The Institute of Medicine's (2000) report, To Err Is Human: Building a Safer Health System, indicated that medication errors contributed to 7,000 deaths annually. One strategy that has been employed in health care settings to reduce medication errors is the use of Barcode Medication Administration (BCMA) systems. Studies have shown up to an 80 percent reduction in the number of medication errors when BCMA systems are used in clinical practice (Chan et al., 2019; Craig et al., 2021; Leung et al., 2015; Lin et al., 2018; Truitt et al., 2016). As nurses are expected to have the knowledge, skills, and abilities related to medication administration when they enter clinical practice, teaching nursing students how to effectively use a BCMA system has become an essential component of clinical nursing education.
Many nursing programs and clinical agencies allow nursing students to use the BCMA systems in clinical agencies during their clinical experiences. Clinical faculty will guide their students in the step-by-step use of BCMA systems, which can be time consuming and limit the time students can spend on developing clinical judgment related to medication administration. Having a BCMA system in a simulation laboratory that is available to nursing students can provide opportunities to practice medication administration and improve medication administration efficiency.
There are currently several BCMA educational products available for purchase (Assessment Technologies Institute, 2021; Elsevier, 2021; Wolters Kluwer Health, 2021). Many cost thousands of dollars annually and are cost prohibitive for nursing programs. In addition, the step-by-step processes used in these educational products may not mimic the processes used at the clinical settings where students practice. There are often limited options to tailor BCMA educational products to the medication formularies and simulation scenarios that were previously created by faculty. To overcome the barriers of cost and suitability of the current educational products, the nursing and computer science departments at a private liberal arts college/university in the Midwest engaged in an interdisciplinary and innovative collaboration that led to the development of a fully functional, low-cost BCMA system.
INTERDISCIPLINARY COLLABORATION
The project was guided by one nursing department and two computer science faculty members. Two senior computer science students working under their guidance developed a BCMA system to be used in the nursing department simulation laboratory. The interdisciplinary nature of the collaboration provided opportunities for students and faculty from two departments, each with unique expertise, to work together to solve a complex problem.
Each project team member brought their discipline-specific domain knowledge to the project and collectively designed and built the system through frequent communication and an iterative process of review and revision until the software was fully functioning. According to Gibson et al. (2019), having such collaborative experiences can help build leadership capacity and develop interpersonal teamwork skills that translate well into professional settings and lead to successful future collaborations.
The software planning and development occurred remotely, because of the COVID-19 pandemic, during a time period of 10 weeks. Because the computer science students did not have any previous knowledge of BCMA systems used in health care, the nursing faculty met with the students weekly to describe the BCMA process and discuss various medication administration scenarios that would be required in the BCMA system. The students also met weekly with computer science faculty to discuss technical details, including the choice of programming language, development platforms, and database design.
The students developed the application using the Ruby on Rails web framework (Hansson, 2004). As is common in Rails-based applications, the BCMA software is structured using a traditional model-view-controller architecture, which divides the application into three interconnected systems: The model handles data storage and validation in the database (which stores user, medication administration record, and patient record data); the controller handles interactions via the user interface; and the views encompass the graphical interface. The system supports plug-in and/or Bluetooth barcode scanners that register as "keyboard" devices. Barcode values operate similar to standard web "login" procedures, granting access to a particular patient record.
USE WITH SIMULATION SCENARIOS
The BCMA system was designed to have several features that mimic the BCMA system process used in the clinical setting where students complete their clinical experiences. The newly developed BCMA system allows students to enter medication orders that immediately populate the medication administration record, document medications, and edit documentation. Faculty can create patient records, document previous doses of medications, set the time to match clinical scenario time, print patient armbands barcodes, and print medication barcodes.
The system was designed to be used with previously developed simulation scenarios and allow faculty to add newly developed scenarios and new medications to the formulary database. In addition to functional medication administration features, the system has audible and visual error messages that appear when a patient armband is not scanned or if an incorrect medication is scanned.
Several medication administration scenarios were created to mimic common scenarios that would be encountered in the clinical setting. Scenarios include medications that require a dual sign-off as well as injections that require a location documentation. They also include insulin sliding scale, insulin carbohydrate coverage, continuous infusions, titrated infusions, partial package doses, patient-controlled analgesia, as-needed medications, transdermal patch removal, and medications that require laboratory value input prior to administration.
COSTS AND BENEFITS
Costs incurred during the development and implementation of the BCMA were the purchase of 11 barcode scanners for $960, modest stipends for the summer work of the faculty moderators, and student employment salaries for the two computer science students. These costs were funded by a faculty development grant from the college/university.
The collaboration has produced several benefits for nursing students. Clinical faculty anecdotally report that simulations using the BCMA system have resulted in nursing students demonstrating an improved transition to the clinical setting and greater confidence with medication administration workflow. During clinical experiences, students now spend time developing the clinical judgment elements of medication administration, and faculty can help stimulate their critical thinking without needing to teach them the process. Further research is needed to examine the effectiveness of using a BCMA system, its impact on student learning in an undergraduate program, and how this affects the medication administration process in clinical settings.
The computer science students had an amazing opportunity to utilize their education beyond academia, to work with a real customer on a real-world project with real impact. Computer science students led the development from all angles using the SCRUM framework (an agile software development technique that the students newly learned for this project) to deal with resource limitations, such as time, and handle ambiguities and changes in project requirements, which inevitably arise when working on a real-world project (Schwaber, 1997). This provided them a rare opportunity to experience what it feels like to have a career as a software engineer in the industry and an opportunity to learn many of the techniques, frameworks, and tools used by today's software developers.
By developing a BCMA system through this interdisciplinary collaboration, undergraduate nursing students now have the required hands-on experience using this technology to safely and effectively administer medications to simulated patients in the nursing simulation laboratory. These experiences may translate into the knowledge, skills, and abilities that students need when giving medications to patients in the live clinical setting and help continue to reduce medication errors in the future.
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