Workarounds to barcode medication administration systems: Their occurrences, causes, and threats to patient safety
Workarounds to barcode medication administration systems: Their occurrences, causes, and threats to patient safety
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DOI：
10.1197/jamia.m2616
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发表时间：
2008-07-01
影响因子：
6.4
通讯作者：
Karsh, Ben-Tzion
中科院分区：
文献类型：
--
作者：
Koppel, Ross;Wetterneck, Tosha;Karsh, Ben-Tzion
作者开发了一种类型的临床医生的工作区时，使用条形码药物管理（BCMA）系统。然后，作者确定每个解决方案的原因和可能的后果。BCMA通常由手持设备组成，用于扫描患者和药物上的机器可读条形码。他们还与电子药物管理记录接口。理想情况下，BCMA有助于确认药物管理的五个“权利”：正确的患者，药物，剂量，途径和时间。虽然据报道BCMAs可以减少给药错误（最不可能被拦截的给药错误），但这些说法尚未得到明确证明。作者通过以下方式研究了5家医院的BCMA使用情况：（1）观察和跟踪2家医院使用BCMA的护士，（2）采访5家医院的工作人员和医院领导，（3）参加BCMA工作人员会议，（4）参加1家医院的故障模式和影响分析，（5）分析BCMA覆盖日志数据。作者确定了15种变通方法，包括将患者识别条形码贴在计算机推车、扫描仪、门框或护士的腰带环上;在推车上携带几种患者的预扫描药物。作者确定了31种解决方法的原因，例如无法读取的药物条形码（起皱，弄脏，撕裂，丢失，被另一个标签覆盖）;扫描仪故障;无法读取或丢失的患者识别腕带（咀嚼，浸泡，丢失）;非条形码药物;电池故障;无线连接不确定;紧急情况。作者发现，4.2%的患者和10.3%的药物被护士忽略了BCMA警报。变通方法的可能后果包括错误的给药、错误的剂量、错误的时间和错误的配方。BCMA的设计、实现和工作流集成中的缺点鼓励解决方法。将BCMA集成到现实世界的临床工作流程中需要注意原位使用，以确保安全功能的正确使用。
The authors develop a typology of clinicians' workarounds when using barcoded medication administration (BCMA) systems. Authors then identify the causes and possible consequences of each workaround. The BCMAs usually consist of handheld devices for scanning machine-readable barcodes on patients and medications. They also interface with electronic medication administration records. Ideally, BCMAs help confirm the five "rights" of medication administration: right patient, drug, dose, route, and time. While BCMAs are reported to reduce medication administration errors-the least likely medication error to be intercepted-these claims have not been clearly demonstrated. The authors studied BCMA use at five hospitals by: (1) observing and shadowing nurses using BCMAs at two hospitals, (2) interviewing staff and hospital leaders at five hospitals, (3) participating in BCMA staff meetings, (4) participating in one hospital's failure-mode-and-effects analyses, (5) analyzing BCMA override log data. The authors identified 15 types of workarounds, including, for example, affixing patient identification barcodes to computer carts, scanners, doorjambs, or nurses' belt rings; carrying several patients' prescanned medications on carts. The authors identified 31 types of causes of workarounds, such as unreadable medication barcodes (crinkled, smudged, torn, missing, covered by another label); malfunctioning scanners; unreadable or missing patient identification wristbands (chewed, soaked, missing); nonbarcoded medications; failing batteries; uncertain wireless connectivity; emergencies. The authors found nurses overrode BCMA alerts for 4.2% of patients charted and for 10.3% of medications charted. Possible consequences of the workarounds include wrong administration of medications, wrong doses, wrong times, and wrong formulations. Shortcomings in BCMAs' design, implementation, and workflow integration encourage workarounds. Integrating BCMAs within real-world clinical workflows requires attention to in situ use to ensure safety features' correct use.