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In the first study of its kind, researchers led by The University of Pennsylvania School of Medicine's Ross Koppel, Ph.D. studied how hospital nurses actually use bar-coded technology that matches the right patient with the right dose of the right medication. The surprising result is that the design and implementation of the technology, which is often relied upon as a "cure-all" for medication administration errors, is flawed, and can increase the probabilities of certain errors.

Equally surprising is that the urgencies of care and the ingenuity of nurses to cope with these shortcomings have the unintended consequences of creating other medication errors. These findings appear in the July/August issue of the Journal of the American Medical Informatics Association (JAMIA). The study also illustrates how adjustments to workflow and the technology can dramatically reduce the risk of these errors.

These barcode systems usually consist of handheld devices and computers that match machine-readable barcodes on patients and medications. If they match, and if they are consistent with the ordered medications, the medications are given. If not, usually a signal goes off telling the nurse of a discrepancy.

The study was conducted at 5 hospitals in the Midwest and on the East Coast, but not at the Hospital of the University of Pennsylvania (HUP) because it does not yet have medication barcoding. Penn's Ross Koppel, Ph.D. and his colleagues from other healthcare systems examined close to a half-million instances where nurses and other staff scanned patients and medications. The researchers found a remarkably high proportion of scans involved nurses overriding the technology with workarounds to compensate for difficulties with the barcode systems. These researchers found that nurses scanning the barcode on the medication or the patient's ID bracelet overrode the technology for 4.2% of patients charted and for 10.3% of medications charted. In contrast, vendors of barcode medication administration (BCMA) systems report error rates that are a small fraction of this study's numbers; but vendors focus primarily on the ability to physically affix and read barcodes, not on the totality of the many processes in actual use. In addition to examining the ½ million scans, Dr. Koppel and colleagues spent years shadowing nurses using the technology, participated in many BCMA implementation meetings, and conducted scores of interviews with pharmacists, nurses, and IT leaders.

Hospital patients, on average, are subject to one medication administration error a day, according to the Institute of Medicine, and in hospitals, medication administration accounts for 26% to 32% of adult patient medication errors. Thus, an automated system using barcodes to reconcile a patient's medications and orders with the patient's identity would be a great advance, helping to ensure the right patient receives the right dose at the right time.

But what Penn's Professor Koppel and his colleagues found in the five study hospitals were 31 "causes" of problems that engendered workarounds by the nurses. These causes included: unreadable medication-barcodes (crinkled, smudged, torn, missing, covered by another label); malfunctioning scanners; unreadable or missing patient-ID-wristbands (chewed, soaked, missing); non-barcoded-medications; medications in distant refrigerators, lost wireless connectivity; problems with patients in contact isolation, and emergencies. In some cases, if the pharmacy sent two 10mg tablets for a 20mg order, the scanners/computers would not accept the medications. Nurses devised workarounds to compensate for the awkward and inconvenient aspects of the barcode technology. These nonstandard procedures consisted of, for example, affixing extra copies of patient ID barcodes on desks, scanning machines, clipboards, supply room, and doorjambs, as well as carrying several pre-scanned patient's medications on one tray. Ross Koppel, Ph.D., Center for Clinical Epidemiology and Biostatistics at the University of Pennsylvania School of Medicine and the Sociology Department at the University of Pennsylvania, emphasized that "It's not that staff are lazy or careless, it's that the system does not work as well as it should. If the refrigerated medication is two floors and a long hallway away, you're not going to wheel your 87 year old patient to the fridge. You make a copy of her barcode. And while you do that, you help another two patients who also need refrigerated medications."

"Bar-coding is still under development," says Koppel. "Administrators and vendors may expect it to be fool-proof, but users know it's not. It's a very promising technology that still requires constant refining and careful observation of on-the-floor workflow to get it right."

The researchers found that in the pressurized, "can-do" culture of today's hospital, nurses compensated for the imperfect technology and workflow by devising 15 types of workarounds. The study also presents typologies of workarounds, BCMA "causes," and the kinds of errors associated with each.