Clinical innovations are ideations resulting from collective experiences that enhance the “norm” and embrace an avenue for change with an invention. As such, collective data that were suggestive of increased medication errors that compromised patient safety initiated the exploration of methods that could reduce multifactorial human errors. The pursuit for an appropriate system followed with the discovery of barcode medication administration system (BCMA) and electronic medication administration system (e-MAR). Prior to the adoption of BCMA and e-MAR, it was crucial to assess the impact of the new medication administration system and the rate of medication administration errors recorded, specifically those that resulted in harm. The purpose of the study was to evaluate BCMA and e-MAR usage outcomes, clinical practices, policies, and processes impacting nurses administering medications in the clinical environment using BCMA and e-MAR system. Thus, an annotated literature review was conducted prior to the implementation of the innovation which analyzed various studies that elaborated on their study methods, data collection and analysis that deliberated on the advantages and disadvantages of barcode medication administration system. It is evident in the researched journals that increased compliance was observed with appropriate guidance, processes and policies in place. There was also a significant reduction in reported errors. The incorporation of barcode technology with electronic medication administration record (e-MAR) had greatly improved the efficiency of the BCMA system. BCMAs method was one of the proposed solutions to medication administration errors and to enhance patient safety measures. As such, the innovation could significantly reduce medication error resulting from intrinsic and extrinsic factors. This paper will further elaborate on the advantages and disadvantages of BCMA and e-MAR, the strategies assumed in the development of BCMA and e-MAR system and its implementation process by identifying and overcoming potential challenges that may arise.
Medication use is a complex process involving medical practitioners, pharmacists and nurses. It is an undeniable fact that medication errors occur in all health care settings. Several steps in the entire process such as transcription, dispensing and administration process may have potential risks for serious errors and patient harm [
The aim of the clinical innovation is to assist nurses in the process of medication administration through the use of the BCMA and e-MAR system to prevent unduly medication errors/near-misses and develop a patient safety culture in the hospital. The goal of the BCMA and e-MAR system is to ensure that the right patient receives the correct medications adhering to the five rights with an electronic validation and documentation system. The information encrypted in barcodes on each medication pack and the patient’s barcode identification tag allow the nurses to scan and verify the required details before each administration. This would improve clinical outcome, reduce medication-related errors and provide cost-effective treatment for the patients.
Bonkowski et al. (2013) conducted an observational study to measure the medication administration error rate before and after the implementation of Bar-code medication administration (BCMA) in an emergency department (ED) as medication administration in the ED is complex and error-prone. Data collection is conducted through an observation protocol by the principal investigator with 3 blinded observers before and after implementation of BCMA. Documentation of the medication administration was compared with the physician order to ensure medication administration accuracy. The study revealed most medication errors were of minor severity [
A pre and post-intervention study was conducted in the review done by Choo, Johnston & Manias (2014) in two hospitals in Singapore to examine the effectiveness of an electronic medication record in reducing medication errors. Retrospective data of the two hospitals studied were analyzed. In one of the hospitals, the inpatient electronic medication record system was being implemented while the other hospital was using the paper-based medication record system. The study revealed there was no significant difference in the incidence of medication errors following the introduction of the electronic medication record system [
A descriptive analytical study was conducted on 242 nurses to investigate the association of nurses’ knowledge of Barcode Medication Administration (BCMA) and the implementation of BCMA in a hospital [
A case-control study was conducted by Gooder (2011) on 59 nurses to examine the perceived impact of barcoded medication administration system (BCMA) on nurses’ ability to give medications, perceptions of medication errors, and nurses’ satisfaction with BCMA process. Self-designed questionnaires were administered for data collection to the experimental group of nurses who use the BCMA system (n = 33) and the control group which BCMA has not been introduced. The study revealed that the overall satisfaction of the nurses following the implementation of the BCMA system has decreased. In addition, nurses faced decreased ability to visually see the medications due, as well as medications previously given following implementation of the BCMA. Although the use of BCMA systems is perceived as a promising technology, the findings have differed from other studies which indicate that nurses are satisfied with the system [
Harrington, Clyne, Fuchs, Hardison & Johnson (2013) evaluated Bar-Code Medication Administration (BCMA) implementation in a 260-bedded hospital on its progress to minimize medication errors to zero. The evaluation was carried out with the review of journals to create an evidence-based checklist with observational audits and interviews with nurses, followed by analyzing data and sharing of findings. There were three issues targeted for improvements and corrective actions were done and the results showed a compliance rate of 81% as compared to 72% that was recorded previously [
A literature review was conducted discussing the factors influencing medication administration safety, the influence of barcode technology and the successful implementation of barcode technology [
A summary of introducing electronic healthcare record (EHR) improved patient safety and implementing medication administration process using technology in a small rural England hospital [
Samaranayake, Cheung, Cheng, Lai, Chui & Chueng (2014) led a mixed methods design study to assess the effects of a barcode-assisted medication administration (BCMA) system on the dispensing process and its users in a teaching hospital. Direct observation is used to assess the process of dispensing errors. Questionnaires and interviews were conducted to assess the attitudes of the nurses and pharmacist using the system. The findings revealed that additional steps were taken in the dispensing process and there were more errors following the implementing of the new system. In addition, nurses have perceived that the system is useful in improving the accuracy of medication administration. BCMA implementation might have slowed down and complicated the dispensing process. However, nurses believe that the system had improved the medication administration process [
Based on the above reviews, various findings were indicative that with appropriate workflow, training, policy and procedures along with support and guidance, BCMA and e-MAR would greatly impact the medication administration process by significantly reducing medication errors.
Medication administration involves performing a series of complex steps for the medication to be administered. Due to the complexity of the process, there are high risks for errors to take place because of interruptions, the complexity of tasks, not following the five rights of medication administration and using workarounds. Workarounds implemented by nurses in the execution of required processes to achieve desired goals can lead to unintended outcomes, including errors [
Traditionally, doctors prescribe medications by writing on the inpatient medication record (IMR). IMR will then be sent to the pharmacy for the pharmacist to prepare the medications and send to the ward. Nurses then prepare and administer the medications from the medication cart pushed into the patient’s cubicle/room. This process seems to be less effective as there were many reported occurrences of medication errors as well as infection control issues especially for patients with undiagnosed transmission-based infections.
The primary function of e-MAR is to enable electronic prescription, administration and record of medications served to patients, thus replaces handwritten IMR that may be misread due to illegible handwriting and inappropriate use of abbreviations. Electronic MAR increases efficiency with the use of BCMA, while reducing medication errors caused by nurses who misread orders, miss, delay or even administer wrong medication and dosage. The development of the BCMA system is aimed to reduce medication administration errors, reduce the related costs incurred by the hospital and improve patient safety. Studies have shown that the rate of medication errors can be reduced up to 87% once an institute implements e-MAR [
The recommended innovation is the implementation of BCMA and e-MAR
Pros | Cons |
---|---|
Reduced errors in physician orders | Change process, resistance to change |
Reduced dosage errors | Non-compliance to change |
Reduced medication errors | Difficulty in using new technology |
Reduced prescription errors | Insufficient training and support |
Compliance resulted in satisfaction | Lack of knowledge |
Improved the efficiency of medication administration | Unfriendly technology, inability to view previously served medication |
Intelligent scanning devices scan the correct dosage to be administered and alert if the wrong dosage is dispensed | Lack of appropriate policy and procedures and workflow |
Improved patient safety | BCMA implementation slow down and complicated the dispensing process |
Better outcome when incorporated with an electronic medication administration system | Use of equipment may hinder direct eye contact with the patient |
Appropriate device and software required | Equipment malfunction |
Automated medication dispensing machine | System downtime |
Effective leadership for a better outcome | Cybersecurity issues |
Higher accuracy of medication administration. | Troubleshooting issues |
Prevents wrong selection of patient as scanner detects patient by scanning barcode identification tag with medication | Lack of technical support |
Prevents human errors caused by lack of concentration and fatigue | Unfamiliar processes |
Reduced cost related to adverse and sentinel events | Lack of communication and understanding by employees |
Enhance Infection control practices | No integration between information technology and nursing processes |
Enhance compliance with training, policy and procedure in place | Change process, resistance to change |
Alert patient’s drug allergies, generate audit reports and statistics such as medication inventory, missed or delayed dose of medication | Non-compliance to change |
system with the use of a Bluetooth barcode scanner and a hand-held device such as IPAD/tablet. The purpose of e-MAR is to prevent errors caused by physicians’ illegible handwriting, missed/ delayed dose of medication. It also ensures the accurate dose is being served to patients with available information about the medication and for correct documentation. The barcode scanner prevents the wrong selection of the patient and ensures that the correct medication and dose is being served and prevents human errors caused by lack of concentration [
The selection of the product includes the hardware and the software. The product identification and evaluation require both the Information Technologist (IT) and Registered Nurses (RN) respectively. The IT is needed to identify the handheld device (IPAD/Tablet) which has a suitable specification to install the software. Subsequently, the RNs who are the end users have an obligation to evaluate two different types of Bluetooth barcode scanners and handheld devices to compare the speed, ease of use and select the most appropriate device for the implementation of BCMA and e-MAR. The other aspect of product evaluation includes the selection of software program that is easily installed, maintained, encrypted and able to form communication links between physicians, pharmacists and nurses to ensure a closed loop system [
Education and training include a structured program to teach the physicians, pharmacists and nurses [
The process modification including a change in the way medication is served. The current medication process involves prescription in inpatient medication record (IMR) by a physician, routing prescriptions and transcribing the prescription at the pharmacy dispensed by pharmacists, administration of medicines and monitoring of patients by nurses [
Once the pharmacist receives the order and clicks on the patient’s details and specific orders, the medication labels will be printed. The advantage of the system is that the medication doses can be entered in the form that it is available. For example, if the physician has ordered 1 g paracetamol, the pharmacists can input the available dose 500 mg per tablet and ensure that two tablets are retrieved for the proper administration of order by pre-setting in the software. This is achieved by the system prompting the nurses to scan the labelled medication for the second time to attain the desired dosage as per prescription. The medication indications, side effects and other pertinent information are also readily available for nurses to refer when the medication order is clicked in the ward.
In the ward, during the medication administration time, the medication that is due to be served and patients with drug allergy will be highlighted with colour (e.g. yellow, red, etc.) to serve as a reminder. The first step towards safe medication administration begins with the scanning of the patient’s wrist tag. Once the wrist tag is scanned, the patient’s information and medication record will automatically launch. The two identifiers verification may be done with the hand-held device (IPAD/Tablet) that shows patients records. Pre-medication assessment for pain, blood pressure, and so forth may be performed at this stage. Once the verifications and evaluations are done, the nurse may proceed to retrieve the medications for the patient. The medication label is scanned, and doses are scanned accordingly as per order. After that, the preparation is verified by a second registered nurse who is required to enter her personal pin code to confirm that the medication is checked by her/him before serving the patient. At this stage, the nurse may refer to the handheld device (IPAD/Tablet) for indication and other pertinent information about the medication, and educate the patient accordingly. Patient education is vital in the identification of adverse drug reactions (ADR) and any other unforeseen events that may arise. Modification of the process and the inclusion of additional steps safeguard the patients and the healthcare professionals from any mishaps.
The use of non-touch technique verification with handheld devices (IPAD/Tablet) assures a good infection control practice. The new practice eliminates the cumbersome disinfection of mobile cart entirely. The medication cart will be stationed outside the patients’ cubicle to prevent contact with unknown airborne infectious diseases and cross-contamination to other patients [
A study conducted by Rack, Dudjak and Wolf (2012) revealed that more than half of the nurses had administered medications without scanning either the medication or the patient during their shift. The reasons for such negligence include technology failures such as the inability to scan labels due to malfunctioning software, damaged labels, and patient’s isolation precaution status (scanner with the computer on wheels used) [
As indicated earlier, the barcode medication administration cannot be used without e-MAR. When the patient’s information is held online, it is prone to cyber-attacks or ransomware. Hackers sometimes hold medical data hostage until they receive the amount of money, their demands resulting in the slowing down of work, unduly stress and confidentiality issues [
BCMA and e-MAR is an exclusive innovation that incurs an excessive cost to many organizations. Adequate financial strategies need to be established to acquire the required technical support, equipment and software to support the innovation. The public sector may request for government funding in consideration of additional developments [
Staff resistance to the implementation of BCMA and e-MAR is a significant barrier that is experienced by many health care facilities. Resistance can be caused by poor communication. The staff feel overwhelmed due to the change of roles, sometimes because of the employees’ negative perception about the technology [
Training of “super users” who may provide technical assistance in the absence of IT will facilitate the implementation of BCMA and e-MAR. It is vital to conduct adequate training for all health care professionals to build their confidence. Proactive vendors and project team are essential to assure that specific modification is addressed in time when necessary [
There have been complaints that barcodes on the medication are placed on surfaces that are difficult to be scanned [
Change is the effect of innovation that emerges in the launch of an invention. The success of innovation involves effective leadership, change management and support of staffs to embrace the change. According to Bucciarelli (2015), Kotter’s eight-stage model is the most popular change model embraced by many organizations as this model begins with the reflection of failure in change and creates a positive attribute to transform the error into stages that create successful change. Kotter’s (2012) eight stages of leading change include establishing a sense of urgency, creating the guiding coalition, developing a vision and strategy, communicating the change vision, empowering broad-based action, generating short-term wins, consolidating gains and producing more change and anchoring innovative approaches in the culture.
The implementation of BCMA and e-MAR in the organization requires cooperation from the management and staff. Hence, to accomplish the goals and embrace transformation, it is crucial for the management to understand the crisis in the increasing number of medication errors. This would prevent complacency in the organization. It is evident that observable catastrophes immensely assist in acquiring attention and escalating the urgency levels. Thus, statistical presentation of the number and types of medication errors, adverse events and seriously reportable events (SRE) would substantiate the significance in the implementation of BCMA and e-MAR. Guiding coalition includes authority, expertise, reliability and strong leadership. This enhances the leader’s proficiency in being a change agent and working with the rest of the team members for a successful change [
The BCMA and e-MAR development comprises of the sharing of the medication error statistics, creating a mutual consent among the staff and management, and generating a performance indicator that aims to reduce medication errors. Qualitative and quantitative details of the products (Scanning device and handheld device) and the end users (registered nurses, physicians and pharmacists) should be shared to prepare the staffs to accept the change in the process. The timeline to launch BMCA and e-MAR into the system and the cost incurred regarding the purchase of hardware and software, process changes and staff training should be budgeted. Lastly, customers’ and staff’s satisfaction rate should be evaluated. This aspect of the clinical innovation is critical, as the goal to reduce medication error is set with the aim to provide quality care for the patients. Therefore, it is necessary to collect relevant data to evaluate the success of the BCMA and e-MAR once it is launched.
Communication is the key factor that creates the path to the success or failure of any initiatives. Henceforth, a well-structured communication design that elucidates the benefits of the change and active listening of the staff and management feedback, and staff empowerment is fundamental [
Identifying supportive staff and team members coupled with appropriate rewards and recognition would encourage them to assist in the project implementation process [
Institutionalized innovative approaches, with strong leadership and identification of the leader’s successor, ensure continuity in the transformation process [
As mentioned by Nelson-Brantley and Ford (2016), change is a social, dynamic and interactive process. As such, the concept of leading change may be evaluated by exploring specific and collective information at the micro, meso and macro level of a system. The evaluation framework provides an evidence-based results for assessing the innovation project design. It will enable the reallocation of resources and improve the project plan as needed.
Project evaluation is a systematic process intended to examine the effectiveness, efficiency and appropriateness of the clinical innovation that is meant to improve clinical outcomes [
Based on the evaluation design, assessment criteria, feedback and audits, the results of findings may be tabulated to determine the degree of success of the innovation and the project plan [
Upon completion of the project upholding the steps discussed above, a pilot study was initiated in one unit consisting of 43 nursing staff and multidisciplinary doctors within an anonymous organization. Prior to the pilot run, a roadshow was conducted for staffs to evaluate the product and process of the new medication management system. The pilot study was conducted for a period of two months in one unit. To ensure the effectiveness of the BCMA and e-MAR system, a project team was deployed to the unit to address any concerns raised by the nurses and doctors. On-the-job training, close supervision, clinical guidance as well as nursing informatics personnel were readily available to troubleshoot and resolve issues raised. Constant feedbacks were gathered from end-users to evaluate the effectiveness of the new system as well as the process.
All medication prescribed was verified by the pharmacists’ team before the medications could be served. The system provided indications and contraindications for each medication, its side effects and adverse reactions as well as correct dilution and diluents for intravenous therapy. The success of the innovation was measured with medication administration audits, staff feedback and the number of hospital occurrence reports raised with regards to medication errors. The BCMA and e-MAR system was widely accepted by the staff as the number of errors reported was significantly reduced. The staff mentioned that the continuous support from the project team increased their confidence to use the new system. There was only 1 near missed error reported over the two months trial period. The investigation revealed that there was non-compliance observed due to understaffing and fatigue.
In the initial stage, resistance was seen among physicians as the added step of prescribing in the system was time-consuming. Other contrary feedback included that the system was slow to log in, load and toggle as the Wi-Fi connection was rather slow. It prolonged medication serving time as well as caused dissatisfaction among patients who received their routine medication later than usual. Although, infection control matters were addressed by the use of handheld devices such as iPad and scanner that was conveniently cleaned before its next use. The nurses expressed the difficulty in transporting the devices and medication cups/trays from room to room to serve medication. They verbalized that a carrier to hold the devices would assist them away from fumbling with multiple items. Overall feedback was gathered and 88.3% of staff were in favor of the BCMA and e-MAR system and the remaining 11.7% were against the idea due to the inconvenience discussed above. Further studies in numerous departments with bigger sample size and extensive study period are recommended to identify other issues faced by staff and also to resolve the internet connection lag before the implementation of BCMA and e-MAR system.
Medication safety is the responsibility of all members of the healthcare team. It is evident from several studies that medication error is one of the leading causes of death in hospitalized patients. The BCMA and e-MAR system would effectively reduce the number of errors with efficient technology. With appropriate training and support, the healthcare team would be able to adhere to a high standard through the use of technological advancement in healthcare and reduce the number of reported errors.
Although in the beginning stage, the implementation process of the BCMA and e-MAR may be cumbersome and cause delays in medication administration, it is doable once it is recognized as being part of the routine care standards. Above all, the success and failure of this clinical innovation depend greatly on the communication strategies and the evaluation design that measures the need of improvisation of the process. The expected outcome of the innovation is to assist the healthcare professionals to perform their clinical roles efficiently and provide cost-effective treatment outcome to the patients.
The authors declare no conflicts of interest regarding the publication of this paper.
Naidu, M. and Alicia, Y.L.Y. (2019) Impact of Bar-Code Medication Administration and Electronic Medication Administration Record System in Clinical Practice for an Effective Medication Administration Process. Health, 11, 511-526. https://doi.org/10.4236/health.2019.115044