OJNI

Nurses’ Perceptions of a (BCMA) Bar-coded Medication Administration System

A Case-Control Study
by
Valerie J. Gooder Ph.D., RN

This article was made possible by an educational grant from
Chamberlain College of Nursing

CITATION

Gooder, V. (June 2011). Nurses’ Perceptions of a (BCMA) Bar-coded Medication Administration System: A Case-Control Study. Online Journal of Nursing Informatics (OJNI), 15, (2), Available at http://ojni.org/issues/?p=703

ABSTRACT

This case-control study examined the perceived impact of bar-coded medication administration system (BCMA) on nurses’ ability to give medications, perceptions of medication errors, and nurses’ satisfaction with the medication administration process. The author developed a questionnaire based on Rogers’ diffusion of innovation theory and established content validity. The participants (BCMA n= 33; control n= 26) were given the questionnaire 1 month prior and 5 months following the implementation of a pilot unit. Participants in the experimental group indicated difficulty determining which medications had been given (p < .000). There was a decrease in the overall satisfaction with the medication process following implementation of the BCMA system (p = .001). This study demonstrates that implementation of BCMA systems may have negative impact on nurses’ attitudes toward the medication administration process and may make the work processes more difficult. Effective implementation of BCMA systems requires an understanding of the impact of the system on nursing work processes.

Key Words: BCMA, Medication administration, Barcode, Nurse satisfaction, Medication error

Introduction

In 1999, The Institute of Medicine (IOM) reported that nearly a million patients each year are injured in hospitals in the United States due to error. Medication errors occur more often than other categories of preventable errors (19%), and most medication errors occurred during medication administration (34%) where they were more likely to directly impact the patient and cause harm (Bates, et al., 1995). The IOM recommended systemic changes to hospital processes including medication administration (Kohn, Corrigan, & Donaldson, 1999).

Bar coded medication administration systems (BCMAs) are one of the proposed solutions to medication administration errors and may reduce reported medication errors by as much as 86% (Baldwin, 2002; Bates, et al., 2001; Cipriano, 2002; Crane & Crane, 2006; Cummings, Bush, Smith, & Matuszewski, 2005; Johnson, Carlson, Tucker, & Willette, 2002; Paoletti, et al., 2007; Rivish & Modeda, 2010). Success of the BCMA system used in Veteran’s Administration hospitals in the 1990s prompted a Federal Drug Administration (FDA) mandate to barcode all prescription and most over-the-counter medications by mid 2006 (Traynor, 2004). Due to supportive efforts by the FDA and the Joint Commission (JC), an increase in the number of hospitals purchasing BCMA systems is expected. Bar-coded medication administration will probably be utilized in the majority of hospitals by 2024 (Roark, 2004).

Despite optimism about the impact of BCMA systems on medication errors, there is some concern about the safety and effectiveness of these systems (Ash, Berg, & Coiera, 2004; McDonald, 2006; Sakowski, Newman, & Dozier, 2008). Ethnographic and observational studies have documented poor compliance with BCMA systems in several settings (Patterson, Cook, & Render, 2002; Patterson, Rogers, Chapman, & Render, 2006). Years after implementation of the first BCMA systems there is still widespread variation in how the systems are used (Carayon, et al., 2007).

One reason for the variations is the fact that implementation of BCMA systems has an impact on the current work processes of nurses, who give the majority of medications in healthcare facilities. Using the BCMA system requires more time than other traditional methods of medication administration documentation such as a paper or computer-based medication administration record (Lawton & Shields, 2005). Implementation of the BCMA prevents workarounds (shortcuts) and other personalized methods used by nurses to administer medications (Englebright & Franklin, 2005). Problems with the BCMA technology may create additional frustration for the already busy bedside nurses. The author of this paper hypothesized that an increasing level of frustration felt by the nurse may lead to a decrease in the level of satisfaction with the medication administration process overall.

Bar-coded medication administration systems are implemented to reduce medication administration errors, but it is unclear if the bedside nurses view the systems as effective in error prevention. Evidence of this is the development of system workarounds that bypass the intentional blocks to medication administration presented by the BCMA system. Workarounds are processes that bypass key safety features of the BCMA system, i.e. shortcuts. For example, a patient’s armband is removed from the patient’s wrist and taped to the bed or doorjamb. Instead of scanning an armband on the patient’s wrist, the nurse scans the armband that is taped to the bed (Koppel, Wetterneck, Telles, & Karsh, 2008). This could result in a patient receiving the wrong medication, one that was intended for the previous occupant of the bed. By using workarounds, nurses bypass safety features of the system and therefore negate the overall purpose of the BCMA.  A key to successful implementation and use of a BCMA system is to understand the level of satisfaction the nurses have with the system and how effective they view the system in preventing errors.

The widespread use of BCMA systems in healthcare organizations may result in a significant decrease in medication administration errors (Coyle & Heinen, 2005; DeYoung, Vanderkook & Barletta, 2009; Sakowski et al., 2005). Despite this benefit, nurse dissatisfaction with the BCMA systems may impact overall compliance with the systems and decrease the overall effectiveness of the systems. Evaluation of nurse satisfaction with the BCMA system and the nurses’ perception of these systems to reduce medication errors may be important in the future design and implementation of these systems.

Description of the Problem

Literature: BCMA

A BCMA system utilizes bar-coded medication doses, patient identification bracelets, and nurse staff badges to facilitate the five rights (right patient, right medication, right dose, right time and right route) of medication administration. The BCMA system includes a server and a wireless handheld device (or a tethered device) coupled with software that interfaces with a hospital’s information system. The system is often integrated with a patient unit-based automatic dispensing machine (ADM) and a pharmacy packaging and dispensing robot.

Prior to administration of the medication, the nurse accesses the software in the handheld bar-coding scanner by scanning her/his badge and using the stylus to type in a secure password. Next, using the stylus, the nurse chooses a patient from a list on the handheld device. In the case of a new medication order, the nurse is prompted to confirm the new medication with the physician’s written order. Once the nurse verifies the medication, the nurse scans the medication that is due to be administered. The software on the handheld device will list the patient’s medication administration record (MAR) and display alerts if the medication is incorrect in any of the following ways: medication, dose of medication, route of medication, or time for administration. Finally, the nurse scans the patient’s armband at the bedside to confirm the “correct patient.” The nurse has the option to attend to or override an alert and give the medication.

 

Literature: Nurse Satisfaction with BCMA

Research has been conducted on the satisfaction of nurses with BCMA technology, but the results have been inconclusive. One preliminary investigation regarding satisfaction of nurses who use BCMA systems have shown that nurses who previously documented medications using a paper-based system were satisfied with BCMA systems (Rough, Ludwig, & Wilson, 2003). The researchers measured satisfaction four months prior to implementation of the BCMA and six months after and reported a 42% improvement in nurse satisfaction with medication administration and documentation after implementation of the BCMA system. Observations by Coyle and Heinen (2005) indicated nursing satisfaction with a BCMA system, but did not include specific timing of the observations or any attempts to quantify satisfaction.

The  Medication Administration System-Nurses Assessment of Satisfaction (MAS-NAS) Scale, developed by Hurley, et al. (2006), was used to compare satisfaction level of nursing staff pre- and post-BCMA implementation. This scale has demonstrated early reliability and validity (Hurley, et al., 2006). Hurley et al. (2007) measured the satisfaction of nurses in a large academic medical center 2-4 weeks prior to deployment and 4 months after implementation. The results indicated a statistically significant improvement in satisfaction following deployment. Of note, the results indicated that the nurses viewed the new system as time consuming, but safer. Selected interviews of participants corroborated the results of the study (Hurley, et al., 2007).

Not all researchers found such promising results. In a longitudinal, descriptive study, Fowler, Sohler, and Zarillo (2009) used the MAS-NAS Scale to evaluate nursing satisfaction with a BCMA system and Category C medication error rates. Category C errors are medication errors that occur and reach the patient, but do not cause harm. They found no difference in satisfaction for the period prior to implementation compared to 6 and 9 months following implementation of BMCA. The researchers found that Category C errors increased following BCMA implementation, but hypothesized that this was due to increased reporting and surveillance. They did not find a decrease in errors related to medications given to the wrong patient (Fowler, Sohler, & Zarillo, 2009).

Marini et al. (2010) developed a 33-question survey based on a model constructed to measure nursing acceptance of a BCMA system based on the image profile of the technology and to determine users’ attitudes. The image profile of the model included three aspects: system functionality, systems usability, and systems impact on nursing practice. The items on the questionnaire were measured using a five-point Likert scale. The questionnaire was sent by e-mail to members of the CARING e-mail list, an informatics-focused listserve. The instrument demonstrated initial reliability and validity. Their results indicated that when nurses valued the safety features of the system, they viewed the system as more useable (Marini, Hasman, Huijer, & Dimassi, 2010).

Despite the potential benefits of BCMA, nurses develop workaround strategies that reduce the overall effectiveness of these systems (Patterson, et al., 2002; Patterson, et al., 2006; Vogelsmeier, Halbesleben, & Scott-Cawiezell, 2008). Workarounds occur as a result of problems with technology, task, organization, patient issues, and the environment (Koppel, et al., 2008). Often workarounds are the result of several of these factors occurring simultaneously. These problems occur because the process has not been reengineered properly (Vogelsmeier, et al., 2008). A case study conducted by Bargren and Lu (2009) described system gaps in the BCMA that created a perceived need for nurses to use workarounds. Use of workarounds may encourage other unsafe practices (Halbesleben, Wakefield, & Wakefield, 2008). The use of workarounds indicates a lack of confidence in the system and may be an indication of decreased satisfaction.

A positive correlation between nursing job satisfaction and job performance motivates nurse managers to investigate causes of low satisfaction among nurses. Frustration with the BCMA system may reduce nursing productivity and therefore negatively impact quality of patient care (Marini, et al., 2010).  Poor work satisfaction is considered a leading cause of turnover resulting in reduced quality of patient care. The successful implementation of BCMA systems that maintain or improve nursing satisfaction require healthcare leaders to address issues that limit workarounds.

Although BCMA systems provide robust technology designed to reduce medication administration errors, there is concern that the benefits of these systems are not fully realized due to a failure to adequately integrate the systems into the current nursing work processes. The development of workarounds may be an indication that nurses feel that the system is not adequately supporting the medication administration process (Halbesleben, Wakefield, & Wakefield, 2008).  The willingness of some nurses to bypass key safety features in the system indicates that they are not fully embracing the ability of the technology to significantly reduce medication administration error rates. Research regarding nursing satisfaction with BCMA systems is limited and conflicting. Understanding the impact of BCMA system implementation on nursing satisfaction with the medication administration process will assist with improving the development and implementation of these systems.

Conceptual Framework

Measuring satisfaction with BCMA technology requires an understanding of how technology is introduced into the healthcare work process. Rogers’ (2003) Diffusion of Innovation Theory (DoI) discusses the key attributes of innovations as being the result of five characteristics: 1) relative advantage – is the innovation is better than what precedes it; 2) compatibility – is the innovation is consistent with the goals of the current process; 3) complexity – does the user consider the innovation complicated; 4) trialability – how much can the new system be tested and experimented with; and 5) observability – how easy is it for users to see the results of the innovation, in this case, a reduction in medication errors (Rogers, 2003). For this study the researcher evaluated the success of BCMA implementation based on the nurses’ views of the relative advantage, compatibility, complexity, and observability. These aspects of the system form a basis of nursing satisfaction with the system.

Purpose

This study investigated nurse satisfaction with the use of a BCMA system as compared to a previous non-barcoded medication administration system. The specific purpose of the research was to: 1) describe the perceived impact of BCMA implementation on nurses’ ability to give medications; 2) investigate nurses’ perceptions of medication errors including near misses (nurse in act of giving medication and then stopped prior to giving it) before and after BCMA implementation; and 3) determine if the implementation of a BCMA system impacted the nurses overall satisfaction with the medication administration process.

 

Methods

Design, Setting, Participants, and Data Collection

A case-control pilot study was designed to test the nursing satisfaction with a medication administration process prior to and after implementation of a BCMA system. The study was approved by the Institutional Review Board of the participating hospital. Implied informed consent was assumed when subjects completed a questionnaire developed by the researcher. The questionnaire was administered to one unit that was implementing the BCMA system (experimental unit) and one unit that was not (control unit), before and 5 months after the implementation. The time of administration of the questionnaire after the implementation was determined by the date of the end of the pilot study on the BMCA unit.

Setting

The study hospital was a 280-bed acute care facility in the western United States. The hospital employed a comprehensive integrated computer-based documentation system. Prior to implementation of the BCMA, medications were ordered on a paper-based physician order sheet and scheduled on an electronic medication administration record (MAR) by pharmacists. Nurses were required to verify the scheduled medications against the paper-based physician orders at the beginning of each shift. The nurses documented medication administration in the electronic MAR. The policy in the facility was to document the medication prior to administration in order to take advantage of the functions of the electronic MAR including alerting.

Procedures

The nurses on the 28-bed medical unit piloted the BCMA system and were recruited as the experimental group. Nurses working on a 28-bed cardio-vascular step-down unit were recruited as a control group. The control unit did not implement the BCMA system and served to demonstrate any impact of extraneous variables on nurse satisfaction with the existing medication process in the facility.

The BCMA system implemented on the experimental unit was the AdminRX® system (McKesson Automation, Inc. Pittsburgh, PA). A handheld device (Symbol®, Motorola, Holtsville, New York) used wireless technology and a bar-coding scanner in the device and microprocessor with a 2.3 x 2.3-inch screen and graphical user interface with a touch pen. The system linked the hospital system’s computerized medication ordering and BCMA system. The handheld device displayed the electronic medication administration record and allowed for verification of new orders entered by the pharmacists, double signatures on certain medications, documentation of medication administration, and alerting.

After thorough testing of the BCMA-hospital information system interface by staff nurses from the experimental unit, pharmacists, vendor support, and the nurses on the BCMA unit were educated on the use of the BCMA systems using a train-the-trainer approach. Sample policy and procedure documents provided by the vendor were reviewed and modified by a small focus group including the nurse manager, a small group of staff nurses, and the nurse informatician. Workflow process changes were introduced to the nursing staff during the software training activities. During the implementation, vendor and hospital informatics personnel were available 24 hours per day, 7 days per week.

Instrument

The questionnaire consisted of eight questions. The first five questions measured the nurses’ perception of how easy the medication administration process was. The following is a complete list of questions included on the questionnaire:

  1. Finding out which medications are due to be given soon is easy.
  2. It takes me too long to give medications.
  3. I always document my medications prior to administration.
  4. I can easily see what medications my patient has had.
  5. The new medications are put in the computer/handheld PC in a timely manner. (This question was designed to detect problems with the delivery and administration of new stat medications and if the nurse could see them on the MAR when ready to give them).
  6. I have had a medication error within the last month.
  7. I have had a medication error within the last month.
  8. I have nearly had a medication error in the last month.
  9. Overall, the medication administration process on my unit is:

The first seven questions used a Likert-type scale from 1 (Strongly Disagree) to 5 (Strongly Agree) with a choice of 3 (Don’t Know) at the center of the scale. The eighth question on the survey asked the subjects to rate satisfaction with the current overall medication administration process on their unit on a Likert-type scale from 1 (Poor) to 5 (Excellent). The survey questions were developed by the researcher, and content validity was tested by colleagues in informatics. Reliability and validity statistics were not computed on the survey due to the low sample size (Feldt & Ankenmann, 1998). Surveys were coded to protect the identity of the subjects. Codes were consistent throughout the study to provide paired data for statistical analysis.

The Statistical Package for Social Sciences (SPSS) (Version 16.0 for Windows, SPSS, Chicago, IL) was used to conduct statistical data analysis. Independent t-tests were used to analyze differences in the individual items on the questionnaire between the experimental and control groups before and after implementation of the BCMA system. Paired t-tests were used to analyze differences the values for individual items on the questionnaire between the experimental group before and after implementation of BCMA and the differences in values for the control group before and after implementation. Following a Bonferroni correction for multiple tests, the a level was set at .016. Chi-square tests were conducted on gender and licensure variables to determine differences between the experimental and control groups. Independent t-tests were used to compare age and years of experience between the experimental and control groups.

Results

Participants

Completion of the questionnaires was voluntary and the return rate of the questionnaires was approximately 42%. A total of 33 staff members returned surveys on the BCMA and 26 returned the surveys on the control unit (Table 1). Twenty-five surveys were collected prior to the implementation on the experimental unit and 22 were collected on the control unit. Following the implementation of BCMA, 33 surveys were collected on the experimental unit and 14 on the control unit. There were 19 paired surveys on the experimental unit and 10 paired surveys on the control unit. The completed surveys had various amounts of missing data.

There were significant differences in the age and years of experience between the experimental and control groups (Table 1). The control group subjects were older and more experienced. This may have had an impact on differences in satisfaction between the two groups. There were significant amounts of missing data, particularly in the results of the control group surveys. This limits the ability to draw inferences about the demographic similarities or differences in the two groups.

Questionnaire

A comparison of satisfaction between the control and experimental units before BCMA implementation demonstrates differences in two areas. The control group was significantly less satisfied with the overall medication administration process, t(44) = 3.33, p = .002. The control group felt that the process of getting medications scheduled by the pharmacy in the computerized system was less timely on the control unit than on the experimental unit t(44) = 2.95, p= .005. Both groups indicated that they agreed with the statement that it was easy to determine what medications were due, M = 4.5 (BCMA) and M = 4.09 (Control).

Following the implementation, the experimental group had decreases in satisfaction with the medication administration process in three areas (Table 2). First, nurses’ satisfaction with their ability to determine which medication was due decreased with use of the BCMA. Second, the nurses indicated that it was more difficult to see what medications the patient had already had, t(43.4) = 4.05, p <.000. Finally, there was a decrease in satisfaction with the overall medication administration process for the BCMA group following implementation of the BCMA, t(52) = 3.54, p = .001. The paired t-tests verified these findings.

A comparison of the control group surveys, pre- and post-implementation of the BCMA system on the experimental unit did not yield any statistically significant differences for any of the satisfaction indices. The paired t-test verified these findings.

 

Discussion

This pilot study indicated that the nurses on the experimental unit perceived that there was a decreased ability to visually see the medications due, as well as medications previously given, on the handheld device following implementation of the BCMA system. Nurses indicated a decrease in the overall satisfaction with the medication process following implementation of the BCMA system. There were no differences in either group related to perceived medication errors or near misses.

The use of BCMA systems is viewed as a promising technology to reduce medication errors in hospital settings, but  implementation of these systems may be less than optimal if they have unintended outcomes on the medication administration process. To date, this is the first case control study evaluating the satisfaction of nurses following implementation of a new BCMA system. Anecdotal evidence suggests that the inability of nurses to view medications due and medications given previously was due to design of the software rather than the screen size on the handheld devices.

This study also demonstrated an overall reduction in nurses’ satisfaction with the medication administration process when the BCMA system was implemented. The control group had no significant changes in responses following the study, lending confidence that the decrease in the satisfaction with the experimental group was due to the implementation of the BCMA system rather than other factors.

These results differ from those of other researchers who indicate that nurses are satisfied with the systems (Hurley, et al., 2007; Coyle & Heinen, 2005; Rough, Ludwig, & Wilson, 2003). Future studies employing larger samples are recommended. Randomization of subjects may be difficult, but the continued use of carefully chosen control groups will provide higher levels of evidence for research in this area. This research provided information that may assist in the future development and implementation of systems that will maximize the benefits rather than introduce new error into an already problematic medication administration system. In this study, nurses were part of the implementation team, but including the nurses at the implementation phase may not be adequate. Research investigating the impact of including nurses in the initial design and development of BCMA systems will provide important answers that may guide future development in ways that maximizes the potential of this new technology.

The implementation of new technologies into healthcare systems can be a complicated endeavor. Due to the significant investment of money required to purchase and implement these systems, discussion of negative outcomes is often not desired or encouraged. Implementation of new technologies requires an honest evaluation of the impact these new systems have on current practice in order to maximize the benefits these systems provide to quality and cost-effective healthcare.

Caryon et al. (2007) concluded that changes in workflow must be assessed and workflow processes reengineered prior to implementation of these systems. Methods used to provide education and change processes can be enhanced to improve the overall satisfaction with these new technologies. Unless implementation staff and software developers acknowledge the impact these systems have on nurses and make adjustments to improve satisfaction, the intended improvements in care of our patients as a result of these new technological innovations may never be realized.

Limitations

There were several limitations to this study. Due to the nature of the BCMA pilot program, the number of subjects available for study was limited. Although surveys were given to all nurses on the units using their unit mailboxes, completion of the questionnaires was voluntary and the return rate of the questionnaires was low. There were no limitations on communications between the experimental or control groups, so cross contamination of the groups may have occurred.

Demographic data on the returned surveys was incomplete. There was no follow up for nursing staff that did not complete their survey, and the sample size was too small to determine statistical reliability of the instrument. The survey was short in order to maximize the response rate by busy clinicians. The MAS-NAS Scale developed by Hurley and colleagues (2006) demonstrates reliability and validity but was unfamiliar to the researcher at the time of this study.

Theories of diffusion of innovation set forth by Rogers (2003) indicate that technology is accepted and integrated into work processes in stages and there would therefore be differences in satisfaction depending upon when measurement took place. Waiting 6 months or longer to measure satisfaction post BCMA may have yielded different results. Measurement of satisfaction and attitudes for this study could not be delayed since the pilot project was ended 5 months after implementation. Ultimately, the healthcare system studied in this research opted to develop a medication bar-coding system rather than to purchase.

 

Conclusion

Bar-coding medication administration may be a technology that will significantly reduce medication errors in hospitals and therefore greatly improve patient safety. However, this study demonstrates that BCMA systems may have a negative impact on nurses’ attitudes toward the medication administration process and may make the work processes more difficult. Therefore, introducing BCMA systems into patient care areas may have unintended consequences, such as workarounds, that may reduce the effectiveness of the system.  So before any decisions are made regarding the overall effectiveness of BCMA, hospitals first need to determine whether the benefits are negated by nurses’ resistance to the change and how that resistance can be minimized.

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AUTHOR BIO

Valerie Gooder, PhD RN began her nursing career in Adult Critical Care Nursing after earning a BSN at the University of Wyoming. She also holds an MSN in Nursing Informatics and a PhD from the University of Utah. She has worked in the Clinical Informatics Systems department of a 300 bed tertiary care center and served as Clinical Information Systems Manager for four years at the same facility. Her areas of research focus in informatics are on decision making and patient safety. She currently teaches an informatics course to MSN students in a graduate program.

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