Reducing Medication Errors With Technology

Providing patient safety is one of the primary responsibilities within the nursing profession. Medication errors not only threaten the patient, they threaten the nursing profession. Roy Simpson (2005) brings to light that nurses are associated with more patient deaths and injuries than any other healthcare profession. This is related to the total time spent with the patient, a shortage in the workforce and weaknesses in operational practices and protocols (Simpson, 2005). Today’s nurse needs to be able to navigate through these obstacles and rely on other resources beyond the “five rights”. Bar code and point-of-care technologies contribute to verification of the five rights, improve workflow and allow for communication between different disciplines. Studies, such as those by Paoletti, Suess, Lesko, Feroli, Kennel, Mahler and Saunders (2007), show a substantial reduction in medication errors in clinical settings that have employed such technology. Information technology provides the means by which a nurse can reduce medication errors, insure patient safety and safeguard the nursing profession in today’s clinical setting.
The nursing shortage has a direct impact on medication errors in the clinical setting. The shortage has led to longer hours and frequent shifts resulting in additional stress and fatigue. As a result, nurses have been associated with an increase in medication errors within the clinical setting (Simpson, 2005). The five rights of right dose, route, drug, time and patient are dependent on the nurse’s ability to identify inaccuracies at the patient bedside. This system becomes compromised when the user is drained and unfocused. Bar code and point of care technology addresses the human error factor by automating the five rights (Wolf, 2007). The process involves scanning the identifying bar codes of the nurse, patient and the medication to be administered. Information is processed through various software systems accessing the patient’s medical profile and comparing it to physician orders and pharmacy protocol. A contradiction of any of the five rights results in an alert, prompting the nurse to further investigate before administering the medication and preventing a possible error.
As technology grows so has the capability of the nurse to go beyond the five rights. Enhancements are capable of alerting nurses to medications that are contraindicated due to vital signs, allergies and/or lab values. This is especially beneficial when giving cardio glycosides and electrolyte supplements. Indicators can caution nurses when using high-risk drugs, such as insulin and heparin, preventing lethal dosing. Errors associated with look-alike/sound-alike drugs can be avoided with customized comments and warnings (Grissinger & Globus, 2004). Information technology allows healthcare providers to customize systems to address the specific needs and barriers of the clinical setting.
In addition to notifying the nurse of potential problems, point of care technology broadens a nurse’s knowledge base by allowing access to the most up to date information at the patient’s bedside (Simpson, 2005). Medicine is constantly advancing and medications are constantly being introduced, updated or, in some cases, taken off the market. Systems can access data regarding new medications, medication/herbal supplement reactions, and signs and symptoms of adverse reactions. This allows nurses to make more informed decisions, faster, resulting in better patient care (Simpson, 2005).
Errors in charting have contributed to the rise medication errors and patient injuries. Patient care and medication administration is dependant on the accuracy, detail and up to date documentation by all team members. Staffing shortages and unpredictable workflow often require nurses to chart at the end of their shift increasing the potential for error (Simpson, 2005). Bar code, point of care technology allows for the nurses to electronically chart patient care and medication administration in real time at the patients bedside. This reduces the risk of errors associated with handwriting, omission and transcription (Paoletti, et al., 2007). Additionally, the time that is spent charting during a shift (which is projected to consume 13%-28% of a nurses total shift) can be focused back toward direct patient care (Braswell & Duggar, 2006).
Data collected from bar code, point of care technology allows nursing managers and pharmacist to generate reports identifying factors that can lead to medication errors. Nurse managers are able to track compliance and address training or other issues as necessary (Braswell & Duggar, 2006, p.14). Pharmacist can use the data to identify opportunities for improvement in storage strategies for medications in nursing-unit decentralized cabinets, separation of look-alike products and formulation differences within the pharmacy department (Paoletti et al., 2007, p 540). The ability to identify the origin of error is the first step and a proactive resource in bringing about positive change. This results in opening lines of communications between the disciplines in the effort to resolve obstacles that might result in error.
The need to incorporate information technology in the clinical setting can be observed in the Paoletti et al. (2007) study at Lancaster General Hospital. Medical observers reported 188 errors related to medication administration prior to the implementation of electronic medical administration records and bar-code medication administration. The errors included wrong time, wrong technique, wrong dose, extra dose, wrong medication and wrong formulation. It was found that errors were more likely to occur at the point of medication administration because safety nets relied on nurses to remember, identify and resolve discrepancies at bedside (Paoletti et al., 2007, p.538). Moreover, of the 188 errors observed, none of them were reported or identified by staff members. Paoletti et al. (2007) assert that the reporting of errors is dependant on the willingness of the provider to file a report. Many of theses errors may be unknowingly committed or go unnoticed by the provider. One can therefore conclude that the prevalence of medication errors is much higher and a greater threat than once understood.
Facilities that have implemented information technology into their medication administration protocol have seen positive results. Lancaster General Hospital had a 54% reduction in medication errors after implementation (Paoletti et al., 2007). Braswell and Duggar (2006) report that the Spartanburg Regional Health System had error rate reductions as high as 78% after implementing bar code, point of care technology systems. Paoletti et al. (2007) write that subsequent to implementation reports were generated identifying possible and prevented errors. Nursing managers were able to use the data to implement training programs to address areas of opportunity. Pharmacy and nursing communication and collaboration during the implementation phase resulted in improved interdepartmental relationships. The commitment to a safer environment has not only been appreciated by patients and nurses, but has served as a recruiting tool for new nurses.
In summary, information technology has a place at the patient’s bedside and within the nursing profession. As the number of qualified nurses begins to diminish, the reliance on technology becomes greater. Wolf (2007) declares that errors will be reduced with the assistance of technology. Technology complements the way a nurse works by supporting the five rights, improving workflow and enhancing communication. The end result is a safer environment for both the patient and the nursing profession.


a. Intervention #1 Bar-coded medication administration
i. Disadvantage 1. Automation of the five rights leads to a decline in nursing diligence.
In its efforts to make the process safer, the administration of medication with the use of bar code technology can lead to a reliance on the system alone (McDonald, 2006). A nurse must still rely on his or her knowledge base as the primary source for decision-making. Automation can lead to a knowledge deficits in different aspects of the nursing profession. With the demands put on today’s nurse (in terms of staffing issues, patient to nurse ratios and high patient demands), nurses are more tempted to look for shortcuts. Bar coding systems are set in place to support the current protocol of addressing the five rights before administrating medication to a patient. McDonald (2006) asserts that systems can create new kinds of errors if not accompanied by well-designed, well-implemented crosscheck processes and a culture of safety.

McDonald, C. (2006, April 4) Computerization can create safety hazards: a bar-coding near miss. Annals of Internal Medicine, 144(7), 510-516. Retrieved February 1, 2008 from Academic Search Premier database.

ii. Disadvantage 2. Hardware and software systems associated with bar coded medication administration are susceptible to technical issues.
Bar-coded medication administration and its users rely on a wireless apparatus capable of connecting to the main system. When hardware and software systems are unable to communicate, the system, as a whole, becomes ineffective. Elizabeth Mims, nurse consultant for the Veterans Health Administration National Bar Code Medication Administration Joint Program Office, noted that problems with wireless transmission can occur due to steel beams in older buildings, rooms with lead shielding, and closed doors (Traynor, 2004). Additional issues include slow response/download times, equipment problems, missing armbands, and illegible barcodes (Heinen, 2003). Technical issues, and the lack of experience and expertise to overcome them, can be costly, frustrate users, disturb workflow, and jeopardize patient safety.

Heinn, M., Coyle, G., & Hamilton, A. (2003, October). Barcoding makes its mark on daily practice. Nursing Management, 34(10), 18-20. Retrieved February 1, 2008 from Academic Search Premier database.

Traynor, K. (2004, October 1). Details matter in beside barcode scanning. American Journal of Health- System Pharmacy, 61(19), 1987-1988. Retrieved February 1, 2008 from Academic Search Premier database.

b. Intervention 2. Point of care technology and electronic patient charting
i. Disadvantage 1. Although point of care technologies and electronic patient charting can provide great benefits, it is also susceptible to infringement on ones medical condition and/or history. Leah Curtin (2005) stresses that the information contained in these databases offers enormous opportunities for prejudice and financial gain. A patient’s medical record, both past and present, is vulnerable to anyone with ability to bypass the safeguards put in place to protect those records (Curtin, 2005). A patients right to confidentiality, and the process put in place by HIPPA to protect that confidentiality, can all be threatened as information is more readily available to a larger number of people. As Curtin (2005, p 352) asserts, healthcare informatics involves healthcare, ethics and informatics – and its practioners must, for the public’s good, be bound by additional ethical, moral and legal responsibilities.

Curtin, L. (2005, October). Ethics in nursing administration. Ethics in informatics: the intersection of nursing, ethics, and information technology. Nursing Administration Quarterly, 29(4), 349-352. Retrieved February 1, 2008 from CINAHL database.

ii. Disadvantage 2. Access to patients’ charts and medical history is dependant on the compatibility of the systems being used.
It was thought that the information maintained on electronic patient charting and patient data would be easily accessible. Philip Darbyshire (2004) states that the basic function of systems being able to “talk to each other” has been one if its shortcomings. Clinicians get little benefit in a system that cannot communicate and/or integrate with other patient care data bases located in various clinics, hospitals, and labs (Darbyshire, 2004). Information entered in point of care systems and electronic patient charts can only be useful if obtainable. Access to a patient’s complete medical history leads to more informative decision making and better patient outcomes.

Darbyshire, P. (2004). ‘Rage against the machine?’: nurses’ and midwives experiences of using computerized patient information systems for clinical information. Journal of Clinical Nursing, 13(1), 17-25. . Retrieved February 1, 2008 from CINAHL database.





References


Braswell, A., & Duggar, S. (2006, October). The new look of beside technology. Nursing Management, 37, 14-32. Retrieved November 7, 2007, from Academic Search Premier database.


Curtin, L. (2005, October). Ethics in nursing administration. Ethics in informatics: the intersection of nursing, ethics, and information technology. Nursing Administration Quarterly, 29(4), 349-352. Retrieved February 1, 2008 from CINAHL database.


Darbyshire, P. (2004). ‘Rage against the machine?’: nurses’ and midwives experiences of using computerized patient information systems for clinical information. Journal of Clinical Nursing, 13(1), 17-25. . Retrieved February 1, 2008 from CINAHL database.


Grissinger, M., & Globus, N. (2004, January). How technology affects your risk of medication errors. Nursing, 34(1), 36-42. Retrieved October 31, 2007, from CINAHL database.


Heinn, M., Coyle, G., & Hamilton, A. (2003, October). Barcoding makes its mark on daily practice. Nursing Management, 34(10), 18-20. Retrieved February 1, 2008 from Academic Search Premier database.


McDonald, C. (2006, April 4) Computerization can create safety hazards: a bar-coding near miss. Annals of Internal Medicine, 144(7), 510-516. Retrieved February 1, 2008 from Academic Search Premier database.


Paoletti, R., Suess, T., Lesko, M., Feroli, A., Kennel, J., Mahler, M., et al., (2007, March 1). Using bar- code technology and medication observation methodology for a safer medication administration. American Journal of Health-System Pharmacy, 64(5), 536-543. Retrieved November 3, 2007, from CINAHL database.


Simpson, R. (2005, January). Patient and nurse safety. Nursing Administration Quarterly, 29(1), 97-101. Retrieved November 3, 2007, from CINAHL database.


Traynor, K. (2004, October 1). Details matter in beside barcode scanning. American Journal of Health- System Pharmacy, 61(19), 1987-1988. Retrieved February 1, 2008 from Academic Search Premier database.


Wolf, Z. (April, 2007). Pursuing safe medication use and the promise of technology. MEDSURG Nursing, 16(2), 92-100. Retrieved November 3, 2007, from CINAHL
Database.