Reinforcement of Barcoding technology in medication delivery process and medication safety education to reduce medication error: A Quality Improvement Project.

Reinforcement of Barcoding technology in medication delivery process and medication safety education to reduce medication error: A Quality Improvement Project. Check the attached image and have it completed by Thursday. Use safety attitudes questionnaires and Evaluation of the Use of Bar-Code Medication Administration in Nursing Practice Using an Evidence-Based Checklist…

Reinforcement of Barcoding technology in medication delivery process and medication safety education to reduce medication error: A Quality Improvement Project.

Paper details

Check the attached image and have it completed by Thursday. Use safety attitudes questionnaires and Evaluation of the Use of Bar-Code Medication Administration in Nursing Practice Using an Evidence-Based Checklist

Solution

Reinforcement of Barcode Technology in the Medication Delivery Process and Medication Safety Education to Reduce Medication Error Rate

Introduction to Project

The publication of the Institute of Medicine’s (IOM) report, “To Err is Human: Building a Safer Healthcare System” has helped enhance the safety of healthcare. Medication errors are among the critical and prevalent issues affecting the safety and quality of care. Preventable medication errors are among the leading causes of medical injuries. Nationally, medication errors account for more than 3.5 million physician visits, one million emergency department visits, and up to 125,000 hospital admissions (da Silva, & Krishnamurthy, 2016).

Further reports by IOM show that medication errors are closely associated with poor patient outcomes, with 1 in 131 outpatient and 1 in 854 inpatient deaths, and an increased risk for readmission (Bijlsma, & Taxis, 2017). Besides costs exceeding $40 billion annually, medication errors are associated with psychological and physical pain, decreased patient satisfaction, and growing distrust in the healthcare system.

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Medication errors are a major clinical issue. Different measures are being utilized across the health continuum to mitigate and reduce medication error rates. Bar-coding medication administration (BMCA) is one of the technological interventions used to facilitate safe medication administration. To maximize safety and optimize quality, BMCA has been implemented and mandated in medication administration (Bijlsma, & Taxis, 2017).

However, the nurses at the M&M unit do not adhere to the use of the bar-coding during medication leading to medication error rates that are relatively high at 17%. The direct improvement project focused on reducing medication error rates by reinforcing the use of BMCA during medication administration.
The effective use and adoption of the BMCA system lead to safer medication administration, coupled with lower hospital costs, improved quality, and higher patient satisfaction.

Studies show that the implementation of the BMCA also has implications on nurse workflows as it reduces the time spent on medication-related activities by 25% (Booth, Sinclair, Strudwick, Hall, Tong, Loggie, & Chan, 2017). Despite safety and operational efficiency benefits coupled by an existing barcode system, reduced use of the technology due to challenges including being understaffed, heavy workloads, nurse burnout, nurse workarounds, lack of adequate training on the technology and non-compliance with CPOE policy are among the factors attributing to the 17% medication error rate in the facility.

Besides, challenges associated with human-machine interface interactions such as lack of adequate training and attitudes that influence perceived usefulness and understanding, limit the competence of nurses in utilizing BMCA (Booth et al., 2017). Reinforcing the use of BMCA in medication administration reduces the medication error rates in the unit, thereby improving safety in the facility. The DPI project implemented a BMCA reinforcement framework that emphasized the use of barcode technology in the medication delivery process by training on the use and usefulness of the technology and medication safety education (Darawad, Othman, & Alosta, 2019).

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The project assessed the current compliance rates among nurses through the Harrington Bar-Code Medication Administration Evidence-Based Checklist tool, used in pre-intervention and post-intervention (Davies, 2019). Clinical records were applied to determine medication error rates pre and post-intervention, and quantitative analysis was conducted on the variables to determine the effect of the intervention. The DPI project was conducted at the M&M unit of a geriatric psychiatric facility.

Background of the Project

The process of medication is complex and requires strict adherence from the point of ordering to administration. Studies indicate that up to 50% of medication errors occurring in the ordering and prescribing stage are readily identifiable compared to errors in the administration phases that are less identifiable (Davies, 2019). With one-third of the errors occurring in the administration phase, nurses are in the frontline in the mitigation of medication errors. Of the medication errors, IOM estimates that 25% t0 95% are preventable (Davies, 2019).

The evidence-based practice supports the use and adoption of the BMCA system in the administration of medication of prescribed medication. Some of the critical issues identified early in the adoption and integration stages include incorporating the input end-users (nurses), adequate training and education on the use of the system, workflow issues, and perceived usefulness and importance to nurses.

Despite the presence of barcode technology in the facility, nurses use workarounds that increase the risk of medication errors. Unit nurses’ failure to effectively use the technology limit its effectiveness in reducing rates of medication errors. According to Othman & Darawad (2020), the sequence of using BMCA begins with scan Self-ID, obtain medications, scan medication barcode, scan patient ID band, give medication to patients and lastly, document administration.

However, only 39% of nurses followed the procedure as recommended in administering medication (Harrington, Clyne, Fuchs, Hardison, & Johnson, 2013). Consequently, nurses create workaround practices such as directly administering medications without scanning the patient and the medication, increasing the risk of medication administration errors.

Workarounds are defined as observed or desired behaviors that vary from organizationally prescribed or intended procedure. In BMCA use, workarounds occur due to either omission of process steps, performing the steps out of order, or unauthorized process steps. Nurses apply workaround practices to alienate perceived workplace hindrances and challenges or reduce the time spent on medication.

The causes of nurse workaround practices are attributed to the challenges associated with human-machine interfaces, organizational policies, patient-affiliated circumstances, or environment-related factors (Harrington, Clyne, Fuchs, Hardison, & Johnson, 2013). Assessments of the unit associate the non-compliance and workaround practices to an increase in workload, being understaffed, frequent interruptions, lack of adequate education/training on the use of bar-coding technology, and non-compliance with CPOE policy.

Perceived usefulness, understanding of the potential hazards of non-compliance and safety measures education, are also critical in determining the level of nurse compliance (Leung et al., 2017). Reinforcing the use of BMCA system in the medication delivery process and conducting medication safety education on the perceived usefulness of the system and potential hazards of non-compliance, will help reduce preventable medication administration errors.

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Problem Statement

Nurse non-adherence to the guidelines and procedures of barcode medication administration systems increases the risk of medication errors. The M&M geriatric psychiatric unit currently has a medication error rate of 17%. The DPI focused on reducing medication error rates by improving compliance during the medication delivery process via medication safety education (Leung et al., 2017).

The DPI eliminates Nurse Workaround practices and shortcuts to accurate application of BMCA, which increases the risk of medication errors. Medication errors are a crucial impediment to safe healthcare and a pivotal hindrance to better patient outcomes and satisfaction rates (Shen, Chen, Liu, GAO, Xiaohua, Hongzhen, & Zhu, 2018).

The problem of non-adherence to set guidelines and recommendations on the BMCA application directly impacts medication error rates by increasing the risk of preventable errors (Shen et al., 2018). Patients in the geriatric psychiatric unit face multi-comorbidities, and high vulnerability to medication errors.

Potential hazards of medication errors may increase costs, length of hospital stay, and readmission rates, while decreasing patient satisfaction with care and the patient’s psychological well-being during treatment (Leung et al., 2017). Nurses using workaround practices fail to fulfill the commitment of a healthcare professional to effectively use the tools useful in the treatment and management of disease to provide safe and highly competent care.

Despite the prevalence of non-compliance to the BMCA system application as recommended, few measures have focused on reinforcing the system’s use in medication administration. The DPI tied reinforcing BMCA use to medication safety education and training and medication error rates in a geriatric psychiatric unit (Shen et al., 2018).

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While research shows that bar-coding technology is a critical technology in medication administration, it was not known if or to what degree the reinforcement of the use of bar-coding technology in medication administration would impact medication errors when compared to the absence of reinforcing and emphasis on its use among geriatric psychiatric nurses (Leung et al., 2017).

Purpose of the Project

Non-adherence to set guidelines in BMCA subsequently affects the ability of nurses to deliver safe and quality care. The contemporary nursing continuum is geared on utilizing the frontline position of nurses to improve the quality of care continuously. Safety and patient satisfaction are key attributes of quality caregiving and directly correlate to reduced medical costs, readmission rates, and length of admissions (Shen et al., 2018).

Over the years, the integration of technology has been geared towards improving operational efficiencies in care while maximizing safety and optimizing quality (Leung et al., 2017). Each technology-led improvement relies on the ability of end-users, health practitioners, to effectively adopt and implement the system for better outcomes. Following guidelines and recommendations is critical in addressing the underlying problems and consequently improving the quality of care.

Improving adherence to BMCA use narrows down influencing the factors hindering effective use and creating frameworks to support the sustainable use of technology in clinical settings (Othman, & Darawad, 2020). Education and training were identified and applied to influence nurse attitudes to BMCA, such as perceived usefulness, ease of use, and the capabilities to use BMCA during medication administration effectively. Medication safety education also focused on creating awareness on the potential hazards of nurse workaround practices and emphasizing on the use of correct guidelines and procedures when applying BMCA (Othman, & Darawad, 2020). Through the reinforcement, the project reduced medication error rates.

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The DPI addresses clinical issues that affect up to 80% of facilities using BMCA systems. The successful implementation of the intervention provides evidence to support effective and safe nurse practices while optimizing nurse performance and workflows. The purpose of this quantitative, meta-analysis project was to determine if or to what degree the reinforcement of barcode medication system among nurses would impact the rates of a medication error when compared to the absence of reinforcement among nurses in a psychiatric unit in a geriatric facility in Miami, Florida over four weeks.

Clinical Question(s)

The reinforcement of BMCA in a clinical setting optimizes the use of technology to address the prevalence of medication errors. In the DPI, the focus is on influencing nurses to accurately implement and use the BMCA system to minimize the risk for medication administration errors (Leung et al., 2017). The independent variable in the research is the intervention, while the dependent variable is the medication error rates in the unit. The clinical question for the DPI project was to what degree does the implementation of reinforcement of barcode technology in the medication delivery process and medication safety education impact medication errors when compared to the absence of reinforcement among nurses in M&M medical CTR?

From the clinical question, clinical PICOT question was formulated with the nurses in the geriatric unit being the population, reinforcement of barcode medication administration technology being the intervention, compared to maintaining the current approach of zero reinforcement and emphasis on following recommended steps for BMCA (Othman, & Darawad, 2020). The expected outcomes are a decline in the medication error rates from the current 17% to 10% within four weeks.

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The decline indicates the success of the intervention in addressing the problem of poor compliance to BMCA use and application recommendation. The PICOT question is (P) Among nurses in M&M medical CTR, (I) reinforcement of barcode technology in the medication delivery process and medication safety education, (C) compared to the absence of reinforcement to reduce medication error rate from (O) 17% to 10%, (T) over a period four weeks?

Advancing Scientific Knowledge

At the core of the project is the change in behavior of nurses and paradigm shift to compliance to set guidelines on BMCA use. Donabedian’s theory, the theory of planned behavior, and the Normalization Process Theory guided the Direct Improvement Project and helped verse the transition pre to post-intervention. Donabedian’s conceptual model was used to evaluate and measure improvements to the quality of care by focusing on the components of the structure, process, and outcomes (Shen et al., 2018).

The model is founded on the concept of structure measures influencing process measures, which subsequently affect outcome measures. Donabedian’s model helped link how medication errors (outcome measure) relate to the use of the bar-coding technology (process measure), and workflow factors such as nurse burnout (structure outcomes) correlate with improving the quality of care at the facility (Othman, & Darawad, 2020).

The Normalization Process Theory provided a framework for implementing, embedding, and integrating the intervention by focusing on human processes that facilitate the adoption of new practices (May et al., 2018). The conceptual model helped in defining the approaches for reinforcing of bar-coding technology in the medication delivery process, medication safety education, ensuring the intervention is accurately embedded into practice and providing sustainable measures for maintaining the practice past the evaluation period. The DPI helped understand how normalization theory can be used alongside TPB and Donabedian’s theory to provide a rationale, culture behavior, and provide a framework for sustained implementation.

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Significance of the Project

The quality improvement project aims at reducing medication errors within the unit to 10%, thereby contributing to patient safety and optimizing the quality of care. The project focuses on reinforcing the adoption of an already existing framework, subsequently improving the operational efficiencies of the bar-coding technology in the system. The project also addresses a gap consistent across the organization and helps alleviate the high risks and costs associated with medication errors (Othman, & Darawad, 2020).

Upon implementation, the intervention will alienate nurse workarounds, consequently improving nurse workflows by up to 25%. The potential results affect critical determinants of patient outcomes, safety, and quality of care (Othman, & Darawad, 2020). The implications range from reduced readmission rates due to medication errors, lower costs, and increased patient satisfaction.

Despite the growing literature on the use of technological solutions for clinical issues such as medication errors and patient falls, few studies examine the long-term application of the systems in line with the compliance of end-users. Current literature on Health IT use and integration dictates that it is imperative to establish monitoring and evaluation frameworks to assess the compliance to set guidelines of use. The DPI project contributed to the design and implementation of an intervention to ensure the sustainable integration of technology-led solutions.

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The intervention can also be used in the implementation and reinforcement of other health IT integrations in clinical settings. The intervention is particularly useful as it creates a framework for behavioral change by addressing underlying attitudes, and providing a path for continuous quality improvement.

With the increase in Health IT in nurse workflows, the project provided a framework for effective system implementation and the approaches to address implementation challenges. The conceptual framework of the project provided a pathway for assessing, improving, and empowering nurses’ abilities in performing technology-related tasks. Besides improving health informatics, the project examined a gap that affects most health IT systems post-implementation.

Rationale for Methodology

The project used a quantitative approach to conduct the research. The method allows the project to apply descriptive statistics in conducting a systematic and empirical investigation. The methodology helped define associations between variables of the project leading to a better understanding of the gap and the implications of the intervention. Quantitative research examined the relationship among variables to identify statistically significant relationships based on objective measurement and observation.

In the methodology, the criteria for crucial research is significance, researchability, feasibility, and interest.
On medication errors and potential change, the research obtained the data from clinical records on the number of medication errors in the facility throughout the four weeks of intervention. Pre-intervention numbers were recorded, and change monitored during the intervention and after the intervention.

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In data analysis, Descriptive statistics described the sample characteristics and variable results. Mean, and the standard deviation was used to examine nurse compliance with Bar-code medication systems. Correlation tests were used to identify correlations between compliance and satisfaction with the BMCA system, perceived usefulness, training and understanding of the systems, and ease of use and the medication error rates in the facility.

Nature of the Project Design

The project used a quantitative quasi-experimental design to conduct the research. The design enabled the DPI project to examine the findings of independent studies and assess the effectiveness of the intervention. The quasi-experimental design allowed the researcher to manipulate the independent variable, but the subjects are not randomized (Xie, 2017). This allows the independent variable to be measured, observed, and manipulated, unlike most research designs. The framework makes quasi-experimental design a non-randomized, pre-post intervention framework. This fits the DPI project, which does not allow randomization, is applied to a specific location in a hospital and has a small sample size.

The quasi-experimental approach is best suited for the research focused on medical informatics as it allows the evaluation and monitoring of pre and post-intervention outcomes. Moreover, quasi-experimental are highly effective because they evaluate the real-world effectiveness of an intervention implemented by hospital staff, rather than the efficacy of an intervention implemented by research staff under research conditions (Van Der Veen et al., 2018). This makes quasi-experimental have a better external validity compared to random controlled trials (RCT), which are considered superior.

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The research was conducted at M& M medical center, Miami, Florida. The population was of a geriatric psychiatric unit with 20 RN nurses. The sample included nurses within the unit, handling patients and medication administration. The sample population was recruited through convenience sampling. The participant had to be RNs, working at the selected unit for at least six months, and administering medications to patients as part of their daily tasks. Physicians and nursing managers, not directly involved with medication administration and the use of the barcode medication system, were excluded from the research.

For data collection, the researchers used NoMAD, a 17-item BMCA evidence-based checklist used by Othman & Darawad (2020), and direct observation. NoMAD was used pre-intervention and post-intervention to determine the nurses’ compliance with barcode medication administration (Van der Veen et al., 2020). The 17-item evidence-based BCMA checklist evaluated administrative, clinical, and technological aspects of BCMA policies, procedures, and utilization. The checklist provides a basis for assessing the compliance of nurses pre-intervention and post-intervention as it assesses best practices.

Othman & Darawad (2020) utilize the checklist and determine that all the checklist items are relevant to the practice environment and consistent with current literature. Direct observation was used, under the approval, to examine the cause of the problem and using analyze the findings using a Root-cause Analysis approach. Upon approval, direct observation will provide empirical data while eliminating problems with self-report bias. The medication errors were measured before the intervention and after the intervention.

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Definition of Terms

• Nurse Workarounds defined as observed or desired behaviors that vary from organizationally prescribed or intended procedure.
• BMCA is “point-of-care technology that integrates nurse scanning of bar-coded medications with the patient’s electronic medication administration record.”
• Perceived Usefulness (PU) is “the degree to which a user believes that using [a] system will enhance his or her performance.”

Assumptions, Limitations, Delimitations

Assumptions

• The research assumes that all RNs taking part in the intervention received adequate training and education to effectively and competently use BMCA.
• All participants (Nurses) are aware of the five rights of medication administration, guidelines, and recommendations for BMCA as well as the facility’s medication administration.
• Despite the bias of self-reporting, the nurses provide accurate answers.
• Workarounds can be both conscious and unconscious, and most nurses use different types of workarounds in medication administration.

Limitations and Delimitations

One of the critical limitations of the study is one the reliance on self-reporting in determining the safe and effective use of BMCA. Nurses may alter the accuracy of the data to downplay the use of workarounds in administering medications. Besides, the DPI utilized a quasi-experimental design, which is limited by lack of randomization (Van der Veen et al., 2020). A non-randomized sample may be prone to bias, especially when coupled with a small sample size. Lastly, the measurements and observations are sufficient to use.

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Summary and Organization of the Remainder of the Project

There is a need to implement an evidence-based method to reinforce the use of barcode technology in medication administration. Despite the safety and operational efficiency benefits coupled by an existing barcode system, reduced use of the technology due to challenges including being understaffed, heavy workloads, nurse burnout, nurse workarounds, lack of adequate training on the technology and non-compliance with CPOE policy are among the factors attributing to the 17% medication error rate in the facility. The project reinforced barcode technology in the medication delivery process and medication safety education to reduce the medication error rate from 17% to 10% in a geriatric psychiatric unit in 4 weeks.

Prior studies show that effective use of barcode technology in medication administration is associated with reduced medication errors and improved operational efficiencies. However, few studies examine how reinforcement of BMCA through medication safety education improves use and integration in clinical settings. The research applies a quantitative approach to collect numerical data on the impact of reinforcing the use of bar-coding technology on medication error data in a geriatric unit. The DPI reduces the medication error rates will improve patient safety and quality of care in the geriatric psychiatric unit.

In Chapter 2, section 2 focused on the theoretical models used in defining the gap and the intervention. Section 3 examined the themes and subthemes in the literature review, tying each theme and subtheme to the gap and interventions of the project. The significance of the project is identified and described in section 4, while section 5 provides a rationale for the quantitative project method, and section 6 discussed the project design.

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Chapter 3 examined the methodology used in the project. The problem is redefined and a rationale for the clinical question provided. The chapter also includes a comprehensive analysis of research methodology and research design. Chapter 3 also defined the population and sample selection mechanism, the research materials and instrumentation, trustworthiness, validity, reliability, and approaches used in data collection and management. The data analysis procedures were also comprehensively examined, ethical considerations analyzed, and the limits and delimitations of the methodology discussed.

References

• Bijlsma, M., & Taxis, K. (2017). Association between Workarounds and Medication Administration Errors in Bar Code-Assisted Medication Administration: Protocol of a Multicenter Study. JMIR research protocols, 6(4), e74-e74.
• Booth, R. G., Sinclair, B., Strudwick, G., Hall, J., Tong, J., Loggie, B., & Chan, R. (2017). Strategies through clinical simulation to support nursing students and their learning of Barcode Medication Administration (BCMA) and Electronic Medication Administration Record (eMAR) technologies. In Health Professionals’ Education in the Age of Clinical Information Systems, Mobile Computing, and Social Networks (pp. 245-266). Academic Press.
• Darawad, M. W., Othman, E. H., & Alosta, M. R. (2019). Nurses’ satisfaction with barcode medication‐administration technology: Results of a cross‐sectional study. Nursing & Health Sciences, 21(4), 461-469.
• Da Silva, B. A., & Krishnamurthy, M. (2016). The alarming reality of medication error: a patient case and review of Pennsylvania and National data. Journal of community hospital internal medicine perspectives, 6(4), 31758. https://doi.org/10.3402/jchimp.v6.31758
• Davies, S. L. (2019). Using the Theory of Planned Behavior to Implement a Multi-Modal Fall Reduction Plan (Doctoral dissertation, Grand Canyon University).
• Harrington, L., Clyne, K., Fuchs, M. A., Hardison, V., & Johnson, C. (2013). Evaluation of the use of barcode medication administration in nursing practice using an evidence-based checklist. JONA: The Journal of Nursing Administration, 43(11), 611-617.
• Leung, A. A., Denham, C. R., Gandhi, T. K., Bane, A., Churchill, W. W., Bates, D. W., & Poon, E. G. (2015). A safe practice standard for barcode technology. Journal of patient safety, 11(2), 89-99.
• May, C. R., Cummings, A., Girling, M., Bracher, M., Mair, F. S., May, C. M., & Finch, T. (2018). Using Normalization Process Theory in feasibility studies and process evaluations of complex healthcare interventions: a systematic review. Implementation Science, 13(1), 80.
• Othman, E. H., & Darawad, M. W. (2020). Nurses’ Compliance with Bar-code Medication Administration Technology: Results of Direct Observation of Jordanian Nurses’ Practice. CIN: Computers, Informatics, Nursing, 38(5), 256-262.
• Shen, M., Chen, S., Liu, X., GAO, J., Xiaohua, W. U., Hongzhen, X. U., & Zhu, J. (2018). Establishment of evaluation pediatrics nursing-sensitive quality indicators system based on Donabedian’s structure-process-outcome theory. Chinese Journal of Practical Nursing, 34(26), 2035-2041.
• Van der Veen, W., Taxis, K., Wouters, H., Vermeulen, H., Bates, D. W., van den Bemt, P. M., & Vasbinder, E. C. (2020). Factors associated with workarounds in barcode‐assisted medication administration in hospitals. Journal of Clinical Nursing.
• Van Der Veen, W., Van Den Bent, P. M., Wouters, H., Bates, D. W., Twisk, J. W., De Gier, J. J., … & Ros, J. J. (2018). Association between workarounds and medication administration errors in bar-code-assisted medication administration in hospitals. Journal of the American Medical Informatics Association, 25(4), 385-392.
• Xie, N. (2017). Nurses’ perceptions of bar code medication administration best practices to increase bar code scanning rates in a mental health setting.

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