条形码给药技术：高警示药物触发因素及临床医生应对措施的特征分析

Bar Code Medication Administration Technology: Characterization of High-Alert Medication Triggers and Clinician Workarounds.

作者信息

Miller Daniel F, Fortier Christopher R, Garrison Kelli L

机构信息

Daniel F Miller PharmD BCPS, at the time of the study, PGY-1 Health-System Pharmacy Administration Resident, Medical University of South Carolina, Charleston, SC; now, Clinical Pharmacy Manager, Department of Pharmacy Services John Randolph Medical Center, Hopewell, VA

Christopher R Fortier PharmD, Manager, Pharmacy Support & OR Services, Medical University of South Carolina; Clinical Assistant Professor, South Carolina College of Pharmacy-MUSC Campus, Charleston.

出版信息

Ann Pharmacother. 2011 Feb;45(2):162-8. doi: 10.1345/aph.1P262.

DOI:10.1345/aph.1P262

PMID:21285409

Abstract

BACKGROUND

Bar code medication administration (BCMA) technology is gaining acceptance for its ability to prevent medication administration errors. However, studies suggest that improper use of BCMA technology can yield unsatisfactory error prevention and introduction of new potential medication errors.

OBJECTIVE

To evaluate the incidence of high-alert medication BCMA triggers and alert types and discuss the type of nursing and pharmacy workarounds occurring with the use of BCMA technology and the electronic medication administration record (eMAR).

METHODS

Medication scanning and override reports from January 1, 2008, through November 30, 2008, for all adult medical/surgical units were retrospectively evaluated for high-alert medication system triggers, alert types, and override reason documentation. An observational study of nursing workarounds on an adult medicine step-down unit was performed and an analysis of potential pharmacy workarounds affecting BCMA and the eMAR was also conducted.

RESULTS

Seventeen percent of scanned medications triggered an error alert of which 55% were for high-alert medications. Insulin aspart, NPH insulin, hydromorphone, potassium chloride, and morphine were the top 5 high-alert medications that generated alert messages. Clinician override reasons for alerts were documented in only 23% of administrations. Observational studies assessing for nursing workarounds revealed a median of 3 clinician workarounds per administration. Specific nursing workarounds included a failure to scan medications/patient armband and scanning the bar code once the dosage has been removed from the unit-dose packaging. Analysis of pharmacy order entry process workarounds revealed the potential for missed doses, duplicate doses, and doses being scheduled at the wrong time.

CONCLUSIONS

BCMA has the potential to prevent high-alert medication errors by alerting clinicians through alert messages. Nursing and pharmacy workarounds can limit the recognition of optimal safety outcomes and therefore workflow processes must be continually analyzed and restructured to yield the intended full benefits of BCMA technology.

摘要

背景

条形码给药技术（BCMA）因其预防给药错误的能力而逐渐得到认可。然而，研究表明，BCMA技术使用不当可能导致预防错误效果不尽人意，并引入新的潜在用药错误。

目的

评估高警示药品BCMA触发因素和警示类型的发生率，并探讨使用BCMA技术和电子给药记录（eMAR）时出现的护理和药房应对措施类型。

方法

回顾性评估2008年1月1日至2008年11月30日所有成人医疗/外科科室的药品扫描和超驰报告，以了解高警示药品系统触发因素、警示类型和超驰原因记录情况。对一个成人内科降级护理单元的护理应对措施进行了观察性研究，并对影响BCMA和eMAR的潜在药房应对措施进行了分析。

结果

17%的扫描药品触发了错误警示，其中55%是高警示药品。门冬胰岛素、中性胰岛素、氢吗啡酮、氯化钾和吗啡是产生警示信息的前5种高警示药品。仅23%的给药记录了临床医生超驰警示的原因。评估护理应对措施的观察性研究显示，每次给药临床医生的应对措施中位数为3次。具体的护理应对措施包括未扫描药品/患者腕带，以及在从单剂量包装中取出剂量后扫描条形码。对药房医嘱录入流程应对措施的分析显示，存在漏服、重复给药和给药时间安排错误的可能性。