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Factors associated with workarounds in barcode-assisted medication administration in hospitals.

ABSTRACT: AIMS AND OBJECTIVES:To identify that workarounds (defined as "informal temporary practices for handling exceptions to normal procedures or workflow") by nurses using information technology potentially compromise medication safety. Therefore, we aimed to identify potential risk factors associated with workarounds performed by nurses in Barcode-assisted Medication Administration in hospitals. BACKGROUND:Medication errors occur during the prescribing, distribution and administration of medication. Errors could harm patients and be a tragedy for both nurses and medical doctors involved. Interventions to prevent errors have been developed, including those based on information technology. To cope with shortcomings in information technology-based interventions as Barcode-assisted Medication Administration, nurses perform workarounds. Identification of workarounds in information technology is essential to implement better-designed software and processes which fit the nurse workflow. DESIGN:We used the data from our previous prospective observational study, performed in four general hospitals in the Netherlands using Barcode techniques, to administer medication to inpatients. METHODS:Data were collected from 2014-2016. The disguised observation was used to gather information on potential risk factors and workarounds. The outcome was a medication administration with one or more workarounds. Logistic mixed models were used to determine the association between potential risk factors and workarounds. The STROBE checklist was used for reporting our data. RESULTS:We included 5,793 medication administrations among 1,230 patients given by 272 nurses. In 3,633 (62.7%) of the administrations, one or more workarounds were observed. In the multivariate analysis, factors significantly associated with workarounds were the medication round at 02 p.m.-06 p.m. (adjusted odds ratio [OR]: 1.60, 95% CI: 1.05-2.45) and 06 p.m.-10 p.m. (adjusted OR: 3.60, 95% CI: 2.11-6.14) versus the morning shift 06 a.m.-10 a.m., the workdays Monday (adjusted OR: 2.59, 95% CI: 1.51-4.44), Wednesday (adjusted OR: 1.92, 95% CI: 1.2-3.07) and Saturday (adjusted OR: 2.24, 95% CI: 1.31-3.84) versus Sunday, the route of medication, nonoral (adjusted OR: 1.28, 95% CI: 1.05-1.57) versus the oral route of drug administration, the Anatomic Therapeutic Chemical classification-coded medication "other" (consisting of the irregularly used Anatomic Therapeutic Chemical classes [D, G, H, L, P, V, Y, Z]) (adjusted OR: 1.49, 95% CI: 1.05-2.11) versus Anatomic Therapeutic Chemical class A (alimentary tract and metabolism), and the patient-nurse ratio ?6-1 (adjusted OR: 5.61, 95% CI: 2.9-10.83) versus ?5-1. CONCLUSIONS:We identified several potential risk factors associated with workarounds performed by nurses that could be used to target future improvement efforts in Barcode-assisted Medication Administration. RELEVANCE TO CLINICAL PRACTICE:Nurses administering medication in hospitals using Barcode-assisted Medication Administration frequently perform workarounds, which may compromise medication safety. In particular, nurse workload and the patient-nurse ratio could be the focus for improvement measures as these are the most clearly modifiable factors identified in this study.

SUBMITTER: van der Veen W

PROVIDER: S-EPMC7328795 | biostudies-literature | 2020 Jul

REPOSITORIES: biostudies-literature

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Factors associated with workarounds in barcode-assisted medication administration in hospitals.

van der Veen Willem W Taxis Katja K Wouters Hans H Vermeulen Hester H Bates David W DW van den Bemt Patricia M L A PMLA

Journal of clinical nursing 20200228 13-14

<h4>Aims and objectives</h4>To identify that workarounds (defined as "informal temporary practices for handling exceptions to normal procedures or workflow") by nurses using information technology potentially compromise medication safety. Therefore, we aimed to identify potential risk factors associated with workarounds performed by nurses in Barcode-assisted Medication Administration in hospitals.<h4>Background</h4>Medication errors occur during the prescribing, distribution and administration ...[more]

PMID: 32043705

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Project description:ObjectiveThis study was conducted to assess the magnitude and contributing factors of medication administration errors among nurses in federal hospitals in Addis Ababa, Ethiopia.DesignA hospital-based cross-sectional study design was employed. Data on medication administration and associated factors were collected using a structured self-administered questionnaire. Multivariable binary logistic regression analysis was done to identify factors associated with medication administration errors on the basis of adjusted OR with 95% CI and a p value less than 0.05.SettingThis study was conducted in federal hospitals in Addis Ababa, Ethiopia.ParticipantsFour hundred and twenty-three randomly selected nurses participated.Outcome measuresThe primary outcome variable is medication administration error, which was ascertained using the following errors: wrong medication, wrong dose, wrong time, wrong route, wrong patient, wrong drug preparation, wrong advice, wrong assessment and wrong documentations.ResultsA total of 59.9% (95% CI: 55.0% to 64.8%) of the nurses in the federal hospitals in Addis Ababa committed one or more medication administration errors in the last 12 months prior to the survey. The most commonly reported medication errors were wrong time (56.8%), wrong documentation (33.3%), wrong advice (27.8%) and wrong dose (20.1%). Medication administration errors among nurses were significantly associated with short work experience (adjusted OR (AOR): 6.48, 95% CI: 1.32 to 31.78), night shift work (AOR: 5.0, 95% CI: 1.82 to 13.78), absence of on-the-job training (AOR: 3.16, 95% CI: 1.67 to 6.00), unavailability of medication administration guidelines in wards (AOR: 2.07, 95% CI: 1.06 to 4.06) and interruptions during medication administration (AOR: 2.42, 95% CI: 1.30 to 4.49).ConclusionIt was found that a high proportion of nurses in federal hospitals committed medication administration errors. Short work experience, night shift work, absence of on-the-job training, unavailability of medication administration guidelines and interruptions during medication administration explained the high magnitude of medication administration errors.

Project description:BackgroundMedication administration error is a medication error that occurs while administering a medication to a patient. A variety of factors make pediatrics more susceptible to medication errors and its consequences. In low-income countries, like Ethiopia, there is no sufficient evidence regarding medication administration error among pediatrics. The aim of this study is, therefore, to determine the magnitude and factors associated with medication administration error among pediatric population.MethodsA prospective observational based cross sectional study design was conducted from January to April 2017. Data collection was done using pre-tested structured questionnaire and blind observation checklist to health professionals in charge of administering selected medications. A total of 1282 medication administrations were obtained using single population proportion formula from patients in the selected public hospitals and the samples were selected using multistage sampling technique. Multivariable logistic regression using odds ratio and 95% confidence interval was used to determine the relationship between the independent and dependent variables. Variables with p-value <?0.05 were considered as independent factors for medication administration error.ResultA total of 1251 medication administrations were observed from 1251 patients. The occurrence of medication administration error was 62.7% with 95% CI (59.6%, 65.0%), wrong dose being the most common type of medication administration error with an occurrence rate of 53.7%. Medications administered for pediatric patients less than 1 month age, administered by bachelor degree holder health professionals, prepared in facilities without medication preparation room, prepared in facilities without medication administration guide and administer for patients who have two or more prescribed medications were more likely to have medication administration error than their counterparts with AOR (95% CI) of 7.54(2.20-25.86), 1.52 (1.07-2.17), 13.45 (8.59-21.06), 4.11 (2.89-5.85), and 2.42 (1.62-3.61), respectively.ConclusionThis study has revealed that there is high occurrence of medication administration error among pediatric inpatients in public hospitals of Tigray, Northern Ethiopia.. Age of patients, educational level of medication administrators, availability of the medication preparation room and guide, and the number of medications given per single patient were statistically significant factors associated with occurrence of medication administration error.

Project description:OBJECTIVES:A commercial barcode-assisted medication administration (BCMA) system was integrated to secure the medication process and particularly the dispensing stage by technicians and the administration stage with nurses. We aimed to assess the impact of this system on medication dispensing errors and barriers encountered during integration process. METHODS:We conducted a controlled randomized study in a teaching hospital, during dispensing process at the pharmacy department. Four wards were randomized in the experimental group and control group, with two wards using the system during 3 days with dedicated pharmacy technicians. The system was a closed loop system without information return to the computerized physician order entry system. The two dedicated technicians had a 1-week training session. Observations were performed by one observer among the four potential observers previously trained. The main outcomes assessed were dispensing error rates and the identification of barriers encountered to expose lessons learned from this study. RESULTS:There was no difference between the dispensing error rate of the control and experimental groups (7.9% for both, p?=?0.927). We identified 10 barriers to pharmacy barcode-assisted system technology deployment. They concerned technical (problems with semantic interoperability interfaces, bad user interface, false errors generated, lack of barcodes), structural (poor integration with local information technology), work force (short staff training period, insufficient workforce), and strategic issues (system performance problems, insufficient budget). CONCLUSION:This study highlights the difficulties encountered in integrating a commercial system in current hospital information systems. Several issues need to be taken into consideration before the integration of a commercial barcode-assisted system in a teaching hospital. In our experience, interoperability of this system with the electronic health record is the key for the success of this process with an entire closed loop system from prescription to administration. BCMA system at the dispensing process remains essential to purchase securing medication administration process.

Project description:ObjectiveTo determine whether the use of computerized physician order entry (CPOE) and electronic medication administration records (eMAR) is associated with better quality of medication administration at medium-to-large acute-care hospitals. DATA/STUDY SETTING: A retrospective cross-sectional analysis of data from three sources: CPOE/eMAR usage from HIMSS Analytics (2010), medication quality scores from CMS Hospital Compare (2010), and hospital characteristics from CMS Acute Inpatient Prospective Payment System (2009). The analysis focused on 11 quality indicators (January-December 2009) at 2603 medium-to-large (≥ 100 beds), non-federal acute-care hospitals measuring proportion of eligible patients given (or prescribed) recommended medications for conditions, including acute myocardial infarction, heart failure, and pneumonia, and surgical care improvement. Using technology adoption by 2008 as reference, hospitals were coded: (1) eMAR-only adopters (n=986); (2) CPOE-only adopters (n=115); and (3) adopters of both technologies (n=804); with non-adopters of both technologies as reference group (n=698). Hospitals were also coded for duration of use in 2-year increments since technology adoption. Hospital characteristics, historical measure-specific patient volume, and propensity scores for technology adoption were used to control for confounding factors. The analysis was performed using a generalized linear model (logit link and binomial family).Principal findingsRelative to non-adopters of both eMAR and CPOE, the odds of adherence to all measures (except one) were higher by 14-29% for eMAR-only hospitals and by 13-38% for hospitals with both technologies, translating to a marginal increase of 0.4-2.0 percentage points. Further, each additional 2 years of technology use was associated with 6-15% higher odds of compliance on all medication measures for eMAR-only hospitals and users of both technologies.ConclusionsImplementation and duration of use of health information technologies are associated with improved adherence to medication guidelines at US hospitals. The benefits are evident for adoption of eMAR systems alone and in combination with CPOE.

Project description:BackgroundIn order to reduce safety risks associated with medication administrations, technologies such as barcode medication administration (BCMA) are increasingly used. Examining how human factors influence adoption and usability of this technology can potentially highlight areas for improvement in design and implementation.ObjectiveTo describe how human factors related determinants for BCMA have been researched and reported by healthcare and human-computer interaction disciplines.Data sourcesThe Cumulative Index of Nursing, and Allied Health Literature, PubMed, OVID MEDLINE and Google Scholar.Study eligibility criteriaPrimary research published from April 2000 to April 2020, search terms developed to identity different disciplinary research perspectives that examined BCMA use, used a human factors lens and were published in English.Synthesis methodsComputerised systematic searches were conducted in four databases. Eligible papers were systematically analysed for themes. Themes were discussed with a second reviewer and supervisors to ensure they were representative of content.ResultsOf 3707 papers screened, 11 were included. Studies did not fit neatly into a clinical or human-computer interaction perspective but instead uncovered a range of overlapping narratives, demonstrating consensus on the key themes despite differing research approaches. Prevalent themes were misaligned design and workflow, adaptation and workarounds, mediating factors, safety, users' perceptions and design and usability. Inadequate design frequently led to workarounds, which jeopardised safety. Reported mediating factors included clarity of user needs, pre/post implementation evaluations, analysis of existing workarounds and appropriate technology, infrastructure and staffing.LimitationsMost studies were relatively small and qualitative, making it difficult to generalise findings.ConclusionEvaluating interdisciplinary perspectives including human factors approaches identified similar and complementary enablers and barriers to successful technology use. Often, mediating factors were developed to compensate for unsuitable design; a collaborative approach between system designer and end users is necessary for BCMA to achieve its true safety potential.

Project description:ObjectiveDue to a lack of appropriate pediatric preparations, health providers frequently use adult formulations in an off-label manner. This study aimed to assess pediatric off-label medication use patterns and associated factors in East Gojjam, Ethiopia.MethodsInstitutional-based cross-sectional study was conducted from December 2020 to June 2021 at three randomly selected hospitals. Data were collected by using self-structured questionnaires and a data abstraction checklist from health care workers and prescriptions, respectively. The collected data were analyzed using SPSS version 25. Logistic regression analysis was used to assess the association between independent and dependent variables.ResultsA total of 285 eligible health professionals from the pediatric unit and pharmacies, and 1,800 eligible prescriptions were involved in the study. The response rate of healthcare workers was 94.37%. Around 74.4% of professionals had good knowledge about off-label medication. Only 8% of participants had taken training on pediatric off-label medications. Of all prescriptions, 27.6% of them have contained at least one off-label medication. Phenobarbitone (16.1%) and phenytoin (12.7%) were the most frequently prescribed off-label medication. In all, 496 (27.6%) prescriptions contained off-label drugs in the form of overdose, cutting adult tablets into small portions, and formulating tablets/capsules into solution. Lack of information on off-label prescribing, shortage of pediatric drugs, and suitable dosage forms showed significant association with off-label prescribing with p-value < 0.001.ConclusionAlmost one-third of pediatric prescriptions contained off-label medication. Only a small number of healthcare workers had taken training on pediatric off-label medications. Lack of sufficient information on risks of off-label medication, shortage of pediatric medication, and suitable pediatric dosage forms were associated with the use of off-label medication compared to non-use. Further research should be done on the long-term effects associated with off-label prescribing in pediatrics to assess whether the potential risks are balanced with the therapeutical benefit.

Project description:ImportanceElevated blood glucose levels are common in hospitalized older adults and may lead clinicians to intensify outpatient diabetes medications at discharge, risking potential overtreatment when patients return home.ObjectiveTo assess how often hospitalized older adults are discharged with intensified diabetes medications and the likelihood of benefit associated with these intensifications.Design, setting, and participantsThis retrospective cohort study examined patients aged 65 years and older with diabetes not previously requiring insulin. The study included patients who were hospitalized in a Veterans Health Administration hospital for common medical conditions between 2011 and 2013.Main outcomes and measuresIntensification of outpatient diabetes medications, defined as receiving a new or higher-dose medication at discharge than was being taken prior to hospitalization. Mixed-effect logistic regression models were used to control for patient and hospitalization characteristics.ResultsOf 16 178 patients (mean [SD] age, 73 [8] years; 15 895 [98%] men), 8535 (53%) had a preadmission hemoglobin A1c (HbA1c) level less than 7.0%, and 1044 (6%) had an HbA1c level greater than 9.0%. Overall, 1626 patients (10%) were discharged with intensified diabetes medications including 781 (5%) with new insulins and 557 (3%) with intensified sulfonylureas. Nearly half of patients receiving intensifications (49% [791 of 1626]) were classified as being unlikely to benefit owing to limited life expectancy or already being at goal HbA1c, while 20% (329 of 1626) were classified as having potential to benefit. Both preadmission HbA1c level and inpatient blood glucose recordings were associated with discharge with intensified diabetes medications. Among patients with a preadmission HbA1c level less than 7.0%, the predicted probability of receiving an intensification was 4% (95% CI, 3%-4%) for patients without elevated inpatient blood glucose levels and 21% (95% CI, 15%-26%) for patients with severely elevated inpatient blood glucose levels.Conclusions and relevanceIn this study, 1 in 10 older adults with diabetes hospitalized for common medical conditions was discharged with intensified diabetes medications. Nearly half of these individuals were unlikely to benefit owing to limited life expectancy or already being at their HbA1c goal.

Project description:Medication administration errors (MAEs) occur frequently in hospitals and may compromise patient safety. Preventive strategies are needed to reduce the risk of MAEs. The primary aim of this study was to assess the effect of central automated unit dose dispensing with barcode-assisted medication administration on the prevalence of MAEs. Secondary aims were to assess the effect on the type and potential severity of MAEs. Furthermore, compliance with procedures regarding scanning of patient and medication barcodes and nursing staff satisfaction with the medication administration system were assessed. We performed a prospective uncontrolled before-and-after study in six clinical wards in a Dutch university hospital from 2018 to 2020. MAE data were collected by observation. The primary outcome was the proportion of medication administrations with one or more MAEs. Secondary outcomes were the type and potential severity of MAEs, rates of compliance with patient identification and signing of administered medication by scanning and nursing staff satisfaction with the medication administration system. Multivariable mixed-effects logistic regression analyses were used for the primary outcome to adjust for confounding and for clustering on nurse and patient level. One or more MAEs occurred in 291 of 1490 administrations (19.5%) pre-intervention and in 258 of 1630 administrations (15.8%) post-intervention (adjusted odds ratio 0.70, 95% confidence interval 0.51-0.96). The rate of omission fell from 4.6% to 2.0% and of wrong dose from 3.8% to 2.1%, whereas rates of other MAE types were similar. The rate of potentially harmful MAEs fell from 3.0% (n = 44) to 0.3% (n = 5). The rates of compliance with scanning of patient and medication barcode post-intervention were 13.6% and 55.9%, respectively.The median overall satisfaction score of the nurses with the medication administration system on a 100-point scale was 70 (interquartile range 63-75, n = 193) pre-intervention and 70 (interquartile range 60-78, n = 145) post-intervention (P = 0.626, Mann-Whitney U test). The implementation of central automated unit dose dispensing with barcode-assisted medication administration was associated with a lower probability of MAEs, including potentially harmful errors, but more compliance with scanning procedures is needed. Nurses were moderately satisfied with the medication administration system, both before and after implementation. In conclusion, despite low compliance with scanning procedures, this study shows that this intervention contributes to the improvement of medication safety in hospitals.

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Factors associated with workarounds in barcode-assisted medication administration in hospitals.

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Factors associated with workarounds in barcode-assisted medication administration in hospitals.

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