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Scanner beep only means the barcode has been scanned

From the June 30, 2011 issue

You might find it hard to believe that wrong patient and wrong drug/dose/time errors can still happen when using a bedside barcode scanning system. One source of error stems from the fact that, regardless of whether the correct product has been scanned or an associated warning has been issued, audible barcode scanners produce the same beeping sound. For example, if a nurse scans the correct patient and medication, the barcode system will issue audible beeps to signify that the patient and medication barcodes have been scanned. Then the system will convey verification of the patient and medication through actions displayed on a hand-held device or the electronic medication administration record (eMAR). If an incorrect patient and/or incorrect medication (i.e., wrong drug, wrong dose, wrong time) have been scanned, the barcode system will issue the same audible beep to signify that the barcode has been scanned, and convey the failed verification of the medication or patient through error messages displayed on the eMAR or hand-held screen. With identical beeps after scanning both a correct and incorrect patient/medication, the nurse can only confirm whether he/she scanned a correct or incorrect patient/medication by reading the actions on the eMAR or hand-held device screen. Unfortunately, some nurses have mistakenly relied on the sound of the beep alone to signal verification of the patient and medication, particularly if the eMAR is not visible during the actual scanning process.

The eMAR is often displayed on a mobile cart (e.g., computer on wheels [COW] or workstation on wheels [WOW]) employed with bedside scanning systems to enhance access during medication selection and administration. Various circumstances may result in not bringing the mobile cart into the patient’s room or to the bedside so the eMAR is visible to the nurse during the scanning process. The cart may not fit in the room or at the bedside due to medical equipment or visitors, or an obstacle, such as a slight rise or bump at the doorway, may make it difficult to move the cart into the room. Or, a nurse may mistakenly believe that it is not always necessary to bring the cart/eMAR to the patient’s bedside, particularly if the nurse had become accustomed to the at-risk behavior of not bringing a paper MAR or eMAR to the bedside before implementation of the barcode scanning technology. If the cart is not at the bedside, the eMAR screen may not be visible to the nurse, thereby increasing the risk of misinterpreting the audible beep during the scanning process as verification of the correct patient and medication, and authorization to administer the drug. Additionally, even if the eMAR is at the patient’s bedside, a nurse may mistakenly rely on the beeping sound to signal successful verification without looking at the eMAR/screen. We highlighted these problems in a previous newsletter in 2009,(1) as did Koppel et al. in a 5-hospital study on bedside bar-coding that uncovered numerous workarounds and misunderstandings about the technology.(2) 

Some hospitals have disabled the audible beep on scanners, believing this will force nurses to view the eMAR or hand-held screen for verification before drug administration. However, silence is not optimal because the beep signals that the scanner has received and read the information on the barcode. Other hospitals have computer monitors in each patient’s room and are using stationary tethered scanners or wireless scanners that communicate with the eMAR. But again, the nurse may simply rely on the beeping sound for verification, without looking at the eMAR on the computer screen at the bedside.  

Another option is wireless scanners that incorporate their own self-contained internal logic to signal whether the barcode scanned is for the correct medication, dose, time, or patient. However, the full eMAR may not be visible on these devices, in large part because the screen may be too small. Computer tablets with scanning capabilities may also be used, but the small screen size could also be an issue with these devices, making it difficult to view the entire eMAR. On a positive note, these devices allow nurses to view alerts associated with scanning a barcode for a wrong patient or medication. However, with some of these devices, nurses have reported lengthy delays while awaiting network re-connection of the device if it times out before the user formally logs off. Also, as with all wireless devices, the self-contained devices tend to work best in newer facilities or newer parts of a facility that have integrated wireless technology in the structural design from the start.

Whether you are in the planning stages for bedside barcode scanning technology or a seasoned user, hospitals need to identify conditions that may result in absent or poor visibility of the full eMAR during the entire medication administration process, including during the scanning process, so these problems can be resolved. This includes situational conditions, such as periods of time when the patient has several visitors at the bedside, so plans can be made regarding how to address these issues. It’s also important to educate users up front about the difference between the audible beep with a registered scan and actual verification of the correct patient and medication when using bar-coding technology. You don’t want to wait until a serious error precipitated by overreliance on an audible beep is being reviewed by a root cause analysis team to first learn about the problem. 

References:
1) ISMP. What does a bar-coding scanner beep mean? ISMP Medication Safety Alert! September 24, 2009.

2) Koppel R, Wetterneck T, Telles JL, Karsh. Technology evaluation: workarounds to barcode medication administration systems: their occurrences, causes, and threats to patient safety. JAMIA. 2008;15:424-29.
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