Study of Nurse Workarounds in a Hospital Using Bar Code Medication Administration System

This study analyzed registered nurse workarounds in an academic medical center using bar code medication administration technology. Nurse focus groups and a survey were used to determine the frequency and potential causes of workarounds. More than half of the nurses surveyed indicated that they administered medications without scanning the patient or medications during the last shift worked. Benefits of this study include considerations when implementing bar code medication administration technology that may minimize the development of these workarounds in practice.

[1]  Carol A. Keohane,et al.  Effect of bar-code technology on the safety of medication administration. , 2010, The New England journal of medicine.

[2]  Tosha B. Wetterneck,et al.  Technology Evaluation: Workarounds to Barcode Medication Administration Systems: Their Occurrences, Causes, and Threats to Patient Safety , 2008, J. Am. Medical Informatics Assoc..

[3]  R. D. Paoletti,et al.  Using bar-code technology and medication observation methodology for safer medication administration. , 2007, American journal of health-system pharmacy : AJHP : official journal of the American Society of Health-System Pharmacists.

[4]  Maribeth Slebodnik,et al.  Bar Code Technology and Medication Administration Error , 2010, Journal of patient safety.

[5]  Colleen O'Leary-Kelley,et al.  Nurses' Perceptions of Causes of Medication Errors and Barriers to Reporting , 2007, Journal of nursing care quality.

[6]  S Stradling,et al.  Errors and violations on the roads: a real distinction? , 1990, Ergonomics.

[7]  Michelle L. Rogers,et al.  Compliance With Intended Use of Bar Code Medication Administration in Acute and Long-Term Care: An Observational Study , 2006, Hum. Factors.

[8]  Judy McNulty,et al.  Methodologies for sustaining barcode medication administration compliance. A multi-disciplinary approach. , 2009, Journal of healthcare information management : JHIM.

[9]  H. Cohen,et al.  Getting to the root of medication errors. , 2008, Nursing.

[10]  Eric G Poon,et al.  Nurses' Satisfaction With Medication Administration Point-of-Care Technology , 2007, The Journal of nursing administration.

[11]  Standardizing Medication Error Event Reporting in the U.S. Department of Defense , 2005 .

[12]  T. Pape,et al.  Applying airline safety practices to medication administration. , 2003, Medsurg nursing : official journal of the Academy of Medical-Surgical Nurses.

[13]  R. Kurzweil,et al.  The Singularity Is Near: When Humans Transcend Biology , 2006 .

[14]  P. Cilliers,et al.  Complexity and post-modernism: understanding complex systems , 1999 .

[15]  Emily S. Patterson,et al.  Research Paper: Improving Patient Safety by Identifying Side Effects from Introducing Bar Coding in Medication Administration , 2002, J. Am. Medical Informatics Assoc..

[16]  Arie Hasman,et al.  Impact of BCMA on Medication Errors and Patient Safety: A Summary , 2009, Nursing Informatics.

[17]  Pascale Carayon,et al.  Evaluation of Nurse Interaction With Bar Code Medication Administration Technology in the Work Environment , 2007 .

[18]  Rhonda R Schoville,et al.  Work‐arounds and Artifacts During Transition to a Computer Physician Order Entry: What They Are and What They Mean , 2009, Journal of nursing care quality.

[19]  J. Belcher,et al.  Reporting Medication Errors Through Computerized Medication Administration , 2002, Computers, informatics, nursing : CIN.

[20]  H. Cohen.  Getting to the Root of Medication Errors , 2002, Plastic surgical nursing : official journal of the American Society of Plastic and Reconstructive Surgical Nurses.

[21]  P. Schneider,et al.  ASHP national survey of pharmacy practice in hospital settings: prescribing and transcribing--2010. , 2011, American journal of health-system pharmacy : AJHP : official journal of the American Society of Health-System Pharmacists.

[22]  Abha Agrawal,et al.  Barcode medication. Administration implementation in an acute care hospital and lessons learned. , 2009, Journal of healthcare information management : JHIM.

[23]  J. Sensmeier.  Close the loop on med errors , 2009, Nursing management.

[24]  C. Neef,et al.  Factors influencing bar-code verification by nurses during medication administration in a Dutch hospital. , 2008, American journal of health-system pharmacy : AJHP : official journal of the American Society of Health-System Pharmacists.

[25]  Thomas H. Payne,et al.  Review Paper: Medication-related Clinical Decision Support in Computerized Provider Order Entry Systems: A Review , 2007, J. Am. Medical Informatics Assoc..