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First published July 23, 2002 as JAMIA PrePrint; doi:10.1197/jamia.M1061
Journal of the American Medical Informatics Association 2002;9(5):540-553
© 2002 American Medical Informatics Association

A more recent version of this article appeared on September 1, 2002
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Submitted on November 16, 2001
Accepted on April 16, 2002

Improving Patient Safety by Identifying Side Effects from Introducing Bar Coding in Medication Administration

Emily S. Patterson PhD1*, Richard I. Cook MD2, and Marta L. Render MD3

Affiliation of the authors: 1 Ohio State University; 2 University of Chicago; 3 VA Midwest Patient Safety Center of Inquiry and the VAMC Cincinnati

* To whom correspondence should be addressed.

Objective In addition to providing new capabilities, the introduction of technology in complex, socio-technical systems, such as health care and aviation, can have unanticipated side effects on technical, social, and organizational dimensions. To identify potential accidents in the making, the authors looked for side effects from a natural experiment, the implementation of Bar Code Medication Administration (BCMA), a technology designed to reduce adverse drug events (ADEs).

Design Cross sectional observational study of medication passes before (21 hours of observation of 7 nurses at 1 hospital) and following (60 hours of observation of 26 nurses at 3 hospitals) BCMA implementation.

Measurements Detailed handwritten field notes of targeted ethnographic observations of in situ nurse-BCMA interactions were iteratively analyzed using process tracing and 5 conceptual frameworks.

Results Ethnographic observations distilled into 67 nurse-BCMA interactions were classified into 12 categories. We identified five negative side effects following BCMA implementation: 1) nurses confused by automated removal of medications by BCMA, 2) degraded coordination between nurses and physicians, 3) nurses dropping activities to reduce workload during busy periods, 4) increased prioritization of monitored activities during goal conflicts, and 5) decreased ability to deviate from routine sequences.

Conclusion These side effects might create new paths to ADEs. We recommend design revisions, modification of organizational policies, and best practices training that could potentially minimize or eliminate these side effects before they contribute to adverse outcomes.




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