Study Near-miss Barcode Medication Errors to Prevent Worse Events
May 1, 2018
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Barcode medication administration (BCMA) errors are a serious threat to patient safety and quality of care, but focusing only on the reported errors could be a mistake. The errors that reach the patient are likely to be quite low, but that does not mean you don’t have a BCMA safety issue in your organization.
A low rate of reported BCMA errors can foster a false sense of security that could eventually result in a patient death or serious harm, say clinicians and researchers who have studied the issue. Direct your attention to the near misses that might indicate more of a problem with BCMA.
Reports of near-miss BCMA events increased more than 2,700% over 12 years in Pennsylvania, from January 2005 through December 2016, says Ellen S. Deutsch, MD, MS, FACS, FAAP, CPPS, medical director of the Pennsylvania Patient Safety Authority (PPSA) in Harrisburg. The vast majority of those errors were caught before they reached the patient, with only 0.5% of all reported BCMA-related events causing patient harm.
“It’s important to pay attention to near misses because they provide information about processes that can be very useful,” Deutsch says. “Understanding why a patient was harmed certainly is important, but if we can understand the factors that contributed to the potential for harm then we may be able to prevent harm even earlier in the process.”
Reporting of BCMA events and near misses, as with any other patient safety issue, is more complicated than it might seem at first, Deutsch says. The number of such events reported isn’t necessarily the number of events that occurred. That number reflects what actually happened, but also people’s sensitivity to both recognizing and reporting those events, she says.
Deutsch notes that reports of BCMA events and near misses may increase once the organization brings attention to the issue. That is not necessarily a bad development.
Instead, the increased number can be due to that mix of actual events, the ability of staff to recognize them, and their willingness to report them. The number of events may not have changed, but the recognition and reporting may have improved so that you’re now seeing a more accurate representation of the issue.
“It may not indicate any worsening of the problem, but instead reflect an increased sensitivity to the problem. That’s a good development if that is the cause of the increase,” Deutsch says. “If organizations find that happening as they collect data, they should not presume the problem is getting worse but look at why people are reporting more. It’s relatively common for the number of event reports to go up after focusing on a problem, but hopefully the number goes down in the long run to reflect a change in processes and behavior.”
Increase in BCMA Issues
PPSA addressed the issue recently in a case study that focused on Blue Mountain Health System in Lehighton, PA. Blue Mountain reduced its barcode-workflow events by 53% between 2014 and 2016, working with PPSA to analyze near misses and improve its BCMA process. (PPSA’s case study is available online at: https://bit.ly/2uscbhs.)
The analysis revealed that BCMA events occurred during each phase of the process. Just under 10% involved more than one step of the process, with errors most common in the administration process, which accounted for 83% of the events. Dispensing accounted for 27% of the events, prescribing for 1.6%, and transcribing for 0.8%.
Staff workarounds were identified as a significant risk for BCMAs, with employees intentionally deviating from standard procedure to save time or overcome a problem in providing medications.
Not Just the Nurse
One interesting finding from the case study was that BCMA issues are not always about the provider administering the medication, Deutsch says.
“There can be a lot of factors that contribute to making accurate selection, dispensing, and administration of medication difficult. Administering medications is the last step in a long series of surprisingly complex events,” she says.
“People don’t always realize how complex that is, and it is easy to point to the last person in that series of events as the one at fault. There are lots of ways to try to understand the process better, and there can be improvements made upstream that can help improve patient safety.”
Deutsch recommends several strategies for improving BCMA. First, she suggests observing how the process actually occurs on a day-to-day basis, keeping in mind that this might be different from the established protocol.
No matter how much faith you have in your clinicians as highly trained, well-intentioned professionals, do not assume that they are carrying out BCMA by the book every time, with every patient.
Direct observation of patient care will produce the best information on how clinicians perform BCMA, but simulations also can be helpful, Deutsch says. Clinicians who are so used to doing tasks their way may reveal that in simulations even though they know they are being observed.
The key, Deutsch says, is to learn not just where clinicians are deviating from established procedures, but why.
“Sometimes there are complexities to equipment that you didn’t know about when the process was designed, and you’re not going to know about those things until you observe, simulate, or conduct interviews,” she says.
“Determining which person in this complex series of events was involved at the moment an error occurred or when there was a deviation from established procedure is not enough. The goal is find out why and take the steps that prevent that from happening again or remove the motivation for that person to use a workaround,” she adds.
PPSA recommends using what it calls the Good Catch ratio, which compares the number of near-miss events to the number of serious events.
Because there will be multiple near-miss events for each serious event, PPSA says a greater Good Catch ratio indicates a “safety culture that values recognition and reporting of hazards before harm occurs.”
Health System Investigates
Blue Mountain Health System’s investigation of BCMA revealed the importance of understanding near misses, says Krista Miller, RPh, MBA, director of pharmacy at Blue Mountain. Near misses will make up a significantly larger pool of data than events that reach the patient and cause harm, she notes, so there is much more to be learned about the BCMA process from studying those events.
The health system found that there were few BCMA near miss reports prior to 2010 and set out to improve the reporting of those events and to identify contributing factors.
The health system’s bedside barcode scanning software was adjusted to capture more data regarding near misses, producing a 172.7% increase in overall medication-administration error reports over one year at the system’s first campus and a 36.4% increase at the second campus.
“The proportion of near-miss event reports … increased more than 280% at both campuses, from 20.5% of total reports in 2011 to 78.6% in 2012,” PPSA reports.
Near misses often do not get the respect they deserve in healthcare organizations, Miller says.
“The attitude you hear a lot is it was a near miss, so we’re lucky it didn’t turn into something serious. It was caught in time, so we’re okay,” Miller says. “Not really. Yes, it’s good that we caught it before it harmed a patient, but that near miss is still a serious issue we need to address, because next time we may not catch it in time. We need to understand what happened, why, and how we can avoid it in the future.”
Look From Different Angles
The health system also found it was important to involve a multi-disciplinary team. Blue Mountain involved pharmacy, nursing, and leadership, but also respiratory therapists and others who may not seem to be most directly involved or responsible for the BCMA process.
“Once you get a number of perspectives from different people, you can start seeing where the potential problems lie. You can see the things that you’ve taken for granted,” Miller says. “You may find instances in which one person’s interpretation of the process doesn’t match your interpretation. That could be from a lack of communication or unclear information that was sent out, but you want to get down to what caused that misunderstanding.”
Combining those perspectives sometimes will reveal that a BCMA process that works well in one department or clinical area doesn’t necessarily work well in another, Miller says.
The Blue Mountain team found that interacting with clinicians during the BCMA process was the most useful for highlighting problems and potential weaknesses in the system, Miller says.
“We thought we had a pretty good idea of what was happening and the best ways to improve it, but when we did walkarounds and just asked staff to show us what they were doing, we learned a lot more,” Miller says. “We learned about issues that hadn’t come up before, things like equipment that needed to be fixed, connectivity with the wireless system. We didn’t know we had dead zones where they could not connect to the system and they were doing the best they could with workarounds.”
After identifying issues like that and applying the correct remedies, Blue Mountain could then have more confidence when identifying individuals responsible for errors or intentional deviations from the process, Miller says.
Even then the approach was not punitive, she says — instead, seeing the opportunity to provide more education to that individual on the proper processes.
Opportunities for Education
That education sometimes focuses on the differences in the BCMA process from one clinical area to another, Miller notes. Float nurses, for instance, must understand the differences in the process from that used in cardiology and that used in behavioral health, and the reasons for those differences.
Blue Mountain also realized that the system may need to accommodate the difference in resources available around the clock. Day shift nurses were able to rely on pharmacy to resolve any BCMA issues, but the night shift didn’t have that resource available.
“We were seeing more issues on the night shift, and at first we didn’t realize why. What was different about the process at those hours?” Miller says. “Then we realized that pharmacy is not a 24-hour service, and so that was a key resource unavailable to those clinicians.”
Addressing BCMA issues should always begin with studying the available data, but also be sure to look for the information you don’t have, Miller says.
Don’t assume that the data you have paints the whole picture and then set out to address problems. You may be overlooking problems you don’t even know about yet.
“Data is always important, but sometimes you can’t fully understand the situation until you go out and talk to those involved on a daily basis and see what might not be included in that data report,” Miller says. “I think a lot of people will be surprised, because you don’t know what you don’t know until you go looking for it.”
SOURCES
- Ellen S. Deutsch, MD, MS, FACS, FAAP, CPPS, Medical Director, Pennsylvania Patient Safety Authority, Harrisburg. Email: [email protected].
- Krista Miller, RPh, MBA, Director of Pharmacy, Blue Mountain Health System, Lehighton, PA. Phone: (610) 377-7198. Email: [email protected].
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