When the systems we are told to use don’t work as expected, people create workarounds to get their work completed. Some of these workarounds are discussed below (and there are probably a few more not mentioned here):
Manual Entry of Bar Codes
One common workaround is the manual entry of bar codes when the scanner fails to read the bar code correctly. Nurses may type in the medication codes directly into the system, which bypasses the scanning process intended to ensure accuracy. While this may save time, it also opens up the possibility of transcription errors.
Borrowing or Sharing Bar Codes
Another workaround involves borrowing or sharing bar codes. Nurses might scan a bar code from a different patient’s wristband or medication label if the correct one is not readily available. This can lead to administering the wrong medication to the wrong patient, even if the nurses are trying to be careful while delivering medications.
Overriding Alerts
BCMA systems often include alert features that notify nurses of potential errors, such as dosage discrepancies or patient allergies. However, these alerts can sometimes be perceived as overly sensitive or irrelevant. In other words, the alerts are false positives and they occur with enough frequency that they numb people to the instances when they are true positives. Because of this, nurses may develop a habit of overriding these alerts without fully addressing the underlying issue, as found by Patterson et al. (2002). This behavior can negate the safety benefits of the BCMA system.
Pre-scanning Medications
To save time, nurses might pre-scan medications for multiple patients at once and administer them later. This practice can lead to errors in matching the right medication with the right patient, especially in busy or chaotic environments where distractions are common.
Bypassing the System Entirely
In some cases, nurses might bypass the BCMA system entirely, particularly if they believe it hinders their ability to provide timely care. For example, if the system is down or too slow, they may administer medications based on their knowledge and experience rather than relying on the BCMA system. Their claims of equipment failure are easy to prove which allows the deviance to continue.
Creating Fake Bar Codes
In extreme cases, nurses might create fake bar codes to circumvent the system. This can happen if a bar code is damaged or missing, and the nurse opts to create a temporary solution rather than wait for a replacement. This practice can lead to serious medication errors and is highly risky. I have not seen this done in my experience, but it is mentioned when you search for BCMA workarounds.
Last Thoughts:
While BCMA systems are designed to enhance patient safety, various technical, workflow, usability, and environmental issues can lead to the development of unsafe workarounds by nurses. These workarounds, such as manual entry of bar codes, borrowing or sharing bar codes, overriding alerts, pre-scanning medications, bypassing the system, and creating fake bar codes, can compromise the safety and effectiveness of medication administration. Addressing the root causes of these problems is essential for ensuring that BCMA systems fulfill their intended purpose of improving patient safety.
References:
– Koppel, R., Wetterneck, T., Telles, J. L., & Karsh, B. T. (2008). Workarounds to barcode medication administration systems: their occurrences, causes, and threats to patient safety. Journal of the American Medical Informatics Association, 15(4), 408-423.
– Poon, E. G., Keohane, C. A., Yoon, C. S., Ditmore, M., Bane, A., Levtzion-Korach, OGandhi, T. K. (2010). Effect of bar-code technology on the safety of medication administration. New England Journal of Medicine, 362(18), 1698-1707.
– Zhang, Y., Walji, M. F., & Johnson, T. R. (2014). Barriers to and facilitators of the use of electronic health records in long-term care facilities: a systematic review. BMC Medical Informatics and Decision Making, 14(1), 1-12.
– Patterson, E. S., Cook, R. I., & Render, M. L. (2002). Improving patient safety by identifying side effects from introducing bar coding in medication administration. Journal of the American Medical Informatics Association, 9(5), 540-553.