Nurse Cognition in Response to Alert Generation During Bar Code Medication Administration (BCMA): An Examination of Human Factors
Doctor of Philosophy
Introduction: Nurses are at the forefront of care delivery, spending more time with patients than most other providers. Paramount to patient safety is the ability for nurses to make clinical decisions free from human error. Yet, the dynamic clinical environment in which nurses work is characterized by uncertainty, urgency, and high consequence, necessitating that nurses make quick and critical decisions. Notably, medical errors related to clinical decision-making, including medication administration errors, may occur more frequently among new graduate nurses. Therefore, the aims of this dissertation study are to 1) examine patterns of alert generation and alert response decisions (decision outputs) during BCMA among a cohort of new graduate nurses and 2) examine the influence of human and environmental factors on BCMA alert generation, cognitive response time, and decision to administer among new graduate nurses over their first year of practice.
Methods: Study objectives were addressed through a descriptive, longitudinal, observational cohort design using secondary data analysis. The setting for the study was a large, urban medical center in the mid-Atlantic region of the United States. The study sample included 132 new graduate nurses who worked on adult, in-patient units and administered medication using BCMA technology. Research variables for this study included individual, human, and environmental factors that may influence nurse cognition when alerts are generated during BCMA. Descriptive analyses and modeling were conducted.
Results: New graduate nurses experienced a total of 587,879 alert and medication administration encounters, administering 772 unique medications to 17,388 unique patients. Nurses in the sample experienced an average medication workload of 28.09 medications per shift, 3.98% of which were associated with alerts, over their first year of practice. The most common types of alerts experienced by nurses included Acetaminophen Max Dose (89.79%) and Patch Removal (8.44%) alerts. Residency cohort, unit type, patient workload, medication workload, and experience were associated with alert frequency (raw and/or adjusted). When considering decision output, residency cohort, alert category, patient workload, medication workload, and previous exposure variables were most often associated with the decision to proceed with administration. Alert-administration interval time was found to have the most associations with study variables, including residency cohort, unit type, alert category, patient workload, medication workload, experience, and previous exposure variables.
Conclusions: This dissertation study addressed a gap in the literature related to alert generation types and frequencies, as well as individual, unit, and organizational factors that contribute to alert generation and response by new graduate nurses during BCMA. By identifying factors associated with alert generation types, frequencies, and decision outputs, particularly among new graduate nurses, interventions or changes to alert rules can be implemented to improve the safety of medication administration. It is important to continue to study nurse cognition and factors that influence nurses’ decision-making, particularly during the process of medication administration, to reduce medical errors and improve patient outcomes.
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Available for download on Saturday, May 02, 2026