Running head: LEADERSHIP STRATEGY ANALYSIS

Leadership Strategy Analysis: Electronic Barcode Medication Administration

Abigail Densmore
Miranda Lindsey
Kathryn Neely
Karen Theus
Ferris State University

LEADERSHIP STRATEGY ANALYSIS

Leadership Strategy Analysis: Electronic Barcode Medication Administration

Introduction
A medication error can be defined as any preventable event that may cause or lead to
inappropriate medication use or patient harm while the medication is in the control of the health
care professional, patient, or consumer (Hughes, 2008). The National Quality Forum (NQF)
was established in 1999 to facilitate widespread healthcare quality improvement by designing
and endorsing national quality of care measurements and reporting system. Since then, facilities
have developed systems or procedures to provide high quality care that relates to the goals of
health care. The major goals of quality and safety initiatives are to provide effective, safe,
efficient, patient-centered, equitable, and timely care. Quality and safety initiative are
implemented to identify and reduce the potential for risk, basically improve the system and not
assign blame. Quality and safety initiatives have been linked to decreased length of stay in
hospitals and decreased risk for mortality in patient care.
Facilities have organized some form of quality management or improvement team to
enforce and monitor safe patient practices. According to Yoder-Wise (2015) the goal of an
organization committed to quality care is a comprehensive, systematic approach that prevents
errors so that adverse events are decreased and safety and quality outcomes are maximized
(p. 362). Quality and safety initiatives have shown to also be cost effective in the decease of
lawsuits in health professionals and the waste of supplies.
Health care is continually changing and improving care and nurses must be prepared to
provide safe quality care. Nurses play an important role when it comes to the interdisciplinary
team, implementing clinical procedures, and improving the quality of care. Nurses are generally
a part of the quality improvement or leadership team and can provide insight to daily practice
and procedures.
Identify Clinical Need

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Medication errors happen daily for many different reasons. Medication errors can be
defined as any preventable error that can lead to undesired results. Since 2000, the Food and
Drug Administration (FDA) has received more than 95,000 reports of medication errors. FDA
reviews reports that come to MedWatch, the agency's adverse event reporting program (FDA,
2009). The FDA uses MedWatch and Pharmacopeial to monitor medication errors but these are
not accurate because it is a voluntary reporting process.
Medication errors happen for many different reasons and majority human facilitated.
Medication errors can result from poor hand writing, incompetent nurses, similar drug names,
poor packaging, and confusing measurements. Majority medication errors impact floor nurses
who administer medication daily. In the article Preventing Medication Errors: A $21 billion
opportunity, (2010) nationally, serious preventable medication errors occur in 3.8 million
inpatient admissions and 3.3 million outpatient visits each year. Medication errors lead to
prolonged patient stay, adverse reaction, and death. In its report To Err Is Human, the Institute
of Medicine estimated 7,000 deaths in the U.S. each year are due to preventable medication
errors, and cost an estimated 21 billion dollars annually according to Preventing Medication
Errors: A $21 Billion Opportunity, (2010).
Included the reader will find the focus here was to target medication errors at the nurse
level and how implementing the 5 rights to medication administrating decreases errors. This
group chose to implement how the barcode method for medication administration decreases risk
for medication errors and, how the interdisciplinary team will implement, monitor, change, and
evaluate the outcome.
Interdisciplinary Team Identification
An interdisciplinary team of health care professionals would be the most appropriate way
to review bar code administration medication errors. The team should include nurses, a nurse
manager, a pharmacist, and or a member of the IT team of the hospital. Nurses should help to

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make up the team of reviewers because they are the workers on the front line. Nurses are
administering medications to patients, working with the bar code system, and potentially making
a medication error. The actions of nurses when administering medications are the main things
that are reviewed when looking at medication errors. Looking at and reviewing the actions of
nurses will help to better understand the behaviors that contribute to medication errors.
Representing nurses on this team will help to get an inside look at how nursing impacts
medication errors. Nurse Managers will help to support this position as well on the team.
Pharmacy should also be represented on the reviewing team. A pharmacist would
represent the pharmacy team in the best way when reviewing bar code medication administration
errors. Nurses connect the behavior of medication errors, however pharmacy can review the why
behind the error. Medications are sent to a unit from pharmacy, where those who work in this
department label medications and ensure that the medication is the proper dose. If the
medication that is administered has the wrong bar code, wrong dose, and or wrong patient, it is
an error that could potentially reflect back on the pharmacy. A pharmacist would be able to
connect with management and or other members who work in the pharmacy to understand why
improper labels are being used.
The team of reviewers on the medication administration error panel should also include a
member of the IT team who can help to understand errors that stem from the bar code system
itself. Medication errors stem from the nurse who is giving the medication, the pharmacy who
may have used the wrong label, as well as the IT department. If the bar code is not recognized in
the system, this is an error that the IT department could represent. A clear understanding of the
system used when administering a medication could help review the source of the error. A
member of the IT department could potentially help to make changes within the bar code system
that would decrease the risk of medication errors.
Data Collection Method

LEADERSHIP STRATEGY ANALYSIS

The team, once established, needs to set up a method to collect data to review medication
errors that are made with bar code medication administration. Observing the actions from start
to finish, at the beginning when the medication is administered to the unit from pharmacy and
then given to the patient by nursing, will help to better understand medication errors. This will
help the team to understand whether medication errors are occurring from a flaw in the system or
a flaw in the nursing practice. Understanding if the error stemmed from a flaw in nursing
practice will help to educate nurses. Perhaps a common flaw is being seen among nurses and
educating the nurses will help to decrease the flaws and amount of medication errors.
Another way to collect data on how medication errors are occurring is to review accident
reports. These reports help the reader to understand the situation as to how the error occurred.
Reviewing these reports will help those on the interdisciplinary team understand how the error
occurred, and what could help to prevent these from occurring again. Also reviewing medication
administration (MAR) records will also help to understand errors. Comments left during
administration entries could also lead to understanding a medication error.
Establishing Outcomes
To prevent medication errors during medication administration, there are steps that can be
taken. It is a large responsibility to administer medications in a safe way to each patient; as the
nurse gains experience. The following are the desired outcomes for medication administration:
1. The nurse will always use the 5 rights checklist when administering medications including
right patient, right drug, right dose, right route, and right time (Frederico, 2015).
2. The nurse will verify medication orders to ensure the right dose and medication are given.
3. The nurse will educate him or herself regarding medications he or she may be unfamiliar with.
4. The nurse will provide education to the patient and family regarding his or her medication
schedule.
Implementation Strategies
These outcomes are obtainable by following some basic steps. To ensure that these steps
are followed, a standard must be established on the patient care unit. It must become
unacceptable to cut corners during patient care and medication administration on patient care

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units. Evidence based practice shows us that if we follow the five rights for medication
administration, there will be less errors that occur. One of the recommendations to reduce
medication errors and harm is to use the five rights: the right patient, the right drug, the right
dose, the right route, and the right time (Frederico, 2015). Following this process is the best
defense against medication errors. It is very simple and doesnt take a lot of time, yet nurses are
skipping this vital part of the medication administration process.
To implement these changes the staff must be receptive to the standards related to
medication administration. The nurse must verify the medication order and ensure that the
dosage on hand is correct. To help ensure extra checks, perhaps implementing a medication
scanning system would be effective. On a smaller scale, the nurse can do the following:
1. Verify the medication order and dosage.
2. Take the MAR to the bedside as one administers the medications.
3. Check the patients arm band every time.
4. Ask the patients to verify their name and birthdate.
5. Propose a scanning system to be piloted on specific units.
A bar code scanning system for medication administration would be an effective way to
help reduce the number of medication errors. They also found a 41 percent drop in
administration errors and a 51 percent drop in potential adverse drug events (Reinberg, 2010).
Proposing a hospital system invest in this type of medication administration system would
improve patient safety and would provide the nurse with a safety net when needed. This does
not excuse the other steps in the medication administration process and the nurse must still
follow the steps outlined above in order to provide the patient with the best quality of care to
prevent medication errors.
Evaluation
The integration of an electronic barcode medication administration system (BCMA) to all
units of the facility will allow for safer and more effective medication administration. According
to the Pennsylvania Patient Safety Advisory, 39% of errors occurred during the prescribing
phase, 12% during transcription, 11% during dispensing, and 38% during administration (2008).

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As you can see, these numbers are very high and pose a great risk for harm to our patients. With
the use of BCMA, these numbers during the dispensing and administration phase can easily be
eliminated. With a BCMA, each patient is given a wrist band with an identification bar code on
it which represents that patients name, date of birth, and medical record number for
communication with the electronic charting system and electronic MAR. Each medication order
is electronically ordered in the computer system. Every medication that is administered has a bar
code included on it. When it is time to administer a medication to a patient, the nurse must ask
the patients name and date of birth, scan the patients wrist band, scan the medication, verify that
the medication was scanned appropriately, ensure the correct dosage is measured if applicable
and administered at the correct time and for the correct reason. Each and every medication
administered must be ordered by the physician, verified by the pharmacy as well as the nurse.
The nurse must know why he or she is administering the medication, what it is for, and provide
an explanation to the patient receiving the medication. With compliance with these steps while
using the BCMA system, an immense decrease in medication errors will occur.
Though the BCMA system will allow for increased patient safety while administering
medications, the risk of error cannot be excluded. A few BCMA system failures that predispose
the patient to medication errors include incorrect bar codes, medications without bar codes,
nurses failing to scan patient wrist bands or medications, patient wrist bands not on patients,
nurses overlooking alerts on computer screens, nurses overriding the bar code scanning and
simply charting that a medication was administered without scanning it first (Pennsylvania
Patient Safety Advisory, 2008). Nurses need to ensure that each patient and medication is
scanned as well as verified each and every time a medication is administered.
Conclusion
Medication errors are unfortunately frequent occurrences in the health care field affecting
not only the outcomes of patients, but also the nursing professionals administering the

LEADERSHIP STRATEGY ANALYSIS

medications. This clinical issue has been identified and it is essential that strategies be used to
decrease the amount of these errors. One such strategy is the integration of the electronic BCMA
system into clinical practice. Through collaboration with an interdisciplinary team that includes
managers, pharmacy, IT, physicians, and nurses, BCMA can be made possible. Nursing leaders,
managers, and followers must be committed to a quality improvement culture. To work
effectively in a quality-focused environment nurses must participate in quality improvement
initiatives (Gabua, S., 2015). BCMA is just one quality improvement initiative and is essential
to quality and safe patient care.

LEADERSHIP STRATEGY ANALYSIS

References
Agency for Healthcare Research and Quality (US); 2008 Apr. Chapter 37. Retrieved from:
http://www.ncbi.nlm.nih.gov/books/NBK2656/
Federico, F. (2015). The Five Rights of Medication Administration. Retrieved from
http://www.ihi.org/resources/Pages/ImprovementStories/FiveRightsofMedicationAdminis
tration.aspx
Gabua, S. (2015). NURS 440 leadership in nursing spring 2015 syllabus. Retrieved from
https://fsulearn.ferris.edu/webapps/portal/frameset.jsp?tab_tab_group_id=_2_1&url=
%2Fwebapps%2Fblackboard%2Fexecute%2Flauncher%3Ftype%3DCourse%26id
%3D_15472_1%26url%3D
Hughes RG, Blegen MA. (2008). Medication administration safety. In patient safety and quality:
an evidence-based handbook for nurses. Rockville (MD): Retrieved from:
http://www.ncbi.nlm.nih.gov/books/NBK2656/
Pennsylvania Patient Safety Advisory. (2008). Medication errors occurring with the use of bar
code administration technology. Pennsylvania patient safety advisory. 5(4). 122-127.
Retrieved from http://patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary /
2008/Dec5(4)/documents/122.pdf
Preventing Medication Errors: A $21 Billion Opportunity. (2010). Washington, DC: National
Priorities Partnership and National Quality Forum. Retrieved from:
http://psnet.ahrq.gov/resource.aspx?resourceID=20529
Quality and Safety Initiatives. New Jersey Health Care Quality Institute. Retrieved from:
http://www.njcth.org/
Reinberg, S. (2010, May 5). Bar codes cut down on hospital medication errors. U.S. health news
& world report. Retrieved from http://health.usnews.com/health-news/managing-yourhealthcare/healthcare/articles/2010/05/05/bar-codes-cut-down-on-hospital-medicationerrors
Yoder-Wise, P. S. (2015). Leading and managing in nursing (6th ed.).St. Louis, MO: Saunders.