Improving Patient Safety by Identifying Side Effects from Introducing Bar Coding in Medication Administration
Open accessAbstract
OBJECTIVE: In addition to providing new capabilities, the introduction of technology in complex, sociotechnical systems, such as health care and aviation, can have unanticipated side effects on technical, social, and organizational dimensions. To identify potential accidents in the making, the authors looked for side effects from a natural experiment, the implementation of bar code medication administration (BCMA), a technology designed to reduce adverse drug events (ADEs). DESIGN: Cross-sectional observational study of medication passes before (21 hours of observation of 7 nurses at 1 hospital) and after (60 hours of observation of 26 nurses at 3 hospitals) BCMA implementation. MEASUREMENTS: Detailed, handwritten field notes of targeted ethnographic observations of in situ nurse-BCMA interactions were iteratively analyzed using process tracing and five conceptual frameworks. RESULTS: Ethnographic observations distilled into 67 nurse-BCMA interactions were classified into 12 categories. We identified five negative side effects after BCMA implementation: (1) nurses confused by automated removal of medications by BCMA, (2) degraded coordination between nurses and physicians, (3) nurses dropping activities to reduce workload during busy periods, (4) increased prioritization of monitored activities during goal conflicts, and (5) decreased ability to deviate from routine sequences. CONCLUSION: These side effects might create new paths to ADEs. We recommend design revisions, modification of organizational policies, and "best practices" training that could potentially minimize or eliminate these side effects before they contribute to adverse outcomes.
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Emerging evidence suggests that health information technology may cause new patient safety concerns and other unintended consequences due to usability issues, disruptions of clinical processes, and unsafe workarounds.
“However, emerging evidence suggests that HIT may cause new patient safety concerns and other unintended consequences due to usability issues, disruptions of clinical processes, and unsafe workarounds to circumvent technology-related constraints.2–16”
From An analysis of electronic health record-related patient safety concerns (2014) · cites this paper as [8]
Technology can introduce new uncertainties and patient safety risks by disrupting established work patterns, creating new risks in practice, and encouraging workarounds.
“research suggests that technology may lead to new uncertainties and risks for patient safety through disrupting established work patterns, creating new risks in practice, and encouraging workarounds.”
From Exploring the sociotechnical intersection of patient safety and electronic health record implementation (2014) · cites this paper as [9]
Some users deviate from written BCMA-use protocols.
“What has been demonstrated is that some users deviate from written BCMA-use protocols.”
From Workarounds to Barcode Medication Administration Systems: Their Occurrences, Causes, and Threats to Patient Safety (2008) · cites this paper as [13]
Suboptimal design and implementation of BCMAs can facilitate new medication administration hazards, lead clinicians to deviate from required safe-use protocols, reduce the technology's safety benefits, and enhance the probability of medication errors.
“These data show that as with all health care technologies, 24-29 suboptimal design and implementation of BCMAs can facilitate new medication administration hazards, 13-15,30-32 lead clinicians to deviate from required safe-use protocols, reduce the technology's safety benefits, 12-15 and enhance the probability of medication errors.”
From Workarounds to Barcode Medication Administration Systems: Their Occurrences, Causes, and Threats to Patient Safety (2008) · cites this paper as [13]
Workarounds are the focus of educational campaigns and appear in the literature.
“They are the focus of educational campaigns and appear in the literature. 12-14”
From Workarounds to Barcode Medication Administration Systems: Their Occurrences, Causes, and Threats to Patient Safety (2008) · cites this paper as [13]
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- Authors
- Patterson, E. S., Cook, R. I., & Render, M. L.
- Affiliations
- University of Chicago (US)
- ORCID
- Patterson, E. S.
- Venue
- Journal of the American Medical Informatics Association
- Publisher
- Oxford University Press (OUP)
- Published
- 2002-09-01
- Volume
- 9
- Issue
- 5
- Pages
- 540-553
- ISSN
- 1067-5027 (ISSN-L)
- 1527-974X
- PMC
- PMC346641
- OpenAlex
- W2160172018
- Cited by
- 370
- References
- 36
- Citations by year
- 2026: 5 · 2025: 3 · 2024: 1 · 2023: 6 · 2022: 5 · 2021: 7 · 2020: 8 · 2019: 10 · 2018: 12 · 2017: 12 · 2016: 9 · 2015: 14 · 2014: 26 · 2013: 22 · 2012: 21
- FWCI
- 31.61
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- Journal of the American Medical Informatics Association (publishedVersion)
- Europe PMC (PubMed Central) (publishedVersion)
- PubMed Central (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Health Sciences › Health Professions › Emergency Medical Services › Patient Safety and Medication Errors
- Health Sciences › Health Professions › Health Information Management › Electronic Health Records Systems
- Health Sciences › Medicine › Surgery › Healthcare Technology and Patient Monitoring
- Keywords
- barcode medication administration, adverse drug reactions, patient safety, nursing workload, goal conflict, socio-technical systems, medication administration
- MeSH terms
- Cross-Sectional Studies, Forms and Records Control, Humans, Medication Errors, Medication Systems, Hospital, User-Computer Interface, Clinical Pharmacy Information Systems, Medical Records Systems, Computerized, Point-of-Care Systems, Drug-Related Side Effects and Adverse Reactions
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