Improving care processes with the help of technology is a common goal among healthcare organisations. To achieve this, the organisations invest in new tools that are set to digitize the existing processes. Yet, why is adapting to the new ways of working often challenging? What can we do to improve the situation? We asked Rune Kristiansen, who studied this topic in the Norwegian health trust Helse Sør-Øst for his master’s thesis.
In his thesis project, Kristiansen focused on nurses’ experiences with the use of barcode-assisted medication administration (BCMA), which is one part of the closed loop medication process. Kristiansen’s organisation, Helse Sør-Øst in south-east Norway, had implemented barcode-assisted medication administration procedure. However, they saw that implementing new work processes that involve technology is challenging.
Reasons to deviate from the process are varied
“We noticed that at some stages of the process, the nurses tended to deviate from the set process by coming up with workarounds. The aim of my thesis project was to take a better look at these deviations: when and where do they occur and why. We wanted to learn what we should focus on when aiming to improve care processes and the use of IT in the hospitals”, tells Kristiansen.
To map where the challenges of following the new digitized work process lie, Kristiansen set out to observe the current process and conducted focus group interviews with the nurses. The interviews confirmed that workarounds do occur. Nurses might jump over some of the steps of the barcode-assisted medication administration process. The reasons behind these deviations varied. “According to my research, the deviations were due to technical issues, competence issues and lack of time, to name a few”, Kristiansen summarises.
Be aware of the whole work process
Kristiansen found out that some of the deviations resulted from a poor fit between the care process and the technological solution the nurses were supposed to use. “When planning a change like this, you need to be aware of the complete work process. If the technological solution does not fit into the process, you will see unwanted workarounds”, he says.
In Helse Sør-Øst, the nurses go on the medication round with a medication trolley that has a drawer for every patient. The medication has been prepared for each patient for the next 24 hours in single-dose sachets. The nurse goes to the patient, identifies them by scanning the patient’s wristband and this way gets their medication list shown on a laptop on the trolley. The nurse opens the patient’s drawer and scans each medicine before giving it to the patient – this is when also the administration documentation automatically takes place. The nurse gets a warning if they scan a medicine that no longer matches the prescription, for example if the doctor has stopped a medication.
Choose tools that fit the process
“The nurses’ feedback was that our medication trolley system works best during regular medication rounds”, tells Kristiansen. “However, we have a problem with medication that is administered on as-needed basis, like when the patient is in pain and requests for additional painkillers. In these cases, the nurses are required to fetch the big trolley, get the laptop up and running and log in to the electronic medical record (EMR), just for this single medication administration.” This takes too much time away from the actual care and leads to deviations from the designed process, because the nurses must get their jobs done. “We come back to the question of considering the complete work process. For the use case of as-needed medication, my interviewees hoped to get a mobile solution that would be easier to carry around and make the process less time-consuming.”
One success factor for the process change is the staff’s competence. The need and justification for the change needs to be clear for everyone involved. In the case of medication, the justification is, of course, increased patient safety1.
Sufficient management support is vital, but so is every professional’s personal commitment. If the ‘why’ is not clear for everyone, problems arise: “There might be just one nurse who does not recognise the need for IT assistance in the medication process. They think that they can do the medication administration safely in the old way. But this has a domino effect; it makes the situation hard for the next nurse who would otherwise comply with the new process”, explains Kristiansen. Of course, it will take some time for the new process to become an everyday routine.
Prepare for surprises
New processes are often designed to reduce human error – particularly so when talking about medication processes. “At the same time, you need to remember that even if the new process is followed by the book, it does not mean that you get rid of all errors at once. More likely, you will see that new kinds of errors occur, and then you need to be prepared to tackle them. My advice is to be aware of this in advance. The better you prepare, the better the implementation will go”, Kristiansen assures.
Define user-friendliness in a broader way
According to Kristiansen, user-friendliness is key to overall success. The common aspects of user-friendliness need to be considered: avoid too many clicks, do your best to ensure the quality of data. “But, we need to define user-friendliness in a broader way. We need to draw attention to the availability of the data: for example, does it help if you can access it on a mobile device carried in your pocket? And always be mindful of the whole work process. User-friendliness starts with aligning the technology with the work process.”
In Helse Sør-Øst, Kristiansen’s thesis work has brought about many steps into the right direction. Need for changes in the regional information system were identified and reported to the right people. More education has been provided for staff to increase competence and change attitudes.
How does Kristiansen judge the success of their project and the potential of technology to lead into positive changes? The direction is right. “When we take all the things that we have discussed here into account, digital technology definitely has a role in preventing medication-related errors.”
1. Truitt et al. (2016). Effect of the Implementation of Barcode Technology and Electronic Medication Administration Record on Adverse Drug Events. Hospital Pharmacy.
Rune’s thesis available online in Norwegian: AURA: Strekkodeassistert legemiddeladministrering (SALA) i sykehus : Omfang og årsaker til handlinger som avviker fra prosedyrer for legemiddelhåndtering (unit.no)
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