|Year : 2014 | Volume
| Issue : 3 | Page : 186-191
Barcode medication administration and patient safety: A case study in Iran
Asghar Ehteshami, Marzieh Azizi, Niloofar Amini, Tahere Fazeli, Mahtab Kasaei
Department of Health Information Technology, School of Health Management and Information Sciences, Isfahan University of Medical Sciences, Isfahan, Iran
|Date of Web Publication||4-Oct-2014|
Master Student in Health Information Technology, Department of Health Information Technology, School of Health Management and Information Sciences, Isfahan University of Medical Sicences, Isfahan
Source of Support: None, Conflict of Interest: None
Introduction: Patient safety is one important aspect of healthcare. Medication errors are among factors threatening such safety. Medication errors not only endanger the healthcare environment but also impose high costs on health system. Therefore, this study investigated the association between nurses' knowledge of Barcode Medication Administration (BCMA) and its implementation at AL-Zahra Academic Hospital, Isfahan, Iran. Materials and Methods: This is an applied descriptive analytical (association) study. The research society included nurses working in different wards of AL-Zahra Hospital with a sample of 242 persons based on Morgan table (95% Confidence Level). A questionnaire with 45 closed questions and a 43 item checklist, the content validity, and reliability of which was confirmed by professors and through Re-Test method and Cronbach's alpha measurement of 0.774, respectively. Data collection was performed through direct reference by researchers, and findings were analyzed using central tendencies and dispersion parameters of descriptive statistics and Pearson Chi-Square tests of analytical statistics. Findings: Findings indicated that the rate of nurses' knowledge of the BCMA and its implementation in AL-Zahra Hospital was 63.1 and 43.9%, respectively, and there was an association of 0.805 between two variables which was not statistically significant. Conclusion: The rate of nurses' knowledge of the BCMA is relatively favorable, its implementation is not desirable, and the association between two variables is strong but insignificant in AL-Zahra Hospital.
Keywords: Academic hospital, Barcode Medication Administration (BCMA), knowledge, medication error, patient safety
|How to cite this article:|
Ehteshami A, Azizi M, Amini N, Fazeli T, Kasaei M. Barcode medication administration and patient safety: A case study in Iran. Int J Health Syst Disaster Manage 2014;2:186-91
|How to cite this URL:|
Ehteshami A, Azizi M, Amini N, Fazeli T, Kasaei M. Barcode medication administration and patient safety: A case study in Iran. Int J Health Syst Disaster Manage [serial online] 2014 [cited 2019 Jan 17];2:186-91. Available from: http://www.ijhsdm.org/text.asp?2014/2/3/186/142208
| Introduction|| |
Today, maintaining patient safety is one main concept in health-providing systems.  Medical errors are damaging and threatening patient safety.  The most common medical error is medication error  i.e. improper intake of medicine causing harm for patient.  The error might be in each phase of drug prescription, documentation, distribution, administration, and surveillance, the most common of which takes place during prescription or administration. , Medication errors have unpleasant outcomes such as increase in mortality of patients, admission time, and treatment expenses , among which venous medication errors enjoy specific significance since they are directly entered into blood circulation. 
We should know, however, that medication errors are always present  ; however, they should be prevented in order to maintain patient safety.
Incidence of medical errors in the healthcare environment, specially in intensive care is high even in better healthcare-providing countries. There have been lots of studies on unpleasant events especially in the USA, Britain, UK, Australia, Denmark, New Zealand, Canada, France, and Spain, indicating that unpleasant events take place in 2.7-16.6% of hospital admissions, 28-56% of which are preventable.  Almost 7.5% of cases in Canada deal with unpleasant event as well, with more than 70% morbidity and 14% mortality. 
About 2,000 outpatients die due to medical errors with an expense around 77 billion dollars  Nearly 7-16% of medical errors in the USA are medication ones,  resulting in about 106,000 deaths due to unpleasant drug reactions with 12 billion dollars cost. 
The rate of medical errors in Iran is higher than global statistics and scientific resources due to different social and economic factors . According to health, treatment and medical education ministry report, millions of dollars are annually spent on patient care due to medication errors and the resultant increase in hospitalization time. An evidence of such claim is higher patients' complaints of physicians to the medical association organization. 
Medication errors form 20% of all medical errors. In 1961, there were just 656 kinds of drugs, while there are 8,000 kinds of drugs with more than 17,000 treatments and generic names now.  This diversity of drugs and the multiplicity of treatments is one reason of error occurrence during prescription or the rate of different drug administrations. Medication errors include 39% for errors of physician prescription, 38% for errors of giving medications to patient by nurse, 12% for errors while dispensing, and 11% for errors related to transition of physician order into drug kardex. 
It is estimated in the USA that each intensive care unit (ICU) and hospitalized patient experience 1.7 and 1 medication errors, respectively.  In 2004, the mortality rate due to medication errors has been more than that of trauma in Germany, and the rate of hospital medication errors has been 10.8% in the UK leading to 850,000 damages in each year. Among them, 34% have had severe damages, 53% have been preventable, and 8% have led to death. 
According to different studies, mean expense of each medication error in hospitalized patients has been estimated to be 4,600 dollars, added by 363-668 dollars for its legal aspects.  The annual expense of mortality and morbidity due to medication errors has been estimated to be 1.56-5.6 billion dollars in the USA.  This rate has cost about 500 billion dollars in British national medicine. 
Health information technology offers some methods to improve healthcare results, especially in terms of patient safety. , Among such technologies, the Barcode Medication Administration (BCMA) system is an important intervention which decreases medication errors up to 48% through controlling patient identity, medication dose, and the time set for drug administration.  Beside decreasing prescription and drug intake errors, and reducing drug complications in healthcare.  Thus, BCMA has been considered for improving drug administration processes and providing patient safety specially in ICUs. 
According to drug administration, nurses are in direct contact with patients and in the front line of preventing medication errors, and according to physician order, give the medication to patients after controlling variables such as patient identity, drug, time, method of administration, and its dose. The electronic order of a physician is sent to the pharmacy in BCMA, and the pharmacy staff would enter prescribed medication information into the patient computer profile of drug treatment while dispensing. Entering the computer profile of the patient at bedside, the nurse would search patient' cuff for confirming his/her identity, and then searches drug dish barcode both through BCMA software. The BCMA software permits the nurse to administer the medication if all variables (including drug, patient, time, method of administration, and dose) are consistent. If there is any inconsistency between these five factors and information in patient computer profile, BCMA warns the nurse to resolve such inconsistencies before giving medication. When the order is accomplished, the nurse confirms it through electronic signature, and the system automatically records the date and time of accomplishment. Using BCMA saves time for nurses and gives them more time for patient care. Moreover, information documentation would improve treatment measures as another factor of improving care quality. ,
Regarding current statistics and resultant costs of medication errors, advanced societies have used new technologies in order to decrease such errors, save people's lives, and decrease its resultant costs. According to experts, such errors are higher in Iran as compared to global statistics. Therefore, since new technologies such as BCMA has spread among developed countries as methods decreasing medical and medication errors, such technologies are required in the health system of these countries, especially in Iran. In 2012, all of the healthcare departments and wards at AL-Zahra Hospital began to implement BCMA to fulfill clinical governance and implementation of patient safety. Hence, this article has studied the association between nurses' knowledge of the BCMA and its implementation in AL-Zahra Academic Hospital, so to take step in decreasing medication errors.
| Materials and Methods|| |
This is an applied descriptive-analytical (association) study with all nurses of AL-Zahra Hospital, Isfahan, Iran as its society. The sample size was calculated 242 persons using Morgan table (Confidence Level 95% and Confidence Interval 5%). Data collection for measuring nurses' knowledge of BCMA was performed by a researcher-made questionnaire (based on studying different texts about BCMA). It comprised 45 questions, and a researcher-made checklist (based on studying different texts about BCMA) comprised 43 components was used in the second phase based on the study objectives in order to measure the rate of BCMA implementation. The method of content validity measurement, and exerting views of professors in medical informatics groups, health information management, and health information technology were used to measure questionnaire and checklist validity. The questionnaire reliability was also calculated through Re-Test method and Cronbach's alpha measurement of 0.774. For data collection, the researchers directly went to healthcare environment in all shifts at summer, 2012, and distributed and collected the questionnaire among nurses through a cluster random sampling. During filling the questionnaire by nurses of each ward, its head-nurse was interviewed and checklists were completed. Version 18 of SPSS software (Statistical Package for the Social Sciences), descriptive statistics (central tendency and dispersion parameters such as frequency, relative frequency, and mean), and parametric statistical analysis (Pearson Chi square and Phi association tests regarding significance rate of 0.05) were used in order to study the association between nurses' knowledge of the BCMA and its implementation. If an knowledge score of each component were 0-50%, it would be considered unacceptable and unfavorable. A knowledge score of 51-80% were considered relatively favorable (requiring modification), and 81-100% was acceptable and favorable (no modification required).
Findings indicate that the highest knowledge of nurses has been about BCMA defects (71%), and the lowest knowledge about the BCMA application in preventing medication errors (61%). As the findings of [Table 1] shows, the higher rate of knowledge among female and male nurses has been about BCMA defects (69 and 77%, respectively), and their lowest knowledge about preventing medication errors (61 and 62%, respectively).
|Table 1: The total score percentage of nurses' awareness about BCMA according to the fields this technology is used in Al-Zahra Educational Hospital|
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According to findings indicated in [Table 2], the rate of nurses' knowledge about BCMA increases with their level of education. This increase is less apparent in nurses having BS as compared to those having diplomas (68%), whereas there has been 14.96% difference between those having MSc compared with those having BS, and 15.64% higher than those having diplomas. Among nurses having a diploma, the highest rate of knowledge was about increasing precision in medication administration using BCMA, using BCMA in pharmacy, and computer-assisted distribution of drugs using BCMA. The lowest rate of knowledge in this group was 12.5% related to components such as "barcode lines," "having no access to precise drug information using BCMA," and "BCMA effect on working times of nurses."
|Table 2: The total score percentage of nurses' awareness of BCMA according to their level of education|
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The highest rate of knowledge in nurses with BS was an 85% response for the component of "data transition to the database using barcode-reader device," and the lowest knowledge was 14.5% for "barcode lines" component.
The highest rate of knowledge about BCMA among nurses having MSc. It was about electronic drug distribution using BCMA, data present in BCMA, various sizes of BCMA cuffs, resistance of BCMA cuffs, increasing nurse precision using BCMA, preventing drug events using BCMA, having access to patient drug history using BCMA, drug distribution in outpatient ward using BCMA, making it possible to recognize drug information using BCMA, the effective role of BCMA in medication administration management, required equipment for initiation of BCMA, converting barcode to electronic signals, transition of information to the database using barcode-reader device, and making it possible in the hospital to print the barcode on the cuff. Also, the lowest rate of knowledge among nurses having MSc was 33.3% related to "disposable barcode cuffs," "possibility of note taking using BCMA cuff," "BCMA effect on error reduction in drug delivery phase," "recognizing dose levels of drugs using BCMA," "using BCMA in neonatal ward," and "BCMA effect on working time of nurses."
According to findings of [Table 3], the rate of BCMA implementation in AL-Zahra Hospital was not as much as expected (43.9%). The realization rate of BCMA advantages in the studied hospital is 49.6% and this technology, also, has not realized prevention of medication errors, absolutely (43.7%).
The association between nurses' knowledge of BCMA advantages and its implementation has been positive but weak (r = 0.225, Approx. Sig. =0.555), i.e. there has been an insignificant association between them. In addition, there has been a positive insignificant association between nurses' knowledge of BCMA infrastructures and their existence in the wards (r = 0.175, Approx. Sig. =0.724). Also, There has been an insignificant association between nurses' knowledge of preventing medication errors using BCMA and the prevention of medication errors can be achieved using such technology (r = 0.313, Approx. Sig. =0.126). Furthermore, in general, the association between nurses' total knowledge of BCMA and its realization is strong positive but insignificant (r = 0.805, Approx. Sig. =0.437).
|Table 3: BCMA implementation percentage according to its objectives in AL-Zahra Educational Hospital wards|
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| Discussion|| |
An increase in professional educational level of nurses has increased their knowledge of BCMA technology so that nurses having MSc obtain the highest knowledge score compared with other nurses. In order to improve nurses' knowledge of BCMA advantages, we can increase their knowledge about using BCMA, using BCMA in confirming order administration by nurse, BCMA effect on drug administration economization, BCMA effect on patient mortality rate, BCMA effects on dispensing process and decreasing nurses' working time, as well as the BCMA role of alarming nurses and informing them.
Low implementation of BCMA in AL-Zahra Hospital might be due to unawareness about advantages and high cost of its equipment and initiation. Realization of resulted advantages of BCMA has been so insignificant and unacceptable (49.6%) in this study. Dwibedi et al. found that BCMA implementation decreased the time of drug administration activities and increased the time reserved for direct patient caring activities by nurses.  Finding of Morris et al. indicates that controlling drug doses, drug name and its day is performed by BCMA.  In this study, however, BCMA could not properly control drug doses, drug name, and its time of administration. One other advantage of BCMA found by Synder et al. has been improved in prescription using BCMA.  However, BCMA has not improved prescription in the current study. Tsai et al. demonstrated that using BCMA in oral medications has decreased half of the time for reporting oral medication.  In this study, however, BCMA could not shorten the time of medication report. Low implementation of BCMA advantages in the current study is due to reasons including: Impossibility of electronically distribute medication, not using BCMA cuffs in all age groups in all departments, impossibility of tracing patients, having low access to the time services were used by patients, not defining any time for discharging patients using cuffs, not using BCMA in distributing all drug products using computer, not alarming nurses of any error using BCMA, no existing electronic signature in order to confirm administration of orders by nurses using BCMA.
The findings of the current study indicate a relatively favorable knowledge (63%) of nurses about BCMA infrastructures, while necessary BCMA structures have had unfavorable and unacceptable condition (39.7%) at AL-Zahra Hospital. Reasons behind such improper knowledge of nurses about BCMA infrastructures include: Incomplete knowledge of nurses about the role of BCMA lines in saving and retrieving medication information, various BCMA cuffs and method of their installation and usage, information elements that could be saved and retrieved by BCMA, making it possible to record nursing notes and notices using BCMA, robots role and usage in electronic distribution of medications using BCMA, method of using mobile software in exploring medication administration barcode, and method of printing medication administration barcode on patient barcode cuff in hospital.
According to Micro et al., using supporting system for clinical decisions and medications has increased medication safety and decreased medication errors.  According to Poon et al., using the electronic system of medication administration barcode has significantly decreased the rate of errors in prescribing, medication administration and the incidence of drug complications.  Such findings are not correspondent with current study. Also, Sheykhtaheri et al. demonstrated that although the cost of BCMA initiation and maintenance is high, it seems that its economic advantages are more, i.e. the importance of decreasing medication errors and improving patient safety worth investment for using such technology.  Therefore, providing necessary infrastructures of BCMA in the hospital is suggested as follows: Providing proper barcode label for drugs, providing proper barcode-reader devices, developing a database for saved information in barcodes, providing BCMA cuffs and equipment for printing barcode on patient cuff, providing portable computer and wireless network for BCMA implementation, equipping inpatient and outpatient wards with BCMA software, providing smart trolley to carry medications for implementation of BCMA, providing portable barcode-reader and mobile software's barcode explorer, providing and using robots recognizing medications and finally distributing them using computer with the help of BCMA.
Findings indicate weakness in nurses' knowledge about BCMA usage in preventing medication errors have been mostly in areas of BCMA effect on decreasing errors of drug delivery phase and errors due to prescription illegibility as well as BCMA usage in correct recognition medication doses. Therefore, it is suggested to consider requiring measurements in order to increase knowledge in such areas. The technology has not played a considerable role in preventing medication errors in AL-Zahra Hospital.
According to what Helmons et al. found, BCMA implementation affected different errors of medication administration in different parts of patient care, and decreased medication administration errors in surgical wards, while it was not the same in different wards.  DeYoung et al. found a significant decrease in medication administration errors of inappropriate time in the healthcare unit for adults.  Morris et al. also found that BCMA decreased the risk of preventable drug complications Another advantage of BCMA found by Synder et al. is a decrease in prescription errors with the help of BCMA.  Poon et al. demonstrated that using BCMA not only significantly decreases errors of prescription, medication administration, and incidence of drug complications, but is also an important intervention to improve patient safety.  Unfortunately, none of the above items were properly realized in the current study and the findings are not correspondent with each other.
The rate of nurses' knowledge according to their working background has been relatively well in all groups. In general, however, knowledge of BCMA has been higher in nurses with more than 20 years working background, which is mostly due to their working experience. In a study titled "the features of medication errors caused by students during administration", Volf et al. indicated that 78% of medication errors are due to nurses' inexperience.  This result is correspondent with our findings.
| Conclusion|| |
The findings indicate relatively favorable knowledge of BCMA among AL-Zahra Hospital nurses, while unfavorable implementation of the technology. Therefore, providing educational courses for nurses in order to improve their knowledge and better usage of this technology would be helpful. In addition, providing explorer and barcode-reader devices and installing related hardware and software are required to initiate and implement such technology.
According to the results of this study, the most important issues to be considered in this study are as follows:
- Insufficient education of nurses about BCMA
- High costs of equipment and primary expenses of BCMA
- Lack of enough trust in new technologies by the nurses
- Existence of no central database for saving data in barcode
- Lack of enough hardware and software associated with BCMA in order to electronically distribute medications.
Generally, lack of knowledge about advantages of BCMA, and its high cost of initiation and equipment is the reason why BCMA is not implemented in the hospital, especially ICU.
| Acknowledgement|| |
The authors would like to express their gratitude all those who helped us with their valuable comments, including hard working nurses in AL-Zahra Hospital, and dear journal experts for their helping.
| References|| |
|1.||Valizadeh F, Ghasemi SF, Nagafi SS, Delfan B, Mohsenzadeh A. Errors in medication orders and the nursing staff′s reports in medical notes of children. Iran J Pediatr 2008;18 (Suppl 1):33-40. |
|2.||Choi JS, Kim D. Technical considerations for successful implementation of a barcode-based medication system in hospital. J Korean Soc Med Inf 2009;15:303-12. |
|3.||Hajibabaee F, Joolaee S, Peyravi H, Haghani H. The relationship of medication errors among nurses with some organizational and demographic characteristics. Iran J Nurs Res 2011. |
|4.||Lane R, Stanton NA, Harrison D. Applying hierarchical task analysis to medication administration errors. Appl Ergon 2006;37:669-79. |
|5.||Poon EG, Keohane CA, Yoon CS, Ditmore M, Bane A, Levtzion-Korach O, et al. Effect of bar-code technology on the safety of medication administration. N Engl J Med 2010;362:1698-707. |
|6.||Pham JC, Story JL, Hicks RW, Shore AD, Morlock LL, Cheung DS, et al. National study on the frequency, types, causes, and consequences of voluntarily reported emergency department medication errors. J Emerg Med 2011;40:485-92. |
|7.||Mohamadnejad E, Hojati H, Sharifnia H. Survey of rate and type of medication errors made by nursing student in urumia medical faculty. Iran J Med Ethics History 2010;3(Special Issue):10. |
|8.||Sharifi N, Alipour A. The effect of modern educational strategies in reducing intravenous drug administration error: A non-randomized clinical trial. Iran J Med Educ 2012;11:590-9. |
|9.||Le Garlantezec P, Aupée O, Alméras D, Lefeuvre L, Souleau B, Sgarioto A, et al. Drug administration error related to computerized prescribing. J Oncol Pharm Pract 2010;16:273-6. |
|10.||Thomson R, Pryce A. Patient safety-epidemiological considerations. Health Care Errors Patient Safety 2009:207-23. |
|11.||Anderson JG. Regional patient safety initiatives: The missing element of organizational change. AMIA Annu Symp Proc 2006:1163-4. |
|12.||Vozikis A. Information management of medical errors in Greece: The MERISproposal. Int J Inf Manag 2009;29:15-26. |
|13.||Wachter RM. Understanding patient safety. New York: McGraw-Hill Medical; 2008. |
|14.||Mohasel S. Medical errors in Iran. Lahti: Atie Press; 2007, Apr, 12 [Persian]. |
|15.||Hodavand N, Javadi M, Gholami K. Medication errors. Razi press. 2005; 11 (16) [Persian]. |
|16.||Sheikhtaheri A, Hashemi N. Patient safety: Information technology should be considered. Homa-ye-salamat 2007;1:6. |
|17.||Holden RJ, Brown RL, Alper SJ, Scanlon MC, Patel NR, Karsh BT. That′s nice, but what does IT do? Evaluating the impact of bar coded medication administration by measuring changes in the process of care. Int J Ind Ergon 2011;41:370-9. |
|18.||Morriss FH Jr, Abramowitz PW, Nelson SP, Milavetz G, Michael SL, Gordon SN, et al. Effectiveness of a barcode medication administration system in reducing preventable adverse drug events in a neonatal intensive care unit: A prospective cohort study. J Pediatr 2009;154:363. |
|19.||Tsai S, Sun YC, Taur FM. Comparing the working time between bar-code medication administration system and traditional medication administration system: An observational study. Int J Med Inf 2010;79:681-9. |
|20.||Rezaei Hachesoo P, Habibi S, Fozonkhah S. Information technology, an effective tool in reducing and preventing medical errors: Suggestions for improvement. Health Inf Manag 2007;4:89-98. |
|21.||Dwibedi N, Sansgiry SS, Frost CP, Dasgupta A, Jacob SM, Tipton JA, et al. Effect of bar-code-assisted medication administration on nurses′ activities in an intensive care unit: A time-motion study. Am J Health Syst Pharm 2011;68:1026-31. |
|22.||Snyder ML, Carter A, Jenkins K, Fantz CR. Patient misidentifications caused by errors in standard bar code technology. Clin Chem 2010;56:1554-60. |
|23.||Mirco A, Campos L, Falcão F, Nunes JS, Aleixo A. Medication errors in an internal medicine department. Evaluation of a computerized prescription system. Pharm World Sci 2005;27:351-2. |
|24.||Helmons PJ, Wargel LN, Daniels CE. Effect of bar-code-assisted medication administration on medication administration errors and accuracy in multiple patient care areas. Am J Health Syst Pharm 2009;66:1202-10. |
|25.||DeYoung JL, Vanderkooi ME, Barletta JF. Effect of bar-code-assisted medication administration on medication error rates in an adult medical intensive care unit. Am J Health Syst Pharm 2009;66:1110-5. |
|26.||Wolf ZR, Hicks R, Serembus JF. Characteristics of medication errors made by students during the administration phase: A descriptive study. J Prof Nurs 2006;22:39-51. |
[Table 1], [Table 2], [Table 3]