COLUMBUS, Ohio -- Researchers have found that a new computer
system that uses bar codes to safeguard patients' medications
will work successfully, but not without creating new, serious
problems for nurses charged with patient care.
"In general, we viewed the system as successful. There
are no magic bullet solutions to human error in any setting,
and even the best systems will require constant maintenance
and flexible redesign after implementation," said Emily
Patterson, a research specialist in Ohio State's Institute
The Veterans Health Administration (VA) recently designed
a drug dispensing system called Bar Code Medication Administration
(BCMA), and asked Patterson to evaluate it.
At issue is whether bar codes could enable healthcare professionals
to verify that a patient is receiving the right drug, at
the right dose, at the right time.
Chapman, another research specialist in Ohio State's Institute
for Ergonomics, is going to investigate how nurses' use of
PDAs, or personal digital assistants, instead of laptop computers
will affect the use of BCMA.
Patterson conducted the research with the VA Midwest Patient
Safety Center of Inquiry in Cincinnati and published the results
in a recent issue of the Journal of the American Medical Informatics
Association. Her coauthors include Marta Render, director of the
center and adjunct associate professor of internal medicine at
the University of Cincinnati, and Richard Cook, director of the
Cognitive Technologies Laboratory at the University of Chicago.
The Department of Veterans Affairs funded the study.
With BCMA, hospital pharmacies label medications with bar codes,
and patients wear bar-coded wristbands. Nurses scan a patient's
wristband, and a laptop computer on the medication cart displays
that patient's prescriptions. Before giving the medicine, the
nurse scans the medicine bottle or other container, and BCMA records
the drug as delivered. If the nurse accidentally scans the wrong
medicine or dosage, or tries to give medicine at the wrong time,
a warning pops up on the computer screen.
Patterson followed the activities of 26 nurses at three VA hospitals
as they dispensed medication with BCMA. She also watched as doctors
entered new prescriptions into the electronic medical record,
and pharmacists labeled prescriptions. Then she interviewed these
people as well as hospital computer support personnel and nurse
managers, to gauge everyone's opinion of the system.
The study did not specifically examine errors caught or prevented
by BCMA, but focused instead on the interaction of users with
the system, in order to find ways to make the system work better.
Nearly all VA hospitals are now using BCMA software version 2.0,
and Patterson and her colleagues are helping create version 3.0,
which will address some of the problems found during the study.
After that, Patterson and her colleagues will continue to help
the system evolve over time.
Patterson cited a 1999 study at Brigham and Women's Hospital
and Harvard Medical School that found medication errors fell 86
percent when doctors began entering their prescriptions orders
via computer. When computer systems are optimized for taking human
factors into account, errors can decrease even further, she said.
The new Ohio State study found five unanticipated negative side
effects of introducing BCMA to hospitals:
-- Sometimes the computer automatically removed medications from
a patient's prescription list.
For example, one patient could not receive his dose of a drug
on time, because he had been away in another part of the hospital
when he was supposed to receive it. When the patient returned
to the ward and the nurse administered his medications, BCMA no
longer displayed the medication because it was dropped when a
time window had elapsed. In most cases, the nurses knew to administer
the medication and so asked a pharmacist to add it back to the
-- There was less coordination between doctors and nurses, compared
to a paper-based system.
Doctors reviewed patient's medication orders less often, because
doing so through the BCMA computer was more difficult or time-consuming
than the old procedure, which involved simply reading the nurses'
notes on a paper medical chart. That means doctors and nurses
were less likely to know if a patient's medication needed to be
-- During the busiest parts of the day, nurses had to ignore
some of the required BCMA procedures to save time.
For instance, bar codes didn't always scan properly on the first
try. To avoid re-scanning a patient during crunch periods, nurses
would often enter the seven-digit bar code number manually.
-- Nurses became anxious about delivering medications on time.
The computer required the nurses to type an explanation when
medications were given even a few minutes early or late, and nurses
were concerned that the late administrations would reflect badly
on their job performance. As a result, nurses tended to make just-on-time
administration of medicines a high priority, compared to other
-- The computer didn't easily accept unusual dosage orders.
While the system streamlined the administration of consistent
dosages of drugs, it wasn't set up to accept dosages that increased
or decreased over time. For example, pharmacists had to enter
14 separate daily doses for a patient whose medicine was supposed
to taper off over a two-week period.
In the future, Patterson and her colleagues will examine how
BCMA is used differently in acute care wards, nursing homes, and
intensive care units. Roger Chapman, another research specialist
in Ohio State's Institute for Ergonomics, is going to investigate
how nurses' use of PDAs, or personal digital assistants, instead
of laptop computers will affect the use of BCMA.
FDA Says Bar Coding Saves Lives