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ISMP Medication Safety Alert! Acute Care Edition. October 19, 2017;22:1-3.
Barcodes can both enhance and degrade the medication administration process. This newsletter article provides examples of problems associated with the use of barcode labels and recommends strategies to reduce risks.
Safety enhancements every hospital must consider in wake of another tragic neuromuscular blocker event.
ISMP Medication Safety Alert! Acute Care Edition. January 17, 2019;24.
Perioperative medication errors: uncovering risk from behind the drapes.
Cierniak KH, Gaunt MJ, Grissinger M. PA-PSRS. Patient Saf Advis. 2018;15(4).
Electronic patient identification for sample labeling reduces wrong blood in tube errors.
Kaufman RM, Dinh A, Cohn CS, et al; BEST Collaborative. Transfusion. 2019;59:972-980.
Implementation of bar-code medication administration to reduce patient harm.
Thompson KM, Swanson KM, Cox DL, et al. Mayo Clin Proc Innov Qual Outcomes. 2018;2:342-351.
Wrong-patient blood transfusion error: leveraging technology to overcome human error in intraoperative blood component administration.
Hensley NB, Koch CG, Pronovost PJ, et al. Jt Comm J Qual Patient Saf. 2019;45:190-198.
Development and implementation of a subcutaneous insulin pen label bar code scanning protocol to prevent wrong-patient insulin pen errors.
MacMaster HW, Gonzalez S, Maruoka A, et al. Jt Comm J Qual Patient Saf. 2018 Sep 26; [Epub ahead of print].
Preventing medication errors in the information age.
Godshall M, Riehl M. Nursing. 2018;48:56-58.
Near-miss event analysis enhances the barcode medication administration process.
Magee MC, Miller K, Patzek D, Madera C, Michalek C, Shetterly M. PA-PSRS Patient Saf Advis. December 2017;14.
Maximize benefits of IV workflow management systems by addressing workarounds and errors.
ISMP Medication Safety Alert! Acute Care Edition. September 7, 2017;22:1-4.
Association between workarounds and medication administration errors in bar-code-assisted medication administration in hospitals.
van der Veen W, van den Bemt PMLA, Wouters H, et al; BCMA Study Group. J Am Med Inform Assoc. 2018;25:385-392.
Factors associated with barcode medication administration technology that contribute to patient safety: an integrative review.
Strudwick G, Reisdorfer E, Warnock C, et al. J Nurs Care Qual. 2018;33:79-85.
The effects of bar-coding technology on medication errors: a systematic literature review.
Hutton K, Ding Q, Wellman G. J Patient Saf. 2017 Feb 24; [Epub ahead of print].
Medication safety in the operating room: literature and expert-based recommendations.
Wahr JA, Abernathy JH III, Lazarra EH, et al. Br J Anaesth. 2017;118:32-43.
Provider risk factors for medication administration error alerts: analyses of a large-scale closed-loop medication administration system using RFID and barcode.
Hwang Y, Yoon D, Ahn EK, Hwang H, Park RW. Pharmacoepidemiol Drug Saf. 2016;25:1387-1396.
The role of radio frequency detection system embedded surgical sponges in preventing retained surgical sponges: a prospective evaluation in patients undergoing emergency surgery.
Inaba K, Okoye O, Aksoy H, et al. Ann Surg. 2016;264:599-604.
Effect of the implementation of barcode technology and an electronic medication administration record on adverse drug events.
Truitt E, Thompson R, Blazey-Martin D, NiSai D, Salem D. Hosp Pharm. 2016;51:474-483.
Comparison of barcode scanning by pharmacy technicians and pharmacists' visual checks for final product verification.
Wang BN, Brummond P, Stevenson JG. Am J Health Syst Pharm. 2016;73:69-75.
Creating a culture of safety around bar-code medication administration: an evidence-based evaluation framework.
Kelly K, Harrington L, Matos P, Turner B, Johnson C. J Nurs Adm. 2016;46:30-37.
Comparison of medication safety systems in critical access hospitals: combined analysis of two studies.
Cochran GL, Barrett RS, Horn SD. Am J Health Syst Pharm. 2016;73:1167-1173.
Patient Safety Supplement.
Middleton J, ed. Nursing Times and Health Service Journal. July 2015:s1-s20.
Preparing challenging medications for barcode scanning.
Waxlax TJ. Am J Health Syst Pharm. 2015;72:1089-1090.
A safe practice standard for barcode technology.
Leung AA, Denham CR, Gandhi TK, et al. J Patient Saf. 2015;11:89-99.
Using Lean "automation with a human touch" to improve medication safety: a step closer to the "perfect dose."
Ching JM, Williams BL, Idemoto LM, Blackmore CC. Jt Comm J Qual Patient Saf. 2014;40:341-350.
Comparison of medication safety effectiveness among nine critical access hospitals.
Cochran GL, Haynatzki G. Am J Health Syst Pharm. 2013;70:2218-2224.
Medication administration errors for older people in long-term residential care.
Szczepura A, Wild D, Nelson S. BMC Geriatr. 2011;11:82.
PSNET: Patient Safety Network
PSNet is produced for the Agency for Healthcare Research and Quality by a team of editors at the University of California, San Francisco with guidance from a prominent Technical Expert/Advisory Panel. The AHRQ PSNet site was designed and implemented by Silverchair.
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