Home Analysis Study finds big gaps in barcode safety

Study finds big gaps in barcode safety

October 2008

Published in the October 2008 issue of Today’s Hospitalist

WHEN IT COMES TO REDUCING inpatient drug errors, few innovations have made a bigger splash than barcode medication administration systems. These systems boast that they harness technology to ensure that the five “rights” of drug administration “the right patient, drug, dose, route and time “take place simultaneously.

But in reality, these systems often don’t mesh well with daily workflow, according to Ross Koppel, PhD, a sociologist at the University of Pennsylvania and a researcher and principal investigator at the Center for Clinical Epidemiology and Biostatistics at UPenn’s School of Medicine. As a result, nurses routinely devise shortcuts around what are supposed to be technological firewalls “and the results can potentially be deadly.

After witnessing such shortcuts in several hospitals, Dr. Koppel pioneered a five-hospital study on the prevalence and effects of barcode system workarounds. The research, which was published in the August 2008 Journal of the American Medical Informatics Association, found that nurses overrode barcode-system alerts for 4.2% of patients charted and for 10.3% of medications administered.

While more than 20% of hospitals now use barcode systems, experts predict that all hospitals will have the technology within 20 years. Failing to address the problems that lead to workarounds now, Dr. Koppel warns, could risk tens of thousands more deaths “and even more errors.

What leads to shortcuts?
When Dr. Koppel and his co-authors analyzed nearly 308,000 medication administrations, they identified 31 causes of workarounds. Those included missing medication barcodes or barcodes that were unreadable or covered by another label; non-barcoded medications; failing batteries; and unreliable wireless connectivity.

While some problems that led to workarounds were caused by technology, many were caused by a mismatch between barcode systems and workflow. That’s when nurses would omit steps in the drug administration process, perform steps out of sequence or create unauthorized steps in the form of shortcuts.

Nurses would try to “fix” the system by affixing patient barcodes to computer carts, for instance, or to supply cabinets. Why? Because that was faster than scanning patients’ wristbands, especially if patients were a long way from supplies. Nurses would also carry several patients’ pre-scanned medications on carts at one time, risking delivering the wrong drug to the wrong patient.

And many shortcuts arose from problems with patients’ wristbands, Dr. Koppel points out. Soiled wristbands become readable, while elderly patients can rip them off or children chew on them. And because babies are so small, nurses often hang their barcode IDs on the crib, increasing the chances that the wrong barcode will be scanned.

Shortcuts as problem-solvers
Sometimes, Dr. Koppel explains, nurses err by trying to be kind. “Maybe a patient has been awake and in agony for hours and has finally fallen asleep,” he says. The nurse doesn’t want to pull his arm out to scan the barcode and risk waking him up.” In that situation, Dr. Koppel says, nurses would simply disable alarms on the scanning devices.

And some workarounds, he points out, attempt to solve problems with physical design. If a patient’s room has an odd shape or an extra large sink blocking the door, a nurse might leave the cart with the computer monitor in the hall and take only the handheld scanner into the room.

Only after she’s administered the medication, however, does she return to the hall and see “wrong patient” on the monitor. In such instances, Dr. Koppel explains, there is no way that the nurse can see or hear the alert.

He is quick to point out that he does not blame nurses. Instead, he says, shortcuts are a symptom of problems in the workflow process, architecture or staffing level “or in the design, implementation or integration of the barcode system itself.

“Each workaround that occurs,” says Dr. Koppel, “addresses a problem.”

Moving to solutions
Experts have recommended one possible solution that is being resisted by pharmaceutical companies. That is to use unit barcoding, where each medication is packaged in a bubble pack with its own barcode.

Unit barcoding would enable pharmacists and nurses to check dosages and medications after a tablet or vial is removed from larger boxes or packages on the hospital floor or in a patient’s room “a system that could reduce dispensing errors.

But even that approach has problems, Dr. Koppel says: If a doctor prescribes 40 mg to be put into a liter of saline solution and the pharmacist draws 40 mg out of a 50 mg vial, many systems would read both the original medication barcode and then the revised volume barcode. Multiple barcodes confound the system, he explains, which is an ongoing vendor issue.

Other technological design flaws include the need for nurses to look at multiple screens to complete a scan. Many consider that too onerous or time-consuming. Alarm fatigue is another problem that needs to be addressed by vendors. Systems that routinely beep for most functions make it hard for nurses to distinguish an alert from business as usual.

Then there are staffing and organizational hurdles to be cleared. “If a medication is in a refrigerator two floors and a long hallway away, nurses are not going to push an 87-year-old patient that distance to scan her wristband and the medication package barcode at the same time,” he says. Instead, nurses are going to make an extra copy of the patient’s wristband and carry it with them to the refrigerator. Given the nursing shortage and patients who are both sicker and using more medications, “the pressure for workarounds is that much greater.”

According to Dr. Koppel, many nurses he interviewed also said they were obliged to override or circumvent the barcode system because they had limited time to administer an average of nine medications to 14 patients. “They said, ‘Do you want me to administer the medications? Or play with a problematic scanner?’ ”

Ongoing scrutiny
Whatever solutions hospitals devise, Dr. Koppel says, they first need to get a firm handle on what’s actually taking place in that hospital.

Note, for instance, if you see nurses taping patient IDs to the nurse’s station or if they start wearing several patient ID bracelets around their wrists at one time.

Organize teams to observe the barcode administration process every week or every month to see where mistakes and shortcuts take place. Once you find problems, work with pharmacists, IT personnel and nurses to fix them.

Dr. Koppel also recommends that hospitals negotiate contracts to make sure that vendors will respond to ongoing clinical, workflow and safety needs. Contracts should also hold vendors accountable for fixing technical problems that lead to scanning system overrides.

However, paying extra for a customized barcode system isn’t the answer. “There are limits to how much customization vendors can do and to what makes sense,” says Dr. Koppel. “If you get tons of customization, what do you do when the next version comes out?”

When devising solutions, take existing workarounds as clues to what needs to be fixed. “We need to address medicine the way it is practiced,” Dr. Koppel adds, “not the way somebody thinks it is practiced.”

Ingrid Palmer is a freelance health care writer based in West Chester, Ohio.

(Potentially deadly) Shortcuts to barcoding systems

  • Scanning medications without visually checking them;
  • failing to check the electronic medication administration record system to verify current medications;
  • administering drugs without reviewing administration parameters;
  • bypassing medication “double check” with another provider;
  • not checking new medication orders before administering meds;
  • failing to scan patient ID to ensure patient identity;
  • administering drugs without checking medication barcode;
  • documenting drug administration before they’re administered or ingested;
  • placing a patient ID on another object before scanning;
  • preparing and scanning medications for more than one patient at a time;
  • scanning drug barcode after the label has been removed;
  • scanning one medication label several times for multiple doses;
  • separating the scanner from the monitor cart so an alarm can’t be seen;
  • giving a partial dose but documenting a full dose; and
  • disabling audio alarms on scanning devices.

Source: Journal of the American Medical Informatics Association