Table 3.
Identified themes and subthemes about BCMA’s impact on problem-solving behavior with example episodes.
| Theme/ Subtheme (# contributing episodes) |
Example episodes | ||
|---|---|---|---|
| Goal | Problem | Problem-solving behavior (and type of behavior/strategy) |
|
|
1. BCMA facilitated novel problem-solving behavior (13) |
Administer right medication at the right time. | Nurse does not know if a medication scheduled to be administered once per shift can be administered yet. | Nurse scans a medication’s barcode to see if the BCMA system accepts the medication, which will tell the nurse whether the medication can be administered at this time. (Electronic solution) |
| Quickly access medication information. | Multiple orders in system make quick information seeking difficult. | Nurse sorts medication orders by name in the BCMA software before printing a copy of the medication order list. (Electronic solution) |
|
|
2. BCMA blocked familiar problem-solving behavior (14) |
Administer total of 20mg of a just-ordered medication right away. | Pharmacy will require some time in order to deliver the 20mg dose, and the BCMA system will not allow anything but a single 20mg dose to be administered, even though 2 × 10mg doses are immediately available. | Nurse cannot immediately administer and document a clinically equivalent therapy of 2 × 10mg, a typical solution pre-BCMA. Instead, nurse recruits the help of a pharmacist to create two new 10mg orders in the BCMA system so that 2 × 10mg can be administered as a substitute for a single 20mg dose. The first order is a standing order for 10mg that the nurse can give once right away; it remains in the system until the pharmacist removes it later. The second order is a one-time 10mg order that is discontinued once documented as administered. Pharmacist informs a fellow pharmacist to modify the original 20mg order so that it does not appear as missed (non-administered). (Collaboration, system workaround) |
|
3. BCMA introduced new problems (62) |
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|
3a. Nurses responded to new BCMA-problems with familiar problem-solving behavior (29) |
Document medication discrepancies in the BCMA system. | Nurse feels uncomfortable using the BCMA system. | Nurse asks a fellow nurse to carry out BCMA documentation tasks in her stead. (Collaboration) |
| Plan the day and carry out planned tasks when needed. | There is a lot of information to keep track of and manage throughout the day. | At the start of shift, nurse selects own patients in BCMA system and for each prints the “Timeline” screen from the BCMA software. Nurse then transfers information from this print-out to a gridded sheet of paper that the nurse will refer to and update throughout the day. (Use of paper artifacts, time management) |
|
|
3b. Nurses responded to new BCMA-related problems by inventing novel problem-solving behavior (13) |
Document/reconcile a missed medication administration. | Nurse does not like default options offered in BCMA software for documenting reason for missed medication. | Nurse finds an option to enter a note for why the medication was missed, providing a narrative description that was not possible using the default menu of options.a (Electronic solution) |
| Identify in BCMA system which patient will receive medication. | Patient is too far away and the nurse is using a tethered BCMA scanner. | Nurse selects patient manually in BCMA. (System workaround) |
|
|
3c. Nurses lacked effective problem-solving behavior to address new BCMA-related problems (20) |
Administer a medication on time. | In initial attempts, medication does not scan into BCMA. | Nurse tries to scan the medication repeatedly, and then at multiple different computer stations, without success. (Try and try again) |
| Administer current dose of scheduled medication, and Avoid taking responsibility for medication missed by nurse on previous shift. |
Previously scheduled dose for a medication was not administered by another nurse on the past shift, and BCMA system requires a reason to be documented before another dose can be administered. | After unsuccessful attempt to have pharmacy clear the previous (missed) dose from the BCMA system, nurse does nothing/waits. (Do nothing/wait) |
|
BCMA = bar coded medication administration
a
Although the free text note feature was built into the system, for whatever reason the nurse was not aware of it and therefore spent several minutes attempting to document the administration in the standard way (using default menu options) before “discovering” the note feature.