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Why Neither the “Five Rights” Nor Bar Code Medication Administration Alone Will Prevent Medication Errors

Medication administration is one of the most error-prone processes in health care delivery. The “five rights” are regarded as a basic goal for safe medication administration: right patient, right medication, right time, right dose, and right route. Many errors, including lethal errors, still occur when practitioners firmly believe that they have verified the five rights before administering a medication. How can this happen? Because the “five rights” are procedural goals of medication administration practices and provide little guidance on “how” to effectively accomplish these goals.1 The “five rights” also focus on the performance of the individual practitioner and do not fully take into account the multidisciplinary efforts involved in medication administration. Poor lighting, inadequate staffing, poorly designed infusion devices, ambiguous or difficult to read medication labels, and lack of an effective double check system for high alert medications can contribute to a failure of the “five rights.”

In addition, the impact of human factors is not considered in the “five rights.” Confirmation bias has been noted in errors involving the selection of the wrong product. Practitioners involved in such incidents report that they are sure that they verified the product they selected, when according to human factors researchers, what they experienced was a misperception that occurs when products look too similar. According to an ISMP alert, “We ‘see’ with both our eyes and our mind. While our eyes, with proper eyesight, have the capacity to take in all information, our mind learns to screen out information that it considers less useful to prevent information overload. Additionally, as we gain experience, we develop a picture in our mind of items in our environment. Thus, as we attempt to locate or recognize items through comparison with our mind’s picture, we are often unable to see any disconfirming evidence if the wrong product is selected.”1 In 2007, ISMP reiterated their position on use of the “five rights” in another safety alert by stating that “To be clear, nurses and other practitioners cannot be held accountable for achieving the five rights; they can only be held accountable for following the processes that their organizations have designed and held out as the best way to verify the five rights.” 2 Therefore, medication administration protocols must be developed by organizations that support practitioners in achieving these goals.

Many hospitals have implemented bar code medication administration (BCMA) as a method of decreasing medication errors. This technology creates a safety barrier between the nurse and the patient that assists the nurse in confirming the patient’s identity, as well as the name, dose, time and form of the medication being delivered. BCMA was developed to specifically decrease the following types of errors: unauthorized drug, wrong form, wrong dose, wrong route, extra dose, and omission.3 However, a false sense of security overshadows medication administration as practitioners assume that BCMA eliminates the risk of human error and will prevent all medication administration errors.

While adoption of BCMA technology has increased, few studies have been conducted to establish its effects on reducing medication error rates. Helmons, Wargel and Daniels conducted a study to evaluate medication administration practices one month before and three months after BCMA implementation in two medical-surgical units and two intensive care units (ICUs) at a 386-bed academic teaching hospital in southern California.3 They discovered that implementation of BCMA resulted in improved patient identification on the medical-surgical units and improved charting and labeling of medication administration in the ICUs. There were fewer omitted medications and a decrease in the number of medications that were not available on the unit. However, total medication errors were not affected by BCMA implementation and, unfortunately, the observers determined that more distractions occurred and the nurses spent less time explaining the medication to the patient. Of note, a 52% increase in I.V. mini-bag errors occurred after BCMA implementation in the ICUs, which may suggest a false sense of security around correct I.V. mini-bag selection with use of BCMA. Most BCMA implementations do not confirm that the correct pump is used for the selected mini-bag or that the mini-bag selected matches the mini-bag it is replacing, particularly when the patient is receiving multiple mini-bag medications.

On average, nurses spend 25% of their time on medication-related activities.4 The potential for BCMA to prevent errors is diminished if nursing workflow is not considered in the implementation of BCMA. Several studies have highlighted work-around strategies that nurses have created to accomplish medication administration using BCMA when work-flow was not adequately considered in policy development.5 A 2010 investigation published by the Joint Commission cited the most frequent reasons why medications were not scanned prior to administration (Table 1).6
 

Table 1. Most Frequent Reason Why Medications Not Scanned Prior to Administration
  1. No bar code on dose
    1. Split dose
    2. Liquid medication in syringe
    3. Bar code on outer box/wrapper discarded with first use (ointment, eye drops, inhalers)
    4. Patient’s own medication; no bar code
  2. Bar code damaged
    1. Bar code torn when unit dose peeled open
    2. Bar code on ointment “crimped” with successive administrations
  3. Bar code hard to read with the scanner
  4. To avoid system default to the next scheduled dose when the current dose is being administered beyond the acceptable time frame set in the bar coding system
  5. Patient off nursing unit; bar code administration system not available
  6. Patient registration not complete; emergency medication needed

Nurses are a resilient group of professionals who will create solutions to overcome barriers to efficiently and effectively deliver care to their patients; they are often praised and take pride in their ability to do so. However, these choices sometimes lead to risky behavior. A nurse in Madison, Wisconsin inadvertently administered bupivacaine intravenously to a mother in labor, resulting in a fatal medication error.6 Upon investigation, the nurse revealed that she pulled the bag of bupivacaine while also pulling the bag of penicillin she was about to deliver in order to be prepared for the anesthesia staff when they arrived. The anesthesia department had recently complained to leadership that the nursing staff was not prepared for them when they arrived to place an epidural. This resulted in the nursing staff taking shortcuts and multi-tasking. The recognized procedure was to only remove and bring medications to the patient’s room that were intended for immediate delivery, but it had now become common practice for the nursing staff to also bring the bupivacaine to the room prior to the anesthesia staff’s arrival. Because of multiple problems with the implementation of BCMA, it had also become routine practice for the nursing staff to scan medications after they were delivered in order to prevent delays in administration. Therefore, the bag of bupivacaine was not scanned prior to delivery. If it had been, the error might have been identified.

BCMA technology has been shown to be a cost-effective intervention and is recommended for safe medication practices, but is only effective at reducing medication administration errors when it is implemented to support nursing workflow in achieving the “five rights”. Barriers to the use of established protocols for safe medication administration should be recognized and addressed in order to prevent workarounds and risky staff behaviors.

References

  1. The “Five Rights”. Acute Care ISMP Medications Safety Alert. 1999. Obtained July 25, 2014.
  2. The Five Rights: A Destination without a Map. Acute Care ISMP Medication Safety Alert. 2007. Obtained July 25, 2014. Helmons PJ, Wargel LN, and Daniels CE. Effects of bar-code-assisted medication administration on medication administration errors and accuracy of multiple patient care areas. Am J Health-Syst Pharm. 2009; 66:1202-1210.
  3. Keohane CA, Bane AD, Featherstone E, et al. Quantifying nursing workflow in medication administration. J Nurs Adm. 2008; 38:19-26.
  4. Patterson ES, Rogers ML, Chapman RJ et al. Compliance with intended use of bar code medication administration in acute and long-term care: an observational study. Hum Factors. 2006; 48:15-22.
  5. Smetzer J, Baker C, Byrne FD, Cohen MR. Shaping Systems for Better Behavioral Choices: Lessons Learned from a Fatal Medication Error. Joint Com J on Qual and Pt Safety. 2010;36:152-163.

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