Establishing and evaluating bar-code technology in blood sampling system: a model based on human centered human-centered design method Shin-Shang Chou, RN, DNS1, Hsiu-Fang Yan, RN1, Hsiu-Ya Huang, RN, MSN1, Kuan-Jui Tseng, RN, MS1, Shu-Chen Kuo, RN, MSN1, 1 Taipei Veterans General Hospital, Taipei, Taiwan Abstract This study intended to use a human-centered design study method to develop a bar-code technology in blood sampling process. By using the multilevel analysis to gather the information, the bar-code technology has been constructed to identify the patient’s identification, simplify the work process, and prevent medical error rates. A Technology Acceptance Model questionnaire was developed to assess the effectiveness of system and the data of patient’s identification and sample errors were collected daily. The average scores of 8 items users’ perceived ease of use was 25.21(3.72), 9 items users’ perceived usefulness was 28.53(5.00), and 14 items tasktechnology fit was 52.24(7.09), the rate of patient identification error and samples with order cancelled were down to zero, however, new errors were generated after the new system deployed; which were the position of barcode stickers on the sample tubes. Overall, more than half of nurses (62.5%) were willing to use the new system. Introduction Patient safety initiatives throughout the healthcare industry and in many hospitals have mandated increasing emphasis on the need for accurately identifying and tracking specimen from patient’s bedside to the laboratory. In the modern hospital, blood sampling process is an area wherein human error can occur and does occur; currently, the accurately identifying patient and placing the blood into correct test tubes are totally dependent on the nurse's compliances to the standard of procedure of identifying patient and the ability to sort through multiple labels and make the correct tube type labeling. To date, many hospitals introducing barcode technology as one of the advanced solutions for patient safety at point of care, and the results achieved in improving compliance and correct labeling are satisfaction1. This study intends to use a human-centered design study method2 to develop a bar-code technology and systematically introduce into clinical setting; and using the users’ satisfaction of the system and the reduction of error sample rate as outcome measures to evaluate the effectiveness of the bar code technology in blood sampling. Methods: This was a three-stage research project; the first stage, the nurses and information technologists teamed up and followed the human-centered design study method principles to collect qualitative data and existing clinical guidelines related to the blood sampling and tracking process, at the end of first stage, a prototype of the barcode technology for blood sampling and tracking has been developed.
NI2012: 11th International Congress on Nursing Informatics 79
In the second stage, the prototype has been major revised 4 times based on the data from 10 users and IT personnel meetings, data collected was using thinking aloud method and a small scale testing by a group of nurses and technicians using the questionnaire. The third stage was implemented the revised bar-code technology system and evaluate its usability using a 5-point Likert’s scale questionnaire based on technology acceptance model3. The questionnaire included 3 dimensions and validated by 5 experts, the content validity index of each dimension was users’ perceived ease of use (8 items) was 0.93, users’ perceived usefulness (9 items) was 0.97, and task-technology fit (14 items) was 0.96. Meanwhile, the data of patient’s identification and sample errors were collected daily by the laboratory. Results 1. The barcode blood sampling and tracking system has five major functions; A. the barcode bracelet on patients wrist, barcode scanner and patient identifying information list in the computer, B. the sampling information; which included active blood test orders, each test and total blood volume needed, special instruction for sampling (i.e., NPO, test tube ice soaking), D. a barcode sticker printer E. sample transportation and tracking record. 2. The data from thinking aloud method and a small scale testing revealed 4 major issues/functions need to be revised to improve the efficiency and the patient and information safety. Revised issues included: A. programming issues, such as patients and test information in barcode sticker, the calculation of total blood volume needed for combining two tests, B. sampling procedure revised based on the hospital policy, such as repeat blood tests, such as blood culture, C. the procedure of sample check out from nursing station and tracking blood sample position; D. barcode sticker size and test tube (ESR) not match. 3. After the system implemented 6 month, a questionnaire survey was conducted and 548 nurses were drawn evenly from each nursing station and invited to joint the survey, 533 nurses replied (response rate 97.3%), the nurses’ characteristics information was listed as Table 1. Table 1. the nurses characteristics n = 533 item n (%) Education level Associated degree 52(9.8) Bachelor degree 427(80.1) Master degree 37(6.9) Missing 17(3.2) Clinical ladder N 27(5.1) N1 90(16.9) N2 284(53.3) N3 64(12.0) N4 50(9.4) NP 2(0.4) Missing 16(3.0)
NI2012: 11th International Congress on Nursing Informatics 80
4. The results of usability evaluation are listed as table 2. Table 2. The system usability evaluation Dimension item Mean Perceived ease of use 8 25.21 Perceived usefulness 9 28.53 Task-technology fit 14 52.24
SD 3.72 5.00 7.09
N=533 Max 35 40 70
Min 11 9 26
5. The data of system effectiveness evaluation showed that comparing the old workflow, 63.2% nurses thought the barcode system can improve the nursing care quality, 85.9% nurses thought the system cam improve the accuracy of patient identification, 54% nurses thought the system can improve the work quality; more than half of nurses (62.5%) were willing to use the new system, 76.6% nurses thought the computer response rate should be improved. 6. The sample error number/month were collected 6 months before and after the system implemented was significantly improved (see table 3), the error type included repeated prescribing tests, wrong test tube, insufficient blood volume, improper storage the test tube. Table 3. The blood sample error number/month pre and post system implemented category Pre-system Post-system t p CBS 10.83±4.92 3.33±3.46 8.03 .014＊ Biochemistry 89.83±15.99 30.67±8.38 3.06 .000＊ ＊ p＜.05 Discussion 1. Success of the barcode computer-based blood sampling process depends on the project team’s decision on using human-centered design study method as the main concept, and using small group testing meeting to collect, anticipate and obviates potential workflow issues, and to respond rapidly to unanticipated user needs to smooth the blood sampling process change. 2. In the manual system, identification errors were generally discovered in the laboratory, often resulting in a delay of reporting, an additional sample collection, and additional time to communicate with doctor. A major benefit of the barcode system is providing online information to the nurses that can then be made a right decision immediately, which were right test tube, enough amount of blood, and right storage of the test tube. 3. The results of error rate of blood sampling were significantly improved, and more than half of the users were satisfied with this system, these results were similar to other barcode technology research projects in healthcare settings4,5. However, the system’ response speed was a major barrier to implement the system and should be improved to make this system more friendly. 4. An unanticipated issue raised was the position of barcode sticker on the test tube, which causes the laboratory machine reading difficulty. The solution was held several education sessions for nurses to place the sticker in right position.
NI2012: 11th International Congress on Nursing Informatics 81
Conclusion Based on the experiences of the users in this study, bar-coding technology can play an important role in improving the patient safety during the blood sampling process through identifying and preventing the identification errors and preparing blood sampling material errors. Moreover, this technology could reduce the workflow complexity related to sampling process. References 1. Bates, D. W., & Gawande, A. A. (2003). Improving safety with information technology. N Engl J Med, 348(25), 2526-2534. 2. Rinkus, S., Walji, M., Johnson-Throop, K. A., Malin, J. T., Turley, J. P., Smith, J. W., et al. (2005). Human-centered design of a distributed knowledge management system. [doi: DOI: 10.1016/j.jbi.2004.11.014]. Journal of Biomedical Informatics, 38(1), 4-17. 3. Ryan, P., Pumilia, N. J., Henak, B., & Chang, T. (2009). Development and performance usability testing of a theory-based, computerized, tailored intervention. Comput Inform Nurs, 27(5), 288-298; quiz 299-300. 4. Morrison, A. P., Tanasijevic, M. J., Goonan, E. M., Lobo, M. M., Bates, M. M., Lipsitz, S. R., et. al. (2010). Reduction in specimen labeling errors after implementation of a positive patient identification system in phlebotomy. Am J Clin Pathol, 133(6), 870-877. doi: 10.1309/ajcpc95yymsllrcx 5. Paoletti, R. D., Suess, T. M., Lesko, M. G., Feroli, A. A., Kennel, J. A., Mahler, J. M., et al. (2007). Using bar-code technology and medication observation methodology for safer medication administration. Am J Health Syst Pharm, 64(5), 536-543.
NI2012: 11th International Congress on Nursing Informatics 82
NI2012: 11th International Congress on Nursing Informatics 79
In the second stage, the prototype has been major revised 4 times based on the data from 10 users and IT personnel meetings, data collected was using thinking aloud method and a small scale testing by a group of nurses and technicians using the questionnaire. The third stage was implemented the revised bar-code technology system and evaluate its usability using a 5-point Likert’s scale questionnaire based on technology acceptance model3. The questionnaire included 3 dimensions and validated by 5 experts, the content validity index of each dimension was users’ perceived ease of use (8 items) was 0.93, users’ perceived usefulness (9 items) was 0.97, and task-technology fit (14 items) was 0.96. Meanwhile, the data of patient’s identification and sample errors were collected daily by the laboratory. Results 1. The barcode blood sampling and tracking system has five major functions; A. the barcode bracelet on patients wrist, barcode scanner and patient identifying information list in the computer, B. the sampling information; which included active blood test orders, each test and total blood volume needed, special instruction for sampling (i.e., NPO, test tube ice soaking), D. a barcode sticker printer E. sample transportation and tracking record. 2. The data from thinking aloud method and a small scale testing revealed 4 major issues/functions need to be revised to improve the efficiency and the patient and information safety. Revised issues included: A. programming issues, such as patients and test information in barcode sticker, the calculation of total blood volume needed for combining two tests, B. sampling procedure revised based on the hospital policy, such as repeat blood tests, such as blood culture, C. the procedure of sample check out from nursing station and tracking blood sample position; D. barcode sticker size and test tube (ESR) not match. 3. After the system implemented 6 month, a questionnaire survey was conducted and 548 nurses were drawn evenly from each nursing station and invited to joint the survey, 533 nurses replied (response rate 97.3%), the nurses’ characteristics information was listed as Table 1. Table 1. the nurses characteristics n = 533 item n (%) Education level Associated degree 52(9.8) Bachelor degree 427(80.1) Master degree 37(6.9) Missing 17(3.2) Clinical ladder N 27(5.1) N1 90(16.9) N2 284(53.3) N3 64(12.0) N4 50(9.4) NP 2(0.4) Missing 16(3.0)
NI2012: 11th International Congress on Nursing Informatics 80
4. The results of usability evaluation are listed as table 2. Table 2. The system usability evaluation Dimension item Mean Perceived ease of use 8 25.21 Perceived usefulness 9 28.53 Task-technology fit 14 52.24
SD 3.72 5.00 7.09
N=533 Max 35 40 70
Min 11 9 26
5. The data of system effectiveness evaluation showed that comparing the old workflow, 63.2% nurses thought the barcode system can improve the nursing care quality, 85.9% nurses thought the system cam improve the accuracy of patient identification, 54% nurses thought the system can improve the work quality; more than half of nurses (62.5%) were willing to use the new system, 76.6% nurses thought the computer response rate should be improved. 6. The sample error number/month were collected 6 months before and after the system implemented was significantly improved (see table 3), the error type included repeated prescribing tests, wrong test tube, insufficient blood volume, improper storage the test tube. Table 3. The blood sample error number/month pre and post system implemented category Pre-system Post-system t p CBS 10.83±4.92 3.33±3.46 8.03 .014＊ Biochemistry 89.83±15.99 30.67±8.38 3.06 .000＊ ＊ p＜.05 Discussion 1. Success of the barcode computer-based blood sampling process depends on the project team’s decision on using human-centered design study method as the main concept, and using small group testing meeting to collect, anticipate and obviates potential workflow issues, and to respond rapidly to unanticipated user needs to smooth the blood sampling process change. 2. In the manual system, identification errors were generally discovered in the laboratory, often resulting in a delay of reporting, an additional sample collection, and additional time to communicate with doctor. A major benefit of the barcode system is providing online information to the nurses that can then be made a right decision immediately, which were right test tube, enough amount of blood, and right storage of the test tube. 3. The results of error rate of blood sampling were significantly improved, and more than half of the users were satisfied with this system, these results were similar to other barcode technology research projects in healthcare settings4,5. However, the system’ response speed was a major barrier to implement the system and should be improved to make this system more friendly. 4. An unanticipated issue raised was the position of barcode sticker on the test tube, which causes the laboratory machine reading difficulty. The solution was held several education sessions for nurses to place the sticker in right position.
NI2012: 11th International Congress on Nursing Informatics 81
Conclusion Based on the experiences of the users in this study, bar-coding technology can play an important role in improving the patient safety during the blood sampling process through identifying and preventing the identification errors and preparing blood sampling material errors. Moreover, this technology could reduce the workflow complexity related to sampling process. References 1. Bates, D. W., & Gawande, A. A. (2003). Improving safety with information technology. N Engl J Med, 348(25), 2526-2534. 2. Rinkus, S., Walji, M., Johnson-Throop, K. A., Malin, J. T., Turley, J. P., Smith, J. W., et al. (2005). Human-centered design of a distributed knowledge management system. [doi: DOI: 10.1016/j.jbi.2004.11.014]. Journal of Biomedical Informatics, 38(1), 4-17. 3. Ryan, P., Pumilia, N. J., Henak, B., & Chang, T. (2009). Development and performance usability testing of a theory-based, computerized, tailored intervention. Comput Inform Nurs, 27(5), 288-298; quiz 299-300. 4. Morrison, A. P., Tanasijevic, M. J., Goonan, E. M., Lobo, M. M., Bates, M. M., Lipsitz, S. R., et. al. (2010). Reduction in specimen labeling errors after implementation of a positive patient identification system in phlebotomy. Am J Clin Pathol, 133(6), 870-877. doi: 10.1309/ajcpc95yymsllrcx 5. Paoletti, R. D., Suess, T. M., Lesko, M. G., Feroli, A. A., Kennel, J. A., Mahler, J. M., et al. (2007). Using bar-code technology and medication observation methodology for safer medication administration. Am J Health Syst Pharm, 64(5), 536-543.
NI2012: 11th International Congress on Nursing Informatics 82
