Roger J. Chapman

Compliance With Intended Use of Bar Code Medication Administration in Acute and Long-Term Care: An Observational Study

Objective: To identify the types and extent of workaround strategies with the use of Bar Code Medication Administration (BCMA) in acute care and long-term care settings. Background: Medication errors are the most commonly documented cause of adverse events in hospital settings. Scanning of bar codes to verify patient and medication information may reduce medication errors. Method: A prospective ethnographic study was conducted using targeted observation. Fifteen acute care and 13 long-term care nurses were directly observed during medication administration at small, medium, and large Veterans Administration hospitals to detect workaround strategies. Results: Noncompliance with recommended practices was observed in all settings and facilities. A larger proportion of acute care nurses than long-term care nurses scanned bar-coded wristbands to identify patients (53% vs. 8%, p = .016). A larger proportion of acute care nurses than long-term care nurses administered barcoded medications immediately after scanning (93% vs. 23%, p < .001). Conclusion: Workaround strategies were employed with BCMA that increased efficiency but created new potential paths to adverse events. There was a significant difference in the rate of use of workaround strategies between acute and long-term care. Application: The extent of workaround strategies varied by care setting and facility. BCMA should be tailored to the long-term care setting, including increasing the efficiency of use. Hospitals implementing bar coding should facilitate the intended use through equipment procurement, implementation, and quality improvement strategies.

Cooperative Problem-Solving Challenges for the Movement of Aircraft on the Ground

In this paper, we discuss issues surrounding aircraft surface movement that were uncovered through a series of ethnographic investigations, including (a) observations of surface movement operations, (b) structured interviews with airline ramp control and dispatch personnel, and (c) critical incident reports. These results are part of the “problem identification” stage of a study aimed at the design of cognitive tools to improve the safety and efficiency of aircraft surface movement. This study is focusing on such issues from an airline operations control perspective (i.e., ramp control and dispatch). We have identified areas of opportunity for aiding airline staff and controllers in this information-intensive cognitive work, which will lead to identifying the nature of cognitive tools and procedures that could improve prioritization, planning, and coordination during surface movement

C-SLANT: an asynchronous communications tool to support distributed work in the National Airspace System

In recent years there have been a number of efforts under the Collaborative Decision Making (CDM) program that have demonstrated the benefits of disseminating both knowledge and goals between organizations in the National Airspace System (NAS), and of collaboratively building decision support tools to assist in the interpretation of the large interrelated dataset produced. The paper describes the development of the Collaborative SLide ANnotation Tool (C-SLANT), an asynchronous communications tool that was developed to support discussion of data from the CDM product Post Operations Evaluation Tool. It is suggested that slide show based, multi-modal, asynchronous, messaging systems appear potentially valuable in this distributed work domain for problem solving during post operations analysis.

The Tradeoffs and Side-Effects of Migrating from Wireless Computer to PDA-Based Support for Medication Administration

This research involved evaluating a PDA application developed to provide a more mobile version of an existing Veterans Administration software program called BCMA (Bar Code Medication Administration). The original application was designed to be operable from a wireless desktop or laptop computer situated on a cart and connected with a bar code scanner to scan patient wristbands and medication labels. The primary goals of this system are to verify the medications about to be given to a particular patient are those ordered and to document the process. The PDA version is intended to meet the same goals utilizing a scanner built into the PDA itself, but also offer the benefits of a small, light-weight, mobile system. The evaluation involved usability inspection, usability testing, and structured interviews. The results describe (1) how the operating systems virtual keyboard display interacted with critical data in the application; (2) how the application software developers dealt with the challenge of a small screen size and the implications of those decisions; and (3) how users adapted their workflow attempting to maximize the benefits of greater mobility, while compensating for a loss in visibility.

Differences in the Use of Bar Code Medication Administration (BCMA) in Acute Care and Long-Term Care Settings

In this paper, we explore how the use of a software package, Bar Code Medication Administration (BCMA), differs in acute care and long-term care settings. Direct observation of BCMA use during medication administration was conducted on acute care (42 hours) and long-term care (37 hours) wards in a small, medium, and large hospital. The following differences were found for all three hospitals: 1) acute care ward nurses used more detailed printed reports to plan medication passes and detect errors in ordering and dispensing than on the long-term care wards, 2) barcoded wristbands were scanned more frequently to identify patients on acute care than long-term care wards (53% vs. 8%), and 3) nurses administered medications immediately after scanning and opening medication packets more frequently on acute care than long-term care wards (93% vs. 23%). The findings highlight the need to tailor the BCMA software for the long-term care setting in order to improve patient safety.

Asynchronous Communications to Support Distributed Work in the National Airspace System

This research involved the evaluation of a multimodal asynchronous communications tool to support collaborative analysis of post-operations in the National Airspace System (NAS). Collaborating authors have been shown to provide different feedback with asynchronous speech based communications compared to text. Voice synchronized with pointing in asynchronous annotation systems has been found to be more efficient in scheduling tasks, than voice-only, or text only communication. This research investigated how synchronized voice and pointing annotation over asynchronously shared slide shows composed of post operations graphical and tabular data differs in its effect compared to text based annotation, as collections of flights ranked low by standard performance metrics are discussed by FAA (Federal Aviation Administration) and airline representatives. The results showed the combined problem solving and message creation time was shorter when working in the voice and pointing mode than the text based mode, without having an effect on the number and type of ideas generated for improving performance. In both modes the system was also considered useful and usable to both dispatchers and traffic managers.

Current Perspectives on Cognition and Decision Making in Aviation

The intent of this symposium is to discuss the most recent research trends with respect to cognition and decision-making in aviation. Participants in the symposium will present several different perspectives on current issues being investigated. Phil Smith will discuss issues involving information management to support collaborative decision making in the national airspace system. Judith Orasanu will present ongoing NASA work looking at pilot risk assessment. Mica Endsley will discuss a recent model developed to examine the effect of disruptions on Situation Awareness and decision making in Air Traffic Control as well as in the cockpit. Kathleen Mosier will present Coherence/Correspondence, Intuition -< Analysis as theoretical frameworks within which to discuss cognition in the automated cockpit. Together, these presentations will provide an overview of the most current developments and perspectives on cognitive processes and decision making in the aviation domain.

Information Management to Support Distributed Decision-Making in the National Airspace System

For Summer 2000, the Federal Aviation Administration introduced a new collaborative procedure for reducing departure delays during weather events. This initiative involved the used of predefined Coded Departure Routes (CDRs). Goals of this procedure included: Providing airline operations centers and FAA air traffic facilities with a process for working collaboratively to develop earlier plans for dealing with predicted constraints. Giving airport control towers greater flexibility to respond to the often rapidly changing picture regarding available airspace during weather events. Keeping airline dispatchers in the loop through the early identification of alternative departure routes to expedite departures from an airport. An analysis of the use of CDRs was completed, based on interviews with staff at six airlines and four enroute air traffic control Centers, on analyses of System Command Center advisories and on analyses comparing filed with flown routes. Based on this analysis, recommendations are made for the design of improved tools for information dissemination and decision support.

Detection and Quantification of Inefficiencies in the National Airspace System

Previous research has indicated that a significant weakness in the functioning of the National Airspace System (NAS) is a lack of adequate feedback to operators such as airline dispatchers and air traflic managers regarding the impacts of their decisions (Billings, 1997; Carlson, et al., 1996; Kerns, et al., 1999; Smith, et al., 1997; Wickens, et al., 1997). In particular, although dispatchers get anecdotal evidence about the air traffic problems that their flights encounter, such as cornerpost swaps and airborne holding, they do not get routine objective data about the frequency and impact of such air traffic mmatives on the llights that they plan. Similarly, air traffic managers make decisions about traffic flows during events like severe weather, but they do not receive any systematic feedback about how successful these plans were or about their costs to the airlines. This inadequacy is in part a hold-over from a system design that decomposed overall system performance into a set of somewhat independent subtasks, so that each person (such as a traffic manager 01 a dispatcher) could do his or her job adequately without too much knowledge or feedback about the performance of other parts of the system. It is also in part due to the fact that different organizations have historically collected different types of data, without any integration of these data sets. As the system has become more integrated, and as the airlines have been given greater flexibility under FAA rmt~atives such as the National Route Program, this lack of data integration and lack of feedback has become a much more important problem. In response to this need, a software system has been developed that integrales FAA data about planned and actual roulings with airline data about planned and actual costs (fuel consumptions and various time metrics such as departure time and time airborne). This soflware system, which is currently being Beta-tested by the Air Traffic Control System Command Center and by 4 airlines, provides post-operations analyses to air traffic managers and dispatchers about routine inefficiencies due to Ilight amcndmcnts. (For example, during one mouth, flights from Chicago to Atlanta departing I 115 Zulu for a particular airline encountered airborne holding 43% of the time, resulting in the consumption of 27% more fuel while airborne and 34% more time.) In addition to such quantitative data, the system provides matching map displays that show planned vs. actual routings. Finally, the software contains data mining tools that can look at the entire NAS for some lime period and help answer questions like: I. What flights routinely experience airborne holding the most and what arc the costs associated with such holding? 2. How often are low altitude departure routes used? How much more often could they be used in situations where there are significant departure delays?