N437 Module 3 Bar-Code Medication Administration Workarounds Example

The Label That Would Not Scan: Bar-Code Medication Administration, a Unit's Workaround and What It Revealed

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Pre-licensure BSN Program, Aspen University

N437: Healthcare Informatics

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The Label That Would Not Scan: Bar-Code Medication Administration, a Unit's Workaround and What It Revealed

Bar-code medication administration asks the nurse to scan the wristband and then every drug before administration, so that the software can confirm that patient, drug, dose, route and timing all match the order. On a composite 28-bed medical-surgical unit, the pharmacy replaced its label printers in March. Within a week, about one in five intravenous piggyback bags would not scan, and nurses began scanning a spare label that someone had taped inside a drawer of the medication cart. This paper describes what bar-code administration prevents, how and why workarounds like this develop, what risks they create and how the unit could fix the cause.

What the Technology Prevents

In a before-and-after study that observed 14,041 medication administrations, units using bar-code administration with an electronic medication administration record had a nontiming administration error rate of 6.8% compared with 11.5% on units without it, a 41.4% relative reduction, and potential adverse drug events from those errors fell by 50.8% (Poon et al., 2010). Transcription errors, which occurred at 6.1% without the system, were eliminated. The same study found that the technology reduced but did not eliminate errors, which is a reminder that its protection depends on how it is used.

The Unit's Workaround

When a bag would not scan, the system offered an override that required a reason and a second nurse's cosignature. Busy nurses found this slow, especially at 9 p.m. when many antibiotics were due. Someone printed a spare label for a common antibiotic and taped it inside the cart drawer. Scanning the spare label satisfied the system, which then recorded that the drug had been verified. Within two weeks, spare labels for four antibiotics were in the drawer. No one had told nurses to do this, and most who used it considered it harmless because they checked the bag visually. One nurse later said she knew it was wrong but could not see another way to get four antibiotics hung on time.

A Taxonomy of Workarounds

A study at five hospitals identified 15 types of workarounds, such as attaching patient barcodes to carts or doorjambs and carrying several patients' prescanned medications, and 31 types of causes, including unreadable medication barcodes, malfunctioning scanners, damaged wristbands, nonbarcoded drugs, failing batteries, uncertain wireless connections and emergencies (Koppel et al., 2008). Nurses in that study overrode alerts for 4.2% of patients and 10.3% of medications. The spare-label workaround on this unit fits the taxonomy exactly: the cause was an unreadable barcode, and the workaround was scanning a substitute that was not attached to the item being given.

Why Nurses Work Around

A systematic review of bar-code workarounds concluded that they arise when the required process does not fit the real workflow, and that nurse executives should address the causes rather than only prohibiting the behavior (Voshall et al., 2013). On this unit, the override path took about four minutes per bag and required a second nurse who was often busy. The nurses' goal, giving antibiotics on time, was a good one. The workaround preserved timeliness at the cost of the safety check, and it did so quietly, which is what makes workarounds dangerous.

What the Workaround Revealed About the System

Workarounds are often described only as violations, but they also carry information. The spare labels told the unit three things it did not know. First, the new printer produced barcodes the scanners could not read reliably, a technical fault that pharmacy had not detected in testing. Second, the override process was too slow for the evening medication pass, when many intravenous antibiotics are due at once. Third, nurses did not feel able to report the problem quickly, since the workaround spread for two weeks before a manager learned of it. Each of these is a system condition. Treating the workaround as a signal, rather than simply removing the labels and warning staff, is what allowed the unit to find and fix all three.

The Risks

The spare label confirms only that the label in the drawer is correct. If pharmacy sent the wrong bag, the wrong concentration or another patient's drug, the scan would still succeed. Koppel et al. (2008) list wrong medications, wrong doses, wrong times and wrong formulations among the consequences of workarounds. The system's record also becomes false, showing verification that never occurred, which misleads anyone who later reviews an error. Finally, a workaround that works for one drug tends to spread, as it did here from one antibiotic to four.

Fixing the Cause

The fix begins with the barcode, not the nurse. The unit's manager reported the problem through the safety reporting system, and pharmacy and informatics tested the new labels with the scanners, finding that the new printer produced a narrower barcode than the scanners could read reliably. Pharmacy adjusted the printer setting. In the meantime, pharmacy reprinted labels for unreadable bags on request within 15 minutes, and informatics shortened the override process for this specific reason while still requiring a visual check. The spare labels were removed, and the manager explained why without punishing the nurses who had used them.

Monitoring

Scan rates are measurable. The unit's weekly report of the percentage of intravenous doses scanned successfully, and the number and reasons for overrides, would show whether the fix worked. A scan success rate above 95% for intravenous bags and a falling override rate would indicate that the cause had been removed. A sudden rise in successful scans without a printer fix would suggest a new workaround. The manager also planned to ask nurses directly, at a huddle a month later, whether any new workarounds had appeared, since data alone may not reveal them and nurses are the first to know.

Conclusion

Bar-code administration substantially reduces medication errors, but only when the scan is real. The unit's spare-label workaround was a rational response to an unreadable barcode and a slow override, and it hollowed out the safety check while leaving the record looking perfect. Treating workarounds as signals of system problems, fixing the cause and monitoring scan data protects both patients and the nurses who care for them.

References

Koppel, R., Wetterneck, T., Telles, J. L., & Karsh, B.-T. (2008). Workarounds to barcode medication administration systems: Their occurrences, causes, and threats to patient safety. Journal of the American Medical Informatics Association, 15(4), 408-423. https://doi.org/10.1197/jamia.M2616

Poon, E. G., Keohane, C. A., Yoon, C. S., Ditmore, M., Bane, A., Levtzion-Korach, O., Moniz, T., Rothschild, J. M., Kachalia, A. B., Hayes, J., Churchill, W. W., Lipsitz, S., Whittemore, A. D., Bates, D. W., & Gandhi, T. K. (2010). Effect of bar-code technology on the safety of medication administration. New England Journal of Medicine, 362(18), 1698-1707. https://doi.org/10.1056/NEJMsa0907115

Voshall, B., Piscotty, R., Lawrence, J., & Targosz, M. (2013). Barcode medication administration work-arounds: A systematic review and implications for nurse executives. Journal of Nursing Administration, 43(10), 530-535. https://doi.org/10.1097/NNA.0b013e3182a3e8ad