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Patient safety is compromised when healthcare workers use workarounds to speed things up when they are busy, or to overcome roadblocks that make it difficult or impossible for them to follow proper procedures in the medication process, warns a recent report from the Pennsylvania Patient Safety Authority (PPSA) in Harrisburg.
The good news is that recognizing those workarounds provides quality leaders the opportunity to redesign the work process so that clinicians are not tempted to deviate from the procedure.
In its work with Blue Mountain Health System in Lehighton, PA, to identify barcode medication administration (BCMA) risks, PPSA found a pattern of near-misses involving a commonly used drug administration check tool that uses point-of-care barcode technology to automatically validate and document the medication administration process. The system is intended to improve patient safety by reducing medication errors.
The health system’s data indicated multiple instances of barcode scans of the wrong patient as the nurse administered medication at the bedside, which generated error reports for each one. When the health system and PPSA investigated, they found that these incorrect barcode scans were intentional: nurses were not clearing the previous patient from the barcode scanner because it was faster and easier to leave the previous patient info in the system. Following the proper procedure to clear one patient before scanning the next required too many mouse clicks and slowed down their work, the nurses reported.
“To understand the nurses’ barcode scanning workflow better, the team surveyed nursing staff about their scanning process, including whether they scan the medication or the patient first. The existing policy set an expectation that the patient is scanned first, then the medication,” the PPSA report explains.
“However, nurses would engage a workaround in certain circumstances (e.g., when the same medication was ordered for multiple patients [e.g., acetaminophen], nurses would first scan the medication). This workaround contributed to some of the wrong-patient scan totals. In addition to policy re-education, nursing directors affixed a STOP sign visual reminder to the mobile computers, which reinforced the proper scanning sequence. This reminder helped reduce the number of wrong-patient scan errors.”
Lack of internet connectivity also led to staff employing workarounds that they thought were the best alternative to following the standard procedures.
“For example, the health system noted certain patient rooms had greater numbers of barcode scanning events than others, which was associated with limited or no internet connectivity,” the report says. “Internet connectivity was expanded to include those areas.”
Financial Disclosure: Author Greg Freeman, Editor Jesse Saffron, Editor Jill Drachenberg, Nurse Planner Jill Winkler, Editorial Group Manager Terrey L. Hatcher, and Consulting Editor Patrice Spath report no consultant, stockholder, speaker’s bureau, research, or other financial relationships with companies having ties to this field of study.
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