Bar Code Medication AdministrationFrom Wikipedia, the free encyclopedia Bar Code Medication Administration (BCMA) is a barcode system designed to prevent medication errors in healthcare settings and improve the quality and safety of medication administration. The overall goals of BCMA is to improve accuracy, prevent errors, and generate online records of medication administration. It consists of a barcode reader, a portable or desktop computer with wireless connection, a computer server, and some software. When a nurse gives medicines to a patient in a healthcare setting, the nurse can scan barcode on the wristband on the patient and make sure that the patient is the right patient. The nurse can then scan the barcode on medicine, the nurse and the software can then verify if it is the right medicine at the right dose at the right time by the right route ("Five rights"). [1] Bar Code Medication administration was designed as an additional check to aid the nurse in administering medications, however it can not replace the expertise and the professional judgment of the nurse. BCMA was first implemented in 1995 [2] at the Colmery-O'Neil Veteran Medical Center in Topeka, Kansas, USA. It was conceived by a nurse who was inspired by a car rental service using barcode. From 1999 to 2001, Department of Veterans Affairs promoted the system to 161 facilities.[3]. Cummings and others recommend the BCMA system for its reduction of errors. They suggest healthcare settings to consider the system first while they are waiting for RFID. They also pointed out that adopting the system takes a careful plan and a deep change in work patterns.[4] Improving Medication Safety with a Wireless, Mobile Barcode System in a Community Hospital By Mitch Work Over the past few years, hospital organizations have increasingly looked to new technology solutions to improve patient safety. Barcode technology is an especially promising approach in the effort to reduce medical errors. While barcode technology has been used for quite some time in many hospital applications, it has only recently been used to address patient safety. The use of barcode technology at the patient's bedside has shown impressive gains in reducing medication administration errors, which may account for as many as 7,000 deaths per year in U.S. hospitals (IOM, 2000). Barcodes provide a valuable verification of medication administration by assuring that the "five rights" are confirmed — right patient, right medication, right dose, right time, and right route of administration. While studies conducted in VA hospitals in the early 1990s showed that the use of barcodes reduced medication administration error rates by up to 86% (Meadows, 2003), community hospitals are just beginning to use this technology to improve patient safety. Recent estimates indicate that only 2% to 6% of hospitals are currently using barcodes to reduce medication administration errors (Center for Business Innovation, 2004). Background This case study examines the use of a wireless, mobile barcode medication administration system at Beloit Memorial Hospital in Beloit, Wisconsin, a 175-bed community hospital with four off-site clinics, serving a population of approximately 175,000 residents living in southwestern Wisconsin and northwestern Illinois. The hospital has a formal affiliation with the University of Wisconsin Hospital System and an active though informal affiliation with Rockford Hospital in Rockford, Illinois. The hospital's Board of Trustees, composed of 10 medical professionals and community leaders, has committed the hospital to a primary goal of providing highquality healthcare services for all patients. In September 2003, Beloit Memorial installed a wireless, handheld barcode medication administration system in its Family Care Center (FCC) unit, consisting of 35 ob/gyn, pediatric, and labor/delivery beds. This pilot resulted in a 67% decrease in medication administration errors within the first four months of operation. With the pilot successfully completed, the hospital expanded implementation of the barcode system to four additional inpatient units. This case study documents Beloit's experience in these units, which included: Special Care Center (SCC) Oncology Multi Care Center (MCC) General Medical Surgical Intermediate Care Center (ICC) Telemetry Critical Care Center (CCC) Critical Care These units presented a more complex environment than the FCC, treating patients with generally more serious medical conditions, who often required more medications. Consequently, these units were more prone to experience medication administration errors. Goals and Objectives The main goal of this study was to identify and measure the benefits of a wireless barcode system to reduce medication administration errors. To address this goal the following specific objectives were established: 1. Conduct an onsite visit, both pre- and post-implementation of the wireless barcode system in the four new inpatient units. 2. Determine pre- and post-implementation medication administration error rates in these units. Methodology Pre- and post-implementation site visits were conducted by an independent consultant who interviewed senior nursing management, the unit managers, and the nurses charged with medication administration responsibilities; and observed the medication administration rounds. The pre-implementation visit was conducted in late June 2004, and the post-implementation visit was conducted in December 2004, to review the results of the system four months after the "go-live" date. This interval was selected to ensure that the nursing staff was familiar with the barcode system and had completed its learning curve of the new system. the hospital approved the further deployment of barcoding for medication administration to include four additional inpatient units due to the FCC's early success. Anticipated Benefits In expanding the use of barcode technology to the additional inpatient units. Barcode Implementation at Beloit In February 2003. 3. which began in July 2003. Implementation of the original pilot and subsequent rollout to the other inpatient units occurred over a 15-month period from July 2003 through October 2004. the barcoding initiative originated from a recommendation by the director of pharmacy. Figure 1. Mobile Barcode System at Beloit Memorial Hospital . Improve patient satisfaction. This culture was key to embarking on a successful patient safety program. the Board of Trustees unanimously approved funding for a bar-code pilot project in the FCC. The SCC went live in March 2004.Patient Safety Goals The hospital Board of Trustees and senior management have focused on establishing a culture of cooperation and communication aimed at improving the quality of patient care. The MCC. while minimally increasing nurse staffing time requirements. 4. While the hospital established a Patient Safety Committee in 2001. Generate positive public relations with the local community. By January of the following year. As a result. CCC. the hospital hoped to achieve the following benefits: 1. 2. Improve patient safety through the reduction of medication administration errors. unified message from senior management that led to the adoption and funding of the new barcode system. and department heads created a positive atmosphere and communicated a clear. the hospital embarked on its initial barcode pilot in September 2003. The alignment of the board and senior hospital management including the CEO. Timeline of Approvals and Implementation Rollouts of the Wireless. and ICC all went live in August 2004. This chronology is shown in Figure 1 below. who felt that additional checks and safeguards at the point of medication administration would be valuable in reducing medical errors. the vice president of nursing. Improve nursing staff job satisfaction. 0 (www.carefusion. This can be attributed to several factors including careful. and ask questions about the system. The MCC." FCC nurses experienced and proficient with the system. the decision was made to bring on three additional units simultaneously. Components of Wireless Barcode System Initial implementation of wireless barcode technology at Beloit was with Care Fusion's wCareMedÅ release 3. A training design similar to that used in the SCC was implemented using super users as well as on-site support from the vendor. a dedicated notebook was placed in the SCC where nurses could write comments.com). were communicated informally by staff nurses throughout the hospital. director of IT. In addition. In addition. The training was conducted by "super users. training staff from the vendor were on site to assist with the 4-hour training sessions. daily management meetings were conducted with the director of pharmacy. barcoding went live in March 2004. Hospital management was extremely pleased with this training approach. and ICC went live in August 2003. and hospital management reported that they were extremely satisfied with the system.Staff Training The SCC. continual communication with nursing staff both prior to and following implementation. Eight super users were utilized in the training and were present on the units during the implementation. Other factors also had a positive influence on the barcode system adoption in these new units including the initial success of the FCC pilot and nursing staff's generally high level of satisfaction with the new system. and it is now being used in all five inpatient units. Once the staff training was completed. was selected as the second unit for barcode utilization implementation due to the fact that it administered many medications yet it was a relatively small unit with seven beds. Going forward. An upgrade to release 4. These super users volunteered to assist in the SCC training. new staff will be trained exclusively by the super users. SCC staff training on the barcode system was conducted over a one-week period immediately prior to go-live. perhaps of equal importance. eliminating the need for ongoing training by the vendor and reducing costs. Daily meetings were held with the nursing staff during the first two weeks following implementation to troubleshoot any problems and to provide rapid response to questions about the system. advance planning. CCU. These factors were publicized both formally by hospital management and. an oncology unit. a flexible training schedule to accommodate all shifts. A total of approximately 100 nurses were trained for these units. The implementation proceeded smoothly. provide feedback. The notebook was reviewed regularly by nursing managers to address issues quickly. Training was conducted 48 hours prior to go-live. and the nurse unit manager to ensure that the system was working properly. and the fact that the barcode utilization process had been carefully integrated into the medication administration workflow processes. In addition. . Based on the success of the implementation in both the FCC and the SCC units. in which all 12 unit nurses were trained.0 is expected in the first quarter. A wireless network (802. several staff were personally involved in situations where the system stopped a medication error from occurring. as required. barcode medication administration system. Further.Implementation Challenges and Solutions Implementing a new system like barcode medication administration can present many challenges as nursing staff adapt to new work processes. successfully demonstrating that their patient's safety had been enhanced through the use of the wireless. Once the system was installed and the CCC staff became more familiar with the new system. the hospital was not required to hire additional pharmacy or nursing staff. though a few minor concerns were expressed about "having to learn new technology. 4 GB RAM) was connected to the wireless network. these concerns did not resurface. Symbol Technologies PPT 8800 handheld wireless devices with integrated barcode scanners are currently being used. Benefits Realized: Patient Safety Improvements A comparison of the medication administration error rates pre. due to a temporary staffing shortage in the pharmacy. However. An interface to the Meditech HIS was implemented during the pilot by Iatrics Systems. and the new system changed work processes in a manner that they felt could potentially compromise patient care.and post-implementation shows that medication administration errors were reduced by an average of 82% for the five units studied (see Figure 2). . Despite the implementation of the new barcode system and the changes in work processes that it necessitated.11b wireless LAN) with 128 bit encryption for data security was installed with access points and connecting sensors in all patient rooms." Implementing the system in the Critical Care Center was somewhat more challenging. The barcodes had not been affixed to some unit dose medications. This issue was quickly resolved and did not reoccur. Initial concerns were expressed regarding the need to administer some drugs on an emergency basis or administering drugs to newborns within one hour after birth to comply with state law. The pharmacy department needs to consider the additional time that will be required to affix medications with barcodes. Another issue that needed to be addressed during the implementation was the lack of barcodes on some of the unit-dose drugs being used. Pentium 4 Xeon 2.8 GHz. this does suggest that the hospital pharmacy must be intimately involved in the planning and implementation of any new barcode utilization system for medication administration. The commitment to safe patient care was reinforced by management as the key treatment goal that would take precedence over the use of the barcode system in emergency situations. Beloit Memorial encountered few objections by the nursing staff. A dedicated server (IBM xSeries 345 Server. 2005. Mobile Barcode System (September 2003 . Medication Administration Error Rates in Inpatient Units Pre.8 to 1. They include: .November 2004) The post-implementation data was collected from the go-live month in each unit through November 30.Implementation of Wireless. All participating units reported significant error reduction with the greatest numeric decline in monthly average medication errors occurring in the MCC. depending on the unit.and Post.Figure 2. the medication administration error rate is decreased even further to an average of 93%. to allow time for learning the new system.25 medication errors per month. missed medication. If the first month of implementation is not included. the most recent data available at the time of this study. 2004. This data includes the first month that the system was installed. The error rate in this unit was high in comparison to the other units because the MCC is the largest unit with a total of 64 licensed beds. Other Benefits Realized The benefits of the barcode system extend beyond a decrease in medication administration errors. or wrong IV bag hung and were documented in the hospital's Med Event Report. The types of medication errors that occurred in these units varied and included instances of wrong dosage. missed drug reaction. when staff learning curves were steepest and errors were most prone to occur. The reported post-implementation time periods ranged from 4 to 15 months experience. which fell from an average of 5. Proposed Wireless. Recruitment of new staff was also mentioned as an additional potential benefit. The nursing staff felt that the hospital was truly committed to improve quality of care by investing in state-of-the-art technology to improve patient safety. hospitals have made little progress in implementing patient safety solutions to reduce medical errors. It is expected that wireless barcoding will be implemented for respiratory therapy by the first quarter. as demonstrated by use of the new system. Figure 3. During the initial implementation. Increased job satisfaction was identified as an additional benefit of the system. Rotary International) to educate the community about the new system and why it was being implemented. the hospital contacted the local media and sent senior management to speak with local citizen groups (e. the hospital is committed to proceeding with the rollout to make full use of other wireless mobile barcode applications.g.Improved nursing staff satisfaction. Patient satisfaction. Nurses reported a genuine sense of appreciation from patients and their families that the hospital was committed to patient safety.. This case study has documented the experiences of one community hospital. . by an average of 82% after being installed for a relatively brief period of time (5 to 15 months). This public relations exposure helped to build on the existing positive relations between the hospital and the local community and resulted in several stories in the local press. which has demonstrated the success of a wireless mobile barcode system. all patients were briefed about the new medication administration system and why it was being installed. Mobile Barcode Application Implementation Schedule for Beloit Memorial Hospital Conclusion Recent reports indicate that five years after the Institute of Medicine's landmark study. in the inpatient units observed. committed to a culture of patient safety. After deciding to implement a new medication administration system. Showing the hospital's advanced use of technology was cited as a positive factor in recruiting new staff in a competitive employment environment. Improved community relations. Other barcode applications will also be installed at the hospital in accordance with the implementation schedule shown in Figure 3. Future Automation Directions Currently. This resulted in a reduction of medication administration errors. 2005. To Err Is Human: Building a Safer Health System (2000). 2004. The rehab unit went live in the fourth quarter. Additional benefits attributed to the barcode system were also identified. Recently.. wireless technology.. sales. He also assists companies to launch new HIT products and establish vertical healthcare technology businesses. (2). control n= 26) were given the questionnaire 1 month prior and 5 months following the implementation of a pilot unit. Currently. and generation of positive press and public relations with the local community. Mitch Work (mitchwork@workgroupinc. 15. He has conducted ROI and best practices studies to demonstrate financial and clinical benefits from HIT. presenter. and nurses’ satisfaction with the medication administration process. a healthcare consulting company delivering strategic marketing. Participants in the experimental group indicated difficulty determining which medications had been given (p < . assisting HIT companies and providers to be more successful.000). The author developed a questionnaire based on Rogers’ diffusion of innovation theory and established content validity. RN This article was made possible by an educational grant from Chamberlain College of Nursing CITATION Gooder. and executive for provider and supplier organizations. he has consulted with several national and international healthcare technology conferences and has served as a co-chairman. he has focused on new technologies for patient safety including barcoding. Available at http://ojni. and panel moderator. fully communicated work plan that included clearly identified new work processes and a thorough staff orientation and training program. Gooder Ph. but also to a carefully constructed. RFID. In the final analysis. Nurses’ Perceptions of a (BCMA) Bar-coded Medication Administration System A Case-Control Study by Valerie J. he serves as president of The Work Group.net) has over 25 years experience in healthcare as a researcher.D. (June 2011). Over the past 18 years. Nurses’ Perceptions of a (BCMA) Bar-coded Medication Administration System: A Case-Control Study. Inc. Over the past year. and the Internet. Online Journal of Nursing Informatics (OJNI). he has been involved in healthcare information technology consulting. success of the barcode medication administration system at Beloit Memorial can be attributed to not only the use of state-of-the-art technology.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. V. educator. perceptions of medication errors. There was a decrease in the overall satisfaction with the medication process following implementation of the BCMA . and public relations services to healthcare IT companies and provider organizations. These include improved staff and patient satisfaction. The participants (BCMA n= 33. Evidence of this is the development of system workarounds that bypass the intentional blocks to medication administration presented by the BCMA system. i. Nurse satisfaction. Berg. Rivish & Modeda. and most medication errors occurred during medication administration (34%) where they were more likely to directly impact the patient and cause harm (Bates. Effective implementation of BCMA systems requires an understanding of the impact of the system on nursing work processes. The IOM recommended systemic changes to hospital processes including medication administration (Kohn. Bush. Sakowski. but it is unclear if the bedside nurses view the systems as effective in error prevention. Johnson. Rogers. Smith. 2004. 2002. & Coiera. 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. 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.e. there is some concern about the safety and effectiveness of these systems (Ash. Medication administration. Key Words: BCMA. Cummings. & Matuszewski. Bates. Corrigan. McDonald. Chapman.... 2010). 2007). & Dozier. who give the majority of medications in healthcare facilities. Ethnographic and observational studies have documented poor compliance with BCMA systems in several settings (Patterson. Medication errors occur more often than other categories of preventable errors (19%). Newman. & Donaldson. Workarounds are processes that bypass key safety features of the BCMA system. 1999). 2004). Years after implementation of the first BCMA systems there is still widespread variation in how the systems are used (Carayon. 2006. Paoletti. 2005). et al. et al. & Render. Medication error Introduction In 1999. Cipriano. For . 1995). The Institute of Medicine (IOM) reported that nearly a million patients each year are injured in hospitals in the United States due to error. Cook. Bar-coded medication administration will probably be utilized in the majority of hospitals by 2024 (Roark. 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. Implementation of the BCMA prevents workarounds (shortcuts) and other personalized methods used by nurses to administer medications (Englebright & Franklin. 2005. Barcode.system (p = . 2002. 2002.001).. Patterson. One reason for the variations is the fact that implementation of BCMA systems has an impact on the current work processes of nurses. 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. 2007. 2002. & Willette. Crane & Crane. 2006. 2001. Bar-coded medication administration systems are implemented to reduce medication administration errors. 2005). et al. et al. Due to supportive efforts by the FDA and the Joint Commission (JC). shortcuts. & Render. 2004). Tucker. Despite optimism about the impact of BCMA systems on medication errors. 2006). 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. an increase in the number of hospitals purchasing BCMA systems is expected. Problems with the BCMA technology may create additional frustration for the already busy bedside nurses. 2008). Carlson. example. Prior to administration of the medication. The researchers measured satisfaction four months prior to implementation of the BCMA . dose of medication. Wetterneck. The system is often integrated with a patient unit-based automatic dispensing machine (ADM) and a pharmacy packaging and dispensing robot. right dose. the nurse is prompted to confirm the new medication with the physician’s written order. DeYoung. the nurse scans the patient’s armband at the bedside to confirm the “correct patient. the nurse scans the armband that is taped to the bed (Koppel.. 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. Ludwig. This could result in a patient receiving the wrong medication. 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. the nurse scans the medication that is due to be administered. Finally. right time and right route) of medication administration. 2003). Instead of scanning an armband on the patient’s wrist. route of medication.” The nurse has the option to attend to or override an alert and give the medication. Telles. and nurse staff badges to facilitate the five rights (right patient. nurses bypass safety features of the system and therefore negate the overall purpose of the BCMA. In the case of a new medication order. or time for administration. 2009. a patient’s armband is removed from the patient’s wrist and taped to the bed or doorjamb. 2005. Next. but the results have been inconclusive. Despite this benefit. Sakowski et al. Vanderkook & Barletta. Literature: Nurse Satisfaction with BCMA Research has been conducted on the satisfaction of nurses with BCMA technology. By using workarounds. 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. 2005). & Karsh. using the stylus. right medication. 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. Once the nurse verifies the medication. 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. & Wilson. patient identification bracelets. one that was intended for the previous occupant of the bed. 2008). Description of the Problem Literature: BCMA A BCMA system utilizes bar-coded medication doses. the nurse chooses a patient from a list on the handheld device. The widespread use of BCMA systems in healthcare organizations may result in a significant decrease in medication administration errors (Coyle & Heinen. 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. Not all researchers found such promising results. 2010).. et al. Workarounds occur as a result of problems with technology. (2007) measured the satisfaction of nurses in a large academic medical center 2-4 weeks prior to deployment and 4 months after implementation. Frustration with the BCMA system may reduce nursing productivity and therefore negatively impact quality of patient care (Marini. task. (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 use of workarounds indicates a lack of confidence in the system and may be an indication of decreased satisfaction. et al. 2008).and post-BCMA implementation. . and systems impact on nursing practice. Category C errors are medication errors that occur and reach the patient. They did not find a decrease in errors related to medications given to the wrong patient (Fowler. & Wakefield. and Zarillo (2009) used the MAS-NAS Scale to evaluate nursing satisfaction with a BCMA system and Category C medication error rates. 2002. 2008). the results indicated that the nurses viewed the new system as time consuming. but safer. Often workarounds are the result of several of these factors occurring simultaneously. 2008). 2008). et al. The results indicated a statistically significant improvement in satisfaction following deployment. These problems occur because the process has not been reengineered properly (Vogelsmeier. In a longitudinal. but did not include specific timing of the observations or any attempts to quantify satisfaction. The image profile of the model included three aspects: system functionality. nurses develop workaround strategies that reduce the overall effectiveness of these systems (Patterson. organization. an informatics-focused listserve.. Sohler. et al. and the environment (Koppel. Hurley et al.. (2006).. Wakefield. Halbesleben. Selected interviews of participants corroborated the results of the study (Hurley. 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. The questionnaire was sent by email to members of the CARING e-mail list. The Medication Administration System-Nurses Assessment of Satisfaction (MAS-NAS) Scale. Huijer... descriptive study. was used to compare satisfaction level of nursing staff pre. This scale has demonstrated early reliability and validity (Hurley. Use of workarounds may encourage other unsafe practices (Halbesleben. 2006. patient issues.and six months after and reported a 42% improvement in nurse satisfaction with medication administration and documentation after implementation of the BCMA system. et al. They found no difference in satisfaction for the period prior to implementation compared to 6 and 9 months following implementation of BMCA. 2007). Patterson. Their results indicated that when nurses valued the safety features of the system. Vogelsmeier. et al. they viewed the system as more useable (Marini. Sohler. 2010). Poor work satisfaction is considered a leading cause of turnover resulting in reduced quality of patient care. & Dimassi. The instrument demonstrated initial reliability and validity. but hypothesized that this was due to increased reporting and surveillance. developed by Hurley. The researchers found that Category C errors increased following BCMA implementation. & Scott-Cawiezell. Despite the potential benefits of BCMA. 2006). A positive correlation between nursing job satisfaction and job performance motivates nurse managers to investigate causes of low satisfaction among nurses. 2009). Marini et al. et al. et al.. Observations by Coyle and Heinen (2005) indicated nursing satisfaction with a BCMA system. Of note. The items on the questionnaire were measured using a five-point Likert scale. & Zarillo. The successful implementation of BCMA systems that maintain or improve nursing satisfaction require healthcare leaders to address issues that limit workarounds. but do not cause harm. Hasman. Fowler. systems usability. 2) compatibility – is the innovation is consistent with the goals of the current process. Methods . & Wakefield. 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. Wakefield. 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. 2008). and observability.Although BCMA systems provide robust technology designed to reduce medication administration errors. in this case. Research regarding nursing satisfaction with BCMA systems is limited and conflicting. compatibility. 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. 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. For this study the researcher evaluated the success of BCMA implementation based on the nurses’ views of the relative advantage. 3) complexity – does the user consider the innovation complicated. The specific purpose of the research was to: 1) describe the perceived impact of BCMA implementation on nurses’ ability to give m edications. These aspects of the system form a basis of nursing satisfaction with the system. and 3) determine if the implementation of a BCMA system impacted the nurses overall satisfaction with the medication administration process. Purpose This study investigated nurse satisfaction with the use of a BCMA system as compared to a previous non-barcoded medication administration system. 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. Conceptual Framework Measuring satisfaction with BCMA technology requires an understanding of how technology is introduced into the healthcare work process. complexity. and 5) observability – how easy is it for users to see the results of the innovation. 2003). The development of workarounds may be an indication that nurses feel that the system is not adequately supporting the medication administration process (Halbesleben. 4) trialability – how much can the new system be tested and experimented with. a reduction in medication errors (Rogers. A handheld device (Symbol®. Pittsburgh. medications were ordered on a paper-based physician order sheet and scheduled on an electronic medication administration record (MAR) by pharmacists. Participants. before and 5 months after the implementation. 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. . Inc. PA). and alerting. vendor support. 7 days per week. The hospital employed a comprehensive integrated computer-based documentation system. During the implementation. The handheld device displayed the electronic medication administration record and allowed for verification of new orders entered by the pharmacists. 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. Sample policy and procedure documents provided by the vendor were reviewed and modified by a small focus group including the nurse manager. documentation of medication administration.Design. After thorough testing of the BCMA-hospital information system interface by staff nurses from the experimental unit.3 x 2. vendor and hospital informatics personnel were available 24 hours per day. The nurses documented medication administration in the electronic MAR. a small group of staff nurses. double signatures on certain medications. The BCMA system implemented on the experimental unit was the AdminRX® system (McKesson Automation. Prior to implementation of the BCMA. Holtsville. and the nurses on the BCMA unit were educated on the use of the BCMA systems using a train-the-trainer approach. Setting The study hospital was a 280-bed acute care facility in the western United States. New York) used wireless technology and a bar-coding scanner in the device and microprocessor with a 2. 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. Motorola. Procedures The nurses on the 28-bed medical unit piloted the BCMA system and were recruited as the experimental group. Implied informed consent was assumed when subjects completed a questionnaire developed by the researcher. Setting. The questionnaire was administered to one unit that was implementing the BCMA system (experimental unit) and one unit that was not (control unit). The study was approved by the Institutional Review Board of the participating hospital.3-inch screen and graphical user interface with a touch pen. Nurses were required to verify the scheduled medications against the paper-based physician orders at the beginning of each shift. Workflow process changes were introduced to the nursing staff during the software training activities. pharmacists. The system linked the hospital system’s computerized medication ordering and BCMA system. 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. and the nurse informatician. Nurses working on a 28-bed cardiovascular step-down unit were recruited as a control group. the a level was set at . The first five questions measured the nurses’ perception of how easy the medication administration process was. Surveys were coded to protect the identity of the subjects. 3. Overall. I have nearly had a medication error in the last month. and content validity was tested by colleagues in informatics. Finding out which medications are due to be given soon is easy. It takes me too long to give medications. The following is a complete list of questions included on the questionnaire: 1. I can easily see what medications my patient has had. 8. Chi-square tests were conducted on gender and licensure variables to determine differences between the experimental and control groups. 2. The survey questions were developed by the researcher. 7. (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. 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 Statistical Package for Social Sciences (SPSS) (Version 16. 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. 5.Instrument The questionnaire consisted of eight questions. I have had a medication error within the last month. The new medications are put in the computer/handheld PC in a timely manner. 9. IL) was used to conduct statistical data analysis. Following a Bonferroni correction for multiple tests. Chicago. SPSS.016. Reliability and validity statistics were not computed on the survey due to the low sample size (Feldt & Ankenmann. Codes were consistent throughout the study to provide paired data for statistical analysis. 4. 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. Independent t-tests were used to compare age and years of experience between the experimental and control groups.0 for Windows. I always document my medications prior to administration. Twenty-five surveys were collected prior to the implementation on the . A total of 33 staff members returned surveys on the BCMA and 26 returned the surveys on the control unit (Table 1). I have had a medication error within the last month. 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). Results Participants Completion of the questionnaires was voluntary and the return rate of the questionnaires was approximately 42%. 1998). 33 surveys were collected on the experimental unit and 14 on the control unit. p = .95. particularly in the results of the control group surveys. There were 19 paired surveys on the experimental unit and 10 paired surveys on the control unit. There were significant amounts of missing data. The control group was significantly less satisfied with the overall medication administration process. 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. t(44) = 3. Following the implementation of BCMA.33. This limits the ability to draw inferences about the demographic similarities or differences in the two groups.002. Questionnaire A comparison of satisfaction between the control and experimental units before BCMA implementation demonstrates differences in two areas. This may have had an impact on differences in satisfaction between the two groups. The completed surveys had various amounts of missing data. .experimental unit and 22 were collected on the control unit. 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. p= . p = . the experimental group had decreases in satisfaction with the medication administration process in three areas (Table 2). nurses’ satisfaction with their ability to determine which medication was due decreased with use of the BCMA.001. the nurses indicated that it was more difficult to see what medications the patient had already had.09 (Control). M = 4.4) = 4. Following the implementation. Both groups indicated that they agreed with the statement that it was easy to determine what medications were due.005. t(43. First.5 (BCMA) and M = 4. Finally.000. p <. The paired t-tests verified these findings.54. t(52) = 3.05. there was a decrease in satisfaction with the overall medication administration process for the BCMA group following implementation of the BCMA. Second. . . pre. These results differ from those of other researchers who indicate that nurses are satisfied with the systems (Hurley. .A comparison of the control group surveys. & Wilson. This study also demonstrated an overall reduction in nurses’ satisfaction with the medication administration process when the BCMA system was implemented. The implementation of new technologies into healthcare systems can be a complicated endeavor. as well as medications previously given. 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. 2003). nurses were part of the implementation team. Future studies employing larger samples are recommended. Coyle & Heinen. et al. In this study. 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 costeffective healthcare. 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.and post-implementation of the BCMA system on the experimental unit did not yield any statistically significant differences for any of the satisfaction indices. this is the first case control study evaluating the satisfaction of nurses following implementation of a new BCMA system. Ludwig. There were no differences in either group related to perceived medication errors or near misses. 2007. 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. on the handheld device following implementation of the BCMA system. 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. The paired t-test verified these findings. 2005. The use of BCMA systems is viewed as a promising technology to reduce medication errors in hospital settings. discussion of negative outcomes is often not desired or encouraged. Nurses indicated a decrease in the overall satisfaction with the medication process following implementation of the BCMA system. but including the nurses at the implementation phase may not be adequate. Due to the significant investment of money required to purchase and implement these systems.. To date. Rough. but implementation of these systems may be less than optimal if they have unintended outcomes on the medication administration process. 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. but the continued use of carefully chosen control groups will provide higher levels of evidence for research in this area. The control group had no significant changes in responses following the study. Randomization of subjects may be difficult. 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. and the sample size was too small to determine statistical reliability of the instrument. Measurement of satisfaction and attitudes for this study could not be delayed since the pilot project was ended 5 months after implementation. hospitals first need to determine whether the benefits are negated by nurses’ resistance to the change and how that resistance can be minimized. the intended improvements in care of our patients as a result of these new technological innovations may never be realized. So before any decisions are made regarding the overall effectiveness of BCMA. Due to the nature of the BCMA pilot program. There were no limitations on communications between the experimental or control groups. There was no follow up for nursing staff that did not complete their survey. Conclusion Bar-coding medication administration may be a technology that will significantly reduce medication errors in hospitals and therefore greatly improve patient safety. such as workarounds. Although surveys were given to all nurses on the units using their unit mailboxes. However. Ultimately. Methods used to provide education and change processes can be enhanced to improve the overall satisfaction with these new technologies. so cross contamination of the groups may have occurred. completion of the questionnaires was voluntary and the return rate of the questionnaires was low. Unless implementation staff and software developers acknowledge the impact these systems have on nurses and make adjustments to improve satisfaction. The survey was short in order to maximize the response rate by busy clinicians. Therefore. 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. that may reduce the effectiveness of the system. the healthcare system studied in this research opted to develop a medication bar-coding system rather than to purchase. Demographic data on the returned surveys was incomplete. (2007) concluded that changes in workflow must be assessed and workflow processes reengineered prior to implementation of these systems. introducing BCMA systems into patient care areas may have unintended consequences. . Limitations There were several limitations to this study. 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. the number of subjects available for study was limited.Caryon et al. Full Text of Background.8% relative reduction (P<0. although it did not eliminate such errors. Full Text of Results. Full Text of Methods.) . The rate of timing errors in medication administration fell by 27. RESULTS We observed 14..BACKGROUND Serious medication errors are common in hospitals and often occur during order transcription or administration of medication.5% error rate) versus 495 such errors on units that did use it (a 6.3% (P<0.1% on units that did not use the bar-code eMAR but were completely eliminated on units that did use it.NCT00243373.001). METHODS We conducted a before-and-after. Our data show that the bar-code eMAR is an important intervention to improve medication safety.001). CONCLUSIONS Use of the bar-code eMAR substantially reduced the rate of errors in order transcription and in medication administration as well as potential adverse drug events. quasi-experimental study in an academic medical center that was implementing the bar-code eMAR.6% with its use..4% relative reduction in errors (P<0. representing a 50. The rate of potential adverse drug events (other than those associated with timing errors) fell from 3. Two clinicians reviewed the errors to determine their potential to harm patients and classified those that could be harmful as potential adverse drug events. We assessed rates of errors in order transcription and medication administration on units before and after implementation of the bar-code eMAR. To help prevent such errors.041 medication administrations and reviewed 3082 order transcriptions.1% without the use of the bar-code eMAR to 1. but the rate of potential adverse drug events associated with timing errors did not change significantly.001). Errors that involved early or late administration of medications were classified as timing errors and all others as nontiming errors. (ClinicalTrials..8% error rate) — a 41... technology has been developed to verify medications by incorporating bar-code verification technology within an electronic medicationadministration system (bar-code eMAR).gov number. Transcription errors occurred at a rate of 6.. Observers noted 776 nontiming errors in medication administration on units that did not use the bar-code eMAR (an 11.