The technology factor: Is it our friend or our foe?
New study highlights errors with bar coding
While The Joint Commission is asking health care facilities to use computerized physician order entry and bar coding technology as an adjunct to arm themselves in managing high-risk medications including anticoagulants, a recent study highlights the errors implicit in this kind of information technology support.
Peter Angood, MD, vice president and chief patient safety officer for The Joint Commission, points out that while technology is helpful, it is not a panacea. "The expectation is that technology will solve the problem," he says. "And it does not."
A first-of-its kind study tackles the problems inherent in IT systems often praised and recommended as first-line defense against medication errors. The study examining flaws in barcode medication administration (BCMA) systems was published in the July/August issue of the Journal of the American Medical Information Association.
Led by Ross Koppel, PhD, lecturer/adjunct professor in the department of sociology at the University of Pennsylvania, researchers looked at five hospitals in the Midwest and on the East Coast and found 15 types of workarounds in which clinicians overrode the BCMA system to compensate for difficulties in the system.
One of the major findings, Koppel says, is "contrary to what is ordinarily discussed in the literature." In the study, he says, about 11% of medication bar codes were unreadable because they were:
- torn, smudged, ripped, sodden, or covered by another label;
- the scanner was outside of the Wi-Fi range for that patient's room.
In other instances, clinicians couldn't use the BCMA system because they were perhaps near the MRI machine or in an X-ray room.
Koppel says the team also found 4% to 5% of patient IDs were unreadable. Some of the reasons include:
- they were from another floor in the hospital;
- patients with dementia had torn them off;
- children ripped them off;
- there was no room for IDs on premature babies with tubing, so they were attached to the crib or the incubator, and Koppel points out these IDs might not be moved when the infant is moved;
- they were covered by sterile gauze dressings;
- they were removed so clinicians could perform clinical procedures, such as taking blood.
"So the usual claim that the bar codes worked 99 point something percent turns out not to be true," Koppel says. So that clinicians could do their jobs, he says, the research team found "tens of thousands of situations" where extra copies of bar codes were made and found on places like door jambs, taped on places like refrigerators or scanning machines, or worn as bangles on nurses' arms that already held all their other patients' IDs.
But Koppel stresses that these instances are not a result of clinicians who are lazy, uncaring, or stupid. It's that systems don't support the reality of processes that need to occur in health care settings, he says.
"No one has thought about the process in its entirety," Koppel says and he gives this example: A nurse has a 94-year-old patient and needs to access a refrigerator two floors down. Instead of wheeling the infirm patient down two floors and a long hospital corridor, the nurse decides to just make an extra copy of the bar code to scan.
What is the answer?
"I don't think anyone is bright enough to predict problems [that can occur with BCMA] a priori," Koppel says, suggesting instead continuous observation of BCMA use and coordinated multidisciplinary discussion.
"Ultimately, it comes down to the quality people, who have to simply not accept vendor claims that nothing can be done or local IT claims that it's not their fault and somebody has to take responsibility for this," he says. In working with vendors, the hospital must have the last word and the final decision. Vendors, he says, can only do their part in fixing the problems but must be directed to priorities by the hospital team.
The future of IT in health care
"Koppel's study is a very important part of a larger literature that's emerged in the last three to five years on the consequences of information technology," says Robert Wachter, professor and associate chairman of the department of medicine at the University of California, San Francisco, and blog author.
"Whenever there's a glitch with a new technology, people always get very wistful and romantic about how good things were before we had it," however unjustified that may be, he says. But in this instance what we had before IT development wasn't working either, he adds.
Early systems are always laden with things to learn, Wachter says, and "no one has done studies like Koppel's study to observe what isn't working and fix it."
Though we're "clearly not" there yet with IT and he applauds Koppel's study, Wachter says, if you take it "the wrong way" and decide to "stop the IT train" than you're just not getting it.
He recently wrote an article about The Joint Commission performance measure on door-to-antibiotic time for pneumonia patients in the emergency department. "It was a mistake," he says, resulting in some patients receiving antibiotics who didn't need them. It was subsequently modified from four to six hours. "Naysayers look at that and say, 'See. We weren't ready for transparency,'" he says. "But you wouldn't get to the place we need to get unless you started somewhere and recognize there's going to be glitches... We have to be smart enough to learn from the experience."
That is what he says progress looks like, learning from errors to improve processes to get to where you want to be.
"If I was buying a bar code system, I would do it with [Koppel's article] in hand and ask the vendor: How do you know these things aren't going to happen? What are the steps that you've taken to ensure they won't happen?"