Workarounds to barcode medication administration systems: their occurrences, causes, and threats to patient safety.
Bar coding technology is being rapidly adopted as a mechanism to prevent adverse drug events, but warnings about their unintended consequences have also been reported. This study combined direct observation, interviews, participation in a hospital's FMEA, and examining bar coding override log data to outline the frequency and causes of workarounds caused by the new technology. Investigators discovered 15 workarounds, categorized as omitted steps, steps performed out of sequence, and unauthorized steps, and then identified 31 different causes to these events. Similar to a past study, the authors conclude with recommendations that focus on improving the design, implementation, and workflow integration of bar coding systems to prevent unsafe workarounds.