JMIR Publications

ABSTRACT

Background:

Globally, healthcare treatment trends are shifting from inpatient to outpatient settings owing to medical advancements and cost-reduction strategies, including shortening hospital stays. Consequently, the workload for outpatient nurses is increasingly complex. Nurses are required to ensure safe and efficient medication administration for high patient volumes; however, discussions on technologies such as Barcode Medication Administration (BCMA) have largely been limited to inpatient settings. Inpatient BCMA models are not directly applicable to outpatients, who present unique challenges, including a lack of identification (ID) wristbands, short visit durations, and high mobility within the hospital.

Objective:

To identify the work system factors that contributed to the adoption and sustainability of a smartphone-based BCMA system in busy outpatient treatment rooms, where both efficiency and safety are paramount. The interactions between nurses and patients using the system, and the surrounding environmental factors, were examined using the Systems Engineering Initiative for Patient Safety (SEIPS) 2.0 framework.

Methods:

A mixed-methods study based on the SEIPS 2.0 framework was conducted in three treatment rooms of a large hospital in Japan. A smartphone-based BCMA with a dual-workflow design for administering injections was implemented. The traditional "Flow A" involved verbal name confirmation and manual entry on a personal computer (PC). The new "Flow B" used the patient’s ID card (with a printed barcode) instead of an ID wristband, scanned via a smartphone (Personal Digital Assistant) linked to the Hospital Information System (HIS). To accommodate the diversity of outpatients, the system was designed to allow nurses to choose either Flow A or Flow B. Quantitative data included injection logs and error-detection rates from August 2023 to March 2025. Qualitative data from participant observations and questionnaires were analyzed using SEIPS 2.0 to determine factors influencing system adoption.

Results:

Within five months of introduction, the usage rate of Flow B for authentication and registration exceeded 50% across all rooms. Subsequently, the usage rate stabilized at 80–90% without decline. Log data revealed that the system detected preventable errors or mismatches in 2% of total injections. Nurses reported in questionnaires that Flow B improved both safety and operational workflow. A complementary system was established in which Flow A was used for patients without ID cards, thereby enhancing safety and efficiency in this high-turnover outpatient setting.

Conclusions:

Our holistic overview based on the SEIPS 2.0 framework revealed the critical roles of nurse and patient capabilities, professional ethics, environmental factors, operational policies, and tool usability. The key factors for successful entrenchment were flexible workflows that adapted to outpatient dynamics and a tool that facilitated patient participation in the safety process. Outpatient nurses should assess patient capabilities and consider strategies to engage patients as active partners in the workflow using intuitive tools.