Patient Safety / Quality

Combating medication verification workarounds in an electronic world

In the classic report To Err is Human: Building a Safer Health System, the Institute of Medicine reported that at least 44,000 of the deaths that occur in the United States annually are directly related to medical errors, and the number may be as high as 98,000. Approximately 7,000 deaths are attributed to medication errors alone. Combining these astonishing figures with the reported number of medication errors committed yearly at our rural hospital, we decided to implement an electronic medication verification program to help decrease the number of medication errors.

We created a multidisciplinary team, made up of staff from the pharmacy, information systems, educational services, and nursing departments. The team then began the arduous job of building a system that met the needs of the institution while providing support to the end users. We knew that an electronic medication program would slow down the administration of medications but ultimately would make nurses’ lives easier and help to ensure patient safety.

Getting it right

We built pop-up screens that appeared before the administration of medications that defined the latest lab values relating to that medication. For example, before administering insulin to a patient with diabetes, a pop-up screen appears to notify the nurse of the patient’s most recent blood sugar. Screens were built that allowed for the communication of warnings and parameters before a medication administration. We also defined processes for completing cross checks and dual verification when high-risk medications were administered.

The implemented system involved a multi-step process to ensure that the correct medication was being given to the correct patient, while also ensuring the right time, right dose, and right route. This process consisted of selecting a patient from the nurse’s list of patients, scanning the bar code on the medication, reviewing a list of the scanned medications for correctness, scanning the patient, and scanning a unique bar code of the nurse administering the medication. We determined that this lengthy process would ensure the staff administered medications in the safest environment possible.

The team was enthusiastic about the process — until we began to hear stories of how nurses at other institutions created “workarounds” to circumvent their electronic medication verification system.

Circumventing the circumventors

There were reported incidences of nurses making copies of a patient’s nameband and taping it to the patient’s room door, wearing a copy of a patient’s nameband on their own wrists, and carrying copies of a patient’s nameband in a notebook. We also heard that nurses were making copies of each other’s barcodes and carrying them around so when the system required a cross check, another nurse did not have to be in the room, or even on duty.


The team began to refocus on how to counter these measures. We spoke with other institutions to better understand why the workarounds were created. Some of the reasons given were lack of hardware, lack of an adequate data signal due to a poor wireless connection, nurses feeling there was not enough time to follow policies, and lack of knowledge concerning the proper processes for the administration of medications.

Dealing with potential issues

To combat the lack of hardware and data signal issues, our information systems department conducted studies of the signal strength and took measures to correct any weaknesses. Additionally, we evaluated the number of computers on each unit and purchased additional mobile computers to ensure we could meet the needs of nurses at times of peak census.

The team also focused on patient safety during end user training and reinforced the proper sequence of scanning for administration of medications. Signage relaying the steps for scanning was placed on each computer for reference during the initial weeks of implementation.

These measures helped to address the patient’s barcode issues, but we still had the issue of the nurse’s barcode. Based on requirements of the Ohio State Board of Pharmacy, we knew that no one could reproduce the bar code on a computer because of the need for an ASCII character (a character that can not be recreated on a keyboard) in the middle of the bar code, but we were unclear how to stop nurses from copying bar codes. Then we discovered that a black bar code on a red background does not copy. Consequently, all personnel who administer medications now wear a red badge printed with their individual bar code along with their nametag.

Success!

All these measures have been effective. In the two years since we went live with our electronic medication verification program, we have averaged 98% compliance with scanning of the medication and 99.7% compliance with scanning the patient — both of which exceed our established goal of 97% for all of the inpatient nursing units, as well as our ambulatory care unit, post anesthesia recovery unit, respiratory therapy, cardiology, and radiology departments. We have also seen a decrease in medication errors as they relate to the wrong medication and no medication errors relating to the identification of the patient.

Michele Garber is the director of nursing services at Union Hospital in Dover, Ohio.

References

Kohn, Linda T., Corrigan, Janet M., Donaldson, MS, editors. To err is human, building a safe health system. A report of the Committee on Quality of Health Care in America, Institute of Medicine. Washington, DC: National Academy Press; 2000

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