Bar-code verification: reducing but not eliminating medication errors.

Philip L. Henneman; Jenna Marquard; Donald L. Fisher; Justin Bleil; Brendan Walsh; Justin P. Henneman; Fidela S. Blank; Ann Marie Higgins; Brian H. Nathanson; Elizabeth A. Henneman

Study

Bar-code verification: reducing but not eliminating medication errors.

December 12, 2012

Henneman PL, Marquard J, Fisher DL, et al. J Nurs Adm. 2012;42(12):562-6.

View more articles from the same authors.

This simulation study identified several mechanisms by which medication errors could occur even when a bar-code medication administration system was used. These included patient identification errors and failure to heed computerized warnings.

PubMed citation

Available at

Related Resources From the Same Author(s)

Nurses' behaviors and visual scanning patterns may reduce patient identification errors.

October 12, 2011

Strategies used by nurses to recover medical errors in an academic emergency department setting.

June 14, 2006

Emergency department medication lists are not accurate.

November 12, 2008

Testing a classification model for emergency department errors.

June 28, 2006

Strategies used by critical care nurses to identify, interrupt, and correct medical errors.

November 17, 2010

Development and implementation of a patient safety program in an academic, urban emergency department.

December 13, 2006

Voluntarily reported emergency department errors.

November 30, 2005

An evaluation of a collaborative, safety focused, nurse–pharmacist intervention for improving the accuracy of the medication history.

November 20, 2013

Pharmacy–nursing intervention to improve accuracy and completeness of medication histories.

April 28, 2010

Improving patient safety in the ED waiting room.

August 8, 2007

Increasing patient safety and efficiency in transfusion therapy using formal process definitions.

January 10, 2007

Recognizing the ordinary as extraordinary: insight into the "way we work" to improve patient safety outcomes.

August 2, 2017

Patient safety and technology.

May 20, 2009

Unreported errors in the intensive care unit: a case study of the way we work.

November 14, 2007

Delays and errors in cardiopulmonary resuscitation and defibrillation by pediatric residents during simulated cardiopulmonary arrests.

October 14, 2009

Using clinical simulation to teach patient safety in an acute/critical care nursing course.

August 3, 2005

Human patient simulation: teaching students to provide safe care.

September 26, 2007

Communication through the electronic health record: frequency and implications of free text orders.

July 29, 2020

A "back to basics" approach to reduce ED medication errors.

April 20, 2011

Clinical practice guideline: safe medication use in the ICU.

August 30, 2017

Parent willingness to remind health care workers to perform hand hygiene.

August 14, 2013

Avoiding the unintended consequences of growth in medical care: how might more be worse?

March 6, 2005

Free-text computerized provider order entry orders used as workaround for communicating medication information.

August 31, 2022

Development of a checklist for documenting team and collaborative behaviors during multidisciplinary bedside rounds.

June 12, 2013

Surveillance: a strategy for improving patient safety in acute and critical care units.

April 18, 2012

Association of rapid response teams with hospital mortality in Medicare patients.

October 19, 2022

Nurse decision making in the prearrest period.

January 6, 2010

Contemporary evidence about hospital strategies for reducing 30-day readmissions: a national study.

November 7, 2012

An evaluation of shared mental models and mutual trust on general medical units: implications for collaboration, teamwork, and patient safety.

November 29, 2017

Using information technology to improve the quality and safety of emergency care.

July 6, 2011

Intensive care unit readmissions in U.S. hospitals: patient characteristics, risk factors, and outcomes.

October 12, 2011

Specimen labeling errors: a Q-probes analysis of 147 clinical laboratories.

November 12, 2008

Assessment of unintentional duplicate orders by emergency department clinicians before and after implementation of a visual aid in the electronic health record ordering system.

January 22, 2020

Medical errors arising from outsourcing laboratory and radiology services.

September 19, 2007

Simulation of in-hospital pediatric medical emergencies and cardiopulmonary arrests: highlighting the importance of the first 5 minutes.

January 16, 2008

Influencing organisational culture to improve hospital performance in care of patients with acute myocardial infarction: a mixed-methods intervention study.

November 22, 2017

High-reliability emergency response teams in the hospital: improving quality and safety using in situ simulation training.

May 1, 2013

Association of hospital participation in a regional trauma quality improvement collaborative with patient outcomes.

June 20, 2018

Guided reflection interventions show no effect on diagnostic accuracy in medical students.

March 20, 2019

Physician engagement in malpractice risk reduction: a UPHS case study.

August 29, 2018

Simulation-based education to train learners to "speak up" in the clinical environment: results of a randomized trial.

December 12, 2018

Realistic distractions and interruptions that impair simulated surgical performance by novice surgeons.

July 25, 2012

Promoting patient safety using an early warning scoring system.

August 27, 2008

Preparing clinicians for transitioning patients across care settings and into the home through simulation.

July 25, 2018

Triggers, bundles, protocols, and checklists—what every maternal care provider needs to know.

April 13, 2016

Significant and sustained reduction in chemotherapy errors through improvement science.

April 5, 2017

Patient safety in North America: beyond "operate through your initials" and "sign your site."

June 24, 2009

Direct observation approach for detecting medication errors and adverse drug events in a pediatric intensive care unit.

April 4, 2007

The disclosure dilemma—large-scale adverse events.

September 8, 2010

Elopement: evidence-based mitigation and management.

October 18, 2023

Association of hospital employee satisfaction with patient safety and satisfaction within Veterans Affairs medical centers.

April 3, 2019

Meaningful use's benefits and burdens for US family physicians.

May 30, 2018

American College of Surgeons and Surgical Infection Society: Surgical Site Infection Guidelines, 2016 Update.

February 1, 2017

Patterns of medical and nursing staff communication in nursing homes: implications and insights from complexity science.

February 8, 2006

Should operations be regionalized? The empirical relation between surgical volume and mortality.

March 6, 2005

Philosophy of science and the diagnostic process.

July 17, 2013

Listen carefully: the risk of error in spoken medication orders.

April 14, 2010

A new tool to give hospitalists feedback to improve interprofessional teamwork and advance patient care.

November 28, 2012

Test-retest reliability of an experienced Global Trigger Tool review team.

October 27, 2021

AHRQ's Hospital Survey on Patient Safety Culture: psychometric analyses.

October 21, 2009

Pharmacists' interventions in prescribing errors at hospital discharge: an observational study in the context of an electronic prescribing system in a UK teaching hospital.

November 3, 2010

Patient handoffs: is cross cover or night shift better?

May 31, 2017

Quantifying and characterizing adverse events in dermatologic surgery.

May 15, 2013

Dual-process cognitive interventions to enhance diagnostic reasoning: a systematic review.

April 13, 2016

An IDEA: safety training to improve critical thinking by individuals and teams.

April 10, 2019

The Daily Goals Communication Sheet: a simple and novel tool for improved communication and care.

October 8, 2008

What causes near-misses and how are they mitigated?

June 5, 2013

Adoption of technology to improve medication safety: perspectives of pharmacy directors.

January 10, 2007

Medication errors among adults and children with cancer in the outpatient setting.

January 14, 2009

How structural racism works - racist policies as a root cause of U.S. racial health inequities.

December 17, 2020

Handoffs and teamwork: a framework for care transition communication.

June 29, 2022

Reducing the rate of catheter-associated bloodstream infections in a surgical intensive care unit using the Institute for Healthcare Improvement Central Line Bundle.

August 20, 2014

Family-initiated dialogue about medications during family-centered rounds.

February 11, 2015

Transition planning for the senior surgeon: guidance and recommendations from the Society of Surgical Chairs.

May 29, 2019

The impact of dedicated medication nurses on the medication administration error rate: a randomized controlled trial.

March 27, 2005

Alternatives to potentially inappropriate medications for use in e-prescribing software: triggers and treatment algorithms.

July 20, 2011

Wrong-site nerve blocks: a systematic literature review to guide principles for prevention.

August 8, 2018

Family-centered rounds on pediatric wards: a PRIS network survey of US and Canadian hospitalists.

July 14, 2010

Making care better in the pediatric intensive care unit.

January 30, 2019

'Care left undone' during nursing shifts: associations with workload and perceived quality of care.

August 14, 2013

Nursing resources and patient outcomes in intensive care: a systematic review of the literature.

November 14, 2007

The impact of traditional and smart pump infusion technology on nurse medication administration performance in a simulated inpatient unit.

May 26, 2010

Improving teamwork on general medical units: when teams do not work face-to-face.

October 3, 2012

Older adults' awareness of deprescribing: a population-based survey.

February 28, 2018

Automated and electronically assisted hand hygiene monitoring systems: a systematic review.

June 18, 2014

Medication errors in HIV-infected hospitalized patients: a pharmacist's impact.

July 10, 2013

Reducing central line–associated bloodstream infections in North Carolina NICUs.

February 26, 2014

Team working in intensive care: current evidence and future endeavors.

September 15, 2010

High performance teamwork training and systems redesign in outpatient oncology.

April 3, 2013

Modification of potentially inappropriate prescribing following fall-related hospitalizations in older adults.

July 10, 2019

Organisational learning in hospitals: a concept analysis.

June 19, 2019

The RCA ReCAst: a root cause analysis simulation for the interprofessional clinical learning environment.

July 14, 2021

Cost of inpatient falls and cost-benefit analysis of implementation of an evidence-based fall prevention program.

February 1, 2023

Physician Quality Officer: a new model for engaging physicians in quality improvement.

June 24, 2009

Parents as partners in obtaining the medication history.

June 29, 2005

How guiding coalitions promote positive culture change in hospitals: a longitudinal mixed methods interventional study.

November 15, 2017

A literature review of the individual and systems factors that contribute to medication errors in nursing practice.

September 16, 2009

Is it time for safeguards in the adoption of robotic surgery?

May 15, 2019

Rural hospital nursing: better environments = shared vision and quality/safety engagement.

April 29, 2009

Inappropriate preinjury warfarin use in trauma patients: a call for a safety initiative.

May 18, 2016

Related Resources

Medication safety amid technological change: usability evaluation to inform inpatient nurses' electronic health record system transition.

October 25, 2023

Improving safety outcomes through medical error reduction via virtual reality-based clinical skills training.

June 21, 2023

"Are we there yet?" Ten persistent hazards and inefficiencies with the use of medication administration technology from the perspective of practicing nurses.

March 22, 2023

Improving administration and documentation of enteral nutrition support therapy in a Veteran Affairs health care system: use of medication administration record and bar code scanning technology.

February 1, 2023

Barcode medication administration software technology use in the emergency department and medication error rates.

August 31, 2022

Real-world virtual patient simulation to improve diagnostic performance through deliberate practice: a prospective quasi-experimental study.

December 15, 2021

Association of simulation training with rates of medical malpractice claims among obstetrician-gynecologists.

October 13, 2021

Barcode medication administration technology use in hospital practice: a mixed-methods observational study of policy deviations.

August 4, 2021

Computer-based simulation to reduce EHR-related chemotherapy ordering errors.

November 18, 2020

Impact of interoperability of smart infusion pumps and an electronic medical record in critical care.

September 23, 2020

An examination of medical malpractice claims involving physician trainees.

August 19, 2020

User-testing guidelines to improve the safety of intravenous medicines administration: a randomised in situ simulation study.

July 29, 2020

Identifying safety hazards associated with intravenous vancomycin through the analysis of patient safety event reports.

April 15, 2020

Simulation-based event analysis improves error discovery and generates improved strategies for error prevention.

July 24, 2019

Electronic patient identification for sample labeling reduces wrong blood in tube errors.

March 20, 2019

Implementation of bar-code medication administration to reduce patient harm.

February 20, 2019

Development and implementation of a subcutaneous insulin pen label bar code scanning protocol to prevent wrong-patient insulin pen errors.

November 21, 2018

Association between workarounds and medication administration errors in bar-code-assisted medication administration in hospitals.

April 25, 2018

Safety with nebulized medications requires an interdisciplinary team approach.

March 7, 2018

Near-miss event analysis enhances the barcode medication administration process.

January 17, 2018

Maximize benefits of IV workflow management systems by addressing workarounds and errors.

September 20, 2017

Factors associated with barcode medication administration technology that contribute to patient safety: an integrative review.

July 26, 2017

Provider risk factors for medication administration error alerts: analyses of a large-scale closed-loop medication administration system using RFID and barcode.

October 5, 2016

Effect of the implementation of barcode technology and an electronic medication administration record on adverse drug events.

August 10, 2016

Nurse interrupted: development of a realistic medication administration simulation for undergraduate nurses.

August 26, 2015

Can medical students identify a potentially serious acetaminophen dosing error in a simulated encounter? A case control study.

April 15, 2015

Analysis of medication errors in simulated pediatric resuscitation by residents.

October 1, 2014

Pediatric medication administration errors and workflow following implementation of a bar code medication administration system.

August 6, 2014

Using Lean "automation with a human touch" to improve medication safety: a step closer to the "perfect dose."

July 30, 2014

Errors and error-producing conditions during a simulated, prehospital, pediatric cardiopulmonary arrest.

June 11, 2014

See More About The Topic

Hospitals

Risk Managers

Information Professionals

Educators

General Internal Medicine

Bar-code verification: reducing but not eliminating medication errors.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Bar-code verification: reducing but not eliminating medication errors.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Submit Your Innovations

Continue as a Guest

Continue Logged In

Submit Your Innovations

Continue as a Guest

Continue logged in

New Users to the PSNet site