1. Federico, Frank RPh


As many as 32% of medication errors occur during administration, so there's good reason to find effective methods to minimize these error opportunities.


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Many reasons contribute to administration errors, including: unfamiliarity with medications; look-alike packaging; look-alike names; interruptions; look-alike/sound-alike patient names.


Hospitals have attempted various interventions to address these contributory factors. Many have undertaken major efforts to minimize look-alike/sound-alike medications. Others have worked on adopting a "sterile cockpit" model used in the airline industry, in which nurses wear a sash or vest indicating that they're in the process of administering medications and shouldn't be interrupted. These are fundamental changes that all hospitals should consider, whether or not they consider using bar code medication administration (BCMA).


Technology like BCMA, if implemented well and used correctly, offers us an opportunity to reduce errors significantly. So why has BCMA not been universally adopted? Challenges include getting staff buy-in, selecting the right vendor, preparing for changes in workflow with the new system, training those who will use it, ensuring technical support, and designing a process for evaluating the impact of BCMA on quality of care.1 Another factor is cost; BCMA is an expensive technology that competes with many other requests.


Implementing the new system

A system will work only as well as it's implemented. Workarounds may have nurses scanning patient wristbands and medications after administering the medications to the patient. The poor placement of workstations may contribute to this failure. Or, nurses may struggle with the scanner to read the bar code on a medication label. The result: delays in medication administration and a frustrated nurse. Researchers identified 15 types of workarounds and 31 types of causes for those workarounds, including unreadable bar codes, missing patient ID wristbands, and malfunctioning scanners.2


To build a solid foundation before implementing BCMA:


* Limit medications to those approved for formulary. This reduces the use of medications with which nurses and pharmacists may have limited familiarity.


* Limit concentrations and dosage strengths to those most commonly used.


* Ensure that high-alert medications aren't available, to reduce the likelihood of administration of these medications without the proper review and preparation.



When selecting a vendor, nurses and pharmacists should test the human/machine interface to determine whether the equipment is easy to use. It's important to consider the availability of equipment at the point of care and its incorporation into the workflow. Other items to consider include: testing labels for readability by scanners; availability of bar codes on commercially available products; and readability of pharmacy-generated labels.


Just enough training

No system will be effective without appropriate training, which should focus on securing a standardized process to ensure that the BCMA system is used as it was designed. If training in your hospital takes many steps and hours, you probably have a complex system that will lead to workarounds. Studies find that cross-training of nurses and pharmacists leads to higher visibility of user issues and garners positive feedback, which can be used to improve the process.3


Other challenges

Proper placement of equipment is a critical component of proper system implementation. Examine the current workflow of the medication administration process. Any technology should support and improve the medication process, not add steps that increase workload without proven value. And as with any technology, there will be scheduled and unscheduled down time. Nurses and pharmacists must work together to develop contingency or backup plans to be used during these periods. An important item that's often overlooked is unintended consequences. Has the BCMA process added time to preparation and dispensing in the pharmacy, or added time to medication administration for nurses?


While hospitals prepare for the implementation of BCMA, they can make the following basic changes to reduce the opportunity for errors:


* Remove high concentrations and high-alert medications from floorstock.


* Deliver medications in ready-to-administer doses to minimize mixing and rework for nurses.


* Ensure that nurses aren't interrupted when administering medications.



Review additional recommendations from the Institute for Safe Medication Practices ( and the Institute for Healthcare Improvement (


Not a magic bullet

Will BCMA reduce all harm? The answer is no. BCMA technology will reduce harm associated with administration errors. The majority of errors identified by BCMA are benign and pose minimal risk to patients.4 With proper planning, use of failure modes and effects analysis, and obtaining feedback from users, pharmacists and nurses can lead the implementation of an effective error-reduction strategy.5




1. Manos D. AHRQ report shows how barcoding medication improves quality and safety. Healthcare IT News. January 23, 2009. [Context Link]


2. Koppel R, Wetterneck T, Telles JL, Karsh B-T. Workarounds to barcode medication administration systems: their occurrences, causes, and threats to patient safety. J Am Med Inform Assoc. 2008;15:408-423. [Context Link]


3. Wideman M, Whittler M, Anderson T. Barcode Medication Administration: Lessons Learned from an Intensive Care Unit Implementation. [Context Link]


4. Sakowski J, Newman J, Dozier K. Severity of medication administration errors detected by a bar-code medication administration system. Am J Health-Syst Pharm. 2008; 65:1661-1666. [Context Link]


5. Using Barcode Medication Administration to Improve Quality and Safety. [Context Link]