HEALTH CARE LITERATURE IS REPLETE WITH DISCUSSION AND STATISTICS about patient safety and the use of bar code medication administration (BCMA) technology. What is often missing from this discussion is what nurses want pharmacists to know about BCMA. Since pharmacy is usually the primary decision maker in BCMA purchases, while nursing is the primary user of the technology at the point of care, it is important for pharmacy to understand the following:

• Developing effective working relationships is a fundamental component to delivering high-quality patient care.
• Information technology and systems must be designed to fit the patient care delivery model.
• All systems must be integrated to support care provider workflow.
• Care providers and decision makers should develop a clear understanding of the care delivery model before the selection process is implemented.
• Human factor design and cognitive systems engineering (CSE) must be applied to ensure optimal utilization.
• Careful attention to each phase of the process will lead to the proper use of systems and decrease the probability of workarounds.

Developing Effective Relationships
Computerized support systems, from computerized physician order entry to automated dispensing systems to bar code reconciliation, can decrease adverse drug events by reducing reliance on human memory, increasing access to information, and improving compliance with best practice safety procedures. Clearly, the technology should be implemented. But fundamental to quality patient outcomes is the relationship and teamwork between the care providers. Physicians, pharmacists, and nurses are integrally linked in the complex process of medication management, and the organizational infrastructure must be built to support this fact. That means representatives of all groups must be present for discussions and given the time to make decisions that meet the needs of all stakeholders.

Designing IT Systems to Match the Care Delivery Model
To use the current vernacular, nurses are at the sharp end of patient care delivery. They stand at the point where all the preceding work and actions of others culminate into actual intervention with the patient. BCMA has been touted as a technology to provide protection at this point of interaction, and to give the nurse a safety net. But is this really the case? Patient safety is realized in the design of the system and the incorporation of technology into the caring relationship developed between patients, families, and care providers.

Keep in mind that this technology is a tool. The introduction of any technology into the caring relationship must be carefully planned. For example, if a component of the care delivery model is to situate patient care items as close to the patient as possible, then implementing a centrally located automated dispensing cabinet will not support the model or nursing’s workflow. Care providers must spend more time caring for the patient than caring for the technology. This can only be accomplished with a multidisciplinary approach to the design of the patient care delivery model and subsequent agreement upon technological solutions to support this design.

Integrating Systems
In the quest to improve the quality of patient care and outcomes, a variety of technology applications are being purchased and installed in hospitals across the country. Some of these applications include clinical information systems for all data entry and retrieval, bar coding systems for lab specimen labels, smart IV pumps, cardiac monitoring systems with increased flexibility in programming, and cell phones for communication, including answering patient call lights. Many of these systems require the end users — the direct patient care providers — to utilize various forms of hardware, including personal data assistants (PDAs), computers on wheels (COWs), scanners, etc. Some of these systems require the use of a proprietary device. Without integration of the hardware, not to mention the software, nurses and other direct care providers will soon have to wear tool belts to carry all of the equipment required for patient care. Pockets are no longer sufficient to handle all of the necessary tools of patient care.

Many organizations are also developing information systems using a hybrid approach. When a main clinical information system is augmented with other “best in class” specialty systems, all of these systems must be interfaced if they are to be properly utilized by care providers. Without interfaces, multiple log on and password entries will slow down care providers and lead to the potential delay of data entry, especially in times of high activity.

These numerous technology strategies all affect the workflow of care providers and, hence, the care delivery to the patient. The literature shows that these technologies can provide a positive effect if implemented appropriately, with adequate training and retraining, and if the safety measures inherent in the system are used rather than bypassed. If the implementation is approached without considering relationship building, multidisciplinary design, and integration, it could prove to be short sighted, with care providers’ involvement initiated much too late in the process for a truly successful application of the technology.

System Selection
Many organizational structures allow each department to independently develop documents for capital purchases, which are then presented to the decision-making committee for approval or rejection. Once approved, the implementation cycle of buy, install, and then end user education and training begins.
Turning this process upside down might be a better strategy. End users, including nurses, clinical pharmacists, and physicians working in well-functioning teams, should first educate the decision makers about patient care delivery and workflow. With a clear understanding of workflow, the decision makers can then purchase technology that fits and enhances the workflow and patient care delivery in all aspects, not just for each individual process or initiative. The medication management process should not be implemented in isolation, rather it should be part of an overall strategy with a master plan of technology application and information system design.

Applied Science
The master plan for technology and information system design must include a careful study of human factors (human-computer interaction, ergonomics, and usability) and cognitive systems engineering (CSE). The knowledge and skills to apply these processes may not be readily available in all organizations. But considering the cost of the hardware and software — usually in the tens of millions of dollars when all projects are considered — it is not only worth investing in the human resources to assist with this application, it is essential to success. Consideration should be given to bringing this talent in-house or accessing the expertise of consultants during the development of the master plan.

Avoiding Workarounds
With the implementation of BCMA and other technologies, many organizations have expected a change in workflow to occur. In the absence of applied science and understanding of workflow, what often occurs is an increase in interruptions, distraction from patient care processes, and the inadvertent creation of “hassle factors,” which lead to workarounds. Hassle factors are those things that complicate workflow, making it difficult for care providers to follow designed procedures.

Some reported hassle factors include:

• Dragging COWs across carpet, into already crowded patient rooms
• Searching for a device that is shared by multiple caregivers
• Too many screens to flip through to access data entry or data display screens
• Multiple attempts needed to scan bar codes on patient wristbands
• Multiple attempts or contortions required to scan bar codes on individual doses or IV bags

All care providers can demonstrate exquisite creativity in meeting patient care needs and will develop workarounds in their use of technology if the hassle factor is too high.

Conclusion
The steps to creating patient safety using BCMA are complex and challenging. Creating layers of patient safety can easily translate to layers of steps, processes, and tools that do not enhance patient care delivery or care provider workflow. Developing effective working relationships and devoting time and money to the design of patient care delivery models is a foundational necessity. The application of technology and information systems to support the design while using CSE and human factors analysis can lead to the successful use of BCMA to improve patient care outcomes.

Dawn A. Straub, MSN, RN, CNAA, BC is the director of nursing resources and development at the Nebraska Medical Center in Omaha, Nebraska, where she is accountable for professional nursing care operations and for the Center for Nursing Research and Evidence Based Practice. She is also responsible for the nursing components of the electronic medical record and BCMA. Previously, Straub oversaw nursing care operations and care delivery in medical/surgical units, including bone marrow and liver transplantation.