Errors Prevented by and Associated with Bar-Code Medication Administration Systems

Cochran, Gary L; Jones, Katherine; Brockman, John A.; Skinner, Anne; Hicks, Rodney W.

doi:10.1016/s1553-7250(07)33034-1

Cited by 39 publications

(29 citation statements)

References 6 publications

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“…In their study, one quarter of the reported misidentification errors involved expressed breast milk [8]. Bar code technology has been introduced for medication administration [2]. So far, there are no reports on this technology for dispensing bottle feeds.…”

Section: Discussionmentioning

confidence: 96%

The role of critical incident monitoring in detection and prevention of human breast milk confusions

et al. 2009

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Feeding a mother's expressed breast milk to the wrong infant is a well-known misidentification error in neonatal intermediate care units (NICU) with potential harmful consequences for the neonate. In this study, we aimed to analyze the role of critical incident monitoring on detection and prevention of human breast milk confusions. The critical incident monitoring made us aware of this misidentification error on our NICU. Despite the implementation of system changes to make breast milk application clearer and safer, we failed to reduce the incidence of breast milk confusions.

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Section: Discussionmentioning

confidence: 96%

The role of critical incident monitoring in detection and prevention of human breast milk confusions

et al. 2009

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“…Two percent of the reports were for medications administered to the wrong patient. Causes of the errors included "stat" medications that were administered without being entered into the system, medications scanned after administration instead of prior to administration, and scanning a patient's ID from the wrong medical record instead of the patient's armband (Cochran, Jones, Brockman, Skinner, & Hicks, 2007). Biometric authentication, or use of a biometric that is permanently associated with a patient (e.g., fingerprint, retinal, 3D facial characteristics), currently is being examined as another way to confirm patient identity.…”

Section: Figure 2 Strategies To Reduce the Risk Of Patient Misidentimentioning

confidence: 99%

Things Are Looking Up: A Ceiling Tile Project Inspires Patients, Family, and Staff & <b>Thursdays</b>

Quinn¹,

Smith²,

Strelec³

2008

Clinical Journal of Oncology Nursing

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“…2 In addition, the patient is provided a bar-code identifier attached to the wristband to ensure correct patient identification. 3 Bar-code medication administration is endorsed as a patient safety intervention by the Agency for Healthcare Research and Quality and the Institute of Medicine. 4,5 Whereas computerized physician order entry reduces prescribing and transcribing errors, BCMA targets errors associated with dispensing and administration of medications.…”

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confidence: 99%

“…4,5 Whereas computerized physician order entry reduces prescribing and transcribing errors, BCMA targets errors associated with dispensing and administration of medications. 3 Emerging evidence suggests that nurses are satisfied overall with the BCMA technology. In a survey of 1,087 nurses and 28 interviews, satisfaction with the conversion to BCMA was assessed.…”

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confidence: 99%

Think Bar-Code Medication Administration Eliminates Adverse Drug Events? Think Again!

O’Malley

2008

Clinical Nurse Specialist

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I am a clinical nurse specialist (CNS) in an academic medical center that is implementing Bar-Code Medication Administration (BCMA). Does BCMA eliminate errors? How strong is the evidence supporting this expensive technology? What is the impact of BCMA on nursing workflow? B ar-code medication administration is the application of a widely used and reliable commercial technology to prevent medication errors. 1 A unique identifier or bar code placed on each medication is read by an optical scanner. Bar-code medication administration uses the National Drug Code, which describes the drug name, dose, drug company, and type of packaging. 2 In addition, the patient is provided a bar-code identifier attached to the wristband to ensure correct patient identification. 3 Bar-code medication administration is endorsed as a patient safety intervention by the Agency for Healthcare Research and Quality and the Institute of Medicine. 4,5 Whereas computerized physician order entry reduces prescribing and transcribing errors, BCMA targets errors associated with dispensing and administration of medications. 3 Emerging evidence suggests that nurses are satisfied overall with the BCMA technology. In a survey of 1,087 nurses and 28 interviews, satisfaction with the conversion to BCMA was assessed. Although medication administration was perceived as more time-consuming, nurses were satisfied with the efficacy and safety provided by BCMA. 6 However, nurses have also identified problems associated with BCMA. Lack of technology flexibility often results in conflicts when reconciling the ever-changing priorities in clinical care, provision of nonroutine medications, and administration of scheduled doses. Furthermore, difficulties in care coordination and nurse-physician communication may be enhanced by BCMA. 6,7 Early evidence suggests that BCMA exerts a significant burden on workload, which is supported by nurses' perceptions that BCMA is a time-consuming process. In a time study of 108 nurses in a 735-bed medical center, one hundred sixteen 2-hour periods of practice were observed to evaluate the impact of BCMA. Result demonstrated that 26.9% of the nurse's time was spent on medication-related activities, which included information retrieval, management of physician orders, waiting, obtaining and verifying medications, medication administration, and documentation. 8 BCMA ErrorsBar-code medication administration errors can occur in the dispensing or administration phases. In a recent report, 515 reports were evaluated from MEDMARX, a national database of voluntarily reported medication errors. 3 In 70 reports, BCMA prevented an error from reaching a patient; 51 of the errors began in the dispensing phase, 14 errors were about wrong doses, and 11 were stocking errors. Nurses intercepted 27% (19) of the 70 errors during medication administration. However, in 445 reports, medication errors were a consequence of BCMA. Two hundred and eighty-four errors were reported as near misses, 160 were nonharmful, and 1 of the 445 errors was deemed harmf...

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Errors Prevented by and Associated with Bar-Code Medication Administration Systems

Cited by 39 publications

References 6 publications

The role of critical incident monitoring in detection and prevention of human breast milk confusions

The role of critical incident monitoring in detection and prevention of human breast milk confusions

Things Are Looking Up: A Ceiling Tile Project Inspires Patients, Family, and Staff & <b>Thursdays</b>

Think Bar-Code Medication Administration Eliminates Adverse Drug Events? Think Again!

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