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using technology effectively

By Dennis Tribble posted 07-03-2018 16:21

  
I really enjoy getting the ASHP Daily Briefing, and today's edition (Friday the 13th!)  contained a summary of a Fierce Healthcare article regarding a Leapfrog assessment of bar code medication administration. 

According to this article, Leapfrog assesses BCMA according to four tenets of use:



  1. A bar-code system is in place across all of the hospital's intensive care, medical and surgical or labor and delivery units.

  2. The bar codes for patients and medications are both scanned in 95% of bedside medication administrations.

  3. All seven decision support elements that are deemed essential by Leapfrog's BCMA Expert Panel are in place.

  4. The five best practices the group has outlined to prevent dangerous workarounds have been deployed.


The results were interesting:



  • 98.7% of hospitals reviewed have BCMA

  • 42% of hospitals using BCMA are not using it correctly. The primary failures appear to occur in scanning both medications and patient wristbands, in the appropriate sequence.



I wish I could say I was surprised. Sadly, I am not. 



  • Workarounds to BCMA are exceptionally well-document. If you haven't read Koppel et al's seminal article on the subject, I commend it to your reading.

  • I worked for several years with a pharmacy compounding device that relies on bar coding to ensure that the correct source products are connected to the device correctly, and saw all manner of workarounds associated with that use. The stories I could tell...


It appears to me that there are likely four problems leading to this experience:



  • Training focuses on 'how' and not 'why'. When people don't understand the reason that they are supposed to scan things, they take shortcuts to get past a function they know they must perform but in which they see no value.

  • Training is inconsistent. I got myself in a lot of trouble several years ago with a blog describing why train-the-trainer doesn't work. But the problem we have is that, without a consistent and well-structured training plan around the use of any particular technology, what gets trained to each successive generation of users reflects what the previous generation of users thought was useful to pass on. Not only does this result in the loss of key information, it also results in the injection of personal bias and workarounds of the 'trainer'. So what any user knows about the proper use of a technology becomes a function of who trained them.

  • There is no follow up review of competence.  One of the things noted in the report on the Leapfrog findings was that there is no regular observation of human performance. This leads to the normalization of deviance. It's a well-known human trait. If you have ever had a speeding ticket (mea maxima culpa), you know that you become very careful about your speed immediately after the ticket, but it doesn't take long for that to wear away until, not much later, you are back to your old driving habits. That's because you don't get caught every time you speed. You know it's wrong, but the lack of consequence permits you to start thinking of it as 'normal'.

  • Magical Thinking. It amazes me how many people I know that think the use of some technology, no matter how badly, somehow automatically protects them from making mistakes. I used to teach in a USP <797> course and met any number of people who seemed to believe that wearing sterile gloves (well... they were sterile in the package) somehow made everything they touched under any circumstances automagically sterile as well. The same is true of bar code use. "I scanned the bar codes and there were no errors reported, so I must be OK".


In my experience, the reality is that all technology was designed to be used a certain way, and that no technology can be made both usable and completely immune to human misuse. My late father had an aphorism about this: "You can't make things foolproof; fools are just too clever."  This is why any technology has to exist within the context of appropriate and consistent training, use only by trained and competent personnel, and regular assessment of that competence. This means you can't just drop a technology into place and expect magic to happen. It takes management, just like anything else.

So I encourage you, dear reader, to take a long hard look at how the technology you use every day is deployed, managed, trained and assessed. Just stand there and watch people use it. You may be pleasantly surprised at how well it is being used. Or you may be horrified.

I would love to hear about your findings.

Dennis A. Tribble, Pharm. D., FASHP
Ormond Beach, FL
DATdoc@aol.com

The opinions expressed herein are my own, and not necessarily those of my employer or of ASHP.
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