a single academic medical center that has utilized computerized provider order entry for over 10 years, and that planned to implement a barcoded system as another way to close the loop on the medication administration processes. Following approval of the Institutional Review Board (IRB), anonymous surveys were distributed and in-person interviews were conducted to assess perceptions and level of satisfaction among clinicians. The sample consisted of a total of 28 nurses who worked in a variety of clinical settings, including medical or surgical intermediate care areas, or in one of several different intensive care settings.

The Medication Administration System-Nurses Assessment of Satisfaction (MAS-NAS) Scale was developed and implemented in an effort to compare rates of satisfaction before and following conversion to barcode/eMAR technology. Clinician satisfaction was defined as the degree to which facility structures and operational policies supported the processes and procedures of delivering medications to patients in a safe but timely manner. Three assessment subscales were developed simultaneously as part of this study, and included

1. Efficacy, dependability, and effectiveness of the system: efficiency, user-friendliness, readily available of supplies needed during administration and documentation, error prevention/reduction, and adequate turnaround time. 2. Safety and system components to assure the nurse that it is correct to administer the medication: pharmacist check, physician/pharmacist agreement, ease of checking, drug alert features, clinician communication, and verification of the “5 rights” of medication administration. 3. Access, having necessary information and medications readily available: ease of finding information about specific medications, managing medication reactions and knowledge of intended and unanticipated side effects, access to needed systems, and knowing exactly where to locate medications.

Results: The typical respondents to this survey were selected by their nurse managers for having above-average computer skills, and most of those participants were accustomed to using a computer in their home. Participants were on average four years younger than the overall population of US nurses, were more heavily represented by the male gender, and were considered more highly educated than their peers.

Conclusions: Although many participants believed that using barcoding and eMARs at the bedside was much more time consuming, they at the same time acknowledged that the extra time was worth it to assure verification. Saving time on transcribing orders or trying to read handwritten paper-based medication sheets was seen by many to be a significant positive change.

An increased sense of safety for both nurses and patients was identified as a common theme among participants, and many verbalized that they felt safer and more confident with the knowledge that medication orders were no longer being transcribed by hand to paper MARs.

The tracking abilities of a barcoded system allowed participants to review when a medication was ordered and by which provider, which pharmacist performed verification of the order, and if the medication was readily available on the unit. Although many participants expressed their views that medication orders were verified more quickly, and the eMAR made it easier to change the priority of pharmacy communications, many still believed there was still a significant delay in pharmacy turnaround times and in obtaining medications so they were available for administration to the patient.

Results from both the surveys and in-person interviews revealed that nurses were very satisfied in general with barcoding and electronic documentation concepts. However, several limitations were also identified which may have negatively impacted the study results. The study was conducted entirely at a single inpatient facility, and only 143 of the 1,087 study participants completed both the before and after surveys. The sample was heavily weighted with male nurses, and also with nurses who were considered more highly educated than the national averages. Additionally, the study was conducted after only about two months’ of experience on the system, and it was widely recognized that the participants’ views may have been much different with additional familiarity with this new technology.

Many procedural components were identified as being more time consuming, but the majority of participants were in general agreement that improved safety and time saved in other areas of the process made the concepts well worth the effort. For example, what was perceived as a “5-second delay” while waiting for the computer to process the administration transaction was a fair tradeoff for the amount of time saved when trying to decipher illegible handwritten paper-based orders.

The role of nurses in the medication ordering and administration process is just one of their many roles in the day-to-day provision of patient care. A medication administration system that nurses view as being effective, by promoting efficacy, safety, and easy access, will in general support their nursing practice. Results of this study can provide confidence to nursing executives that nurses can indeed be satisfied with the implementation of technology to ease access to system components while simultaneously allowing nurses to provide safer and more efficient care to their patients.

Kevin Connett