1. Voshall, Barbara DNP, RN
  2. Piscotty, Ronald PhD, RN-BC
  3. Lawrence, Jeanette DNP, CRNA
  4. Targosz, Mary DNP, CPNP


Safe medication administration is necessary to ensure quality healthcare. Barcode medication administration systems were developed to reduce drug administration errors and the related costs and improve patient safety. Work-arounds created by nurses in the execution of the required processes can lead to unintended consequences, including errors. This article provides a systematic review of the literature associated with barcoded medication administration and work-arounds and suggests interventions that should be adopted by nurse executives to ensure medication safety.