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  1. Gozdan, Marie J. RN, CNS, MSN

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MANY LIVES AND BILLIONS of healthcare dollars are lost each year due to preventable medication errors. Regulatory bodies such as The Joint Commission (TJC), the FDA, and the Institute for Safe Medication Practices are focusing national attention on adopting technology proven to prevent medication errors.1,2 At least three of TJC's 2009 National Patient Safety Goals focus on improving medication administration and patient identification.


At our hospital, we believe that technology can help us meet our goal of improving patient safety. In this article, I'll tell you how we implemented technology for medication administration and how we got nurses to buy in. Then I'll describe research I did to evaluate the project and our results.


Getting started

In 2004 we developed plans for an integrated electronic medical record (EMR) that included an electronic medication administration system. I was part of a multidisciplinary project team challenged to implement that plan. In Phase I in 2005, we implemented electronic documentation and order entry. In Phase II in 2006 and 2007, the nursing staff began to use an electronic medication administration record (EMAR) and a handheld device for scanning patient ID bands to positively identify patients before administering medications.


Preparing for implementation

We educated all nurses who'd be using the EMAR and scanning device on proper workflow and medication administration processes, including hospital policies and procedures. We used teaching methods appropriate for adult learners, including hands-on training on giving medications to patients using the new documentation system and bedside scanning device. We also used online interactive videos, lectures with user manuals, and troubleshooting handouts. When the EMAR went live, the clinical informatics team, computer technicians, pharmacists, and "super users" (nurses with additional training) provided support in all nursing units 24 hours a day for 3 days.


Troubleshooting steps

As part of the clinical informatics department, my role would be to support and educate staff about safe medication practices and to help develop new bar-code scanning practices. Nurses called "knowledge experts" participated in unit rounding to provide ongoing support and education, monitor system utilization, identify system or technology issues, and obtain information from nursing staff for changes needed to improve nursing workflow.


The knowledge experts shadowed nurses to document workflow and the medication administration process. We discussed our findings to determine if workflow had improved and if policies and procedures were being followed when the electronic process was used. We identified these issues:


* Nurses thought that using the electronic medication administration system with scanning increased the time required to administer medications.


* Some nurses weren't following policies and procedures for medication administration. For instance, some weren't scanning the ID band before giving medications.


* We noted workarounds such as documenting medications administered on the EMAR instead of on the handheld device.


* We weren't able to identify a standard workflow for medication administration.


* Nurses didn't perceive that patient safety was improved by scanning ID bands for positive patient identification. They thought that addressing patients by name was sufficient for identification.


* When the technology wasn't working as expected, nurses didn't use it.


* Some nurses didn't want to change, and some were afraid of the technology.



Solving problems

Now our team needed to address these issues. To develop a plan to optimize workflow and improve nurses' use of technology, we scheduled interdisciplinary task force meetings. Attendees included nurse managers and staff nurses, and representatives from pharmacy, integrated technology, and clinical informatics. We discussed workflow issues and flowcharts developed for the medication administration process. Our plan included the following:


* ensure technology is working properly by testing all devices, verifying that wireless computers are functioning correctly, and making sure that enough computers and devices are available


* provide continuing education through a monthly newsletter


* conduct monthly end-user and unit manager meetings


* measure compliance using patient-scanning compliance reports


* spend time in the units to answer questions, provide positive feedback, and demonstrate and discuss best practices.



We provided additional education that staff found helpful. Continued unit rounding provided added support but improving technology gave us the biggest win. After we addressed the problems of the wireless network, the Computers on Wheels and scanning devices didn't lose connectivity. As reliability improved, nurses began to trust the technology and incorporate it into their workflow processes.


Nurses are now more consistently using the EMAR and the bedside scanning device for positive patient identification before administering medication. After we began to provide monthly reports to all unit managers to track staff nurse compliance in their units, the nursing units started a friendly competition to see which unit could achieve the highest scan rates.


Now I was ready to undertake a project to evaluate how effective we were in reducing medication errors.


When and why errors occur

As nurses, we've been taught to follow "the five rights" when giving medications to our patients: right dose, right time, right route, route medication, and right patient. Our hospital has added a sixth right, right documentation.


Based on what we learned during unit rounding, I decided to examine medication administration errors within the hospital. I wanted to know if electronic medication administration improved staff accountability for all six rights. To evaluate the impact of EMAR and scanning on medication administration errors, I used data collected by the quality improvement department before, during, and after implementation. I collected data from 2005 to 2007. I did a literature search for other research on electronic medication administration errors, using these terms: medication errors, electronic medication administration, medication administration devices, bar coding, and patient scanning.


Several research studies have examined electronic medication administration errors. One study by Leape and colleagues found that 39% of all errors occur during the ordering process, 38% during administration, 12% during transcription, and 11% in pharmacy preparation.3 Other studies support these findings.1,4


Evaluating the data

To begin the analysis, I first compared Leape's categories with our hospital data.3 Next I looked at all errors in the medication administration process in each of the six rights. The results were much better than anticipated. Total medication errors and total medication administration errors decreased. Most significantly, we'd made fewer errors in the right patient category, indicating that our goal of implementing technology to improve patient safety was being met. The increase in patient scanning improved safety because nurses using the scanner were alerted before they gave the wrong medication or dose. Although gains were made in other areas, our hospital's focus was on scanning compliance.


When we shared the results with nursing staff, they were amazed that changing a process and using technology had improved patient safety. See A dramatic drop in medication errors.


Standardizing the medication administration process is well on its way. Because the technology is now more dependable, the staff is more comfortable with it and complains less about how much time using it takes. Hospital-wide scanning compliance has increased.

Table. A DRAMATIC DR... - Click to enlarge in new windowTable. A DRAMATIC DROP IN MEDICATION ERRORS

Future plans

Our hospital is now ready to implement the final phase of the bar-code project, which will close the loop for the medication administration process. The process will include scanning the ID band for positive patient identification, using an EMAR, and scanning the medication bar code to meet all six rights prior to administration. All medications and I.V. solutions will have a bar code on the outside of the package and must be scanned with the handheld device for administration. Patient safety should improve even more with this completed process.


Computerized prescriber order entry (CPOE) for all orders including medications will be next. CPOE will improve legibility of all orders and decrease turnaround time for medication order entry. Our hospital continues to move toward our goals of an integrated EMR and improved patient safety.




1. Englebright JD, Franklin M. Managing a new medication administration process. J Nurs Adm. 2005;35(9):410-413. [Context Link]


2. Sakowski J, Leonard T, Colburn S, et al. Using a bar-coded medication administration system to prevent medication errors in a community hospital network. Am J Health Syst Pharm. 2005;62(24):2619-2625. [Context Link]


3. Leape LL, Bates DW, Cullen DJ, et al. Systems analysis of adverse drug events. ADE Prevention Study Group. JAMA. 1995;274(1):35-43. [Context Link]


4. Galusha C, Brown M-M, Kelly J. Bedside bar codes: protecting patients and nurses. http://ojni.org/7_3/galusha.htm. [Context Link]