Using QR Code Technology to Reduce Self-Administered Medication Errors

Introduction

Over the years in the health-care profession, medication errors, including missed dosages, wrong dosages, and unintended drug interactions, have mitigated the effects of high-quality patient care. Today, patient error and confusion when reading and understanding medication labels is prevalent and results in a significant amount of disabilities, hospitalizations, and even death. In fact, the US Food and Drug Administration (FDA) ¹ receives tens of thousands of reported medication errors every year of which more than one-third are from self-administered medications.

According to the National Coordinating Council for Medication Error Reporting and Prevention, a medication error is defined as “any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional, patient or consumer.” ² This would include, for example, taking a medication at the wrong time, at the wrong dosage, or inadvertently with another medication that creates a harmful side effect.

One of several factors contributing to outpatient medication error is insufficient labeling on both prescribed and over-the-counter drugs and supplements. ³ This was confirmed in a study indicating that “up to 25% of all medication errors are attributed to name confusion and 33% to packaging and labeling confusion.” ³ A similar study conducted by Miriam Klein and Henry Cohen ⁴ identified risks associated with poor labeling of intravenous drug administration and emphasized the importance of implementing new labeling systems to improving patient safety. It is this type of perceptual label confusion that can cause patients, or even caregivers, to maladminister medication with serious consequences.

In addition, interactions, especially for those taking several prescription drugs and/or supplements, unaware of the consequences, can create serious, harmful patient complications. ⁵ For example, warfarin, which is a prescription blood anticoagulant, and Ginkgo biloba, a commonly used herbal supplement, can each reduce blood clotting; consequently, “taking any of these products together may increase the potential for internal bleeding or stroke.” ⁵ This is especially problematic in older patients who generally have more “complex clinical problems and take multiple treatments,” as their cognitive abilities may be impaired, increasing the likelihood of errors. ⁶ Overall, it is evident that clear, concise, and readily available information is essential to reducing the risk of misadministration and interactions of medications. This would also assist in raising awareness of the unintended consequences of mixing and combining certain dietary supplements and medications.

Furthermore, people tend to ignore or discard the sometimes complex and potentially confusing printed information provided with their prescribed medications. ⁷ For instance, in one study conducted in community pharmacies and patients’ homes in England, 456 patients were asked questions about their patient information leaflets (PILs), which are written instructions received with every prescribed medication bottle. The results indicated that 97% of all patients were aware of the leaflets; however, 87% of frequent users of prescriptions “had never or rarely looked at the leaflet after the first time.” ⁸ In fact, these PILs tend to be thrown away after a patient returns home from the doctor’s office. ⁷ This has serious implications, since important information may change over time or new medications or supplements may be added to a person’s daily intake after the medication has been prescribed by a doctor. This also underscores the importance of developing new ways to improve patient access to critical information and thereby improving administration of medication for the best possible outcome.

Several studies point to promising new technological solutions that can reduce medication errors and improve patient outcomes. A vast amount of literature and research have suggested that the use of barcoding on medications, by health-care professionals in hospitals and other health-care settings, improves patient care. ^{9 -13} For example, in one study conducted in 13 nursing homes, it was found that the use of a hand-held device, called a pharmacy-led barcode medication system, improved registered nurses and care staff awareness of drug errors and reduced stress and confusion. ¹³ The barcode system included specific information about the patient, dosages, prescribed times, and so on. Overall, it was found that this system made it more efficient for trained health-care professionals to properly administer medications to their patients.

Another study discussed the barcode medication administration system, which allowed educated and trained nurses to scan “the patient’s wristband barcode and the barcode on the medication to be administered.” ⁹ If an issue was flagged regarding this administration of medication, the system would alert the nurse to not administer the medication; this, as a result, reduced errors. However, currently, this barcoding system is currently only used by less than 25% of US hospitals. ⁹

Although procedures utilizing barcoding are becoming more and more common in health-care settings, the effectiveness of barcoding on self-management warrants further research. In one previous study, 61 patients taking multiple medications were asked to evaluate the usefulness of information provided by an app reading a barcode on their medications packaging. ¹² They were provided 2 different questionnaires, where they responded subjectively on perceptions and experiences utilizing this technology. The results indicated that the patients were favorable to this intervention, finding it “useful for safer use of medicines.” ¹²

With this in mind, this current study seeks to build on and complement previous literature and studies by proposing that implementation of Quick Response (QR) code technology, which can provide substantially more embedded information than bar coding, could benefit not only trained health-care professionals but also patients and caregivers self-administering medication by providing convenient access to important information in much more detail than is available on current prescription and over-the-counter labels. Accordingly, the focus of the current research is to determine the extent to which QR code technology can improve medication labels to reduce medication errors among self-administered individuals. It seemed prudent to first see if such information would be of any benefit before developing an app for a QR code reader and deciding on the mode of information delivery (voice, text, and visualizations) that could be pursued in a human factors–type usability study. Thus, in this initial study, participants received text output that could be contained in a QR code and did not use an actual QR reader.

Hypotheses

Methods

Results

In all analyses, P values <.05 were considered as statistically significant. All data from the questionnaires were analyzed with multivariate analysis of variance using SPSS version 25. As seen in Figure 1, the main effect (Fisher’s F) of condition (label vs QR) indicated that both students and senior citizens in the experimental group, the QR code condition, had significantly more correct answers (Students mean [M] = 14.4, standard error [SE] = 0.61 and Seniors M = 9.0, SE = 0.74) than those in the control group (Students M = 2.9, SE = 0.66 and Seniors M = 1.3, SE = 0.81), F _{1, 51} = 181.57, P < .001, η² = 0.78.

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Figure 1.

Correct answers for medical information with bottle labeling only or Quick Response code for students and senior citizens (bars are standard error).

Similarly, as seen in Figure 2, a significant main effect of labeling was also found for correct answers per minute, as both age groups in the experimental group had significantly more correct answers per minute (Students M = 1.4, SE = 0.08 and Seniors M = 0.73, SE = 0.09) than those in the control group (Students M = 0.31, SE = 0.09 and Seniors M = 0.08, SE = 0.11), F _{1, 51} = 87.9, P < .001, η² = 0.63.

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Figure 2.

Correct answers per minute for medical information with bottle labeling only or Quick Response code for students and senior citizens (bars are standard error.).

In addition, there was a significant main effect of age, where students had significantly more correct answers than seniors, F _{1, 51}= 24.4, P < .001, η² = 0.33, and also when measured as correct answers per minute, F _{1, 51}= 23.6, P < .001, η² = 0.32. Thus, there was significant interaction between age and labeling for both correct answers, F _{1, 51} = 6.98, P < .001, η² = 0.12, and for correct answers per minute, F _{1, 51}= 5.7, P < .05, η² = 0.1.

Discussion

The results of this study were considered against the initial hypotheses. All 3 hypotheses were supported. A significant main effect of labeling (QR code or bottle label only) was seen for both students and older populations, showing increased benefits of QR code labeling for both age groups. This supported the prediction that those using the QR code would make less errors due to the additional medication information. Overall, the very poor scores (<3 out of 17 possible) based on information obtained from medication labels in this study indicates that the current bottle labeling for prescribed and over-the-counter drugs and supplements seems insufficient. Using a knowledge test seems an adequate proxy for predicting medication error, as the FDA has indicated that “ambiguities in product names, directions for use, medical abbreviations or writing…patient misuse because of poor understanding of the directions for use of the product” are contributing factors in medication errors. ¹⁴

Also, older age groups tended to make more errors than younger age groups in both the QR code and the bottle label condition. This supports the hypothesis that older age groups are more prone to make errors and have difficulty comprehending and understanding the available information regardless of the amount of additional written information provided to them. This is not surprising, as cognitive and sensory abilities tend to decline with age. ⁶

Finally, the QR code condition proved to be more time efficient than the bottle labeling condition, resulting in less time consumption and less errors from both students and seniors in the experimental group.

By measuring correct answers and correct answers per minute on various age groups, such as undergraduate students and senior citizens, specific factors effecting dependent variables became evident. If all participants were measured without regard to age differences, it would have been difficult to ascertain a main effect of age on the efficacy of QR code technology as a tool to reduce self-administered medication errors. While speed of determining medication administration may not seem important, it could be a factor that affects if and when assistance is sought by a patient due to frustration or confusion. However, the results showed that information stored in QR codes help young and old alike. Thus, the benefits are not due solely to sensory or cognitive limitations of older adults. Consequently, this innovation has widespread application beyond geriatric populations.

This study indicated that QR code technology could play a significant role in reducing medication errors regardless of age; however, it has its limitations. For example, due to a small sample size (33 ASU undergraduates and 22 senior citizens), the results should be tentatively generalized, and larger samples could be tested. On the other hand, the main effect of QR code versus current labeling had large effect sizes when measured be either correct answers alone, F _{1, 51} = 181.57, P < .001, η² = 0.78 or correct answers per minute, F _{1, 51} = 87.9, P < .001, η² = 0.63, and the calculated power was = 1.

Another notable limitation with this present study was that the participants who enrolled were not representative of patients taking these specific medications. If it would have been noted that the participants would have been taking these specific medications themselves on a regular basis, it may have provided different results. However, caregivers helping administer medications may not be as familiar with medications and supplements and the additional information available through the QR codes could assist in those situations.

Finally, younger age groups (college students) may be more familiar and comfortable using technology, such as QR codes, than older age groups (senior citizens older than 70 years); this could have contributed to the lower correct answers in the older age-group relative to the higher correct answers in the younger age groups, specifically in the experimental group. Further studies could examine the best modalities (visual [text and images] and auditory) to deliver the information and perhaps doing so redundantly through multiple modalities.

Based on the reported data, this kind of research can be applied in both inpatient and outpatient settings, where it could improve the administration of both prescribed medications and over-the-counter drugs and supplements. Since it is evident that information currently available on medication bottles is insufficient and requires further clarification, the application of QR codes on prescription drug and supplement packaging could reduce common patient errors.

One could argue that the information used in the QR code condition of this experiment can be found in the supplemental information supplied with prescribed medications. However, previous research mentioned earlier shows this information is often discarded, so having that information readily available on the medication container at all times is advantageous. It is important to recognize that prescribed medications are often only part of a patient’s health regimen, and over-the-counter supplements and medications that could interact with those prescription medications have little if any packaging information like that contained in this study’s QR condition. This study is suggesting that both prescription and nonprescription labeling should be considered in any attempt to reduce medication errors.

It is important to note that since the results of this study indicated that QR codes do not completely eliminate errors, further improvements need to be explored. Rather than simply providing additional barcode information, patients could benefit from novel technological improvements related to QR code technology. For example, patients could use a smartphone or app to scan the code in order to receive information in a graphic, text, or audible format.

Current successful innovations, such as voice-assistant devices, could be utilized to reduce medication errors. Through a digital assistant, the patient could receive alerts and reminders tailored to their specific medical background and prescribed treatment. For example, it could remind self-administered patients to take their medications and supplements as prescribed. This technology could not only track prescribed medications but any supplements a patient is taking and sound the alert for any potentially dangerous interactions. Furthermore, this could reduce reliance on health-care providers by giving people easy access to important medication information concerning potential side effects and other relevant warnings from an alternate yet reliable and trusted source. This can help reduce the amount of hospital visits, because people will be able to get credible information about side effects and warnings from a reliable and trusted source. QR Code implementation on medication labels would be beneficial for all age groups regardless of diagnosis; however, it would especially benefit older patients who are more likely prescribed multiple medications.

Conclusion

This study investigated whether the implementation of QR code technology could increase the effectiveness of medication labeling and the reduction in self-administered medication errors. The results indicated that regardless of age, bottle labels cannot provide enough information to avoid information errors that could lead to medication errors. However, QR code technology could be implemented to deliver vital information via smartphone apps in audible, graphic, or text format. Accordingly, future research is warranted to explore the feasibility and implementation of this technology with the goal of improving health-care outcomes.

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