Deriving the Most Benefit from Bar Coded Medication Administration
To the Editor:
Dr. McLesky's article “Bar Coding May Reduce Drugs Errors” was remarkable for its optimism about this technology. The few research-based examinations of the efficacy of these systems do not support such an optimistic view. Instead, they indicate that, like other complex information technology, bar coded medication administration (BCMA) is likely to create new problems, open new pathways to failure, and generate a new variety of counter-productive incentives in an environment already rather well-burdened with them.
One published study of the Veterans Administration BCMA system shows that BCMA application produces rigid sequencing of work, narrow "keyhole" computer generated views of work process, and potential for precise timing and tracking of bar code reading activities—all characteristics that poorly match the needs of workers in busy clinical settings.1
For example, BCMA may increase both the pressure to produce records showing “on-time” delivery and the penalties for failing to do so. The time delays associated with ordinary order entry, processing, review by pharmacy, and medication “delivery” to the caregiver fluctuate with the tempo of operations. Confronted with interruptions or critical needs, caregivers may divert the drug from one patient to another. From a BCMA perspective, this is either wrong drug or wrong patient, and generates a time-stamp that is difficult or impossible to reconcile.
Similarly, apparent improved performance on “right time” measures may reflect work-arounds as much as real progress. We have been told of instances where nurses have photocopied patient wristbands and scanned them to generate “right time” documentation for the computer while actually delivering the medication at a different time. The incentives to do this are the difficulty in working with balky equipment, the rigid structure of work enforced by the information technology, and the potential for becoming a statistical quality control point outside “acceptable limits.” The important patient safety consequence is the loss of BCMA's potential value in assuring the “right drug” delivered to the “right patient.” There are no data on how often this sort of work around is actually used; it is likely more common than we could be comfortable with.
Audits of administration time made possible by BCMA are a potent incentive for practitioners to adopt practices that increase their “on time delivery,” but undo the potential increase in safety from such systems. But what are the underlying drivers for the practices that we perceive to be unsafe? Is it laziness? Moral turpitude? Willful disregard of safety by capricious practitioners? We think not. Instead, the causes of this behavior include ongoing short-staffing of nurses, the lack of high quality support tools to manage work at the bedside, and so forth. None of these are addressed by the institution of BCMA.
Authors advocate eliminating timing data
Avoiding perverse incentives may mean sacrificing lower priority goals for higher ones. We have a concrete recommendation for proponents of BCMA. Throw away the timing data. The pressing motivation for BCMA was the desire to prevent wrong medications being given by providing computer-based matching of patient with drug. Make that the cornerstone of the BCMA safety program. Rather than have the computer record the time the band was “scanned,” have it record only that the drug was given sometime during the shift. Eliminate all automated recording of timing. Allow workers to enter the actual time if they choose to do so. Doing this will remove the incentive to "game" the system, and send a clear message about what really matters—that matching drugs and patients is vastly more important than small discrepancies in administration times.
Greatest value is insuring the right drug for the right patient
The introduction of BCMA into more widespread clinical use will reduce the incidence of some problems and create new ones. Careful design of such systems and deliberate avoidance of perverse incentives will increase the chances that they improve safety rather than hamper it.
References
Surgeon Patient Suffers Poor Quality Care —Advocates for
Professionalism
To the Editor:
I would like to relate an experience I recently had at what is felt to be the premier hospital in our region. I am a surgeon at another institution and had a major elective procedure performed that was not available at my hospital. I participated in the usual preoperative screening and reported at 5:30 a.m. for my planned 7:30 case.
While in the holding area, a man pulled my chart, and on questioning, stated he was an anesthesiologist. He did not ask any questions, nor did he examine me in any way. After replacing my chart, he wandered off. A middle-aged woman next pulled my chart, and on questioning replied to me she was a nurse anesthetist. She asked no questions, neither did she check my airway or examine me in any way.
A few minutes later, the anesthesiologist came back with Versed and administered 1 mg (I asked). I have no memory lapse for that time period. Several minutes later, the crew came to take me into the OR. A completely new young man stated, as he pushed something else in my IV, that he was the student nurse anaesthetist. From that moment on, I have no recall of events until PACU.
I am a physician, and even as such, to this day I have no idea who actually administered my anesthetic, nor what was done. I am grateful there were no complications, as no one questioned nor examined me, much less informed me of the plan, options, or risks.
I feel this is an example of bad care and dangerous medicine. If anesthesia providers want to function as simply a machine that performs a task, they should expect to be treated, and reimbursed as such.
As a surgeon, I consider my anesthesia providers partners in the care of the patient. I am present for the induction and wake-up of my patients, and feel I can speak with some authority on the subject. I could not and would not take patients to an institution where what I experienced was thought to be an acceptable standard of care.
| The Editor of the APSF Newsletter invites readers’ comments on this letter and this physician’s experience. |
TRI: Position vs. Dilution
To the Editor:
I read the letter from Dr. Lambert1 and the response by Drs. Pollock and Horlocker2 in the fall 2003 issue of the APSF Newsletter with interest.
Over a 6-month period I have used 50-100 mg of lidocaine (subarachnoid) (Abbott 1% MPF lidocaine or AstraZeneca 2% MPF Xylocaine) in over 50 supine patients (mostly knee arthroscopy), and I followed up with a telephone interview. All had satisfactory anesthesia, and no patient had any significant complaint. However, I did not ask questions specific to transient radicular irritation (TRI).
Is it possible that the dilution of “hyperbaric” lidocaine (specific gravity = 1.034 -1.011) reported by Pollock et al.3 was ineffective in reducing the incidence of TRI because a hyperbaric solution is more likely to pool in the sacral region and expose the cauda equina to the lidocaine for periods longer than might occur with an “isobaric” or “hypobaric” solution? Even minimally hyperbaric solutions are likely to pool in the sacral region. Unlike the hyperbaric solutions that Pollock et al.3 used, my solutions (specific gravity around 1.0007) were isobaric or even hypobaric. Therefore, they would be more likely to distribute over a different area in the CSF in the supine patient and be less likely to “pool” in the cauda equina region.4,5
Interestingly Alley and Pollock reported on a patient given a hypobaric lidocaine spinal anesthetic (1% lidocaine, s.g. not measured) and placed in the prone jack-knife for pilonidal cyst excision who developed TRI.6 This would seem to contradict my hypothesis that hypobaric lidocaine might prevent TRI. Indeed, Alley and Pollock propose that sciatic stretch rather than “maldistribution” caused the TRI in their patient. However, in the jack-knife position, the hypobaric solution likely gravitates to the sacral region (the same way that a hyperbaric solution does during a “saddle block”). This exposes the cauda equina to lidocaine for a longer interval than would be the case if the patient were positioned supine after the injection the way that my patients were positioned.
The title of the Pollock and Horlocker letter2 states, “More research on TRI is needed.” A starting point might be a randomized and blinded study of the effect of the dilution of isobaric lidocaine on the incidence of TRI.
References