Errors Related to Bar Code-Assisted Medication Administration

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.