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The Critical Nature of Early Nursing Involvement for Introducing New Technologies

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Heather N. Weckman, MS, CNL, RN-BC
Sandra K. Janzen, MS, RN, NEA-BC, FAAN

Abstract

This article emphasizes the crucial role of early nursing involvement whenever a new technology, such as a Bar Code Medication Administration (BCMA) system, is introduced in a patient care setting. The authors of this article describe how nurses participated on interdisciplinary teams during the design, planning, implementation, and evaluation phases of BCMA point-of-care technology at their facility. They illustrate the benefits of early nursing involvement in all phases of introducing BCMA technology, and the problems that can arise in the absence of this early nursing involvement, using real-life examples of lessons learned during the initial implementation and further expansion of the BCMA system at their facility.

Citation: Weckman, H., Janzen, S., (May 31, 2009) "The Critical Nature of Early Nursing Involvement for Introducing New Technologies" OJIN: The Online Journal of Issues in Nursing, Vol. 14, No. 2, Manuscript 2.

DOI: 10.3912/OJIN.Vol14No02Man02

Key words: Bar Code Medication Administration, BCMA, technology implementation, nursing involvement in technology implementation, patient safety, interdisciplinary team

Technology specialists are experts in the field of technology; they understand the mechanics of a new technology. In the same way, nurses are experts in the field of nursing; they understand the dynamic flow of patient care and the frequent interactions needed between numerous healthcare providers while providing nursing care. It is important both for nurses to understand a new technology, and for technology engineers to understand how the equipment and software will need to interface with the facility’s existing systems. In this article we consider technology to include both the hardware (equipment) and the related software of a given technology,

Involving nurses who work at the point of care in all phases of introducing a new technology facilitates a smooth transition to using the new technology and increases nurses’ buy-in of the system (Hunt, Sproat, & Kitzmiller, 2004). The Standish Group (1995) has noted that without user involvement the chance of failure increases dramatically. Kramer and Schmalenberg (2008) have observed that nurses will and do adopt new technologies if they have had the opportunity to provide input into the planning and implementation processes by conducting trials of various types of equipment in different clinical settings, and also the evaluation process by which they can confirm whether changes designed to improve the work environment have been effective. The authors of this article will describe efforts to promote early nurse involvement when introducing a new technology, specifically the Bar Code Medication Administration (BCMA) system. After describing the context in which they worked to introduce this technology and the BCMA system, they will share their early attempts to introduce a BCMA system and then describe how this implementation process was facilitated by active nurse involvement in the later planning phase, as well as in the implementation and evaluation phrases.

The Context for Introducing Bar Code Medication Administration Technology

Our experience in introducing a BCMA system took place in the James A. Haley Veterans’ Hospital, a 569-bed Magnet hospital. In 1998, the Department of Veterans Affairs embraced the Patient Safety Goal of reducing adverse events by 50% in five years. To support this goal, the Veterans Health Administration (VHA) began implementing the BCMA system nationwide. This technology was first introduced at our facility as a pilot program on a medical-surgical unit, and then expanded to all inpatient units (except the intensive care unit [ICU]), once the pilot was deemed successful. ICU implementation occurred later because the project leaders (risk manager and informatics nurse) were aware that specific risks needed to be anticipated, and planned for, before practice changes could be initiated in the ICU setting, so as to enhance patient safety. Informatics nursing involvement in conducting a Healthcare Failure Modes and Effects Analysis™ (DeRosier, Stalhandske, Bagian, & Nudell, 2002) with the interdisciplinary team prior to implementing BCMA in the ICU was a highly effective process that prevented adverse patient outcomes in BCMA implementation and subsequent enhancements. The team also created the BCMA Contingency Plan for planned and unplanned down times. This plan is taught to new employees, and is tested annually on all units, during the unit’s busiest medication administration times, to ensure nurses remain familiar with the process.

The Bar Code Medication Administration System

The BCMA system software is a point-of-care system for validating that the correct medication is about to be given in the correct manner. The BCMA system software is a point-of-care system for validating that the correct medication is about to be given in the correct manner. The system is used primarily by registered nurses (RNs) and Licensed Practical Nurses (LPNs). Respiratory Therapists (RTs) may also use the system to administer breathing treatments in the inpatient setting. In routine situations, a valid provider’s order must first be entered into the patient’s computerized medical record, verified by a pharmacist, and made active in the Computerized Patient Record System (CPRS) before a medication can be administered. Although BCMA is a tool to help prevent medication errors related to patient identification and the correct medication, route, dosage, and timing, it is not intended to replace the clinical judgment of the nurse who has the final responsibility in preventing a medication error.

The basic process for unit-dose medication administration using the BCMA system begins with the user removing medications from locked storage and logging into the BCMA system with user-specific codes. The user then enters an electronic signature which links the medication administration act with the user name in the electronic record. Next, the bar-coded wristband on the patient is scanned using a handheld barcode scanner or Pocket Personal Computer (PC) scanner which opens the specific patient record. In the next step the nurse then compares the patient data displayed in the BCMA confirmation box with the patient wristband. After the patient’s identification has been confirmed, the nurse selects “yes” to open the virtual due list (VDL). The VDL is similar to the traditional Medication Administration Record (MAR). Once the VDL opens, allergies are displayed. This enables nurses to confirm that the patient is not known to be allergic to any of the medications about to be administered. The VDL only displays medications that are due during the current time frame. If administering medications outside of the acceptable time frame, the nurse has to expand the virtual due list to view the medication to be given and then enter the reason why the medication is being given early or late.

Next, the nurse selects the medication to be administered by left clicking or using a touch screen, confirms that the scanner status is ready, and scans the bar code on the medication. If the medication bar code does not scan, the nurse checks to determine whether the medication and dose are correct. If necessary, the internal entry number may be entered after which the pharmacy is notified that the drug had a scanning failure. This allows for the needed correction in the system. If the patient refuses the medication or is not able to swallow the medication, or if the medication is dropped, the nurse may “undo” the action and mark the medication as “not given” in the medication administration history. Additional features of BCMA include PRN Clinical Reminders for documentation of PRN effectiveness and the ability to access the ‘Vitals Package,’ which can provide vital sign information to the nurse when recent vital signs need to be assessed before a medication is given.

BCMA hardware generally includes not only the computer or handheld or pocket PC scanner, but also the cables, connectors, and power supply units. Additionally it may include peripheral devices, such as the keyboard, mouse, e-pad for electronic consents, audio speakers, monitors, internal wireless cards, antennas, and printers as parts of the computer system. Other equipment may include mobile or stationary workstations, integrated medication carts (carts that include everything needed to administer and store medications), automated dispensing cabinets, or integrated workstations (similar to integrated medication carts, but with less room for storage). Infrastructure factors, such as access to power (enough outlets to adequately charge short- or long-life batteries), are necessary. The type of equipment available to nurses varies according to the unit on which they are working; the size of the unit, the physical layout of the unit, and the number of staff needing to administer medications, all influence the selection of the specific types of equipment.

In this system, medications are easily marked ‘held’ or ‘refused.’ Additionally, the nurse is able to see on the VDL list when the last medication was given. The process is similar for scanning intravenous (IV) and piggyback medications mixed by pharmacy and labeled for the specific patient. When medications are not being administered, the nurses either lock their workstation or log off the system to maintain information security and patient privacy.

Early BCMA Design Attempts

...purchasing separate pieces of equipment for each working nurse seemed outrageously expensive...However, limited supply of equipment created wait times...slowing patient care and increasing staff frustration.When we first implemented BCMA on a pilot unit, it was expected that the equipment, such as scanners and work stations, would be shared among the nursing staff. Early on, the purchasing of separate pieces of equipment for each working nurse seemed outrageously expensive in terms of equipment and infrastructure costs. These costs might include ample electrical circuits, wireless access coverage, physical space, batteries, additional outlets to charge devices, and increased technical support. Consequently, we implemented the system without adequate equipment. However, this limited supply of equipment created wait times for the nurses as they sought to gain access to the BCMA equipment, thereby slowing patient care and increasing staff frustration. The wireless network in the hospital was designed for 100 devices and we later discovered that three times that amount was needed as new units opened and as nursing units moved from a team to a primary care model. These additional devices slowed the wireless network response time, thus slowing medication administration. Also, computer network connection errors; lack of nurses’ understanding regarding black screens due to time out, shutdown, and reboot processes; and nurses’ limited understanding of the differences between character-based and graphical-user interface software, which required different log-in methods, increased nurse frustration.

Furthermore at that point in time, many users had minimal computer experience and were reluctant to learn a computer-based system, such as BCMA. One strategy for dealing with this reluctance was to create nurses who were ‘Super Users’ or ‘champions’ on each unit. These nurses were well prepared to teach and motivate nurses who were reluctant to learn the new system or feared doing so. Some users did not recognize the full value of the system, and so did not accept the system, until the bar-code scanning system actually alerted them to the fact that they were about to give a wrong medication. After such an experience they were much more willing to accept the system. This was an important step forward in promoting patient safety, because Leape et al.’s (2005) analysis of 334 medication errors from 11 acute-care wards reported that 38% of medication-error adverse events occur at the time of administration by nursing personnel.

Equipment design flaws produced some humorous, yet costly situations illustrating the lack of early nurse involvement. Equipment design flaws produced some humorous, yet costly situations illustrating the lack of early nurse involvement. A poignant example we experienced was the placement of the antenna on the mobile workstation. In one design the antenna was placed on top of the computer tablet screen where nurses used it to adjust the tilt of the screen, thereby blocking the wireless signal. This led to a time-consuming reboot of the system. In a later workstation design, a curved antenna was mounted at the back of the work surface. Because it looked like a handle on the back of the cart, the antenna was used to pull the workstation, as one would pull a traditional cart. This broke the antenna which disabled its use on the network. Diverse users, from novice to expert, initially failed to understand the technology well enough to use it appropriately. Providing the nurses with an opportunity to trial the equipment before purchasing may have prevented this situation.

One example of a design flaw demonstrated a risk that went unnoticed until an adverse event occurred. Even though the nurses in the nursing home setting were involved in designing the integrated medication cart for their unit, they did not recognize a feature needed to prevent patient falls. Soon after the demonstration equipment was put into use on their unit, a patient experienced a fall. A root cause analysis uncovered the fact that the demonstration model of the integrated medication cart had no brakes. Despite the fact that the equipment itself was inspected by the biomedical engineering department following the normal protocol, this safety risk was not anticipated until there was an incident. In a long-term care setting, fluids and snacks on top of carts may attract residents to the cart. If the cart does not have brakes, it may be dangerous to keep the cart in the hallway. After this incident, and upon realizing that brakes could be purchased as an optional item, all future carts and mobile workstations were ordered “with brakes.” This experience has alerted our nurses to an important consideration in planning future technology changes.

Nursing involvement in equipment design makes the equipment simpler and safer for nurses to use. Another “lesson learned” involved the need for full documentation of intravenous (IV) fluids. The first version of BCMA did not include documentation of IV fluids except to mark the fluid as ‘hanging’ or ‘discontinued.’ Although the IV fluid had a readable bar code, there was no link between the BCMA and the drug file. There were no safety checks in the system to ensure the right fluid was being hung. In other words, the system could not discern normal saline from normal saline with potassium. Hence there was still a significant safety risk if bags “looked” similar. As part of the ongoing development of the software, the second version of the BCMA software was developed in partnership with nurses and pharmacists to include patient-specific IV medications with readable bar codes. This gave the nurse the ability to scan the IV and validate it electronically against the patient order in the CPRS. This enhancement allowed us to safely implement BCMA in the ICU setting in 2002.

Nursing involvement in equipment design makes the equipment simpler and safer for nurses to use. Greater nurse understanding and involvement in the design process may have prevented some of the early equipment problems we experienced when we tried to implement the BCMA system in a patient care environment. Once nurses began providing input into the actual medication practices and equipment, workarounds became much less frequent. We learned that engaging nurses early helps them to avoid adverse incidents and technology-related stress. Providing the nurses with the opportunity to practice using the system before it ‘goes live’ may reduce the learning curve for many users.

Nursing Involvement in the Planning Phase

As nursing involvement in designing this new system increased, the more their value was recognized and the more their continued involvement was requested. According to Lewis (2005), 75% of the time for initiating a new project should be spent planning so as to ensure successful implementation. The Project Management Institute’s PMBOK® Guide (2002) is an excellent resource for new project managers, informatics nurses, and/or clinical nurse leaders involved in introducing any new technology. It provides detailed information about the planning phase.

As the planning for the BCMA system moved forward, and especially as plans were developed to implement the Pocket PCs in 2004, nurses worked more closely with the interdisciplinary team. This team included, in addition to staff nurses and nursing managers, biomedical engineers, information technology (IT) specialists, patient safety experts, educators, informatics nurses,  laboratory staff, pharmacists, electrical engineers, biomedical staff, quality improvement specialists, and vendors. These team members all needed to be exemplary listeners so they could hear what was being said by staff nurses and other front-line workers, understand the concerns, and accurately share these concerns with the team. It was also important to designate, early on, point persons for all staff to call when they ran into difficulties.

The interdisciplinary team was responsible for determining the requirements for the project, including the technical, clinical, and medication requirements. The minimal requirements for BCMA included equipment to allow matching of the bar code with the patient and the patient’s medication,  identification of the nurse administering the medication, and availability of mobile equipment to deliver medications at the bedside. Facility staff and vendor representatives remained in contact by sharing telephone numbers, hours of availability, and on-call schedules, as well as a 24 hour hotline, and an online enhancement request website.

Planning for the technical requirements included clarification of contact information as noted above, determination of facility backup, establishment of test and computer training accounts that were compatible with the current software versions of the computerized patient record system, identification of the size and capacity of a separate server, and preparation of a backup power supply. Planning for the training of the Pocket PCs required selecting a location with a wireless access point, setting up the devices needed for the training with assistance from Information Resource Management Specialists, and charging devices and spare batteries.

Clinical requirements planning included finding available workspace and training space in which to prepare nurses to use the BCMA system. E-mail groups were created to facilitate communication between the clinical and technical staff. An important step in the planning phase was the development of training plans and clarification of vendor participation in this training. Equipment delivery points and times needed to be negotiated with the pilot unit. All training materials and user manuals for the new devices were put on the nursing web page for easy access from any workstation. Training periods were carefully planned in collaboration with the nurse manager. It was also essential to actively encourage staff participation in the process. Flexible times for classes (all three shifts) for one week were established. Failure to address patient care needs, which primarily involved addressing nurse staffing, could have led to project failure or an extended implementation period. The roll-out needed to be scheduled in advance to fit with mandated nurse-scheduling plans and the availability of the trainees. The nursing members of the team were knowledgeable about the staffing requirements and communication patterns of the units and were able to facilitate the planning of the training sessions.

Medication requirements included the development of medication models for training purposes. In this regard, nurses arranged for comprehensive patient orders and names, as well as bar-coded medication labels and the test account wristbands to use in educating nurses in the new process. Nurses also selected realistic patients to be used during the training.

Selection of the initial site for roll-out was also an important planning consideration. The site selected needed to have a committed manager and to be small and manageable in size. It also needed to have a moderately stable patient and staff population. We decided to select the unit that had the greatest number of challenges to overcome to better prepare us to implement the technology on a variety of other units. For example, the unit we selected had the highest concentration of isolation and negative pressure rooms of any unit in the facility. Other challenges on this unit included high non-compliance with initial BCMA system procedures due to problems related to the wireless network, computer freezes, dead zones, and internal network interface cards not being strong enough to work with our system.

This unit also had the need for additional electrical power. Additionally, a crowded and aging infrastructure, with inherent space limitations and two-to four-bed patient rooms, produced unique problems regarding equipment storage and location, privacy issues and staff workspace challenges. Carts could not be taken inside isolation rooms, but leaving the carts at the door left the nurse at the risk of information security and breach of patient privacy violations. Having the team pilot the project on this unit enabled the team to quickly learn the weak points in the system implementation thus allowing corrections in a rapid-cycle fashion.

The unit we selected did have the advantage of being the closest unit in the facility to the training room so more staff were able to attend the training with less impact on patient care. The small unit did allow for less financial impact as they had a smaller team to train. Once the technical, clinical, and medication requirements were arranged, timelines for implementation were created.

In the actual hands-on training for nurses on the pilot unit, each user had access to a hand-held device and learned the procedure to remove and replace the stylus, change the battery, reboot if the device locked up, and practice scanning an actual test-patient wristband and test medication. A screen was used to project each of these procedures on the wall, using pocket controller software. This allowed the RN educator, who was provided by the vendor, to point out specific features on the screen as she slowly walked the staff through each screen. This device made it much easier to train up to 30 users at a time. A DVD of the presentation was distributed to the units for subsequent viewing by new staff members or those who may have missed the training session. The RN educator visited each unit as it went ‘live’ to provide assistance and to answer questions.

Nursing assistants had different training needs than did the RNs. Training in vital sign entry was conducted separately for nursing assistants because they did not need to learn how to use the system in administering medications. Before the system was initiated, nursing assistants had hand-written the vital sign measurements on a piece of paper immediately after assessing the vital sign. They recorded these measurements in a computer at a later date. This meant nurses often needed to reassess the vital signs, so as to have up-to-date information before giving a medication. Training was done on each unit with interested nursing assistants, thus providing up-to-date vital sign information for the RNs as they administered medications. 

Initially BCMA users on the pilot unit had been trained by the informatics nurse and the RN who served as a champion on the pilot unit. As the BCMA system was initiated on other units, nurses viewed training programs that had been installed on computer workstations in their unit demonstrating the use of BCMA or visited the pilot unit for one-on-one training. The RN champion on the pilot unit carried a pager providing 24 hour support during the initial implementation. BCMA reference manuals were also available on each unit. Training was required for each new piece of equipment as we moved to more integrated workstations. Monthly Super User meetings were held to keep staff up-to-date with the latest software changes. These regular updates have been a key to our continuing success.

Nursing Involvement in the Implementation Phase

Modifications in longstanding practices regarding medication administration inevitably occur when the technology changes. Nurses are in an excellent position to provide crucial feedback regarding these changes, both during the trial periods and after the official implementation of the new technology. This section will discuss the nurses’ role in providing feedback during the trial periods. The next section will discuss the nurses’ role in evaluating the overall program.

The interdisciplinary team provided ongoing support throughout implementation. Units were brought up one-by-one to promote a successful implementation. Super Users were available to offer assistance during the implementation phrase. Additionally, users could call the Administrative Officer at night or during the weekend or utilize the BCMA pager for immediate assistance. The pilot unit provided assistance to other units on all shifts as needed, and especially during the initial implementation phase on other units.

During the trial period, almost all of the initial steps needed to be modified. In this phase the Plan-Do-Study-Act (PDSA) cycle became very useful because it supported rapid-cycle change and fully engaged staff in identifying, defining, and resolving problems. For example, implementation of the BCMA system revealed how complicated a relatively simple-looking task, such as scanning a wristband, can be. Smearing, spacing, barcode location/direction, durability when wet, and patient comfort were a few of the issues that led to scanning failures. These issues, coupled with dead zones in the wireless network, resulted in numerous workarounds by the nursing staff.

Nurses systematically investigated the challenges involving the no “quiet zone” (white space) between the printed information on the wristband and the bar code printed immediately next to it. The bar codes initially looked fine even without a quiet zone. However, when the wristbands were sent to the national bar code program office for testing, the bar code verifier graded our wristbands as an “F.” Once the quiet zone deficiency was determined, the programmers adjusted the wristband print program so there was a larger amount of white space on our wristbands, after which the wrist bands scanned 100% of the time (grade A) for the entire facility.

With this fix, the nursing staff knew their voices were being heard; we celebrated this nursing success in grand style. We now have an annual requirement that wristbands from all locations be mailed to the national bar code office for proactive verification. Figure 1 demonstrates how nurses used the PDSA cycle to address the challenges of age-related wear of wristbands which interfered with the scanning of the wristband.

Often several PDSA cycles were in process concurrently during the implementation phase to address various issues as they arose. Throughout the implementation process, PDSA cycles worked effectively to address the small issues that are readily fixed. However, we have found that many of the issues took a broader evaluation because they involved system issues. Some of these system concerns will be presented in the section describing the Evaluation Phase.

As we addressed nurses’ concerns in the pilot unit we increased staff compliance with using bar code scanning at the point of care by 50% within six months... An additional resource to facilitate implementation of the BCMA system is the Veterans Health Administration (VHA) Office of Information (OI). This Program Office was established to provide centralized leadership within the VA system, and develop the strategic direction required to ensure a standardized approach for the critical BCMA system that has a major impact on patient safety and medication-use management. Local BCMA Multidisciplinary Committees (now known as Clinical Bar Code Multidisciplinary Committees) provide advice and guidance for the management of BCMA and related medication processes at the facility level. This multidisciplinary approach serves to resolve, monitor, and control business/operational issues associated with BCMA and its interdependent processes.

BCMA Coordinators at each facility or healthcare system are the primary point of contact for all BCMA related issues (the first author was BCMA Coordinator until October 2008). These coordinators act as liaisons between the National BCMA Program Office and facility-level management. They bridge the gap between local administration, clinical staff, and Information Resource Management (IRM) regarding BCMA and the medication management process.

Throughout the implementation process the BCMA Collaborative Team systematically searched to identify the factors contributing to various problems we were confronting. In many cases, by ruling out confounding factors, we were able to determine the root of the problem. As an example, Table 1 lists the additional resources nurses felt would increase the scanning process. Appropriate utilization of the BCMA system continued to improve as each scanning issue was addressed and additional resources were provided. The only way we were able to address the ‘more time’ issue, however, was to provide the Pocket PCs that enabled nurses to have the scanning equipment readily at hand.

The collaborative also initiated a BCMA survey. One hundred and fifty nurses completed this initial survey. This high level of survey participation likely resulted from the many challenges nurses were experiencing at the time of the survey. As we addressed nurses’ concerns in the pilot unit we increased staff compliance with using bar code scanning at the point of care by 50% within six months as measured by pre and post surveys. Subsequent BCMA survey participation for the past several years has diminished because equipment failures are less likely and more equipment is available. Surveys continue to be conducted as needed for continual process improvement. One survey assessed the reasons nurse gave for not scanning the wristband for patient identification. Reasons given by the nurses are listed in Table 2.

...careful listening to the nurses’ comments was crucial...because these technology changes in practice have the potential to create a ripple effect in other aspects of their work flow... It was also very important during the implementation phase for project managers, nurse managers, and organizational leaders to use a listening and learning approach when seeking nursing staff input. Careful listening to both staff members’ off-handed comments and also to their direct feedback provided insight into recurring problems and potential solutions. One recurring problem was identified by a nurse’s comment, “I didn’t see the order,” when asked why the patient did not receive the medication. This comment, taken seriously, eventually led to running more frequent “missed medication reports” in BCMA to identify new medication orders that were entered during the time the nurse was actively administering medications. This procedural change has become one of the 15 best practice recommendations within the Veterans Administration. The practice is titled, “Nurses Should Print Medication Reports Once a Shift “(Patterson, Rogers, & Render, 2004). In our busy facility, we recommend running the Missed Medication Report after every major medication administration.

During system implementation, nurses frequently voiced frustration with the lack of integration of the systems. They also expressed many concerns regarding the numerous changes in the planned improvements. Again, careful listening to the nurses’ comments was crucial. It was important to address these concerns because these technology changes in practice have the potential to create a ripple effect in other aspects of their work flow leading to unanticipated and undesired consequences.

Nursing Involvement in Project Evaluation

...focus groups with direct-care nurses were very useful in determining whether concerns were unit specific or involved the entire system...non-compliance...frequently reflected system deficiencies rather than the nurses’ unwillingness to follow procedure. Several strategies were employed to evaluate the overall BCMA program. We found that focus groups with direct-care nurses were very useful in determining whether concerns were unit specific or involved the entire system. Talking with groups of nurses identified that the workaround of bypassing the BCMA process and typing in the patient identification number instead of scanning the wristband was a practice pattern that evolved as a result of chronic system failures. Brief, focused surveys were also used to assist in determining the severity of a problem and to identify practice patterns regarding compliance. We found that non-compliance to procedures frequently reflected system deficiencies rather than the nurses’ unwillingness to follow procedure.

Another lesson we learned was that vendor diversification pays big dividends, as there are bound to be failures in supply deliveries. For example, Hurricane Katrina destroyed a factory where some of the parts for our existing carts were made. The ability quickly to access equipment from different vendors allowed the project to continue without interruption. Another example involved the adoption by some units of Pocket PCs, which continue when the network is down as long as the system is up, because they run on a separate server. Units now using Pocket PCs are able to carry on without downtime while units without PCs need to go to the paper contingency back-up system when the network is down.

A concern in implementing the BCMA system was our initial lack of a Health Level Seven (HL7) interface for the Vitals Package. HL7 is an organization that provides standards for the exchange, management, and integration of data that supports clinical patient care. It is also a messaging standard that enables disparate health care applications to exchange key sets of clinical and administrative data, (Smith, 2002). This interface was needed to allow nursing assistants to take vital sign measurements and enter them into the system prior to the RN or LPN administering medications that involved assessing parameters related to heart rate, blood pressure, or temperature. Early on, one vendor had assured our facility that the vital sign monitors they demonstrated had real-time capability, i.e., the vital signs would be entered immediately from the device into the electronic record. Later it was discovered that this HL7 interface did not exist. Hence, the device would not “talk” to our computerized patient record. It took several years and networking with an informatics nurse at another VA facility who had completed a time study demonstrating the effectiveness of a newer, interfaced software system produced by a different company, before we were able to adopt a solution that immediately downloaded “real-time vital signs.” Because we had already successfully developed our online patient assessment tool using the company that developed this newer software system, we could build on our already established relationships with this company, and the company’s information technology specialists and outside vendor programmers, to further integrate our system.

...we learned was that it was much more difficult and often more costly to retrofit older equipment than to purchase new equipment... This integrated solution is now working well for us, thanks to biomedical and IT support and the involvement of informatics nurses. In this situation we learned was that it was much more difficult and often more costly to retrofit older equipment than to purchase new equipment to integrate, for example, the vital sign monitors, into the system. By utilizing lessons learned at other facilities, we decreased the probability of project failure and were able to convince senior management that the change would be an improvement.

Another system-wide problem that nurses identified was the failure of the original BCMA procedures to support good infection control practices for patients in isolation (ASHP Research and Education Foundation, 2004). It was the bedside nurses who found a workable, safe, and reasonable infection control practice to use with patients in isolation. This practice involved using a plastic bag to cover the scanner or pocket personal computer during medication administration. This practice is now another VA BCMA Best Practice (Patterson et al., 2004). This solution does add an additional step to the medication administration process, but the step is necessary to prevent the spread of infection.

Nurses...have been active in identifying...unnecessary steps in the BCMA system, as requiring too many steps may result in nurses creating workarounds [and] circumventing the safety parameters. ..It was bedside nurses who found a workable, safe, and reasonable infection control practice to use with patients in isolation. Nurses at our facility have been active in identifying and limiting all unnecessary steps in the BCMA system, as requiring too many steps may result in nurses creating workarounds to save time, thus circumventing the safety parameters. It is the professional nurses who have the judgment to weigh the pros and cons of additional steps being considered and to make the decisions as to which steps are essential for quality care and which are ‘nice to have’ but not essential. In some situations, the facility BCMA procedures were revised and/or shortened based on recommendations from the Informatics Nurse/BCMA Coordinator and the Chair of the Practice Council. Changes were then approved by the Practice Council members and the Nurse Executive.

Equipment integration remains a large part of our continuing project evaluation. Equipment needs change over time because of newer technology, lack of integration with existing or new equipment, equipment failures due to continuous usage 24 hours a day, or failure to meet initial expectations by having high repair rates. Continuous evaluation of equipment function is essential because insufficient or non-functional equipment leads to workarounds by nurses resulting in the system losing its effectiveness. Super Users, staff nurses, and health unit coordinators are trained to initiate immediate work orders on all shifts to ensure equipment is fixed in a timely manner. A supply of the hand held PCs now serve as backup for some of the equipment. Spare equipment has been ordered to decrease wait time for service and/or parts or other equipment or supplies. This continuous evaluation over time on the part of all VA facilities has resulted in the development of the 15 Best Practice Recommendations for Bar-Code Medication Administration in the Veterans Health Administration (Patterson et al., 2004). Figure 2 lists these 15 Best Practice recommendations which are as relevant for all healthcare organizations as they are for the VA facilities.

Conclusion and Summary

...it is the nurses who are in the best position to identify the clues needed to resolve underlying systemic issues and offer ideas for possible resolution. Progress has been made in developing new technology so as to improve patient care. Nurses’ involvement throughout all phases of the process, including the design, planning, implementation, and evaluation phrases, is an important key to success in using these technologies. Listening carefully to the comments and feedback from nurses is essential, because it is the nurses who are in the best position to identify the clues needed to resolve underlying systemic issues and offer ideas for possible resolution.

In this article the authors have described efforts to promote early nurse involvement in introducing a new technology, specifically the Bar Code Medication Administration (BCMA) system. After describing the context in which they worked to introduce this technology, and the BCMA system itself, they reported early attempts to introduce the BCMA system. They then described how this implementation process was facilitated by active nurse involvement in the later planning phases, as well as the implementation and evaluation phrases.

Authors

Heather N. Weckman, MS, CNL, RN-BC
E-mail: heather.weckman@va.gov

Heather Weckman served the James A. Haley Veterans’ Hospital in Tampa, Florida, as the Clinical Nursing Informatics Coordinator from 2001 through 2008. The additional role of Bar Code Medication Administration Coordinator was added in 2005; and she continued in this role until 2008. She is now serving as nurse manager in the new Spinal Cord Injury Community Living Center Ventilator unit. Ms. Weckman received her BSN degree from The University of Tampa in 2001 and her MS from the University of South Florida College of Nursing in 2007. She is currently credentialed by the American Association of Colleges of Nursing as a Clinical Nurse Leader. Ms. Weckman was the first Tampa VA nurse to be certified as an Informatics Nurse by the American Nurses Credentialing Center. Heather served as a nurse and labor representative for software development on the national Bar Code Medication Administration (BCMA) Health Systems Committee from 2004 through 2008, She has also served on a number of other local, regional, and national task forces and committees, and has presented nationally on topics related to spinal cord injury, stress management, Super Users, bar code medication administration, and patient safety.

Sandra K. Janzen, MS, RN, NEA-BC, FAAN
E-mail: sandra.janzen@va.gov

Sandra K. Janzen is the Associate Director, Patient Care/Nursing Services at the James A. Haley Veterans’ Hospital, Tampa, Florida, where she has served as the nurse executive for over 22 years. She is responsible for approximately 1,200 employees in all healthcare settings at the hospital, two Community Living Centers, and several satellite and community-based clinics across Central Florida. Ms. Janzen actively supports innovative programming, research-based practice, and interdisciplinary functioning for nurses in an environment that promotes ethical standards, caring, and a spirit of inquiry. Under her leadership, the James A. Haley Veterans' Hospital achieved recognition as a Magnet hospital in March, 2001, was re-designated a Magnet facility in 2005, and was awarded the inaugural Magnet Prize Award in 2003 for Exemplary Innovation in Patient Safety Research. Ms. Janzen’s willingness to adopt new technology was pivotal in the planning, acquisition, and deployment of both the electronic patient record and BCMA. Throughout the multi-year changeover from a paper to an electronic record, Ms. Janzen’s leadership supported both the information technology and the nursing involvement, enhancing this successful transformation.

References

ASHP Research and Education Foundation. (2004). Pharmacist's toolkit: Implementing a bar coded medication safety program. Retrieved 4/27/2009 from: www.ashpfoundation.org/MainMenuCategories/Education/SpecialPrograms/BarCodeGuide.aspx.

DeRosier, J., Stalhandske, E., Bagian, J. P., & Nudell, T. (2002). Using health care failure mode and effect analysis™: The VA national center for patient safety’s prospective risk analysis system. Journal on Quality Improvement, 28(5), 248-267.

Hunt, E. C., Sproat, S. B., & Kitzmiller, R. R. (2004). The nursing informatics implementation guide. New York: Springer.

Kramer, M., & Schmalenberg, C. (2008). Confirmation of a healthy work environment. Critical Care Nurse, 28(2), 56-63.

Leape, L.L., Bates, D.W., Cullen, D.J., Cooper, J., Demonaco, H.J., Gallivan, T., et al. (1995). Systems analysis of adverse drug events. ADE Prevention Study Group. JAMA 274, 35-43.

Lewis, J. P. (2005). Project planning scheduling and control: A hands-on guide to bringing projects in on time and on budget (4th ed.). New York: McGraw-Hill.

Patterson, E. S., Rogers, M. L., & Render, M. L. (2004). Fifteen best practice recommendations for bar-code medication administration in the Veterans Health Administration. Joint Commission Journal on Quality and Safety, 30(7), 355-365.

Project Management Institute, (2002). A guide to the project management body of knowledge. (PMBOK® guide). Author: Newton Square, PA.

Smith, K. (2002). Technical standards used in health care informatics. In S. P. Englebardt & R. Nelson (Eds.). Health care informatics: An interdisciplinary approach (pp. 361-394). St. Louis, MO: Mosby.

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Table 1. Perceptions of resources needed to increase the number of times wristbands would be scanned at the point of care.

Resources Needed to Increase Scanning

Number of Times Each Resource was Identified

Wristbands that Scan

10

More Equipment

10

More Staff

7

Equipment that Works

6

Wireless Scanners

5

Smaller Scanners

5

More Time

4

Table 2. Reasons why something other than scanning a patient’s wristband was used for patient identification.(ASHP Research and Education Foundation, 2004)

Major/Sub-Category for Reason Identified

Number of Times Reason was Identified

Equipment

 

  • Wristband Would Not Scan
  • 18

  • No Wristband
  • 8

  • Not Enough Scanners
  • 4

  • Computer Scanner Not Working
  • 2

  • BCMA Med Cart Immobile
  • 1

  • Could Not Get Around Equipment
  • 1

    People

     

  • Staff Convenience
  • 4

  • Patient Agitated/Paranoid
  • 2

    Process

     

  • PRN’s/Single Medication without a cart
  • 4

  • Blood Sugar
  • 2

  • Piggybacks
  • 1

    Environment

     

  • Patient on Isolation
  • 17

     

    Figure 1. PDSA cycle for wristbands

    Plan

    Implement a proactive method of reducing problems with wristbands that do not scan because of age-related wear.

    Do

    Collaborate with the unit coordinator to print, routinely, new wristbands for patients on the pilot unit every 14 days to prevent scanning problems. (Seven days was considered unnecessary and would have contributed to unnecessary costs related to bands).

    Study

    Start printing replacement wristbands March 1, 2004.

    Act

    Assess reduction in scanning problems associated with wristbands in preparation for implementation on other units: Distribute paper copies of BCMA survey to pilot unit on March 18, 2004, to capture follow-up data.

    Figure 2. Fifteen Best Practice Recommendations for BCMA in the VHA

    1. Put in place a standing interdisciplinary committee.

    2. Train all users. Cross-train pharmacists and certain physicians.

    3. Communicate known problems.

    4. Display contact information for resources to resolve different types of problems.

    5. Do not employ a double documentation system.

    6. Schedule planned downtimes to minimize disruptions.

    7. Replace malfunctioning equipment during its servicing.

    8. Develop a procedure for cleaning BCMA related equipment.

    9. Scan wristbands and medications prior to medication administration.

    10. Caregivers should personally document at the time of medication administration.

    11. Verify allergy information displayed in BCMA prior to administration.

    12. Support staff personnel should print a report at the beginning of a shift for nurses to use as an overview worksheet.

    13. Nurses should print Missed Medication Reports once a shift.

    14. Alert nurses to new Stat (Urgent) orders.

    15. Replace wristbands as needed and periodically in Long-Term Care.


    © 2009 OJIN: The Online Journal of Issues in Nursing
    Article published May 31, 2009


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