Development and application of a closed-loop medication administration system in University of Hongkong-Shenzhen Hospital

In the traditional paper-driven process of medication administration, two nurses manually double-check the medication information including name, dose, time, route of medication, and the patient’s identity before the medication is administered.14

With the closed-loop medication administration system, the process of medication administration requires nurses to scan the barcodes on the patient’s wristband as well as the barcodes on the medication before it is administered.15,16 If the dose being scanned corresponds with the approved medication order of a pharmacist and the patient is due to receive this medication, the administration is automatically documented in real time. However, if the medication does not correspond to a valid order, the system issues a warning.

Since the closed-loop medication administration system provides an additional layer of safety with the real-time scanning of barcodes,17 we changed the process of medication administration after application of the system from requiring two nurses at the bedside to perform the double-check to the following two methods: a single nurse (a) manually checked as routine at the bedside and (b) scanned the barcodes on both patient’s wristband and the medication before medication administration.

The study was implemented in four pilot general wards. We used a before-and-after design and collected data on oral medication administration times before and after the system implementation. We also evaluated the MAE alert logs after the implementation and surveyed the nurses’ satisfaction with the system.

Self-reported satisfaction questionnaires were used for the survey. A brainstorming meeting of the clinical head nurses was used to design the first draft of the questionnaire. A pretest of the questionnaire was conducted in the pilot wards; based on the results of the pretest, we further modified the questionnaire to develop the formal version. The formal questionnaire contained questions from five perspectives, including the quality of nursing, patient safety, nurse workload, work efficiency, and nurses’ views of the PDA. Each question was answered according to five degrees: strongly disagree, disagree, neutral, agree, and strongly agree.

Four nursing students observed and recorded the oral medication administration times in the four pilot wards respectively before and after intervention (December 12–16, 2016, and January 2–6, 2017). The satisfaction questionnaire survey was conducted in the four pilot wards on January 6, 2017, using the Wenjuanxing Internet platform (https://www.sojump.com/).

IBM SPSS Statistics for Windows, version 20.0, was used for analysis. The nursing time required for medication administration was presented as the mean ± standard deviation. We applied two independent sample t-tests to analyze the difference in nursing time before and after implementation of the closed-loop medication system. The degree of satisfaction of the nurses in the pilot wards was calculated as frequencies and percentages.

The nursing times required for oral medication administration before and after implementation of the closed-loop medication administration system are shown in Table 1. The average nursing time of the four wards before the new system was 31.56 ± 10.88 minutes, which was reduced to 18.74 ± 5.60 minutes after the implementation of the system.

Table 1

Average nursing times for oral medication administration before and after implementation of the system in the pilot wards.

The nurses’ satisfaction with the closed-loop medication administration system is shown in Table 2.

Table 2

Nurses’ satisfaction with the system (n = 70).

There were only 27 MEA alert logs from the repeated scans of 3,428 instances of medication administration during the observation period.

As Table 1 shows, there was a significant difference (t = 8.85, P < 0.00) between the two groups. The closed-loop system provides an additional layer of safety by real-time scanning of barcodes, which relieves one nurse during medication administration. Medication administration could be performed by a single nurse, who manually checks at the bedside and scans both the barcodes (on patient’s wristband and on the medication).18 This system can provide nurses more time to focus on the professional steps of medication administration, such as monitoring for adverse events and continuous patient assessment. The system offered a significant improvement in this aspect.

Table 2 shows that 60.00% (n = 42) of nurses considered the system to be helpful for their work and 82.86% (n = 58) thought that the system was helpful to improve checking accuracy and reduce MAEs to ensure patient safety. This is a key point for the development and customization of such systems. Developers and implementer must consider nursing workflow in order to make the system easy to access.

The MAE alert rate was 1.22% during the one-year observation period in a previous study, suggesting that the closed-loop medication administration system contributed to improving patient safety by preventing potential MAEs.² In the limited time since the implementation in the present study, there were only 27 MAE alert logs among 3,428 medication administrations during the observation period. The full impact of the closed-loop medication administration system on patient safety will be evaluated and analyzed in future studies.

This study had three limitations. First, the main weakness of this study is that data were only collected from four pilot wards. Second, the system has only been trialed for half a month, since the open tender process of the PDA was unsuccessful. Third, the project failed to follow the schedule. The MAE alert logs have been evaluated for half a month, which is insufficient for further analysis. The success of the pilot work has laid the foundation for further research and implementation of the system throughout the hospital.