September 14, 2009
Uncoupling BCMA from its Unintended Consequences
By Jamie Kelly
For The Record
Vol. 21 No. 17 P. 8
Shining a spotlight on some of bar code medication administration’s (BCMA) strengths and weaknesses in front of hundreds of bar-code supporters might not seem like the best stance to take, but as Rodney Hicks, MD, PhD, RN, FNP, BC, FAANP, the University Medical Center Health System Endowed Chair in Patient Safety at Texas Tech University Health Sciences Center, and Manisha Shah, RRT, director of Patient Safety for the Hospital Corporation of America (HCA), demonstrated, if the goal is improving patient safety, it is a risk worth taking.
Hicks and Shah were two of nearly 40 presenters at the fourth annual unSUMMIT for Bedside Barcoding this past May. The unSUMMIT, an interdisciplinary conference, strives to cover every aspect and angle of the bar code point-of-care process, including instances when the technology limits optimal EHR results.
BCMA systems, as the term suggests, are used during the medication administration phase of the medication use process. This stage is often referred to as the “sharp end,” since there are so few safeguards against errors once a medication reaches this point; it is the final barrier. Errors occurring upstream in the medication use process that have gone undetected and those made during the administration phase are unlikely to be intercepted, making a safety system such as BCMA critical to patient care.
The technology is not new. Grocery stores have used it since the ‘70s, but as a patient safety tool, bar coding is still an emergent—and thus imperfect—technology. Reflecting on the combined experience of more than 200 hospitals using BCMA technology, Hicks and Shah set out to explain that the so-called unintended consequences were the side effects of an evolving process. The errors associated with or caused by BCMA use were not necessary evils, but indications of the need to refine the medication administration phase through new, safer standards of practice. The first step, then, was to identify the sources of error.
Where Mistakes Occur
In the summer of 2006, a team from the U.S. Pharmacopeia (USP) began collecting data on errors reported between January 1, 2000, and December 31, 2005. Their source was MEDMARX, USP’s voluntary error reporting program. By using a free text search for various forms of “bar code,” the team was able to identify errors which occurred with a BCMA system in place. The team then spent the next two months analyzing the data.
One of the first questions that had to be answered was whether there were specific points in the BCMA process that were more susceptible to these errors. The data indicated that there were. Over and over again, certain types of errors popped up and the USP team was able to distill them into the following eight categories:
• mislabeled bar codes;
• missing bar codes;
• those that would not scan;
• occurrences of staff overriding the error warnings;
• bar codes that were not scanned;
• staff workarounds;
• wrong patient; and
• system not available.
Then, with a clearer picture of which types of errors were occurring, the team focused on the likely causes.
Of all the categories, mislabeled bar codes were the most common cause of BCMA-related errors. These fell into two trends: those that were mislabeled with another product’s bar code and those that were the right product but were labeled with the incorrect dosage. More than likely, these were the result of repacking, a human interface. Repackaging is often needed as many of the medications are not sold prepackaged in the unit of use. In addition, repackaging can be cost-effective as bulk medications are cheaper. Unfortunately, this practice can leave the door open for medication errors.
Often, less expensive products create more problems. Inferior materials, such as the ink or paper used to make the bar codes, lead to smeared labels. Also, the team noted that “although technology using ‘pens’ or ‘wands’ is generally less expensive than using handheld devices, difficulties reading bar codes on curved or uneven surfaces have been reported when scanned with pens and wands.”1
During the presentation, Shah chronicled the HCA’s failure mode and effect analysis into the causes of workarounds. Direct observation revealed that when technology was applied to existing processes, there was opportunity for short cuts. Initial steps were taken to address the issue, but another series of direct observation surveys revealed that additional interventions were needed. The problem was that there was a discrepancy between the staff’s perception and the reality of the situation. Some did not consider the shortcut to be a patient safety issue. Others believed that their BCMA process was as it should be. Clearly, there was something missing in their policy.
Teams of 12 were formed to examine each of the five causes of workarounds (technology, tasks, organization, patient safety, and environment) as cited in the article “Workarounds to Barcode Medication Administration Systems.” Each team worked independently over a six-week period, performing staff surveys and interviews, report analysis, and site inspections.
Their findings coincided with the Koppel workaround study.2 For example, the team assigned with examining the technological reasons found that relatively high numbers of workarounds were associated with lost connectivity, scanner malfunctions, and issues with the bar codes. The other teams found similar correlations between their respective categories and the results. What’s more, each team now had a grasp of the specific sources of workarounds and were no longer working under ill-defined assumptions. Six weeks of study and analysis revealed the most likely failure points. They now had the knowledge to address and ultimately prevent the workarounds.
Redefining Best Practices
The failure mode and effect analysis did not stop once the most likely causes of workarounds were found. After all, the purpose was to first learn the reasons why shortcuts were occurring and then to develop a list of recommendations that would significantly lower the likelihood of future workarounds. The analysis provided the teams with an objective and empirical basis from which new standards of practice could be developed.
Yet, these standards had to address more than the limited concerns of the 12 test facilities. If they were to meet the failure mode and effect analysis’ criteria, the recommendations would have to be instituted across the multihospital system. It is a testament to the analysis’ value that all hospitals, big and small, can now follow these recommendations.
The Consequences of Continual Quality Improvement
As with any new technology, there will be changes to the process. Time will be spent adjusting to a new workflow, and staff will need to be trained to use it properly. Where BCMA falls in the spectrum of patient safety technologies is hard to say; it is also irrelevant. While both the USP and the private healthcare failure mode and effect analysis show that complications or additional steps to a process often result in staff workarounds or other breakdowns in the process, the priority of BCMA is not staff convenience. A perfect BCMA system is not necessarily the one that reduces the time spent administering medication; it’s the one that makes the process safer. Thus, the main measure of BCMA’s value cannot be the amount of work involved but rather the number of errors that never reach the patient.
In fact, the point the presenters wanted to drive home was that continual quality improvement relies on continual quality assessment. This entails reviewing the error reports on a consistent basis. It is likely that the error profiles will continue to change and that previously sound and sufficient policies will have to be updated.
The commitment to refining how BCMA systems are used will result in what Hicks called a “marriage” of staff and technology. BCMA will no longer be viewed as an auxiliary tool or an alternative method. Rather, it will be seen as an inherent part of the medication use process, well worth the time spent remedying its unintended consequences.
— Jamie Kelly is an independent marketing consultant serving HIT vendors and the co-organizer of the annual unSUMMIT for Bedside Barcoding educational forum.
1. Cochran GL, Jones KJ, Brockman J, Skinner A, Hicks RW. Errors prevented by and associated with bar-code medication administration systems. Jt Comm J Qual Patient Saf. 2007;33(5):293-301.
2. Koppel R, Wetterneck T, Telles JL, Karsh BT. Workarounds to barcode medication administration systems: Their occurrences, causes, and threats to patient safety. J Am Med Inform Assoc. 2008;15(4):408-423.