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Automation and adaptation: nurses’ problem-solving behavior following the implementation of bar-coded medication administration technology

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Abstract

The most common change facing nurses today is new technology, particularly bar-coded medication administration technology (BCMA). However, there is a dearth of knowledge on how BCMA alters nursing work. This study investigated how BCMA technology affected nursing work, particularly nurses’ operational problem-solving behavior. Cognitive systems engineering observations and interviews were conducted after the implementation of BCMA in three nursing units of a freestanding pediatric hospital. Problem-solving behavior, associated problems, and goals were specifically defined and extracted from observed episodes of care. Three broad themes regarding BCMA’s impact on problem solving were identified. First, BCMA allowed nurses to invent new problem-solving behavior to deal with pre-existing problems. Second, BCMA made it difficult or impossible to apply some problem-solving behaviors that were commonly used pre-BCMA, often requiring nurses to use potentially risky workarounds to achieve their goals. Third, BCMA created new problems that nurses were either able to solve using familiar or novel problem-solving behaviors, or unable to solve effectively. Results from this study shed light on hidden hazards and suggest three critical design needs: (1) ecologically valid design; (2) anticipatory control; and (3) basic usability. Principled studies of the actual nature of clinicians’ work, including problem solving, are necessary to uncover hidden hazards and to inform health information technology design and redesign.

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References

  • Alper SJ, Scanlon MC, Murkowski K, Patel N, Kaushal R, Karsh B (2008) Routine and situational violations during medication administration. Paper presented at the 9th international symposium on human factors in organizational design and management, Sao Paulo

  • Ash JS, Sittig DF, Dykstra R, Campbell E, Guappone K (2009) The unintended consequences of computerized provider order entry: findings from a mixed methods exploration. Int J Med Inform 78S:S69–S76

    Article  Google Scholar 

  • Bainbridge L (1983) Ironies of automation. Automatica 19:775–779

    Article  Google Scholar 

  • Berg M (1999) Patient care information systems and health care work: a sociotechnical approach. Int J Med Inform 55:87–101

    Article  Google Scholar 

  • Beuscart-Zephir MC, Pelayo S, Anceaux F, Meaux J–J, Degroisse M, Degoulet P (2005) Impact of CPOE on doctor-nurse cooperation for the medication ordering and administration process. Int J Med Inform 74:629–641

    Article  Google Scholar 

  • Beyer H, Holtzblatt K (1998) Contextual design: defining customer-centered systems. Morgan Kaufmann, San Francisco

    Google Scholar 

  • Bowers BJ, Lauring C, Jacobson N (2001) How nurses manage time and work in long-term care. J Adv Nurs 33:484–491

    Article  Google Scholar 

  • Carayon P, Wetterneck TB, Hundt AS, Ozkaynak M, DeSilvey J, Ludwig B, Rough SS (2007) Evaluation of nurse interaction with bar code medication administration technology in the work environment. J Patient Saf 3:34–42

    Article  Google Scholar 

  • Carroll JM, Campbell RL (1989) Artifacts as psychological theories: the case of human-computer interaction. Behav Inf Technol 8:247–256

    Article  Google Scholar 

  • Cescon DW, Etchells E (2008) Barcoded medication administration: a last line of defense. JAMA 299:2200–2202

    Article  Google Scholar 

  • Cook RI (2005) Lessons from the war on cancer: the need for basic research on safety. J Patient Saf 1:7–8

    Article  Google Scholar 

  • Cook RI, Render ML, Woods DD (2000) Gaps: learning how practitioners create safety. Br Med J 320:791–794

    Article  Google Scholar 

  • Cummings J, Bush P, Smith D, Matuszewski K (2005) Bar-coding medication administration overview and consensus recommendations. Am J Health Syst Pharm 62:2626–2629

    Article  Google Scholar 

  • DeSanctis G, Poole MS (1994) Capturing the complexity in advanced technology use: adaptive structuration theory. Organ Sci 5:121–147

    Article  Google Scholar 

  • Eisenhauer LA, Hurley AC, Dolan N (2007) Nurses’ reported thinking during medication administration. J Nurs Scholarsh 39:82–87

    Article  Google Scholar 

  • Farrington-Darby T, Wilson JR (2009) Understanding social interactions in complex work: a video ethnography. Cogn Technol Work 11:1–15

    Article  Google Scholar 

  • Forsythe DE (1996) New bottles, old wine: hidden cultural assumptions in a computerized explanation system for migraine sufferers. Med Anthropol Q 10:551–574

    Article  Google Scholar 

  • Gurses AP, Carayon P (2007) Performance obstacles of intensive care nurses. Nurs Res 56:185–194

    Article  Google Scholar 

  • Halbesleben JRB, Wakefield DS, Wakefield BJ (2008) Work-arounds in health care settings: literature review and research agenda. Health Care Manag Rev 33:2–12

    Article  Google Scholar 

  • Hardey M, Payne S, Coleman P (2000) ‘Scraps’: hidden nursing information and its influence on the delivery of care. J Adv Nurs 32:208–214

    Article  Google Scholar 

  • Harrison MI, Koppel R, Bar-Lev S (2007) Unintended consequences of information technologies in health care—an interactive sociotechnical analysis. J Am Med Inform Assoc 14:542–549

    Article  Google Scholar 

  • Holden RJ (2011) Cognitive performance-altering effects of electronic medical records: an application of the human factors paradigm for patient safety. Cogn Technol Work 13:11–29

    Article  Google Scholar 

  • Holden RJ, Alper SJ, Scanlon MC, Murkowski K, Rivera AJ, Karsh B (2008) Challenges and problem-solving strategies during medication management: a study of a pediatric hospital before and after bar-coding. Paper presented at the Proceedings of the 2nd international conference on healthcare systems ergonomics and patient safety, Strasbourg

  • Holden RJ, Brown RL, Alper SJ, Scanlon MC, Patel NR, Karsh B (2011) That’s nice, but what does IT do? Evaluating the impact of bar coded medication administration by measuring changes in the process of care. Int J Ind Ergon 41:370–379

    Article  Google Scholar 

  • Hollnagel E, Woods DD (1983) Cognitive systems engineering: new wine in new bottles. Int J Man Mach Stud 18:583–600

    Article  Google Scholar 

  • Hollnagel E, Woods DD (2005) Joint cognitive systems: foundations of cognitive systems engineering. CRC Press, New York

    Book  Google Scholar 

  • Hollnagel E, Woods DD, Leveson N (eds) (2006) Resilience engineering: concepts and precepts. Ashgate, Aldershot

    Google Scholar 

  • Institute of Medicine (2007) Preventing medication errors. National Academies Press, Washington

    Google Scholar 

  • Institute of Safe Medication Practices (2010) CMS 30-minute rule for drug administration needs revision. ISMP Medicat Saf Alert 8(9):1–6

    Google Scholar 

  • Jones PH, Nemeth CP (2005) Cognitive artifacts in complex work. In: Cai Y (ed) Ambient intelligence for scientific discovery. Springer, Berlin, pp 152–183

    Chapter  Google Scholar 

  • Karsh B (2011) Dropping the ball despite an integrated EMR. AHRQ WebM&M, March. Retrieved from http://www.webmm.ahrq.gov/case.aspx?caseID=237

  • Karsh B, Alper SJ (2005) Work system analysis: the key to understanding health care systems. In: Advances in patient safety: from research to implementation. Agency for Healthcare Research and Quality, Rockville, pp 337–348

  • Karsh B, Weinger MB, Abbott PA, Wears RL (2010) Health information technology: fallacies and sober realities. J Am Med Inform Assoc 17:617–623

    Article  Google Scholar 

  • Karsh B, Wetterneck TB, Holden RJ, Rivera-Rodriguez AJ, Faye H, Scanlon MC, Alper SJ (2011) Bar coding in medication administration. In: Yih Y (ed) Handbook of healthcare delivery systems. CRC Press, Boca Raton, pp 47-1–47-17

    Google Scholar 

  • Koopman P, Hoffman RR (2003) Work-arounds, make-work, and kludges. IEEE Intell Syst 18:70–75

    Article  Google Scholar 

  • Koppel R, Wetterneck TB, Telles JL, Karsh B (2008) Workarounds to barcode medication administration systems: their occurrences, causes, and threats to patient safety. J Am Med Inform Assoc 15:408–423

    Article  Google Scholar 

  • Larrabee S, Brown MM (2003) Recognizing the institutional benefits of bar-code point-of-care technology. Jt Comm J Qual Saf 29(7):345–353

    Google Scholar 

  • Majchrzak A, Rice RE, Malhotra A, King N, Ba S (2000) Technology adaptation: the case of a computer-supported inter-organizational virtual team. MIS Q 24:569–600

    Article  Google Scholar 

  • McAlearney AS, Vrontos J, Schneider PJ, Curran CR, Czerwinski BS, Pedersen CA (2007) Strategic work-arounds to accommodate new technology: the case of smart pumps in hospital care. J Patient Saf 3:75–81

    Article  Google Scholar 

  • McRoberts S (2005) The use of bar code technology in medication administration. Clin Nurse Specialist 19(2):55–56

    Article  Google Scholar 

  • Miles MB, Huberman AM (1994) Qualitative data analysis. Sage, Thousand Oaks

    Google Scholar 

  • Miller DF, Fortier CR, Garrison KL (2011) Bar code medication administration technology: characterization of high-alert medication triggers and clinician workarounds. Ann Pharmacother 45:162–168

    Article  Google Scholar 

  • Mumaw RJ, Roth EM, Vicente KJ, Burns CM (2000) There is more to monitoring a nuclear power plant than meets the eye. Hum Factors 42:36–55

    Article  Google Scholar 

  • Neuenschwander M, Cohen MR, Vaida AJ, Patchett JA, Kelly J, Trohimovich B (2003) Practical guide to bar coding for patient medication safety. Am J Health Syst Pharm 60:768–779

    Google Scholar 

  • Novak LL, Brooks J, Gadd CS, Anders S, Lorenzi NM (2012) Mediating the intersections of organizational routines during the introduction of a health IT system. Eur J Inf Syst. doi:10.1057/ejis.2012.1052

  • Patterson ES, Cook RI, Render ML (2002) Improving patient safety by identifying side effects from introducing bar coding in medication administration. J Am Med Inform Assoc 9:540–553

    Article  Google Scholar 

  • Patterson ES, Rogers ML, Render ML (2004) Fifteen best practice recommendations for bar-code medication administration in the veterans health administration. Jt Comm J Qual Saf 30:355–365

    Google Scholar 

  • Patterson ES, Rogers ML, Chapman RJ, Render ML (2006a) Compliance with intended use of bar code medication administration in acute and long-term care: an observational study. Hum Factors 48:15–22

    Article  Google Scholar 

  • Patterson ES, Woods DD, Roth EM, Cook RI, Wears RL, Render ML (2006b) Three key levers for achieving resilience in medication delivery with information technology. J Patient Saf 2:33–38

    Google Scholar 

  • Pedersen CA, Gumpper KF (2008) ASHP national survey on informatics: assessment of the adoption and use of pharmacy informatics in US hospitals—2007. Am J Health Syst Pharm 65:2244–2264

    Article  Google Scholar 

  • Poon EG, Keohane CA, Bane A, Featherstone E, Hays BS, Dervan A, Gandhi TK (2008) Impact of barcode medication administration technology on how nurses spend their time providing patient care. J Nurs Adm 38:541–549

    Article  Google Scholar 

  • Poon EG, Keohane CA, Yoon CS, Ditmore M, Bane A, Levtzion-Korach O, Gandhi TK (2010) Effect of bar-code technology on the safety of medication administration. N Engl J Med 362:1698–1707

    Article  Google Scholar 

  • Rasmussen J (2000) Human factors in a dynamic information society: where are we heading? Ergonomics 43:869–879

    Article  Google Scholar 

  • Reason J (2008) The human contribution: unsafe acts, accidents and heroic recoveries. Ashgate, Aldershot

    Google Scholar 

  • Roth E, Scott R, Deutsch S, Kuper S, Schmidt V, Stilson M, Wampler J (2006) Evolvable work-centred support systems for command and control: creating systems users can adapt to meet changing demands. Ergonomics 49:688–705

    Article  Google Scholar 

  • Saleem JJ, Russ AL, Justice CF, Hagg H, Ebright PR, Woodbridge PA, Doebbeling BN (2009) Exploring the persistence of paper with the electronic health record. Int J Med Inform 78:618–628

    Article  Google Scholar 

  • Sarter NB, Woods DD, Billings CE (1997) Automation surprises. In: Salvendy G (ed) Handbook of human factors & ergonomics, 2nd edn, pp. 1926–1943

  • Spear SJ, Schmidhofer M (2005) Ambiguity and workarounds as contributors to medical error. Ann Intern Med 142:627–630

    Article  Google Scholar 

  • Stead WW, Lin HS (eds) (2009) Computational technology for effective health care: immediate steps and strategic directions. National Academies Press, Washington

    Google Scholar 

  • Taylor C (1997) Problem solving in clinical nursing practice. J Adv Nurs 26:329–336

    Article  Google Scholar 

  • Tucker AL, Edmondson AC (2003) Why hospitals don’t learn from failures: organizational and psychological dynamics that inhibit system change. Calif Manag Rev 45:55–72

    Article  Google Scholar 

  • Tucker AL, Spear SJ (2006) Operational failures and interruptions in hospital nursing. HSR. Health Serv Res 41:643–662

    Article  Google Scholar 

  • Tucker AL, Edmondson AC, Spear SJ (2002) When problem solving prevents organizational learning. J Organ Change Manag 15:122–137

    Article  Google Scholar 

  • Uhlig PN, Brown J, Nason AK, Camelio A, Kendall E (2002) System innovation: concord Hospital. Jt Comm J Qual Improv 28:666–672

    Google Scholar 

  • van Onzenoort HA, van de Plas A, Kessels AG, Veldhorst-Janssen NM, van der Kuy PHM, Neef C (2008) Factors influencing bar-code verification by nurses during medication administration in a Dutch hospital. Am J Health Syst Pharm 65(7):644–648

    Article  Google Scholar 

  • Vicente KJ (1999) Cognitive work analysis: toward safe, productive, and healthy computer-based work. Erlbaum, Mahwah

    Google Scholar 

  • Vicente KJ, Roth EM, Mumaw RJ (2001) How do operators monitor a complex, dynamic work domain? The impact of control room technology. Int J Hum Comput Stud 54:831–856

    Article  MATH  Google Scholar 

  • Vogelsmeier AA, Halbesleben JRB, Scott-Cawiezzel JR (2008) Technology implementation and workarounds in the nursing home. J Am Med Inform Assoc 15:114–119

    Article  Google Scholar 

  • Wears RL, Berg M (2005) Computer technology and clinical work: still waiting for Godot. JAMA 29:1261–1263

    Article  Google Scholar 

  • Weinger MB, Slagle J, Jain S, Ordonez N (2003) Retrospective data collection and analytical techniques for patient safety studies. J Biomed Inform 36:106–119

    Article  Google Scholar 

  • Woods DD (1998) Designs are hypotheses about how artifacts shape cognition and collaboration. Ergonomics 41:168–173

    Article  Google Scholar 

  • Woods DD, Dekker SWA (2000) Anticipating the effects of technological change: a new era of dynamics for human factors. Theor Issues Ergon Sci 1:272–282

    Article  Google Scholar 

  • Woods DD, Patterson ES, Cook RI (2007) Behind human error: taming complexity to improve patient safety. In: Carayon P (ed) Handbook of human factors and ergonomics in patient safety. Lawrence Erlbaum, Mahwah, pp 459–476

    Google Scholar 

  • Xiao Y (2005) Artifacts and collaborative work in healthcare: methodological, theoretical, and technological implications of the tangible. J Biomed Inform 38:26–33

    Article  Google Scholar 

  • Xiao Y, Schenkel S, Faraj S, Mackenzie CF, Moss J (2007) What whiteboards in a trauma center operating suite can teach us about emergency department communication. Ann Emerg Med 50:387–395

    Article  Google Scholar 

  • Yang Z, Ng B-Y, Kankanhalli A, Yip JWL (2012) Workarounds in the use of IS in healthcare: a case study of an electronic medication administration system. Int J Hum Comput Stud 70:43–65

    Article  Google Scholar 

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Acknowledgments

The authors wish to thank the study participants and colleagues involved in the Bar Coding study. This work was supported by a grant from the Agency for Healthcare Research and Quality (AHRQ) (R01 HS013610) and National Library of Medicine (R01 LM008923) to author BK and by a National Institutes of Health pre-doctoral training grant (TL1 RR025013-01), AHRQ post-doctoral training grant (T32 HS000083-11), and Hertz Foundation Fellowship to author RJH. None of those agencies had any role in the study or publication except for providing funding for the study.

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Authors and Affiliations

  1. Departments of Medicine and Biomedical Informatics, Center for Research and Innovation in Systems Safety, Vanderbilt University School of Medicine, 1211 21st Ave. S, Ste. 732 MAB, Nashville, TN, 37212, USA

    Richard J. Holden

  2. Department of Industrial Engineering, Clemson University, Clemson, SC, USA

    A. Joy Rivera-Rodriguez

  3. Institut de Radioprotection et de Sûreté Nucléaire, Direction Sûreté des Réacteurs-Service d’Etude des Facteurs Humains, Fontenay-aux-Roses, France

    Hélène Faye

  4. Department of Pediatrics, Division of Critical Care, Medical College of Wisconsin, Wauwatosa, WI, USA

    Matthew C. Scanlon

  5. Departments of Industrial and Systems Engineering, Family Medicine, Population Health Sciences, and Biomedical Engineering, University of Wisconsin-Madison, Madison, WI, USA

    Ben-Tzion Karsh

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  1. Richard J. Holden
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  2. A. Joy Rivera-Rodriguez
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  3. Hélène Faye
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  4. Matthew C. Scanlon
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  5. Ben-Tzion Karsh
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Correspondence to Richard J. Holden.

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Holden, R.J., Rivera-Rodriguez, A.J., Faye, H. et al. Automation and adaptation: nurses’ problem-solving behavior following the implementation of bar-coded medication administration technology. Cogn Tech Work 15, 283–296 (2013). https://doi.org/10.1007/s10111-012-0229-4

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  • DOI: https://doi.org/10.1007/s10111-012-0229-4

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