2023 Quality Report

Hospital Quality Improvement Projects - Hudson Hospital & Clinic

Medication Safety

Barcode medication administration (BCMA) is a technology-driven system that helps health care providers ensure the right patient receives the right medication in the right dosage, through the use of barcoded medication and patient identification. It is a critical component of medication safety, and its implementation has been shown to significantly reduce medication errors. Despite the benefits of BCMA systems, compliance with the system can sometimes be a challenge. A recent incident that highlighted this issue was the case of a nurse who faced criminal penalties after inadvertently administering a lethal dose of a paralytic medication to a patient. 

This event spurred conversations among hospital leaders determined to find ways to improve BCMA compliance. At Hudson Hospital and Clinic, Emergency Center Nurse Manager Cortney Haus, DNP, MAOL, RN, PHN, TCRN, and Director of Pharmacy Darla Klementz, Pharm D, RPh, led this charge. 

Klementz recognized there may be barriers to overcome. “When nurses need to bypass the BCMA process, the system requires them to select the reason for the override. This data allows us to focus on solving those barrier issues.” Most often this includes technical issues, user error, or accessibility problems. “We had to start by focusing on BCMA device accessibility and staff training.”

Haus, using the knowledge recently gained through her DNP program, understood the importance of cultivating a culture of safety that encourages staff to report medication errors and near misses without fear of retribution. 

“This confidence emboldens nurses to take immense pride in their personal and professional practice and recognize that their daily actions are essential in ensuring patient safety," said Haus. "During one-on-one meetings with staff members it was emphasized to follow commitment to safe patient care by utilizing BCMA technology whenever possible. If there are situations where this is not possible, it’s important that we look for solutions to overcome those obstacles.” 

Leveraging technological resources was key. The hospital’s analytics database provides leaders with a breakdown of compliance of medication scanning versus patient, scanning by department, and then by individual. Providing feedback on an individual level is paramount. The Emergency Center nurses can see their overall team scores and also a list of those individual superstars who surpass the 95% goal. Emphasizing the significance of each person’s professional practice fosters a culture of safety. 

To keep the momentum of this work moving in the right direction the team is utilizing the electronic patient safety reporting system. It is here that nurses report when a medication won’t scan due to labeling issues or other technological issues. Medication errors and near misses can be flagged for contributing factors such as BCMA override. Reports run from the system help feed the medication safety discussions across the hospital. The positive improvements in the Emergency Center have been replicated in other departments.