BARCODE MEDICATION ADMINISTRATION: USING ROOT CAUSE ANALYSIS TO ENHANCE LEARNING
Background: The hallmark report by the Institute of Medicine “To Err is Human: Building a Safer Health System”, exposed the dramatic scope of medical error in the US Healthcare System, and adverse drug events (ADE) were singled out as one of the most frequently occurring errors . The risk for ADE in an inpatient hospital setting increases along with the number of medications a patient takes, and many occur due to medication administration errors. Bar Code Medication Administration (BCMA) was designed to add an additional layer of safety by using bar codes to confirm the “5 Rights” of medication administration (right patient, right drug, right dose, right time, and right route). BCMA has been required in hospitals since 2004, but medication errors continue to occur. A microsystem assessment of an inpatient medical unit revealed that nurses’ perception of the BCMA process worked well, but many variations in the BCMA process were observed during the microsystem assessment. This study was designed to provide staff with information about best practices in BCMA, engage them in a root cause analysis of the variations in BCMA, and solicit recommendations for improvement.
Methods: Participants will be recruited from staff working on a medical floor in the northwestern United States. Information about BCMA and the microsystem assessment will be provided to the participants in an educational workshop. Participants will complete a short BCMA knowledge quiz before and after the presentation, and also engage in a root cause analysis of BCMA workarounds that were observed during the microsystem assessment. Recommendations for improvement will also be solicited during the workshop. Additional data will be collected after the workshop to assess changes from baseline scanning rates, type and frequency of BCMA workarounds after the workshop.
Results: Findings will be reported at the poster session.
Implications: Implications will be reported at the poster session.