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Background: Bar Code Medication Administration (BCMA) has been shown to reduce medication errors and improve patient outcomes. The utilization of this technology- driven approach enhances patient care and has emerged as a potent strategy to decrease medication errors.

Purpose: This project aimed to examine the impact of descriptive analytics in improving BCMA compliance to reduce medication errors in acute outpatient settings.

Methods: In March 2021, baseline data revealed that overall BCMA compliance was 87%, with only 1 out of 20 outpatient units meeting the 95% benchmark. To enhance overall efficiency and effectiveness, our team took a multi-faceted approach, including streamlining the data file, involving nursing staff and leadership, and redesigning nursing workflows. Utilization of interactive pivot tables and slicers within the BCMA data file allowed for cogent conversations between nursing educators and staff to review areas of opportunity, barriers, override reasons, and technical reasons why medications could not be scanned.

Results: Initial analysis of the data revealed variability across each center, with over 700 overrides and a compliance of 87%. After the implementation of the revised data file in October 2021, BCMA compliance improved to 97%, with a greater than 50% reduction in override entries noted. The results of a dependent t-test showed a statistically significant 10.4% point increase in BCMA compliance in the post- implementation phase (t[19] = -9.470, p < .001).

Conclusions: Utilizing innovative data solutions for BCMA to bridge the gap between nursing education and practice can improve engagement, accountability, quality, and patient safety.

Keywords: Patient safety, BCMA, outpatient, leapfrog, medication administration compliance

INTRODUCTION

Medication errors continue to be a leading cause of adverse drug reactions and death in the United States (Tariq et al., 2023). A study conducted in a tertiary

care emergency department catego- rized the highest administration errors as occurring in the stages of prescribing (53.9%) and administering (34.8%) (Patanwala et al., 2010). As such,

PERFORMANCE IMPROVEMENT

ABSTRACT

The Use of Descriptive Analytics to Improve Nursing Compliance with Bar Code Medication Administration in the Outpatient Setting Janisse P. Marin, RN, MSN, MSHA, DHSc; Stefania Granados, BA, LSSGB; Elyse Garcia, MSN, RN, FNP-BC, CEN, LSSGB; Gloria Arteaga, MBA, LSSGB; Cristina Lopez, MHA, LSSGB

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healthcare organizations have imple- mented several safety nets to combat medication errors, such as bar code medication administration. Bar Code Medication Administration (BCMA) is an electronic verification process utilizing scanner technology to scan a patient’s wristband and medications prescribed. This allows the nurse to verify and ensure the right medication is administered to the right patient, thus reducing the potential for patient harm. This method of verification ensures that allergies, route, dose, patient, and medication are cor- rect before the medication is adminis- tered to the patient. However, BCMA is not fail-proof, as the margin for human error is not eliminated. Several variables, including high patient volume, lack of bedside computers with scanners, and limited mobile computers with scanners, hinder the use of BCMA. These variables may also delay patient throughput and discharge from the outpatient center. Interruptions and multitasking are com- mon occurrences in clinical settings and have been shown to affect overall per- formance and increase the risk of error (Westbrook et al., 2018). These issues may contribute to nurses using the override scanning feature of BCMA.

Performance Improvement (PI) pro- jects are vital for the continuous improve- ment toward zero harm to our patients. After conducting a value stream map- ping of our process, we determined that BCMA was not being used appropriately due to the frequent use of override scan- ning. Furthermore, the current BCMA data file report did not allow further vali- dation to pinpoint where the fallouts occurred. Utilizing data effectively can lead to substantial benefits by driving decision-making and providing insight for strategy development. Descriptive ana- lytics is the use of data to identify a pat- tern or trend (Cote, 2021). Using descrip- tive analytics provides a multidimensional presentation of data output. It can assist in optimizing BCMA data to allow the identification of any fallouts. By collecting historical data and analyzing that data,

we could focus efforts on the areas requiring improvement. This PI project aimed to improve BCMA compliance to reduce medication errors by utilizing descriptive analytics.

METHODS

Initial Steps

Our organization is a non-profit healthcare system in South Florida. This project focused on 20 of our urgent care outpatient centers. As part of the organi- zation’s journey to high reliability, the goal was to develop methods to visualize data in a more structured three- dimensional view to help identify specific opportunities for BCMA compliance improvement. In January 2021, the team learned that several outpatient centers utilized differing criteria for excluding, col- lecting, and reporting data relating to unscanned medications or patients, such as excluding patients from the denomi- nator due to staffing shortages or physi- cian non-compliance. In March 2021, the data file was revised to incorporate descriptive analytics. The first step in the process of utilizing descriptive analytics was to centralize the data collection pro- cess to a data steward and create a sin- gle criterion for exclusion—only cases of unscanned medications or patients dur- ing technology downtime would be excluded. This crucial step allowed for the standardization of the data collec- tion process and the removal of bias related to the exclusions. Following cen- tralization, historical data were obtained to create a baseline. The second step was to identify key performance indica- tors to guide data extraction and its dis- play on the dashboard. The team creat- ed a descriptive analytics report using Microsoft Excel with multiple tabs and interactive pivot tables. The raw data was imported from an automated data- base into the monthly outpatient services BCMA Site Compliance report each month. The team ensured that all data was validated and corresponded to each site accordingly. Site leaders could navigate and review the report for spe-

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cific site metrics and individual metrics for each clinical staff member’s compliance rate.

Search for the Best Practice

The Leapfrog Group is a national not- for-profit organization that assigns letter grades to hospitals based on patient safety and reports information publicly to consumers (Austin et al., 2022). Public reporting by the Leapfrog Group enables consumers to make informed decisions when seeking healthcare and mitigates potential injuries and errors in the healthcare setting. The Leapfrog Group developed an expert panel to identify best practices related to the implemen- tation and use of BCMA in hospitals. The panel was charged with reviewing best practices and developing the framework for Leapfrog’s BCMA standard. The BCMA standard set by the panel focuses on four domains. The first domain of the standard relates to the implementation of BCMA technology in the hospital, the second domain focuses on BCMA utiliza- tion, the third domain focuses on deci- sion support systems for BCMA, and the fourth domain focuses on BCMA monitor- ing, compliance, and potential barriers to BCMA compliance. Our goal was for all the sites to reach the Leapfrog stand- ard of a 95% compliance rate.

Educating Outpatient Site Nurses

In May 2021, nursing educators creat- ed targeted education for the nursing staff, focusing on Leapfrog’s fourth domain: monitoring, compliance, and potential barriers to BCMA compliance. Educational objectives and goals includ- ed increasing BCMA compliance by nurs- ing staff and improving knowledge relat- ed to medication safety. Educators also reviewed override reasons with nurses and held small group discussions to examine barriers to BCMA implementa- tion. The most discussed barrier amongst staff and educators was the patient vol- ume of the site and the limitation of on-site equipment. Knowledge of these barriers was considered when providing

feedback during on-site rounding. For sites that had near ranges of 94% reflect- ing “caution or action needed,” our ded- icated quality educators, site leadership, PI team, and pharmacy team worked side by side to identify opportunities and initiate action plans to mitigate the con- cerns.

Ethical Considerations

Per the organization’s policy, this PI project did not meet the criteria for human subjects research and, therefore, did not require approval from its Institu- tional Review Board.

RESULTS

In March 2021, the cumulative aver- age of BCMA compliance was 87% across the 20 outpatient centers, with on- ly one outpatient center meeting the goal of 95% (Table 1). The centers had a total of 702 overrides (including patient and medication scanning) (Figure 1) and 1,299 unscanned medications (Table 2). After the project in October 2021, 18 out of the 20 outpatient centers met the goal of 95% compliance, with a cumulative average of 97% (Table 3). There was a reduction in overrides (n = 218), repre- senting a 70% decrease (Figure 2). In addition, there was a 73% decrease in medications not scanned (n = 345)(Table 4). Our objective to reach beyond the 95% benchmark was successfully achieved, and the feedback related to the accessibility and detailed data file was overwhelmingly positive. The outpa- tient centers have been able to maintain compliance above 95% since the end of the project. Furthermore, the results of a dependent t-test to examine percent compliance across all 20 outpatient centers showed a statistically significant difference in compliance between p re- implementat ion and post – implementation [t(19) = -9.470, p < .001] (Table 5). Pre-implementation and post- implementation percent averages were 86.41% (SD = 5.81) and 96.44% (SD = 1.77), respectively, yielding a mean difference of 10.30% (SD = 4.74). Throughout this PI

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project, there were no unintended con- sequences or missing data.

DISCUSSION

The results of this project showed that the 95% benchmark compliance rate was cumulatively achieved for 18 of the outpatient centers. These results are fur- ther supported by the statistically signifi- cant 10.4% point increase in BCMA com- pliance in the post-implementation phase. The user non-compliance dash- board was rapidly developed, resulting in a 45% reduction in non-compliant scan- ners within 10 weeks and an 81% reduc- tion in 23 weeks. In response to reaching the benchmark, the outpatient teams were challenged to outperform them- selves. Our executive leaders encour- aged our site leaders to increase the benchmark to 98%. The purpose of this challenge was to provide positive encouragement for exceeding the 95% Leapfrog benchmark to raise the bar for preventing medication errors, thus sup- porting the organization’s journey to high reliability and zero patient harm (Ho & Burger, 2020). This aim has resulted in healthcare organizations that engaged accountability from nursing to leadership on the safety nature of the BCMA report and the descriptive analytics it can pro- vide (Van Ornum, 2018). Leapfrog's BCMA standard offers a comprehensive guide outlining best practices for the secure administration of medications at the bedside. This has proven successful at facilities that have elected to participate in the Leapfrog hospital survey (Austin et al., 2022). As of April 2023, 100% of our outpatient centers have met the 98% benchmark. Each site continues to con- duct its own PI projects with the self- identification of non-compliant team- mates and the development of nurse- specific action plans.

One of the greatest benefits of an automated data file is the ability to repli- cate the tool for additional outpatient centers. At this time, we have extended the use of the descriptive analytics data tool to eight other outpatient centers

within the organization (e.g., off-campus emergency departments, express care centers, and infusion centers). These cen- ters have also reported improved BCMA compliance and reduced medication overrides. Outside of BCMA, our team has implemented the use of descriptive analytics for several other metrics, such as medication history collection, pain assessment, and fall screening.

As discussed previously, barriers were identified throughout the project, leading to recommendations from our team. One alarming barrier was the lack of access to scanners. We recommended that each nurse have their own workstation on wheels with a scanner available. This would prevent forced overrides and unscanned medications by eliminating the need to override due to scanner in- accessibility. Additionally, bedside docu- mentation is currently being piloted at one of our outpatient centers; each workstation is equipped with its own scanner. This is a pivotal step as we con- tinue to move toward high reliability and zero patient harm in our outpatient cen- ters.

CONCLUSION

This PI project highlights the im- portance of medication safeguards, such as BCMA. It also demonstrates the value behind the use of descriptive analytics to represent the data in a way that has a positive impact on compliance. Some gaps were also identified, such as the need to have sufficient on-site equip- ment to aid in the use and compliance of BCMA. We discovered throughout this project that lack of equipment discour- ages nursing staff from using the BCMA medication safeguard. Lack of equip- ment interrupts the normal workflow by delaying medication administration until a scanner is available, leading to medi- cation overrides and unscanned medi- cations. By using descriptive analytics, we reached and surpassed the goal of achieving the Leapfrog benchmark of 95% BCMA compliance. Lastly, we have collaborated and continue to collabo-

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rate with outpatient center site leader- ship to encourage the provision of neces- sary equipment as we continue to strive for high reliability and zero patient harm related to medication administration.

DECLARATION OF INTEREST

The authors report no conflicts of inter- est. The authors alone are responsible for the content and writing of the paper.

AUTHORS

Janisse P. Marin, RN, MSN, MSHA, DHSc Assistant Vice President, Chief Nursing Officer, Baptist Outpatient Services, Baptist Health, Miami, FL, US. Correspond- ence regarding this paper can be di- rected to: [email protected]

Stefania Granados, BA, LSSGB Accreditation and Performance Im- provement Specialist, Baptist Outpatient Services, Baptist Health, Miami, FL, US.

Elyse Garcia, MSN, RN, FNP-BC, CEN, LSSGB, Manager of Quality and Perfor- mance Improvement, Baptist Outpatient Services, Baptist Health, Miami, FL, US.

Gloria Arteaga, MBA, LSSGB Manager of Quality Operations, Baptist Outpatient Services, Baptist Health, Miami, FL, US.

Cristina Lopez, MHA, LSSGB Manager Patient Experience, Baptist Outpatient Services, Baptist Health, Miami, FL, US.

REFERENCES

Austin, M. J., Bane, A., Gooder, V., Salts- man, C., Wilson, M., Burggraf Stewart, K., Derk, J., Danforth, M., & Michalek, C. (2022). Development of the Leap- frog Group's bar code medication administration standard to address hospital inpatient medication safety. Journal of Patient Safety, 18(6), 526– 530. https://doi.org/10.1097/ PTS.0000000000001052

Cote, C. (2021, November 9). What is de- scriptive analytics? 5 examples. Har- vard Business School Online. https:// online.hbs.edu/blog/post/descriptive- analytics

Ho, J., & Burger, D. (2020). Improving medication safety practice at a com- munity hospital: A focus on bar code medication administration scanning and pain reassessment. BMJ Open Quality, 9(3), Article e000987. https:// doi.org/10.1136/bmjoq-2020-000987

Patanwala, A. E., Warholak, T. L., Sanders, A. B., & Erstad, B. L. (2010). A prospec- tive observational study of medica- tion errors in a tertiary care emergen- cy department. Annals of Emergency Medicine, 55(6), 522–526. https:// doi.org/10.1016/ j.annemergmed.2009.12.017

Tariq, R. A., Vashisht, R., Sinha, A., & Scherbak, Y.(2023). Medication dis- pensing errors and prevention. StatPearls Publishing. https:// www.ncbi.nlm.nih.gov/books/ NBK519065/

Van Ornum, M. (2018). Improving bar code medication administration com- pliance in a community hospital through a nursing leadership initiative. Journal of Nursing Care Quality, 33(4), 341–347. https://doi.org/10.1097/ NCQ.0000000000000320

Westbrook, J. I., Raban, M. Z., Walter, S. R., & Douglas, H. (2018). Task errors by emergency physicians are associated with interruptions, multitasking, fatigue and working memory capacity: A prospective, direct observation study. BMJ Quality & Safety, 27(8), 655 –663. https://doi.org/10.1136/bmjqs- 2017-007333

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Table 1

Pre-Implementation: BCMA “Pivot Summary” Tab for March 2021 (N = 10,823)

Outpatient Site Medication

Administered Patient

Scanned Medication

Scanned BCMA

Compliance

n n % n % n %

All Outpatient Sites 10,823 10,104 93 9,524 88 9,447 87

Outpatient 1 1,071 987 92 944 88 941 88

Outpatient 2 436 413 95 406 93 401 92

Outpatient 3 446 442 99 383 86 383 86

Outpatient 4 376 372 99 338 90 338 90

Outpatient 5 293 274 94 260 89 256 87

Outpatient 6 1,282 1,206 94 1,152 90 1,146 89

Outpatient 7 976 798 82 716 73 713 73

Outpatient 8 397 392 99 332 84 331 83

Outpatient 9 411 405 99 396 96 395 96

Outpatient 10 147 132 90 124 84 124 84

Outpatient 11 376 350 93 328 87 326 87

Outpatient 12 1,457 1,382 95 1,341 92 1,341 92

Outpatient 13 162 135 83 127 78 125 77

Outpatient 14 406 397 98 381 94 375 92

Outpatient 15 1,308 1,222 93 1,192 91 1,167 89

Outpatient 16 395 366 93 326 83 324 82

Outpatient 17 131 128 98 104 79 103 79

Outpatient 18 209 196 94 186 89 180 86

Outpatient 19 242 212 88 206 85 198 82

Outpatient 20 302 295 98 282 93 280 93

Note. The “Pivot Summary” tab is an overall roll-up of all the sites and their percentage.

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Table 2

Pre-Implementation: BCMA “Medications not Scanned” Tab for March 2021 (N = 1,299)

Medications Not Scanned Total

Lidocaine 187 Ceftriaxone 173 Mupirocin topical 145 Bacitracin topical 92 Aspirin 70 Sodium Chloride 0.9% intravenous solution 53 Fluorescein ophthalmic 51 Proparacaine ophthalmic 46 Acetaminophen 45 Ibuprofen 41 Ondansetron 35 Ophthalmic irrigation, extraocular 33 Ketorolac 28 Tetanus/diphth/pertuss (Tdap) adult/adol 24 Alprazolam 20 Albuterol 17 Famotidine 16 Benzoin topical 16 Methylprednisolone 15 Lidocaine-epinephrine 15 Lidocaine topical 15 Ciprofloxacin otic 14 Ciprofloxacin ophthalmic 13 Magnesium hydroxide/aluminum hydroxide/ simethicone

12

Silver Sulfadiazine topical 11 Dicyclomine 11 Docusate 10 Lidocaine/epinephrine/tetracaine topical 9 Diphenhydramine 8 Carbamide peroxide otic 8 Orphenadrine 8 Erythromycin ophthalmic 7 Prednisolone 7 Ipratropium 5 Lactated Ringers Injection intravenous solution 4 Phenylephrine nasal 3 Silver nitrate topical 3 Clonidine 3 Metoclopramide 3 Epinephrine 3 Azithromycin 2 Meclizine 2 Dexamethasone 2 Potassium bicarbonate-potassium chloride 2 Penicillin G benzathine 1 Tranexamic acid 1

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Table 3

Post-Implementation: BCMA “Pivot Summary” Tab for October 2021 (N = 11,583)

Pentafluoropropane-tetrafluoroethane topical 1 Levofloxacin 1 Morphine 1 Potassium chloride 1 Insulin regular 1 Ammonia 1 Tetanus-diphth toxoids (Td) adult/adol 1 Prednisone 1 Cyclobenzaprine 1 Gelatin hemostatic 1

Note. The "Medications not scanned" tab is a list of medications that were not scanned by clinicians. This list was given to the pharmacy team for further evaluation.

Outpatient Site Medication

Administered Patient

Scanned Medication

Scanned BCMA

Compliance

n n % n % n %

All Outpatient Sites 11,583 11,441 99 11,238 97 11,220 97

Outpatient 1 1,057 1,045 99 1,040 98 1,039 98

Outpatient 2 445 441 99 434 98 433 97

Outpatient 3 565 563 100 558 99 558 99

Outpatient 4 490 484 99 475 97 474 97

Outpatient 5 384 383 100 378 98 378 98

Outpatient 6 1,278 1,271 99 1,233 96 1,231 96

Outpatient 7 883 854 97 841 95 838 95

Outpatient 8 476 469 99 456 96 452 95

Outpatient 9 591 584 99 584 99 582 98

Outpatient 10 210 203 97 200 95 199 95

Outpatient 11 443 437 99 433 98 432 98

Outpatient 12 1,362 1,355 99 1,338 98 1,337 98

Outpatient 13 190 189 99 179 94 179 94

Outpatient 14 323 319 99 307 95 307 95

Outpatient 15 1,210 1,194 99 1,180 98 1,180 98

Outpatient 16 491 480 98 465 95 465 95

Outpatient 17 207 204 99 193 93 193 93

Outpatient 18 286 279 98 274 96 274 96

Outpatient 19 371 367 99 352 95 352 95

Outpatient 20 321 320 100 318 99 317 99

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Table 4

Post-Implementation: BCMA “Medications not Scanned” Tab for October 2021 (N = 345)

Medications Not Scanned Total

Ceftriaxone 51

Bacitracin topical 36

Lidocaine 24

Mupirocin topical 23

Sodium Chloride 0.9% intravenous solution 23

Fluorescein ophthalmic 16

Acetaminophen 14

Carbamide peroxide otic 14

Ibuprofen 14

Ondansetron 11