12/20/2017
Near-Miss Event Analysis Improves Barcode Medication Administration Process

​Medication errors in oncology care, unplanned NICU admissions, warming devices, and more in the December 2017 Pennsylvania Patient Safety Advisory

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Harrisburg, Pa., December 20, 2017 — Since 2005, Pennsylvania healthcare facilities have increasingly reported to the Pennsylvania Patient Safety Authority certain patient safety events associated with barcode medication administration (BCMA), a technology used to prevent medication-administration errors.

"The likelihood of the right patient, receiving the right medication, at the right dose, at the right time increases when barcode medication administration processes have been properly vetted for deficiencies," said Dr. Ellen S. Deutsch, medical director for the Pennsylvania Patient Safety Authority.

Of the 1,309 events related to BCMA processes that occurred from 2005 through 2016, nearly all were reported as Incidents, including 453 "near misses," or events that might have caused harm but did not reach the patient because of chance or active effort by caregivers. Of the overall events, 857 reached the patient, including 6 resulting in patient harm, and 1 resulting in a patient's death.

Reporting, but more importantly, the analysis of near misses to improve processes can reduce the potential for patient harm, a practice recognized by the Authority and Pennsylvania healthcare facilities alike. Near misses can warn healthcare facilities about hazards before patient harm, much as a lighthouse warns ships about high-risk areas.

In general, the Authority identified a considerable statewide increase of near-miss BCMA events over the 12-year period. BCMA events occurred during each point of the medication-management process. The majority of events involved administering medication, while the remaining events involved dispensing, prescribing, and transcribing errors.

In 2007, Blue Mountain Health System committed to becoming a high-reliability organization and focused on high-risk processes such as medication management, including BCMA. Thereafter, the Authority recognized a pattern of BCMA workflow-related near-miss events reported by the health system and contacted health system representatives, who invited the Authority to observe their efforts.

A 2015 spike in near-miss BCMA events was attributable in part to the health system's specific efforts to identify and report such events. Administration issues were evident as well, including what appeared to be intentional barcode scans of the wrong patient. In its direct observations of the health system's workflow, the Authority identified the perceived wrong-patient scans were a matter of workarounds that staff employed to pursue better efficiency. Other challenges the Authority and the health system identified were variations in access to records, resulting in potential wrong-patient selections, and lack of internet connectivity in certain areas, leading to additional staff workarounds.

The Authority and Blue Mountain Health System collaborated to improve Blue Mountain's BCMA process. Between 2014 and 2016, the health system reduced its BCMA-workflow events by 53%.

"As demonstrated by Blue Mountain Health System's efforts, near-miss event analysis provides valuable information that can identify patient safety hazards and be used to fix system weaknesses," said Deutsch. "Identifying hazards even before patients are harmed is an important component of event reporting. Pennsylvania healthcare facilities are always encouraged to engage the Authority to address opportunities to make patient care safer."

In the Authority's December 2017 Pennsylvania Patient Safety Advisory article, "Near-Miss Event Analysis Enhances the Barcode Medication Administration Process," the Authority shares the story of Blue Mountain Health System and provides a comprehensive list of risk reduction and best practice strategies for reducing errors related to BCMA. A visual abstract accompanies the article and demonstrates to healthcare facilities how near-miss event analysis can add value to their performance improvement initiatives.  

Download the full article.

Also published in this Advisory:

  • Medication Errors in Outpatient Hematology and Oncology Clinics:
    Oncology care is increasingly provided in outpatient settings because of its patient convenience and decreased cost. Reported medication errors in this setting have not been fully explored and give cause for examination.

  • Preparing for Unplanned Admissions to the NICU:
    Providers in Pennsylvania asked the Pennsylvania Patient Safety Authority to review and report conditions and trends related to unplanned admissions to the neonatal intensive care unit (NICU) identified in reported events.

  • Warming Blankets and Patient Harm:
    In August 2017, following news coverage of a pediatric patient's death associated with use of a warming blanket, the Authority received inquiries about patient harm associated with these devices. In response, analysts queried the reporting database for reports of patient safety events involving warming blankets.

  • Complications Linked to Iatrogenic Enteral Feeding Tube Misplacements:
    Analysis of enteral feeding tube misplacements over a six-year period found more than half led to complications, including death. The analysis was prompted by a request from the American Society for Parenteral and Enteral Nutrition, which was looking for current statistics about enteral feeding tube misplacements in Pennsylvania.

  • Patient Safety: No Harm, No Foul?:
    Collecting data based on patient harm, without limiting reporting to events involving error, will bring us closer to the goal of safe patient care. Enlarging that perspective to include events in which hazards were recognized, harm was avoided, and patient care was improved will help us achieve the safest patient care.

For more information about the Authority, patient safety topics, Advisory articles, and safety tips for patients, please visit patientsafety.pa.gov.

The Authority's mission is to improve the quality of healthcare in Pennsylvania by collecting and analyzing patient safety information, developing solutions to patient safety issues, and sharing this information through education and collaboration. Its vision is safe healthcare for all patients.

©2018 Pennsylvania Patient Safety Authority