Abstract
Bar code-assisted medication administration (BCMA) systems have generally been shown to improve medication administration accuracy and with the US Office of the National Coordinator (ONC’s) endorsement of the technology by including the use of automatic identification and capture technology (such as bar coding) as a requirement for Meaningful Use certification of the Electronic Health Record, the adoption of BCMA systems is skyrocketing; however, this chapter seeks to point out a few cases where the technology did not improve patient care. In fact, there are some scenarios when bar code technology has inadvertently led to medication errors. This chapter includes three cases describing scenarios where insufficient training and programmatic oversight, including pre- and post-implementation evaluation and support, led to less than optimal outcomes. Analysis and solutions including the importance of including human factors and usability principles in the software design are also discussed.
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Adams R. A short history of bar code [Internet]. Adams Communications; 2013 [updated 20 May 2013, cited 20 October 2014]. Available from: http://www.adams1.com/history.html.
Laurer G. Engineering was fun. May 2012. Published by lulu.com.
Mims E, Tucker C, Carlson R, et al. Quality-monitoring program for a bar-code-assisted medication administration. Am J Health Syst Pharm. 2009;66:1125–31.
Seibert HH, Maddox RR, Flynn EA, et al. Effect of barcode technology with electronic medication administration record on medication accuracy rates. Am J Health Syst Pharm. 2014;71(3):209–18.
Bonkowski J, Carnes C, Melucci J, et al. Effect of barcode-assisted medication administration on emergency department medication errors. Acad Emerg Med. 2013;20(8):801–6.
Szczepura A, Wild D, Nelson S. Medication administration errors for older people in long-term residential care. BMC Geriatr. 2011;11(1):82.
Poon EG, Hayes J, Churchill WW, et al. Effect of bar-code technology on the safety of medication administration. N Engl J Med. 2010;362(18):1698–707.
Helmons PJ, Wargel LN, Daniels CE. Effect of bar-code-assisted medication administration on medication administration errors and accuracy in multiple patient care areas. Am J Health Syst Pharm. 2009;66(13):1202.
DeYoung JL, Vanderkooi ME, Barletta JF. Effect of bar-code-assisted medication administration on medication error rates in an adult medical intensive care unit. Am J Health Syst Pharm. 2009;66:1110–5.
U.S. Department of Health and Human Services Food and Drug Administration. Guidance for industry: bar code label requirements questions and answers. Silver Spring, MD: Office of Communications; 2011.
United States. Medicare and Medicaid Programs: Electronic Health Record Incentive Program-Stage 2. Federal Register; 2012 Sep. Retrieved 24 October 2014 from the Internet at https://federalregister.gov/a/2012-21050.
Eisenhauer LA, Hurley AC, Dolan N. Nurses’ reported thinking during medication administration. J Nurs Scholarsh. 2007;39:82–7.
Norman DA. The design of everyday things. New York: Basic Books; 1988.
Koppel R, Wetterneck T, Telles JL, et al. Workarounds to barcode medication administration systems: their occurrences, causes, and threats to patient safety. J Am Med Inform Assoc. 2008;15(4):408–23.
Chabris CF, Simons DJ. The invisible gorilla: and other ways our intuitions deceive us. New York: Crown Publishing Group; 2010.
Holden RJ, Rivera-Rodriguez AJ, Faye H, et al. Automation and adaptation: nurses’ problem-solving behavior following the implementation of bar-coded medication administration technology. Cogn Tech Work. 2013;15(3):283–96.
Holden RJ, Brown RL, Alper SJ, et al. That’s nice, but what does IT do? Evaluating the impact of bar coded medication administration by measuring changes in the process of care. Int J Ind Ergon. 2011;41:370–9.
National Institute for Standardization and Technology. Usability. 2010 [updated March 2014, cited 22 October 2014]. Available from: http://www.nist.gov/healthcare/usability/index.cfm.
International Organization for Standardization. About ISO. Geneva, Switzerland. 2014 [cited 22 October 2014]. Available from: http://www.iso.org/iso/home/about.htm.
Grigg SJ, Garrett SK, Craig JB. A process centered analysis of medication administration: identifying current methods and potential for improvement. Int J Ind Ergon. 2011;41:380–8.
Rojas C. The informatics nurse specialist role in electronic health record usability evaluation. Comput Inform Nurs. 2014;32(5):214–20.
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Bagby, J.S. (2016). Errors Related to Bar Code-Assisted Medication Administration. In: Agrawal, A. (eds) Safety of Health IT. Springer, Cham. https://doi.org/10.1007/978-3-319-31123-4_5
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DOI: https://doi.org/10.1007/978-3-319-31123-4_5
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