Andrew Godwin February 5, 2012 Nursing Leadership II Informatics Case Study You are a nurse on a busy medical-surgical unit

in a large teaching hospital that has achieved Magnet status. Nurses who work at this hospital use a bar-coded medication administration system (BCMA) when administering medications to patients. You have observed your peers using a variety of workarounds; processes that intentionally bypass key safety features of the BCMA system, while administering medications. For example, one nurse prints out her patients barcodes and tapes them to her patients beds. Instead of scanning the patients armbands when she administers medications, she scans the barcodes that are taped to the bed. You also have heard many negative comments about the BCMA system. At a recent Quality Council meeting, you learn that the hospital is experiencing a sudden increase in the number of medication errors. You volunteered to join a subcommittee formed out of the Quality Council to investigate the cause of the medication errors and implement evidence-based nursing practices to reduce the number of medication errors. 1. The Chairperson of the medication error subcommittee asks the group to list factors that are contributing to the increase in medication errors. Based on your clinical experiences, information in this case study and current evidence, provide 3 factors that contribute to medication errors when a BCMA system is used. Include rationale to support why these factors contribute to medication errors. The most obvious problem with the bar-coded administration (BCMA) system implemented at this hospital is that nurses are using workarounds, and bypassing the systems key safety features. This is basically rendering this quality and safety intervention system mute. Nurses taping patient barcodes to beds and finding other ways around scanning the patients armband at the time of medication administration are undermining the BCMA system. The system can therefore isnt given a chance to work and warn nurses of improper or dangerous medication administration situations. The second issue with the BCMA system in place at this hospital is that nurses are complaining about the system. Complaining is typically a sign of frustration. It is quite possible that the nurses on the unit where I work are having issues with using the BCMA system and are having difficulty understanding the procedure of administering the medication with using the BCMA system. This frustration lead to decreased compliance with the BCMA system, which thus leads to an increase in the amount of medication errors.

The third issue that is common among BCMA systems that commonly contributes to non-compliance is that bar-coded wristbands often wear out and dont read. It might also be the case that there are an insufficient number of functional bar-code scanners on the unit. When patients wear wristbands for days or weeks at a time, the barcode is less likely to scan properly. This can lead to the nurse looking for a short cut to the barcode scanning system. The same idea applies to the nurse who cannot locate a working barcode scanner when they need to administer a medication. They may then elect to bypass the BCMA system instead of running around to find a barcode scanner. These problems once again lead to decreased BCMA compliance and the system cannot provide the safety and security that it was designed for. 2. Discuss one evidence-based solution that the nursing and/or hospital staff could implement to address each of the factors you listed in question #1 (you need one solution for each factor, so you will end up with 3 different solutions). To solve the problem of nurses using workarounds to the BCMA system I would suggest that all staff nurses be required to attend an education seminar regarding the dangers of bypassing the BCMA system and what possible dangers it could mean for the patient. I the educational seminar would also instruct nurses to be accountable for one another and encourage each other to properly implement the BCMA system. An incentive program would also be put into place to monitor how often each nursing unit was missing scans. Units with the lowest score would be given recognition as well as a small reward for their hard work and improvement. To solve the issue of nurses becoming frustrated and complaining about the BCMA system I would suggest that a interdisciplinary committee be formed to hear and evaluate the concerns of the nursing staff and then integrate this information into the systems themselves. In an article by Weckman & Janzen (2009) it is suggested that by involving nurses in the process of developing and implementing BCMA systems early on, then nurses are much more likely to see value in the system and are thus more likely to properly utilize the system. In a pilot study, a multidisciplinary team was established early in the development of a new BCMA system that included nurses. After six months of the newly designed plan being implemented nursing compliance with using the barcode scanning at the point of care increased by 50%. The BCMA system in this hospital would also benefit from the hiring of a qualified nursing informatics specialist to better integrate the BCMA system into nursing practice. This nurse could lead the drive to design employee education programs in regard to new information technologies being integrated into practice. A well-trained clinical informatics nurse specialist is better able to communicate with nursing staff and assess and address their concerns. This improved communication leads to better-informed employees who are better able to utilize information technologies into their practice.

To solve the equipment-based problems I would make sure that each unit on the hospital was properly supplied with functioning barcode scanners. I would also set aside a reserve set of barcode scanners that could be brought into use when broken scanners were undergoing maintenance. In an article by Weckman & Janzen (2009) there are numerous best practice interventions listed that are designed to increase proper BCMA system use. They support my decision to ensure that each unit is properly equipped with functioning scanners and that scanners undergoing maintenance are replaced during their downtime. They furthermore suggested that there should be scheduled downtimes to complete routine maintenance. These downtimes should be well advertised to staff with proper notice to minimize disruptions. 3. The chairperson of the quality council suggests that the hospital hire a clinical informatics nurse specialist. Describe the role of the clinical informatics nurse specialist. Describe the educational background for a nurse who has this degree. What value would a nurse with this specialty provide to the hospital and the nursing staff? The role of the clinical informatics nurse specialist revolves around increasing the integration between healthcare information technologies being introduced and the nursing staff that are meant to implement them ("Clinical Informatics Nurse," 2004). They are also required to continually assess the information technology systems within the hospital, looking for areas of concern and improvement. They then use interventions aimed at bettering the systems. The informatics nurse must then evaluate their intervention to determine if it was indeed effective. Clinical informatics nurse specialists are also responsible for coordinating staff education sessions regarding information technologies. A clinical informatics nurse specialist must obtain their masters degree in clinical informatics. It is also recommended that a clinical informatics nurse specialist have at least 5 years experience as a nurse in a hospital ("Clinical Informatics Nurse," 2004). Additionally they should also have 2 years working with healthcare informatics and a certification in nursing informatics obtained from the American Nurses Credentialing Center (ANCC). They must be experts at all of the information systems that are used by the hospital so they are better able to facilitate the needs and questions of the nursing staff that they serve. They must also have a current nursing license for the state in which they intend to practice. 4. The hospital system owns a home health agency, a rehabilitation center, an outpatient surgery center, and a network of primary care clinics. The executives of the hospital system have decided to adopt an electronic health record (EHR) system within the next year. Their vision is to have a system in which patient information can be shared across all of the various units and facilities within the hospital system. Because of your excellent work on the medication error subcommittee, you have been asked to serve on the committee to begin the initial planning phase for the HER. You experience frustration on a daily basis when trying to find information for patients who are being

admitted from other sites within the system or trying to coordinate the transfer of information for patients who are being discharged. How will this new EHR system help nurses in all areas of the hospital system function more effectively? How will the system affect patient safety? Nurses and patients in all areas of the hospital system will benefit in numerous ways from the implementation of the new EHR system. Unlike paper documentation that cannot travel across care settings, an EHR is easily transferable from one setting to another (Bell & Thorton, 2011). Information on a patients EHR that is documented is updated in real time. Other healthcare providers working with the patient can then access this newly updated information from a qualified computer terminal, which could even be at a physicians home. This greatly increases the efficiency and accuracy in which healthcare information such as diagnostic test results can be communicated between nurses, doctors, and other members of the healthcare team. This system would cut down on nursing having to hunt down charts and even allows multiple users to access the chart at once. More importantly this increase in efficiency and accuracy in health record communication can drastically reduce the amount of medical errors. One way in which an EHR system can increase patient safety is by better informing the nurse and other healthcare providers of patient allergies. With an EHR, allergy lists are also much easier to maintain, standardize, consolidate, and access on a single screen (Bell & Thorton, 2011). The EHR integrated with a BCMA system could also warn the nurse before administering a drug that contains a potential allergen. This allows for easy checking of drug-todrug and drug-to-allergy interactions. All of these can positively affect a hospital's safety record. 5. How will the EHR affect patient care? A well-functioning electronic health record system will drastically affect patient care. To begin from the moment that the system is live the EHR system will begin to gather data. This gathered data is then sent to computer systems and experts to analyze (Kudyba, 2010). This data mine allows trends and areas of improvement to be identified. This way changes may be made to processes and efficiencies are gained. The future potential for this system is mindboggling as mountains of quality data can lead to better designed hospitals providing more evidence-based care. EHR screens can also then be especially tailored and streamlined to accommodate for specific illnesses and situations. This would allow for a more focused clutter free assessment of patient data (Paperless, 2009). 6. You become a team leader during the implementation of the EHR. What evidence-based interventions can you and your nursing unit implement to prepare for the implementation process? Provide 3 conflicts, issues or problems you will anticipate will

most likely happen during the implementation process. Discuss how you will address each of these conflicts, issues, or problems. The first problem that can occur during the implementation of an EHR system is that staff may not be properly educated on the use of the system and therefore are prone to errors and frustration that may lead to the loss of an employee. To reduce the amount of misunderstanding and increase proper use of the new EHR system I would work in collaboration with the newly hired clinical informatics nurses specialist to design an education seminar that all staff nurses would be required to attend. I would also put in place a technology team headed by the clinical informatics nurse specialist. This team would consist of employees from every unit on the hospital most of them being nurses. These team members would be specially trained by the informatics specialist and sent back to their unit as resident experts whose knowledge can quickly be drawn upon if question arise with the EHR system. A second problem that may arise with the implementation of a new EHR system may be that the system is not user friendly and several nurses find problems or inefficiencies with it at the point of care. To solve this problem I would have a permanent multidisciplinary committee formed that is headed by the newly hired clinical informatics nurse specialist. The committee would be in charge or gather the complaints and feedback of the staff nurses using the system and would then seek to reform the system to work more efficiently. This should be an ongoing process that is constantly evolving. The third problem that may be encountered when implementing the new EHR system in the healthcare system is computer system bugs and downtime. The hospital must be prepared for the event of the EHR to crash. Therefore there should be paper charting forms still keep on the units in case they need to fall back on them in the event of an outage in the EHR system. A welltrained maintenance team must be kept on hand and well managed by the clinical informatics nurse specialist to ensure that problems like this are minimal and that maintenance downtimes are well advertised and prepared for.

References Bell, B., & Thornton, K. (2011). from promise to reality achieving the value of an EHR.. (cover story). Hfm (Healthcare Financial Management), 65(2), 50-56. Kudyba, S. (Performer) (2010). What is healthcare informatics? [Web]. Retrieved from http://youtu.be/pzS--PaGC9o?hd=1 Paperless: showing EHR benefits in HIV care. (2009). AIDS Alert, 24(10), 112-113. [Web log message]. (2004, November). Retrieved from http://www.informaticsnurse.com/forums/informatics-job-descriptiondatabase/18814-clinical-informatics-nurse-specialist.html Weckman, H., & Janzen, S. (2009). The critical nature of early nursing involvement for introducing new technologies. Online Journal Of Issues In Nursing, 14(2), 1-11.