Bar code medication administration workarounds : a learning experience
Gullett, Lynda Marie
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The Institute of Medicine (IOM) created a report "To Err is Human: Building a Safer Health System" in 1999, bringing to light the scope of Adverse Drug Events (ADE). Ranked one of the most common types of medical error, medication administration errors harm at least 1.5 million people every year, while only 2% of ADEs are caught before reaching the patient. Thirty-eight percent of ADEs occurred during medication administration by nurses that could have been prevented. Bar Code Medication Administration (BCMA) is considered the gold standard, adding an additional layer of security, ensuring quality and safety during the process of medication administration. A microsystem assessment was conducted and the perception of BCMA by the nurses was a process that "worked well", however many workarounds occurred during BCMA, which increased the risk for ADEs. The purpose of this project was to improve awareness of BCMA workarounds amongst the nursing staff on the medical floor. The global aim of this project was to engage the direct care nursing staff in a root cause analysis (RCA) to identify reasons why workarounds occur on the unit during BCMA. The specific aims were to improve overall nursing compliance rates for medication and patient scanning by at least 1% and overall knowledge of BCMA policy and procedures by 20%. Background and rationales for BCMA, agency policy and procedures governing the process, and flowcharts depicting the workarounds observed during the assessment were reviewed prior to engaging the staff in a root cause analysis. The RCA focused on finding out the cause(s) of the observed workarounds. The results included meeting the specific aims with a 31% increase in overall nursing knowledge of the policy and procedures for BCMA, as well as having greater than 1% increase in scanning compliance. Feedback from the RCA resulted in a new awareness from nursing staff in how thinking in a problem solving fashion forces them to evaluate how and why they manage their workflow in the manner in which they do.