Bryan Houliston AURA Laboratory, School Of Computing and Mathematical Sciences, Auckland University of Technology (Thursday, 3.00, Science 1)

1. Procedural Error Identification in
Ward-based Drug Administration
with RFID
Bryan Houliston Rob Ticehurst
Dave Parry
Aura Laboratory

2. Contents
1 Adverse Drug Events
2 Ward-based dispensing
3 BCMA and workarounds
4 Smart Drug Tray
5 Conclusion

3. Adverse Drug Events
• 151 deaths, 4871 injuries per year in NZ
(Johnston, 2007)
• Estimated 20% of public health spending
due to AEs (Ministerial Review Group, 2009)

4. ‘Five Rights’
• Right patient
• Right drug
• Right dose
• Right time
• Right route

5. Ward Dispensing Errors - Scope
• 86 ward dispensing activities
– 79 potential errors (Lane et al, 2006)
Selection
Read
Administer chart
drugs Retrieval Action
Prepare
drugs Checking
by dispensing stage by type of activity

6. Ward Dispensing Errors - Data
• From literature review : (McDowell et al, 2010)
73% of administrations
– Incorrectly diluted 31%
• From observation : (Westbrook et al, 2010)
74% have ‘procedural’ error
– Not identifying patient 59%
25% have ‘clinical’ error
– Drug given at wrong time 64%

7. Causes of Error
• ‘… fatigue, inexperience, and haste are
known generally to increase error
rates…[Open for debate is the] question
of whether the chance of an error at
some later stage is dependent on
occurrence of an error at an earlier stage’
(McDowell et al, 2010)
• Do procedural errors make clinical errors
more likely?

8. Importance of Procedure
• 50% of AEs result from “system factors”
including lack of procedure or non-
adherence (Davis et al, 2003)
• 28% of drug errors result from
‘procedure / protocol not followed’
(Hicks & Becker, 2008)

9. IT Solutions Enforce Procedure
• Right patient
• Right drug
• Right dose
• Right time
• Right route ?

10. Barcode Medication Admin
• Scan patient wristband and drug label
• Appear to reduce ADEs, if implemented
and used correctly (Poon et al, 2010)

11. If implemented correctly…
• Poor implementation leads to
“a lot of overhead because [staff] must
constantly log in and out of devices at
hand, starting and stopping sets of
applications, and browsing each to
present the proper view for alternating
activities” (Bardram & Christensen, 2007)

12. And used correctly…
• Staff routinely work around problems
(Koppel et al, 2010)
– Barcodes damaged,
faded, obscured
– Patient in wrong
position
– COWs unwieldy,
limited battery

13. RFID for BCMA
• Radio Frequency Identification
– Readers and tags communicate wirelessly
• Advantages over barcodes
– No markings to smudge, fade
– Don’t need line of sight
– Tags have unique ID numbers

14. Existing RFID - Portable
• Handheld reader attached to COW
(Lai et al, 2007)
• Phones with NFC (Bravo et al, 2008)
– Short range = risk of
nosocomial infection
(Ulger et al, 2009)
• Nurse has to drive
application

15. Existing RFID - Embedded
• In personal screens
(Bardram et al, 2004)
• Ceiling/wall mounted
(Ohashi et al, 2008)
• Application detects nurse activity and
drives itself

16. In between: Smart Drug Tray
• Portable tray with embedded reader
• Should be able to
– Warn if drug given before patient identified
– Know patient wristband has been read
– Know when drug removed from tray
• Should not
– Tethered to COW
– Very short range
– Require nurse to drive

17. Prototype Design
• Tray with reader
– Battery powered
– Bluetooth
– Audible and visual
feedback
– Continuous reading
• Patient wristband
– UHF tag
• Tagged medication
containers

18. Evaluation
• Reading patient wristbands
– Range
– Through material
– Wristband position
• Reading tagged drugs
– Different containers
– Location on tray
• Detecting failure to identify patient
• Battery life

19. Battery Life
• With
– One read per second
– Bluetooth active
– LEDs and speaker active
• Minimum = 4 hours, 50 minutes
• Average = 6 hours, 20 minutes

20. Reading Patient Wristbands
Covered by blanket
On outside of wrist
Tag state
On top of wrist
On inside of wrist
On bottom of wrist
0 10 20 30 40 50 60 70 80
Distance (cm) for 80+% read rate

21. Reading Tagged Drugs
100% 0%
100% 100%

22. Reading Tagged Drugs Again
100%
100%
100%
100%

23. Reading More Tagged Drugs
99% 100%
15%
0% 97% 0%
46%

24. Failure to Identify Patient
• Simple VB application developed
• Demonstration

25. Further Development
• Some work before user evaluation
– Raising alarms – beeps, LEDs
– Fully embed reader
– Embed second reader
• Further checks for procedural errors
– All medications given
– Medications correct for patient
– Time correct

26. Conclusion
• ADEs cost lives and resources
• Improving adherence to procedures may
reduce ADEs
• BCMA systems are routinely worked
around
• RFID enables easier reading of patient
wristbands
• But challenges remain in reading
medication containers

27. References
Bardram JE. Applications of Context-Aware Computing in Hospital Work - Examples and
Design Principles. Symposium on Applied Computing, 2004.
Bardram JE, Christensen HB. Pervasive Computing Support for Hospitals: An Overview
of the Activity-Based Computing Project. Pervasive Computing. 2007;6(1):44-51.
Bravo J, Hervas R, Fuentes C, Chavira G, Nava SW. Tagging for Nursing Care. Second
International Conference on Pervasive Computing Technologies for Healthcare;
Tampere, Finland: IEEE; 2008.
Davis P, Lay-Yee R, Briant R, Ali W, Scott A, Schug S. Adverse events in New Zealand
public hospitals II: preventability and clinical context. New Zealand Medical Journal.
2003;116(1183).
Hicks RW, Becker SC. An Overview of Intravenous-related Medication Administration
Errors as Reported to MEDMARX, a National Medication Error-reporting Program.
Journal of Infusion Nursing. 2006;29(1):20-7.
Johnston M. Wired for saving lives. Weekend Herald, August 25. 2007;Sect. B4. Koppel
et al, 2010
Lai C-L, Chien S-W, Chang L-H, Chen S-C, Fang K. Enhancing Medication Safety and
Healthcare for Inpatients Using RFID. Portland International Center for
Management of Engineering and Technology Conference; Portland, Oregon: IEEE;
2007.

28. References
Lane R, Stanton NA, Harrison D. Applying hierarchical task analysis to medication
administration errors. Applied Ergonomics. 2006;37(5):669-79.
McDowell SE, Mt-Isa S, Ashby D, Ferner RE. Where errors occur in the preparation and
administration of intravenous medicines: a systematic review and Bayesian analysis.
Quality and Safety in Health Care. 2010;19(4):341-5.
Ministerial Review Group. Meeting the Challenge: Enhancing Sustainability and the
Patient and Consumer Experience within the Current Legislative Framework for
Health and Disability Services in New Zealand. Wellington, 2009.
Ohashi K, Ota S, Ohno-Machado L, Tanaka H, editors. Comparison of RFID Systems for
Tracking Clinical Interventions at the Bedside. American Medical Informatics
Association Annual Symposium; 2008 8-12 November; Washington, DC.Poon et al,
2010
Ulger F, Esen S, Dilek A, Yanik K, Gunaydin M, Leblebicioglu H. Are we aware how
contaminated our mobile phones with nosocomial pathogens? Annals of Clinical
Microbiology and Antimicrobials. 2009;8(7).
Westbrook JI, Woods A, Rob MI, Dunsmuir WTM, Day RO. Association of Interruptions
With an Increased Risk and Severity of Medication Administration Errors. Archives
of Internal Medicine. 2010;170(8):683-90.