JMIR Publications

ABSTRACT

Background:

Worldwide, treatment trends are shifting from inpatient to outpatient settings owing to technological advancements and medical strategies to shorten hospital stays. Accordingly, the workloads of outpatient nurses are becoming increasingly complex as nurses must ensure safe and efficient medication administration for high patient volumes. However, discussions on Barcode Medication Administration (BCMA) have been largely limited to inpatient settings. Inpatient BCMA models are not directly applicable to outpatients, who present with unique challenges, including a lack of identification (ID) wristbands, short visit durations, and high hospital mobility.

Objective:

We aimed to identify the work-system factors that contribute to the adoption and sustainability of a smartphone-based BCMA system in busy outpatient treatment rooms where both efficiency and safety are paramount. Work-system interactions among nurses, patients, and technology were examined using the Systems Engineering Initiative for Patient Safety (SEIPS) 2.0.

Methods:

A mixed-methods study using the SEIPS 2.0 framework was conducted in three treatment rooms of a large hospital in Japan. A smartphone-based BCMA with an intentional dual-workflow design was implemented. The traditional "Flow A" involved verbal name confirmation and manual entry on a personal computer (PC). Instead of an ID wristband, the new "Flow B" used the patient’s ID card (with a printed barcode), which was scanned via a smartphone linked to the Hospital Information System (HIS). To accommodate outpatient diversity, the nurses were granted situational autonomy to choose Flow A or Flow B. Quantitative data included injection logs and system telemetry alerts from August 2023 to March 2025. Qualitative data from participant observations of nursing operations and survey questionnaires completed exclusively by nurses (without patient surveys) were analyzed using SEIPS 2.0 to determine factors that influence system adoption.

Results:

Within five months of introduction, the usage rate of Flow B for authentication and registration exceeded 50% across all rooms, eventually stabilizing at 80–90%. System logs recorded system telemetry alerts (procedural sequence artifacts and workflow entries) of 0.19–0.72%, acting as point-of-care forcing functions rather than reducing clinical errors. The surveyed nurses reported that Flow B supported operational workflow, reduced cognitive strain, and enhanced process reliability. Crucially, the hybrid dual-workflow model was maintained as a deliberate sociotechnical design choice, utilizing Flow A for specific cases, such as patients without ID cards, thereby preserving efficiency and perceived safety in this high-turnover setting.

Conclusions:

Guided by SEIPS 2.0, this study indicates that sustained adoption hinges on flexible workflows that are adaptable to unique outpatient dynamics. Granting nurses situational autonomy through dual workflows maintained operational efficiency while introducing safeguards to mitigate cognitive strain and enhance process reliability. Moreover, point-of-care mobile tools facilitate patient participation. Ultimately, workflow flexibility and intentional hybrid designs offer a practical approach for supporting human-centered medication safety and process reliability in busy outpatient environments.