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Medication Errors Occurring with the Use of Bar-Code Administration Technology

02/02/2009

Below is a very nice article on how to overcome workarounds and process improvement.

My ‘beef’ with this and many other bar code studies is that it assumes that BCMA is a good thing. This is a false assumption.

The studies and references in this paper do not support the benefit statements.

"Studies have shown that BCMA can reduce medication errors by 65% to 86%. 5,6,7 "

  • *Reference 5 is a HIMSS presentation (no peer review)
  • *Reference 6 is pure speculation piece in AJHP (no science)
  • *Reference 7 is based on reportable errors. What if folks where so busy or ticked off that they did not report errors, post implementations. The author of this reference even has communicated to me that this study was never intended to be used as evidence for showing decrease errors.

Also: "one hospital in Pennsylvania showed that the direct-observation accuracy rate before BCMA was 86.5%; after BCMA, the rate rose to 97%.8"

  • *This reference is a post study from complete manual to full eMAR and BCMA. What if 99% of the benefit was with eMAR and not bar coding?

 

Medication Errors Occurring with the Use of Bar-Code Administration Technology

Medication Errors Occurring with the Use of Bar-Code Administration Technology
Pa Patient Saf Advis 2008 Dec;5(4):122-6.

Abstract

Bar-code medication administration (BCMA) systems can improve medication safety by verifying that the right drug is being administered to the right patient. Studies have shown that BCMA technology can reduce medication errors by 65% to 86%. But BCMA technology alone does not ensure a safe medication-use system. A number of reports submitted through PA-PSRS describe medication errors that occurred in organizations that used a bar-code system for administration. Some of these errors result from failures to use this technology appropriately, employing workarounds or overriding alerts, disruptions in the medication administration process, and dispensing errors that arise in the pharmacy. Strategies to address problems with this technology include reviewing BCMA logs to evaluate overrides and identify system weaknesses and monitoring and measuring compliance with the technology to identify and remove any barriers to its appropriate use.

A prospective cohort study of medication errors by Leape et al.1 determined that 39% of errors occurred during the prescribing phase, 12% during transcription, 11% during dispensing, and 38% during administration. Close to half of the errors that occurred during the prescribing phase were intercepted before they reached the patient; in contrast, only 2% of errors that occurred during the administration phase were intercepted. Another study using direct observation in 36 healthcare facilities found that medication administration errors occurred in almost 20% of doses administered.2 Data from U.S. Pharmacopeia’s (USP’s) medication error reporting database, MEDMARX®, indicates that an error at the point of administration is least likely to be intercepted before reaching the patient, compared to other phases of the medication-use process.3

One form of technology that may address administration errors is a bar-code medication administration (BCMA) system. BCMA c…

[Pharmacoinformatics Feed From Poikonen’s Evernote]

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