Barcode medication administration (BCMA) is a mechanism to prevent adverse medication events, but unintended consequences have also been reported when BCMA is not used appropriately. Researchers observed nurses administering medications and identified task-related, organizational, technological, environmental, and nurse-related BCMA policy deviations. Researchers provide several strategies for hospitals wishing to implement or improve BCMA systems.

… factors including nurse workload and nurse staffing . … Van der Veen W, Taxis K, Wouters H, Vermeulen H, Bates DW, van den Bemt P. Factors associated with workarounds in …

Dispensing errors are a common source of preventable adverse events in community pharmacies. Dutch investigators evaluated the effectiveness of an electronic system in reducing drug name confusion among similar medications. Users found the system was helpful for preventing dispensing errors and did not feel it contributed substantially to alert fatigue.

Workarounds occur frequently in health care and can compromise patient safety. In this prospective study, researchers observed 5793 medication administrations to 1230 inpatients in Dutch hospitals using barcode-assisted medication administration (BCMA). Workarounds occurred in about two-thirds of medication administrations. They found a significant association between workarounds and medication administration errors. The most frequently observed medication administration errors included omissions, administration of drugs not actually ordered, and dosing errors. The authors suggest that BMCA merits further evaluation to ensure that implementation of this technology promotes safety effectively. A past PSNet perspective discussed workarounds on the front line of health care.

Medication errors are common and particularly dangerous when they involve chemotherapy. Investigators surveyed Swiss oncology nurses about double-checking medications before administration, a widely practiced strategy. Most nurses endorsed double-checking as an effective safety tool, despite the fact that double-checking promotes workflow interruptions, is labor intensive, and is less effective than automated barcode scanning.

Not all pill-form medications can be safely crushed to administer to patients who have difficulty swallowing. In this before and after intervention study in a nursing home, adding warning symbols and educating staff about crushing medications led to a decrease in pill-crushing errors. The authors conclude that education and warnings enhanced this aspect of medication safety.

Chemotherapy medications can cause severe patient harm if incorrectly dosed or administered. This cross-sectional survey of oncology nurses revealed that most chemotherapy double-checking is conducted jointly rather than independently. Of note, many nurses reported being interrupted to engage in a double-check.

An educational program that included lectures, ward-based teaching sessions, and protocols significantly decreased the rate of intravenous medication errors in an intensive care unit in Vietnam. However, clinically significant errors still occurred in nearly half of all medication administrations (down from 64% pre-intervention).

More than half of hospitalized patients in this Dutch study experienced an adverse drug event, most of which were not preventable and had minimal clinical consequences.

This study noted no significant difference in medication administration errors regardless of whether medication cart filling methods were dictated by medication name or round time.

This study describes the development of decision support algorithms designed to prevent prescribing errors within a computerized provider order entry system. The decision support system was developed and tested in comparison to errors identified by a trained pharmacist.

A decision support system combined with computerized provider order entry significantly reduced incorrect prescriptions, but the incidence of clinical adverse drug events was unchanged.

Although most inpatient adverse drug events are considered preventable, this study found that independent reviewers reached only fair agreement regarding the preventability of individual errors.