Barcoded medication administration: a last line of defense.
Barcoding technology is recognized as a mechanism to prevent adverse drug events, but unintended consequences and workarounds have been reported after implementation. Early success with the technology also prompted its use to prevent retained surgical instruments and errors in blood transfusion, expanding on the potential for its application. This commentary discusses the background of barcoding for medication administration, reviews current experiences and benefits, and also outlines the downsides and costs. The authors do point out that, like most technologies, barcoding may lead to new problems, and careful evaluation of such systems is required. They conclude with a series of recommendations, including requirements for drug manufacturers to offer all medications in single-unit doses with barcode labeling, and legislative flexibility to keep up with evolving technologies.