Mindful Workarounds in Bar Code Medication Administration.

Bar-Coded Medication Administration systems (BCMA) are often used with workarounds. These workarounds are usually judged against standard operating procedures or the use of the technology as 'designers' intended'. However, some workarounds may be reasonable and justified to prevent safety errors. In this conceptual paper, we clarify BCMA safety mechanisms and provide a framework to identify workarounds with BCMA that nullify the error prevention mechanisms inherent in the technology design and process. We also highlight the importance of understanding the purpose behind a nurse's workaround in BCMA, focusing on the notion of mindful (thoughtful) workarounds that have the potential to improve patient safety.

What causes medication administration errors in a mental health hospital? A qualitative study with nursing staff.

OBJECTIVE: Medication administration errors (MAEs) are a common risk to patient safety in mental health hospitals, but an absence of in-depth studies to understand the underlying causes of these errors limits the development of effective remedial interventions. This study aimed to investigate the causes of MAEs affecting inpatients in a mental health National Health Service (NHS) hospital in the North West of England. METHODS: Registered and student mental health nurses working in inpatient psychiatric units were identified using a combination of direct advertisement and incident reports and invited to participate in semi-structured interviews utilising the critical incident technique. Interviews were designed to capture the participants' experiences of inpatient MAEs. All interviews were transcribed verbatim and subject to framework analysis to illuminate the underlying active failures, error/violation-provoking conditions and latent failures according to Reason's model of accident causation. RESULTS: A total of 20 participants described 26 MAEs (including 5 near misses) during the interviews. The majority of MAEs were skill-based slips and lapses (n = 16) or mistakes (n = 5), and were caused by a variety of interconnecting error/violation-provoking conditions relating to the patient, medicines used, medicines administration task, health care team, individual nurse and working environment. Some of these local conditions had origins in wider organisational latent failures. Recurrent and influential themes included inadequate staffing levels, unbalanced staff skill mix, interruptions/distractions, concerns with how the medicines administration task was approached and problems with communication. CONCLUSIONS: To our knowledge this is the first published in-depth qualitative study to investigate the underlying causes of specific MAEs in a mental health hospital. Our findings revealed that MAEs may arise due to multiple interacting error and violation provoking conditions and latent 'system' failures, which emphasises the complexity of this everyday task facing practitioners in clinical practice. Future research should focus on developing and testing interventions which address key local and wider organisational 'systems' failures to reduce error.

Efficiency analysis of a barcode-enabled and integrated medication-tracking system.

PURPOSE: Operational efficiency improvements for pharmacy workflow processes were evaluated using a barcode-enabled and integrated medication-tracking system for medications dispensed from the pharmacy to the emergency department (ED). METHODS: The preimplementation study period (Period 1) was defined as November 17-December 16, 2015; system implementation and training, were defined as December 17, 2015-January 18, 2016; and postimplementation (Period 2) was defined as January 19-February 17, 2016. Periods 1 and 2 were compared to (1) quantify the number and type of phone calls received related to medication inquiries, (2) evaluate the percentage of redispensed doses per total dispensed doses, and (3) assess the rate of medication administration record (MAR) messages received per total dispensed doses. RESULTS: A reduction in the total number of phone calls by 77% was observed (from 125 to 29 calls). A 0.7% difference was detected for re-dispensed doses as well as MAR messages (0.009% difference in rate) between the 2 study periods. This difference was observed despite an increase in the total amount of dispensed doses that occurred for both redispensed doses (936) and MAR messages (920) during Period 2. CONCLUSION: A barcode-enabled and integrated medication-tracking system was successfully implemented into the medication distribution process in the ED. The process change increased operational pharmacy efficiencies by decreasing medication status phone calls, redispensed doses, and MAR messages.

Five key recommendations for the implementation of Hospital Electronic Prescribing and Medicines Administration systems in Scotland.

NHS Scotland is about to embark on the implementation of Hospital Electronic Prescribing and Medicines Administration (HEPMA) systems. There are a number of risks associated with such ventures, thus drawing on existing experiences from other settings is crucial in informing deployment.Drawing on our previous and ongoing work in English settings as well as the international literature, we reflect on key lessons that NHS Scotland may wish to consider in going forward. These deliberations include recommendations surrounding key aspects of deployment strategy surrounding: 1) the way central coordination should be conceptualised, 2) how flexibility in can be ensured, 3) paying attention to optimising systems from the outset, 4) how expertise should be developed and centrally shared, and 5) ways in which learning from experience can be maximised.Our five recommendations will, we hope, provide a starting point for the strategic deliberations of policy makers. Throughout this journey, it is important to view the deployment of HEPMA as part of a wider strategic goal of creating integrated digital infrastructures across Scotland.

Verification system for postoperative autologous blood retransfusion.

Medical staff members should match blood products with patients using a barcode authentication system for blood transfusion to prevent medical accidents. However, our hospital only verifies the blood products of the Japanese Red Cross Society and the preserved autologous blood, not the autologous blood salvaged during the operation or from the oxygenator. In this study, we developed the barcode medication administration system and mobile device for verification. This system will prevent blood transfusion errors in the ward setting.

Comparative evaluation of different medication safety measures for the emergency department: physicians' usage and acceptance of training, poster, checklist and computerized decision support.

BACKGROUND: Although usage and acceptance are important factors for a successful implementation of clinical decision support systems for medication, most studies only concentrate on their design and outcome. Our objective was to comparatively investigate a set of traditional medication safety measures such as medication safety training for physicians, paper-based posters and checklists concerning potential medication problems versus the additional benefit of a computer-assisted medication check. We concentrated on usage, acceptance and suitability of such interventions in a busy emergency department (ED) of a 749 bed acute tertiary care hospital. METHODS: A retrospective, qualitative evaluation study was conducted using a field observation and a questionnaire-based survey. Six physicians were observed while treating 20 patient cases; the questionnaire, based on the Technology Acceptance Model 2 (TAM2), has been answered by nine ED physicians. RESULTS: During field observations, we did not observe direct use of any of the implemented interventions for medication safety (paper-based and electronic). Questionnaire results indicated that the electronic medication safety check was the most frequently used intervention, followed by checklist and posters. However, despite their positive attitude, physicians most often stated that they use the interventions in only up to ten percent for subjectively "critical" orders. Main reasons behind the low usage were deficits in ease-of-use and fit to the workflow. The intention to use the interventions was rather high after overcoming these barriers. CONCLUSIONS: Methodologically, the study contributes to Technology Acceptance Model (TAM) research in an ED setting and confirms TAM2 as a helpful diagnostic tool in identifying barriers for a successful implementation of medication safety interventions. In our case, identified barriers explaining the low utilization of the implemented medication safety interventions - despite their positive reception - include deficits in accessibility, briefing for the physicians about the interventions, ease-of-use and compatibility to the working environment.

Techniques for improving efficiency in the emergency department for patients with acute ischemic stroke.

The past 15 years have witnessed significant strides in the management of acute stroke. The most significant advance, reperfusion therapy, has changed relatively little, but the integrated healthcare systems-stroke systems-established to effectively and safely administer stroke treatments have evolved greatly. Driving change is the understanding that "time is brain." Data are compelling that the likelihood of improvement is directly tied to time of reperfusion. Regional stroke systems of care ensure patients arrive at the most appropriate stroke-capable hospital in which intrahospital systems have been created to process the potential stroke patient as quickly as possible. The hospital-based systems are comprised of prehospital care providers, emergency department physicians and nurses, stroke team members, and critical ancillary services such as neuroimaging and laboratory. Given their complexity, these systems of care require maintenance. Through teamwork and ownership of the process, more patients will be saved from potential death and long-term disability.

How many medication orders are entered through free-text in EHRs?--a study on hypoglycemic agents.

Computerized Provider Order Entry (CPOE) can reduce medication errors; however, its benefits are only achieved when data are entered in a structured format and entries are properly coded. This paper aims to explore the incidence of free-text medication order entries involving hypoglycemic agents in an ambulatory electronic health record (EHR) system with CPOE. Our results showed that free-text order entry continues to be frequent. During 2010, 9.3% of hypoglycemic agents were entered as free-text for 2,091 patients. 17.4% of the entries contained misspellings. The highest proportion of free-text entries were found in urgent care clinics (49.4%) and among registered nurses (31.5%). Additionally, 92 drug-drug interaction alerts were not triggered due to free-text entries. Only 25.9% of the patients had diabetes recorded in their problem list. Solutions will require policy to enforce structured entry, ongoing improvement in user-interface design, improved training for users, and strategies for maintaining a complete medication list.

[Discussion on establishment of quality control system for intensive hospital monitoring on traditional Chinese medicine injections].

Hospital centralized monitoring is an important method to adverse drug reaction (ADR) of traditional Chinese medicine (TCM) injection. Nowadays, our hospital centralized monitoring to TCM injection is difficult to carry out normally, because of little attention that the medical staffs pay to, poor professional knowledge of researchers, unsound reporting system, unreasonable organization structures of ADR and so on. We hope to establish a quality control system of hospital centralized monitoring to TCM injection, by means of emphasizing the importance of ADR monitoring to TCM injection, establishing and perfecting the management mechanism, strengthening staff member training, building the four-steps inspecting rule, implementing barcode monitoring, to strengthen safety supervision of TCM injection, guarantee medication safety.

[Research on establishment of clinical safety intensive hospital monitoring net of traditional Chinese medicine injection].

The establishment of clinical safety monitoring net of traditional Chinese medicine (TCM) injection is the one of the key issues of the monitoring work. The monitoring net is including varieties of types of net, such as clinical monitoring net, multimedia network platform, the net of experts or talents. The paper will introduce the establishing method of clinical safety monitoring net, the establishing of clinical safety monitoring net, and the establishing of network based on the internet, the knowledge network construction of experts, the net construction of talents are all included, to assure the development for clinical safety monitoring work.

Development and implementation of a method for characterizing clinical pharmacy interventions and medication use in a cancer center.

PURPOSE: Develop and implement a method to characterize clinical pharmacy activities and the associated medication use in a comprehensive cancer center. A standard characterization of clinical pharmacy services facilitates benchmarking and informs continuous development. METHODS: A set of quantifiable parameters to describe clinical pharmacy activities and the associated medication use was proposed and validated by peer review. For implementation, clinical pharmacy interventions for six clinical pharmacy services at the King Hussein Cancer Center in 2008 were prospectively documented and the numbers of patients and medications dispensed for the same period were obtained from the admission office and pharmacy database respectively. RESULTS: The method comprised four main aspects: (1) number of interventions, (2) type of interventions, (3) number of doses dispensed, and (4) the NNI which is the number of doses dispensed for one intervention to occur. A total of 8552 interventions were recorded for 37,784 patient days. Interventions were highest in the pediatric oncology and ICU with 2612 (31%) and 1867 (22%) respectively, followed by medical oncology 1563 (18%), BMT 998 (12%), palliative care 792 (9%), and surgery 720 (8%). Interventions per 1000 patient days were: ICU 555, pediatric oncology 326, BMT 319, palliative care 244, medical oncology 137, and surgery 83. Main intervention categories for all services: therapeutic 3055 (36%), safety 2195 (26%), quality assurance 2376 (28%), and education-information 925 (10%). The number of doses dispensed per 1000 patient days was: BMT 19,404, palliative care 17,272, ICU 12,290, medical oncology 13,182, pediatric oncology 12,093, and surgery 8976. Finally, NNI was as follows: ICU 22, pediatric oncology 39, BMT 60, palliative care 71, medical oncology 96, and surgery 109. CONCLUSION: A method for characterizing clinical pharmacy interventions and medication use was developed and used to compare different oncology clinical pharmacy services. Further work is warranted to refine and validate the parameters proposed.

Discussion on establishment of quality control system for intensive hospital monitoring on traditional Chinese medicine injections / 中国中药杂志

Hospital centralized monitoring is an important method to adverse drug reaction (ADR) of traditional Chinese medicine (TCM) injection. Nowadays, our hospital centralized monitoring to TCM injection is difficult to carry out normally, because of little attention that the medical staffs pay to, poor professional knowledge of researchers, unsound reporting system, unreasonable organization structures of ADR and so on. We hope to establish a quality control system of hospital centralized monitoring to TCM injection, by means of emphasizing the importance of ADR monitoring to TCM injection, establishing and perfecting the management mechanism, strengthening staff member training, building the four-steps inspecting rule, implementing barcode monitoring, to strengthen safety supervision of TCM injection, guarantee medication safety.

Research on establishment of clinical safety intensive hospital monitoring net of traditional Chinese medicine injection / 中国中药杂志

The establishment of clinical safety monitoring net of traditional Chinese medicine (TCM) injection is the one of the key issues of the monitoring work. The monitoring net is including varieties of types of net, such as clinical monitoring net, multimedia network platform, the net of experts or talents. The paper will introduce the establishing method of clinical safety monitoring net, the establishing of clinical safety monitoring net, and the establishing of network based on the internet, the knowledge network construction of experts, the net construction of talents are all included, to assure the development for clinical safety monitoring work.

[Results of a counselling programme in antibiotic treatment in a secondary hospital]. / Programa de asesoramiento en tratamiento antibiótico en un hospital de segundo nivel: resultados de un año de actuación.

BACKGROUND: The inappropriate use of antimicrobial agents may contribute to the development of bacterial resistance to the principal antimicrobial drugs. There is no provision in the immediate future of marketing of new broad-spectrum antibiotics, especially with activity against Enterobacteriaceae, so programs should be implemented to optimize antimicrobial therapy. We describe the results of a year of a counselling program in antibiotic treatment in a secondary Andalusian hospital. METHODS: We describe 276 interventions of a multidisciplinary non-compulsory counselling program of antimicrobial management on the Costa del Sol Hospital in Marbella. We evaluated the adequacy of empirical treatment, possibility of antibiotic de-escalation, duration and dose used. We analyzed the evolution of the sensitivity profile of the main microorganisms as well as a cost-effective analysis. RESULTS: 90% of the recommendations were accepted. The main actions were assessment of empirical therapy and deescalation in relation with the result of cultures. The main drugs tested were imipenem, meropenem, cefepime, and linezolid. The sensitivity profile of imipenem and meropenem improved slightly over previous years. It was found a considerable savings in annual drug spending. CONCLUSIONS: The non-compulsory counselling programs are useful tools for optimization of antimicrobial therapy, can prevent an increase of antimicrobial resistance and reduce the cost of antibiotic treatment.

Setting up an emergency stock for metabolic diseases.

INTRODUCTION: Therapeutic management of inborn errors of metabolism (IEMs) is complicated. The drugs involved are classified as orphan, and their supply depends on whether they are orphan medicines, investigational drugs, or need to be prepared as a compounded formula. MATERIALS AND METHODS: We analyzed emergency criteria, availability, and permanent location of metabolic drugs within the hospital. Information on therapeutic usage, administration, and dosage was also recorded. RESULTS: A stock for treating IEMs should include chelating agents, drugs to treat deficiencies, enzyme supplements, and other specific treatments. Hyperammonemia was considered to be life-threatening; therefore, an emergency supply of drugs to treat this condition should be kept permanently in the hospitalization unit. CONCLUSIONS: Emergency drug stocks are highly recommended in tertiary hospitals in order to improve care for patients susceptible to IEM.

Comparing the working time between Bar-Code Medication Administration system and traditional medication administration system: an observational study.

BACKGROUND: The medical institutions had paid attention to the medication error via Bar-Code Medication Administration system (BCMA) to improve the accuracy of the medication process for patient safety. Yet, the working time of drug delivery was under investigated. OBJECTIVES: Comparing the working time of oral drugs between Bar-Code Medication Administration system and traditional medication administration system. METHODS: Purposive sampling, observational and questionnaire study design was used. Participants were invited from a medical center in North Taiwan, 51 nurses from three neurosurgical wards who were using the BCMA system; 51 nurses from three neurological wards who were using traditional medication administration record (MAR). The working time of oral medication administration including order transcribing, verifying, drug giving, and renew in BCMA and traditional group were observed and recorded. RESULTS: (1) Working time for oral medication administration reduced from 36.49 to 18.42 s after BCMA implementation. (2) In the same period, working times for oral drug administration were 62.89 and 56.07 s before and after BCMA implementation in the traditional group. (3) Most nurses (66.7%) felt BCMA could save their oral drug administration time under 50%. (4) Frequent crash of the wireless network, which extended the oral drug administration time was the major threat in the process of BCMA implementation. (5) 93.5% nurses think that BCMA could enhance patient oral medication safety and promote quality of oral medication. CONCLUSIONS: The results demonstrated that implementation of BCMA for oral medication could reduce half of the time for oral medication delivery. Nurses coordinated the hardware and software by accommodating the new facilities and operating BCMA system. The stability of wireless Internet was the main threat. However, 93.5% nurses think that BCMA could enhance patient oral medication safety in spite of making more effort in learning new technology.

A model of innovation. Designing a medication-administration system for the smallest patients was a huge challenge.

A culture that promotes team-based efforts, multidisciplinary collaboration and evidence-based practice is key to innovation. The hospital environment needs to be viewed holistically across different clinical applications, such as EMR, CPOE, eMAR and imaging. It is the combined power of these tools that allows an organization to provide superior care. The IT department must work closely with clinician leadership. A culture of continuous performance improvement underlies innovation.

Maintaining the enterprisewide continuity and interoperability of patient allergy data.

PURPOSE: The efforts, results, and challenges of a large tertiary care, academic health care system to standardize and integrate allergy information across clinical information systems are discussed. SUMMARY: The University of Michigan Health System and its Information Technology Strategic Advisory Committee recognized the necessity for storing and maintaining allergy information in a single repository; therefore, the clinical data repository (CDR) was named as the central database for coded allergens and reactions for the University of Michigan Hospitals and Health Care Centers (UMHHC) electronic medical record. The Enterprise Allergy Project (EAP) began in June 2005 with the formation of a steering committee that included representatives from clinical departments with order-entry systems. The initial phase of the EAP consisted of several components. One component was a one-time conversion of existing free-text allergy information into coded allergens and reactions. Before the implementation of the EAP, the order-entry system only supported the entry of uncoded allergen and reaction information. An initial process of allergy matching reduced the list of un-coded allergens from 272,519 to 29,500 by using terms that indicated no allergies were present and trimming and modifying free-text strings that closely matched or easily translated to a coded allergen counterpart. Another component of the EAP consisted of the interface and technical build to support allergy information processing between the CDR and University of Michigan (UM)-Carelink. One goal of the EAP was to transfer data bidirectionally, but that goal could not safely be accomplished. CONCLUSION: Implementing a strategy for enterprise allergy integration at UMHHC has improved the quality of allergy information documented as measured by a significant decrease in the amount of uncoded allergens.

Barcode medication administration: supporting transitions in articulation work.

Articulation work is that which enables coordinated activity among colleagues distributed in time and space. Despite its important role in clinical settings, this work remains largely invisible in process flowcharts. When process-oriented information systems are implemented, the informal, flexible, contingent activities of participants that enable coordinated work are suddenly placed in a new context. Articulation work must adapt to new contexts of automation, and there are opportunities for clinical systems to better support coordination activities. This research explores the articulation work involved in medication administration, how it is affected by the implementation of barcoding, and strategies for support and problem resolution in this arena.