Creating a Culture of Safety Around Bar-Code Medication

JONAVolume 46, Number 1, pp 30-37Copyright B 2016 Wolters Kluwer Health, Inc. All rights reserved.

T H E J O U R N A L O F N U R S I N G A D M I N I S T R A T I O N

Creating a Culture ofSafety Around Bar-CodeMedication AdministrationAn Evidence-Based Evaluation Framework

Kandace Kelly, DNP, RN-BC

Linda Harrington, PhD, DNP, RN-BC

Pat Matos, DNP, RN, NEA, BC

Barbara Turner, PhD, RN, FAAN

Constance Johnson, PhD, MS, RN, FAAN

Bar-code medication administration (BCMA) effective-ness is contingent upon compliance with best-practiceprotocols. We developed a 4-phased BCMA evalua-tion program to evaluate the degree of integration ofcurrent evidence into BCMA policies, procedures, andpractices; identify barriers to best-practice BCMA use;and modify BCMA practice in concert with changesto the practice environment. This program providesan infrastructure for frontline nurses to partner withhospital leaders to continually evaluate and improveBCMA using a systematic process.

As healthcare organizations strive to consistently max-imize quality and reliability while minimizing costs,integration of health information technology (HIT)into practice has emerged as an increasingly impor-tant strategy. The effects of HIT implementation onclinician workflow and care processes are not benignand if ignored can lead to unintended consequencessuch as development of workarounds that may po-tentiate errors as serious as those the technology was

intended to prevent.1-4 However, sociotechnical im-pacts of HITare seldom considered during implementa-tion or assessed in postimplementation evaluations.1-3

This article presents a framework for evaluation ofbar-code medication administration (BCMA) tech-nology that addresses these concerns.

Background

BCMA is a medication administration process thatuses bar-code technology to support nurses adminis-tering medications by automating the process of theB5 rights[: right patient, right medication, right dose,right route, and right time.4,5 Implementation ofBCMA technology is associated with significant re-ductions in medication errors.4-9 However, BCMAimplementations do not consistently meet these ex-pectations; medication errors still occur on units withBCMA technology.1,4,5,8,10

BCMA workarounds, also known as deviationsfrom policies and procedures, are well documentedin the literature.1,4,8,10-16 When BCMA is implemented,nurses must modify medication administration work-flows to meet the demands of the new technology.1,2,14

Nurses commonly compensate for poorly designedprocesses by relying on workarounds.2 Workaroundsmay also be a response to operational failures (eg, in-efficient resource allocation, equipment malfunction).1,14

Regardless of the cause, workarounds negate BCMAsafeguards and impose significant risk to medication ad-ministration safety.1 Workflow modifications associatedwith BCMA implementations can potentiate additional

30 JONA � Vol. 46, No. 1 � January 2016

Author Affiliations: Performance Improvement and MagnetProgram Director (Dr Kelly) and Chief Nursing Officer (Dr Matos),UCLA Resnick Neuropsychiatric Hospital, Los Angeles, California;Vice President and Chief Nursing Informatics Officer (Dr Harrington),Catholic Health Initiatives, Texas Division, Englewood, Colorado;Director (Dr Turner), Doctor of Nursing Practice Program, andAssociate Professor (Dr Johnson), Duke University School ofNursing, Durham, North Carolina.

The authors declare no conflicts of interest.Correspondence: Dr Kelly, Resnick Neuropsychiatric Hospi-

tal, 757 Westwood Plaza Ste 4502H, Los Angeles, CA 90095([email protected]).

DOI: 10.1097/NNA.0000000000000290

Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.

sources of error11-13,15,16 such as increased nurse con-fusion, decreased communication between physiciansand nurses, task omission by nurses under time pressure,and decreased ability to deviate from routine sequencesin emergencies.12

To avoid preventable medication errors, effortsmust be taken to integrate evidence into practice andminimize negative impacts of BCMA implementationon nursing care.1,13 Maintaining a user-centric ap-proach during design and preimplementation testingis important.17 However, continuous postimplemen-tation evaluation is also needed because (a) the trueimpact of BCMA on practice can be realized onlyafter implementation1-3,6; (b) practice impact variesbased on technology-related, people-related, task-related, organizational, and environmental factorsspecific to the organization or unit where BCMA isimplemented1-3; and (c) practice is a dynamic processthat evolves over time.6,10,18 To achieve high reliabilityin medication administration processes and ensuresafety, BCMA use and effectiveness must be continu-ously evaluated to identify and address workaroundsand unintended consequences.4,6,10,14,18

The complexity of healthcare creates significantchallenges to evaluation of BCMA.3 Health informa-tion technology, such as BCMA, is deployed withina context of multiple sociotechnical dimensions: hard-ware and software computing infrastructure; clinicalcontent; human-computer interface; people, work-flow, and communication; internal organizationalpolicies and culture; external rules, regulations, andpressures; and system measurement and monitoring.Consideration of their collective impact is critical toevaluation of BCMA effectiveness.3 HIT evaluation bestpractices also emphasize frontline user input.10,17-19

BCMA evaluation programs that are based on thetenets of cultures of safety, ensure frontline staff involve-ment, aim to improve policy and workflow, addressequipment failures, and provide continued end-usereducation have been shown to improve bar-code scan-ning rates and are associated with overall reduction inmedication errors17 and scanning compliance.10,18

Harrington and colleagues10 developed anevidence-based BCMA checklist to evaluate adminis-trative, clinical, and technological aspects of BCMApolicies, procedures, and utilization. This articledescribes the expansion of their innovative approachinto a comprehensive evaluation framework thataddresses the degree to which current evidence isintegrated into BCMA policies, procedures, andpractices; identifies and addresses barriers to best-practice BCMA use; and modifies BCMA practice inconcert with changes to the practice environment.Results of the program will be reported in a futurepublication.

BCMA Evaluation Program

Consistent excellence in healthcare delivery requireseffective leadership and a culture of safety that em-powers staff at all levels to continuously evaluatepractice in order to identify and address safety threatsusing robust improvement methodologies.20 Basedon these concepts, we developed a BCMA evaluationframework and program that provide an infrastruc-ture for frontline nurses to partner with hospitalleaders in a systematic process of ongoing evalua-tion, improvement, and integration of best practices inBCMA use (Figure 1). This program included unit-based medication safety champions who served asBCMA subject-matter experts, remaining current withevidence to ensure integration of newly developed BCMAinto unit best practice. They also continually evaluatedthe medication administration process by directly ob-serving nurses administer medications to identify work-arounds and barriers to best practice and workedcollaboratively with nurse leaders to track/analyze/address each identified workaround and barrier usingthe framework described below. Additionally, theBCMA evaluation program included monthly BCMArounds with the information technology departmentto identify and resolve equipment-related issues.

Program Implementation

To implement the evaluation program, we assembleda multidisciplinary task force of nurse leaders, phar-macists, and frontline nurses from shared governanceunit practice councils (UPCs) to gain widespread buy-inand provide accurate assessments of implementationbarriers and facilitators. After obtaining leadershipand UPC buy-in, the program was presented to nurs-ing staff at change-of-shift unit huddles and staff meet-ings and a call for clinical nurse medication safetychampions was made. Champions were selected basedon expressed interest and clinical performance. Collec-tively, the champions and implementation task forceformed the BCMA evaluation team, which met reg-ularly to evaluate and monitor BCMA use.

Framework

Evidence Identification

The Harrington BCMA Checklist (32 evidence-basedyes/no items evaluating administrative, clinical, andtechnological aspects of BCMA policies, procedures,and use) provided a basis for BCMA best practices.10

Before conducting evaluations, we used the method-ology of Harrington et al10 to review the BCMA liter-ature and identify new evidence or population-specificconsiderations for inclusion in our evaluations. Weevaluated all checklist items for relevance to the practiceenvironment and consistency with current evidence.

JONA � Vol. 46, No. 1 � January 2016 31


At the time of our evaluations, all checklist itemsremained current with the literature.

Practice Evaluation

Organizational EvaluationThe 1st step in the evaluation phase was to determinethe degree to which organizational policies, proced-ures, and technological workflows were consistentwith BCMA best practice. To do so, we conducted agap analysisVa process that compared current po-licies to best practices, identifying gaps or discrepan-

cies.21 Data for this analysis were gathered by obtainingall hospital documents related to BCMA use, includ-ing written policies, procedures, practice guidelines,and instructional aids. Documents were reviewed andcompared with the Harrington BCMA Checklist10 toidentify discrepancies.

Practice EvaluationThe 2nd step in the evaluation phase was to deter-mine consistency between practice and policy and toidentify challenges to best practice use by directly

Figure 1. BCMA evaluation framework.



observing nurses_ use of BCMA to administer medi-cations on all shifts and monitoring BCMA scanningcompliance with the hospital-based computer-generated BCMA compliance report. These proce-dures were intended only to evaluate BCMA use andcompliance with best-practice workflows and not todetect medication errors or identify violations to the5 rights of medication administration. No informa-tion linking individual nurses to observations or theidentification of medications given was collected.

Before conducting the observations, we informednurses that these observations would be conducted toevaluate BCMA compatibility with nursing work-flows and identify processes that negatively impactthe nursing process. To capture observation data,we recorded all steps associated with each observedmedication administration and conducted informalinterviews with nurses on an ad hoc basis to provideadditional information in order to clarify observations.Using this data, we created process maps (Figure 2)(visual diagrams depicting workflows) to enhance un-derstanding, facilitate workflow comparisons, and showthe impact of each step on the overall process.21,22

Each process map was compared with the HarringtonBCMA Checklist to identify deviations in the BCMAprocess. Each observed deviation from best practicewas defined as a workaround. After analyzing eachprocess map, we described all identified workaroundsin detail. All workarounds were categorized basedon identified themes. These themes were used totrack the frequency of various types of workaroundsand evaluate the impact of practice changes onBCMA use.

Performance ImprovementTo address observed BCMA practice shortcomings,we engaged hospital leadership and clinical nurses ina collaborative performance improvement process.Using identified discrepancies between organizationalpolicies and defined best practices as a starting point,the team revised policies and procedures to reflectdefined best practices, while accounting for the needsof each department and its respective patient popula-tion. The team evaluated each discrepancy to identifyorganizational and population-specific factors thatmight give rise to a clear mismatch between clinicalpriorities and defined BCMA best practices. Theseconsiderations were addressed in policy revisions togive nurses flexibility to use clinical judgment whenadministering medications and to clearly define sit-uations in which deviating from BCMA workflowswas clinically appropriate.1,10

The next step of the performance improvementprocess was to determine the causes of observedworkarounds. Using the root-cause analysis (RCA)

methodology of the B5 whys,[23 we conducted RCAswith frontline nurses to identify workaround causesand barriers to best practice by retrospectively posinga series of Bwhy[ questions related to the cause ofeach observed workaround.23 Factors considered inRCAs included interruptions, process delays, patient-related factors, patient diagnoses, application usability,technology failures, technological workflows, resourceadequacy, unit design/layout, bar-code issues, medi-cation preparation, unit rounding schedules, devices,and workflow. We mapped each identified cause toits subsequent effect to create cause-and-effect dia-grams (Figure 3). We then superimposed cause-and-effect diagrams to visualize relationships betweencauses, identify workarounds that occurred as down-stream effects of a co-occurring workaround, andidentify workaround causes associated with multipleworkarounds.

Based on this analysis, we determined the overallpatient safety risk and impact on nursing practice ofeach workaround and its respective causes and pri-oritized performance improvement initiatives accord-ingly. High-risk, high-impact workaround causes thatcontributed to the largest number of workaroundswere considered priorities for improvement. We ad-dressed each identified priority through a user-centricapproach that employed rapid improvement cycles.Coupling user-centric methods with systematic per-formance improvement methodologies ensures thatsolutions are generated by those best positioned toinform process changes; thus this approach has thegreatest potential to yield sustainable, effectivesolutions.18-20,22

Discussion

Organizations cannot simply rely on BCMA technol-ogy to achieve desired improvements to medicationsafety. Instead, structures and processes that enablecontinual evaluation of BCMA use and impact onnursing practice are needed to ensure adherence tobest practice and minimize the potential for error.The BCMA evaluation framework and program de-scribed here provide an evidence-based method forfrontline nurses to evaluate BCMA use in collabora-tion with hospital leadership to identify barriers tobest practice use. Although this framework was de-veloped specifically to evaluate BCMA, its conceptsand structure framework may be generalized to otherhealth information technologies.

Involving frontline nurses in each phase of theBCMA evaluation process is critical to success.10,18,19

As end users of BCMA technology, frontline nursesprovide valuable information related to causes ofworkarounds and challenges to best-practice BCMA



Figure 2. Process map example. An example of how process maps were juxtaposed to identify workarounds. The processmap on the left is an example of a best-practice workflow. The process map on the right is an example of an observedworkflow. Observed deviations were defined as workarounds.



use. They are best positioned to inform sustain-able user-centric solutions to identified performanceimprovement needs. Creating an environment condu-cive to a user-centric, peer-to-peer evaluative processis challenging and requires an organizational cultureconsistent with a culture of safety. Cultures of safetyare achieved through trusting relationships that encour-age error reporting to drive visible system improve-ments.20 By empowering frontline staff to monitorpractice and partner with leadership to address iden-tified barriers to best practice, our methodology sup-ports the development of such a safety culture. Whilethis methodology aligns with the tenets of safety cul-tures, trust remains a prerequisite for program success.Leaders must create a supportive environment and actas facilitators, advocates, and coaches to provide thefoundation necessary to instill trust and engage front-line nurses in this BCMA evaluation program.24 Fur-thermore, evaluations must be grounded in transparencyand used to collaboratively identify and remove bar-riers to best practice.

Although a significant threat to medications safety,BCMAworkarounds are valuable in that they provideinsight into the shortcomings of technology. Whendiscovered, workarounds should not be met with pu-nitive action, but rather embraced as opportunities to

improve care. Most commonly, workarounds are im-plemented by nurses as solutions to barriers to patientcare1,2,13 and are so deeply ingrained into practicethat they are neither perceived as workarounds norseen as safety hazards.1,10 Thus, practice evaluationsthat use only self-reported methodologies (end-userinterviews, focus groups, or event-reporting databases)in the absence of direct observation are unlikely tocapture all workarounds. Similarly, evaluation strat-egies relying solely on computer-generated BCMAcompliance reports cannot capture workaround dataor provide the sociotechnical context needed to in-form BCMA performance improvement initiatives.While BCMA compliance is important when evalu-ating practice, complementing compliance monitor-ing with efforts to identify and address sociotechnicaltechnical factors that impede compliance has thegreatest capacity to improve effectiveness. Giventhe complexity of the factors that impact its use, theeffectiveness of BCMA is best evaluated from a mul-timodal systems perspective, which includes policy,procedure, and technology evaluations; direct obser-vations; and end-user interviews.1,3,10,19

BCMAworkarounds are caused by system defectsand ineffective processes related to technology, people,task-related, organizational, and environmental

Figure 3. The 5 whys: workaround cause identification. A high-level example of how the 5 whys were used to identifyworkaround causes. The figure depicts how cause-and-effect diagrams were superimposed to depict relationship betweenvarious workarounds and their respective causes.



factors.1 A workaround rarely occurs as an indepen-dent event with singular cause; it is far more likely tobe associated with multiple upstream and downstreamimplications.1,3,10 Nurse leaders must consider thecollective impact each of these domains has on nurs-ing practice to ensure that BCMA policies, processes,and structures are consistent with best practice andalign with demands of bedside nursing practice. Fo-cusing on individual workarounds or causes in isola-tion precludes the ability to recognize the interrelatednature of workarounds and evaluate relationshipsamong multiple causes of noncompliance.1,3 Movingaway from linear causal analyses enables identifica-tion of the relationships among all sociotechnical di-mensions that affect BCMA use.3 The B5 whys[ RCAmethodology provides an easy, effective, and efficientmethod to identify and understand the collective im-pact of multiple factors on BCMA workarounds.

Ensuring that organizational policies and proced-ures are consistent with current evidence may be a1st step to reducing workarounds. Yet, BCMA bestpractices are not consistently integrated into practice.10

The Harrington BCMA Checklist10 provides an ef-fective measure of best practice integration, as wellas a method to evaluate BCMA use while identifyingquality improvement needs. However, it does not in-clude items on hardware and software computing in-frastructure, human-computer interface, organizationalculture/environment, and external rules, regulations,and pressures. Although these factors were considered

during causal analyses of workarounds, our method-ology is limited in that it does not provide compre-hensive evaluation of each of the 8 sociotechnicaldimensions of Sittig and Singh_s3 Sociotechnical HITEvaluation Model. More research is needed to de-termine how each dimension contributes to BCMAworkarounds and affects overall BCMA effectiveness.As new BCMA best practices are developed, reeval-uation and addition of checklist items will be critical.

Conclusion

Organizations must take a proactive approach toevaluate and improve BCMA through a systematicprocess that integrates new evidence into practiceto ensure medication administration safety.1,4,10,14

This process must be adaptable to changing demandsof nursing practice.10 As technology is increasinglyintegrated into practice, nurse leaders must work col-laboratively with frontline nurses to evaluate technol-ogy use, identify and remove barriers to best practice,and continually adapt technology to complement nurs-ing practice.

Acknowledgment

The authors thank Susan Rappaport, MSN, the 4East UPC, and the 4 East clinical nurses for theircontributions to the development and implemen-tation of the framework and overall support of theproject.

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