Workarounds to Barcode Medication Administration Systems: Their Occurrences, Causes, and Threats to Patient Safety

Center for Clinical Epidemiology and Biostatistics, School of Medicine, Sociology Department, McNeil Building, University of Pennsylvania, Philadelphia, PA 19104, USA.
Journal of the American Medical Informatics Association (Impact Factor: 3.5). 04/2008; 15(4):408-23. DOI: 10.1197/jamia.M2616
Source: PubMed


The authors develop a typology of clinicians' workarounds when using barcoded medication administration (BCMA) systems. Authors then identify the causes and possible consequences of each workaround. The BCMAs usually consist of handheld devices for scanning machine-readable barcodes on patients and medications. They also interface with electronic medication administration records. Ideally, BCMAs help confirm the five "rights" of medication administration: right patient, drug, dose, route, and time. While BCMAs are reported to reduce medication administration errors--the least likely medication error to be intercepted--these claims have not been clearly demonstrated. The authors studied BCMA use at five hospitals by: (1) observing and shadowing nurses using BCMAs at two hospitals, (2) interviewing staff and hospital leaders at five hospitals, (3) participating in BCMA staff meetings, (4) participating in one hospital's failure-mode-and-effects analyses, (5) analyzing BCMA override log data. The authors identified 15 types of workarounds, including, for example, affixing patient identification barcodes to computer carts, scanners, doorjambs, or nurses' belt rings; carrying several patients' prescanned medications on carts. The authors identified 31 types of causes of workarounds, such as unreadable medication barcodes (crinkled, smudged, torn, missing, covered by another label); malfunctioning scanners; unreadable or missing patient identification wristbands (chewed, soaked, missing); nonbarcoded medications; failing batteries; uncertain wireless connectivity; emergencies. The authors found nurses overrode BCMA alerts for 4.2% of patients charted and for 10.3% of medications charted. Possible consequences of the workarounds include wrong administration of medications, wrong doses, wrong times, and wrong formulations. Shortcomings in BCMAs' design, implementation, and workflow integration encourage workarounds. Integrating BCMAs within real-world clinical workflows requires attention to in situ use to ensure safety features' correct use.

Download full-text


Available from: Tosha Wetterneck
    • "These practices have been identified in many different situations, and not only in the context of IS. They include non-compliance with management policies, inconsistent record keeping in bureaucracies and non-standard decision-making processes with customers (Halbesleben et al., 2008; Koppel et al., 2008). However, a number of scholars agree that such practices remain under-investigated and under-theorized (Pollock, 2005; Safadi & Faraj, 2010; Allen et al., 2013). "
    [Show abstract] [Hide abstract]
    ABSTRACT: This paper discusses how research with practitioners can help reconcile the top-down requirements of headquarters with the bottom-up local needs in the context of global information systems. Based on a 12-month canonical action research project that took place at the Chinese branches of a French multinational corporation, our research revealed and addressed workarounds that the Chinese users of a company-wide global enterprise resource planning system had put in place that were not expected nor desired by company headquarters. From the local users' point of view, they were necessary to deal with Chinese legislation and cultural practices, but from the French headquarters' point of view, they meant that many of the potential gains of global standards were lost. Activity theory was used as a focal theory to analyse each of these workarounds and business process management as an instrumental theory to design solutions to the workarounds. We describe in detail how we used canonical action research to successfully deal with exemplars of each of the three types of workaround identified (data adjustments, process adjustments and parallel-system adjustments). Unusually, the research relates to post-implementation change rather than to that looking at change occurring before and during implementation. We argue that canonical action research and the particular combination of activity theory and business process management are appropriate for dealing with workarounds and this has not been demonstrated previously. Further, our research – deemed successful by managers, users and researchers alike – took place in China where previous literature suggests only limited success with such global systems.
    No preview · Article · May 2015 · Information Systems Journal
  • Source
    • "Variations in practice lead to a conflicting or uncertain outlook . We know this is the case from our feedback and a range of studies showing differences between official and actual use[15,42], workarounds[43]and differences across international contexts[44]. Clinical practice varies, as does the level of training[45]. "
    [Show abstract] [Hide abstract]
    ABSTRACT: The focus of this paper is on the challenges and opportunities presented by developing scenarios of use for interactive medical devices. Scenarios are integral to the international standard for usability engineering of medical devices (IEC 62366:2007), and are also applied to the development of health software (draft standard IEC 82304-1). The 62366 standard lays out a process for mitigating risk during normal use (i.e. use as per the instructions, or accepted medical practice). However, this begs the question of whether “real use” (that which occurs in practice) matches “normal use”. In this paper, we present an overview of the product lifecycle and how it impacts on the type of scenario that can be practically applied. We report on the development and testing of a set of scenarios intended to inform the design of infusion pumps based on “real use”. The scenarios were validated by researchers and practitioners experienced in clinical practice, and their utility was assessed by developers and practitioners representing different stages of the product lifecycle.
    Full-text · Article · Feb 2015 · Journal of Biomedical Informatics
  • Source
    • "Medication errors have been identified at all stages of medication prescribing, administration, and monitoring in both in-and outpatient settings (Kaushal et al., 2001; Gurwitz et al., 2003; Koppel et al., 2005; Patterson et al., 2006; Bates 2009). New technologies may reduce errors and enhance patient safety but, if improperly designed, they can have negative unintended consequences on efficiency and safety (Koppel, 2008; Karsh, 2010). For example, Nebecker et al. (2005) found an adverse drug events (ADEs) incidence density of 70 ADEs per 1000 patient days; 86% of the reviewed ADEs may have been caused by recently implemented health information technologies. "
    [Show abstract] [Hide abstract]
    ABSTRACT: The Office of the National Coordinator for Health Information Technology (ONC) has been tasked with managing the integration of usability best practices into electronic health record development but, has provided little guidance on how to conduct Summative Usability Testing (SUT). We reviewed three aspects of SUT in four publicly available SUT vendor reports. Significant deviations from human factors engineering (HFE) and user-centered design (UCD) best practices and clear methodological errors were found in all four reports. The main sources of variation involved non-representative participant selection, instructions that led participant performance, and varied interpretation of results reporting requirements. Although ONC has made significant gains in implementing best practice UCD approaches, more explicit guidance may be needed to enhance integrity and reduce variation.
    Full-text · Article · Oct 2014
Show more