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Medication Errors Linked to Hospital Technology Flaws

Jul 2, 2008 | Parker Waichman Alonso LLP

Ross Koppel, Ph.D., led research at the University of Pennsylvania (HUP) School of Medicine on how hospital nurses use bar-coded technology that matches patients with their medication.  This was the first such study of its kind and revealed that both the technology design and its implementation—often relied upon as a "cure-all" for medication administration errors—is flawed and can increase the likelihood of some errors.  Even worse, it seems that “the urgencies of care” and creative attempts to cope with the problems have caused other medication errors.  Findings appear in the July/August issue of the Journal of the American Medical Informatics Association (JAMIA).  The study also reveals how workflow and technology adjustments can dramatically reduce the risk of such errors.

The study was conducted at five Midwest and East Coast hospitals, but not HUP, as it does not utilize the technology.  Koppel and colleagues from other healthcare systems examined nearly a half-million instances where nurses and other staff scanned patients and medications and found a significant amount of scans involved nurses overriding the technology with workarounds to compensate for difficulties with the barcode systems, which typically consist of “handheld devices and computers that match machine-readable barcodes on patients and medications.” If the data match and are consistent with prescribed medications, medications are administered, otherwise a signal should alert the discrepancy.  The group found 31 "causes" of problems resulting in workarounds, including:  “Unreadable medication-barcodes (crinkled, smudged, torn, missing, covered by another label); malfunctioning scanners; unreadable or missing patient-ID-wristbands (chewed, soaked, missing); non-barcoded-medications; medications in distant refrigerators; lost wireless connectivity; problems with patients in contact isolation; and emergencies.”

Research revealed nurses scanning the barcode on the medication or the patient's ID bracelet overrode the technology in 4.2% of patients and 10.3% of medications charted.  Conversely, barcode medication administration (BCMA) system vendors report much smaller error rates; however, such vendors only look at the technology’s ability to affix and read barcodes.  Researchers also “spent years studying nurses using the technology; participated in many BCMA implementation meetings; and conducted scores of interviews with pharmacists, nurses, and IT leaders.”

On average, hospital patients are subject to one medication administration error daily, according to the Institute of Medicine; in hospitals, medication administration accounts for 26% to 32% of adult patient medication errors.  Koppel emphasized, "It's not that staff are lazy or careless, it's that the system does not work as well as it should.  If the refrigerated medication is two floors and a long hallway away, you're not going to wheel your 87-year-old patient to the fridge.  You make a copy of her barcode.  And while you do that, you help another two patients who also need refrigerated medications."

The researchers found that today’s high pressure hospital culture may have also played a part in the nurses compensating for the imperfect technology and workflow by devising 15 types of workarounds. The study also presents “typologies of workarounds,” BCMA "causes," and the kinds of errors associated with each.