PRACTICE REPORTS  Barcode technology

PRACTICE REPORTS

Effect of barcode technology

with electronic medication administration
record on medication accuracy rates
Heather H. Seibert, Ray R. Maddox, Elizabeth A. Flynn, and Carolyn K. Williams

M
edication errors and con-
sequent deaths continue to
escalate, costing health care
systems billions of dollars each year.1
It is estimated that at least 1 medica-
tion error occurs per day per hospi-
talized patient. An estimated 450,000
adverse drug events—medication
errors that result in patient harm—
occur annually, approximately 25%
of which are preventable.2
Various technologies have been
introduced to help improve the ac-
curacy of medication administration,
including automated dispensing cab-
inets, computerized prescriber order
entry (CPOE), “smart” (computer-
ized) i.v. infusion pumps, barcode-
assisted medication administration
(BCMA) systems, electronic medica-
tion administration records (eMARs),
and wireless connectivity and inte-
gration with hospital information
technology. A recent report on the
adoption rates of medication-safety
technologies revealed that health
care organizations have implemented
smart pumps more than other tech-
nologies.3 BCMA is the second most
Purpose. The effect of barcode-assisted
medication administration (BCMA) with
electronic medication administration
record (eMAR) technology on the occur-
rence of medication administration errors
was evaluated.
Methods. A pretest–posttest nonequiva-
lent comparison group was used to in-
vestigate the effect of BCMA-eMAR on
the medication administration accuracy
rates at two community-based hospitals.
Patient care units included three matched
pairs in the two hospitals—two medical–
surgical, two telemetry, and two rehabilita-
tion units—plus a medical–surgical inten-
sive care unit, an emergency department,
and both an inpatient oncology unit and
an outpatient oncology service at one of
the hospitals. Medication administration
accuracy rates were observed and recorded
before (phase 1) and approximately 6 and
12 months after (phases 2 and 3, respec-
tively) the implementation of BCMA-eMAR.
Results. The overall accuracy rate at hos-
pital 1 increased significantly from phase
1 (89%) to phase 3 (90%) (p = 0.0015); if
commonly implemented technol-
ogy, followed by CPOE with deci-
sion support.
wrong-time errors are excluded, the accu-
racy rate improved from 92% in phase 1 to
96% in phase 3 (p = 0.000008). The overall
accuracy rate did not change significantly
from phase 1 to phase 3 at hospital 2; when
wrong-time errors were excluded from
consideration, the accuracy rate improved
from 93% in phase 1 to 96% in phase 3
(p = 0.015).
Conclusion. Implementation of BCMA-
eMAR in two hospitals was associated with
significant increases in total medication
accuracy rates in most study units and did
not introduce new types of error into the
medication administration process. Accu-
racy rates further improved when wrong-
time errors were excluded from analysis.
The frequency of errors preventable by
BCMA-eMAR decreased significantly in
both hospitals after implementation of that
technology. BCMA-eMAR and direct obser-
vation were more effective than voluntary
reporting programs at intercepting and
recording errors and preventing them from
reaching patients.
Am J Health-Syst Pharm. 2014; 71:209-18
Medication errors can be identi-
fied and quantified through at least
four different processes. The most

Heather H. Seibert, Pharm.D., M.B.A., is Manager and Clinical
Pharmacy Specialist, Centers for Medication Management; and
Ray R. Maddox, Pharm.D., FASHP, is Director, Clinical Pharmacy,
Research and Pulmonary Medicine, St. Joseph’s/Candler Health
System, Savannah, GA. Elizabeth A. Flynn, Ph.D., is Independent
Research Consultant, Artesia, NM. Carolyn Williams, B.S.Pharm.,
is Medication Safety Specialist, Clinical Pharmacy, St. Joseph’s/
Candler Health System.
Address correspondence to Dr. Seibert (hugenerh@sjchs.org).
The authors have declared no potential conflicts of interest.
Copyright © 2014, American Society of Health-System Pharma-
cists, Inc. All rights reserved. 1079-2082/14/0201-0209$06.00.
DOI 10.2146/ajhp130332

Am J Health-Syst Pharm—Vol 71 Feb 1, 2014 209

 PRACTICE REPORTS  Barcode technology
common way of identifying a medi-
cation error is through the volun-
tary reporting of events recognized
during the medication-use process
by clinicians caring for the patient.
However, this method vastly under-
reports the number, frequency, and
outcomes of medication errors. 4
Other commonly used methods in-
volve computerized monitoring and
manual chart review, though com-
puterized monitoring may identify
fewer errors than chart surveillance.5
A more-thorough method of iden-
tifying medication errors is direct
observation of medication adminis-
tration by caregivers in patient care
areas. Direct observation is resource
intensive and seldom used but is
recognized as the gold standard of
identifying and documenting medi-
cation errors.4 Lastly, data from vari-
ous medication-safety technologies
(smart pumps, BCMA, CPOE) that
intervene and prevent errors from
occurring present a picture of the
“potential” medication error rate in
health systems where these technolo-
gies are deployed.6-8
Studies have shown that the per-
centage of medication misadventures
attributable to errors in drug admin-
istration ranges from 2.4% to 11.1%
but may be as high as 34–49%, ac-
cording to some international evalu-
ations.9 Few of these errors are inter-
cepted before reaching the patient.
For this reason, the use of BCMA to
help improve the accuracy of medi-
cation administration at the point of
care has seemed particularly promis-
ing. However, the implementation of
BCMA has proved challenging, with
fewer than half of nonfederal hospi-
tals having adopted this technology.3
Published research substantiating
the efficacy of BCMA in decreasing
the frequency of medication er-
rors is limited.8,10-15 An Institute of
Medicine (IOM) report cited a lack
of solid evidence demonstrating the
effect of technology on medication
errors. 1 The IOM Committee on
Identifying and Preventing Medication
210 Am J Health-Syst Pharm—Vol 71 Feb 1, 2014
Errors recognized the potential value
of bedside BCMA verification but
noted that data from observational
studies of medication administration
are needed.1 There is also a need for
evidence comparing the accuracy of
such electronic systems to the recog-
nized gold-standard error-detection
method (direct observation).4
This study evaluated the effects of
a BCMA-eMAR system on the rate
of medication administration errors
in both regular and special care units
in two community, nonteaching hos-
pitals and analyzed the differences in
event rates from voluntary reporting,
interventions caught by BCMA tech-
nology, and interventions identified
through direct observation.
Methods
Setting. St. Joseph’s/Candler
Health System comprises two tertiary
care, community hospitals totaling
644 beds, with an annual patient
volume of 22,807. The hospital staff
includes 455 community-based, pri-
vate practice physicians, 1,245 nurs-
es, and 53 pharmacists. Although
most patients in these hospitals are
adults, one hospital is a high-volume
provider of obstetric services.
Technology used for BCMA-
eMAR. At the time of BCMA-eMAR
implementation, the health system
used health information technol-
ogy that was integrated across both
hospitals (Meditech Magic 5.61,
Westwood, MA). During the course
of the BCMA-eMAR implementa-
tion, an upgrade to a higher version
of the software (Magic 5.64) was
completed, but no significant chang-
es to the BCMA-eMAR component
were made.
Mobile medication carts with
thin client computers and tethered
scanners were initially provided for
each staff member who administered
medications. Within a few months,
the tethered scanners were replaced
with wireless scanners. Shortly after
the system went live, the decision
was made to install inroom terminals
with wireless scanners in the criti-
cal care areas and negative-pressure
isolation rooms. The change in
hardware resulted in significant im-
provements in staff acceptance, the
scanning rate, and system use.
BCMA-eMAR implementation.
In 2006, the medication safety team
evaluated the state of BCMA tech-
nology at both hospitals, completed
the American Hospital Association
(AHA) and Institute for Safe Medica-
tion Practices (ISMP) Readiness Plan
for BCMA,16 and identified infra-
structure improvements that would
be needed before implementation
could proceed. Improvements iden-
tified as a result of the AHA/ISMP
assessment included the need for
all medications to have a machine-
readable barcode, new patient wrist-
bands that contain machine-readable
barcodes, significant changes in the
computer database, and equipment
and training for pharmacy, nursing,
and respiratory staff. Completion of
the project was divided over three
years, allowing the health system to
spread the cost of equipment over
several budget cycles.
Implementation of BCMA-eMAR
began in fall 2007. Before the
BCMA-eMAR system went live, the
decision was made to conduct a
research study on implementation
to assess whether medication errors
were prevented or new errors were
introduced through the implementa-
tion of the BCMA-eMAR system.
Data collection. A pretest–posttest
nonequivalent comparison group
design was used to investigate the
effect of BCMA used in conjunction
with an eMAR on the rate of medica-
tion administration errors. Observa-
tions of medication administration
errors were made before (phase 1)
and approximately 6 and 12 months
after (phases 2 and 3, respectively)
implementation of the BCMA-eMAR
system. Postimplementation data
were collected via direct observation
after the study unit staff were fully
trained, the system was operational

for at least 6 months, and study
unit nurses achieved an electronic
scanning rate of at least 80%. Post-
implementation data were not col-
lected at the same time for all study
units. Study units were reevaluated
approximately 12 months after
BCMA-eMAR implementation.
The study population comprised
randomly observed nurses who ad-
ministered at least one medication to
adult patients on the selected units
during the observation times. Nurse
subjects were those working in the
selected patient care units when
observation occurred. In order to
maintain nurse confidentiality and
due to the complexity of trying to
collect sufficient doses, no attempt
was made to match the preimple-
mentation and postimplementation
observations for individual nurses.
Instead, observations were made by
patient care unit.
To facilitate extrapolation of the
results to other institutions, data
were collected on patient care units
that had a diversified adult patient
population to whom a wide variety
of medications was administered.
Patient care units were selected
for study inclusion if their use of a
medication distribution system was
deemed either typical (i.e., similar to
like units in other hospitals, such as
internal medicine and critical care)
or included special interest units (i.e.,
emergency department and outpa-
tient chemotherapy infusion center).
Patient care units included three
matched pairs in the two hospitals—
two medical–surgical, two telemetry,
and two rehabilitation units—plus a
medical–surgical intensive care unit
(ICU), an emergency department,
and both an inpatient oncology unit
and outpatient oncology service at
one of the hospitals.
Investigators estimated the sample
size (number of doses to be observed)
needed to achieve 90% confidence
that the true medication administra-
tion error rate was being measured.
Based on similar studies,17 a 10%
PRACTICE REPORTS  Barcode technology
medication administration error rate
was used to estimate the sample size
needed for 90% confidence.
The direct observation method
of Barker et al.18 was used to collect
data. Direct observation is a scientifi-
cally validated technique for measur-
ing medication errors and provides
an accurate description of how many
errors occur and insight into how er-
rors may be prevented. This method
of collecting errors is nonjudgmental
and nonpunitive.
Errors were documented and
tabulated in the AU MEDS system
(MedAccuracy LLC, Lenexa, KS).
This system is a nationally standard-
ized method for monitoring medica-
tion error rates based on the direct
observation of nurses preparing and
administering medications.19 Data
were collected by 15 licensed health
care professionals (7 pharmacists, 8
nurses) and the research pharma-
cist, all of whom were employed by
the health system. These individuals
were certified medication observers
trained by the AU MEDS specialist.
Observers witnessed nurses in the
selected units providing standard
patient care; observers did not inter-
fere with any activities and were not
involved with patient care in any way.
On the other hand, if at any time an
error could potentially result in pa-
tient harm, the research pharmacist
intervened as discreetly as possible to
correct the issue.
The observer introduced the study
to the nurses, recorded drug prepara-
tion and administration, reviewed
the original medication orders, and
compared the orders with what was
administered to determine if any er-
rors occurred. Observers’ notes were
reconciled with the original physi-
cians’ orders to identify any discrep-
ancies between what was written and
what was observed.
Discrepancies were classified by
the type of error that had occurred:
wrong time, wrong route, wrong
technique, omission, wrong form,
extra dose, and unauthorized drug.
Am J Health-Syst Pharm—Vol 71 Feb 1, 2014
These error types are defined in the
appendix. All doses observed during
the study period were entered into
the AU MEDS software program for
analysis. Data collected by all observ-
ers were maintained in a secure mas-
ter database.
Observers did not count doses as
opportunities for error if a drug was
left at the patient’s bedside for self-
administration and the administra-
tion was not actually witnessed by
the observer, if a dose was associated
with an uninterpretable written or-
der, or if the observer did not witness
the entire process of administration.
Any deviation between the order and
what was observed was recorded as
an error. After examining all doses
witnessed, the observer tallied all
omitted doses. The medication
administration error rate was calcu-
lated by dividing the number of ob-
served errors by the sum of all doses
witnessed and all omitted doses.
Definition of terms. A medication
administration error was any discrep-
ancy between a prescriber’s interpre-
table medication order and what was
administered to a patient. Drug ad-
ministration more than 60 minutes
before or after the scheduled time
was considered a wrong-time error.
For routine doses, the administra-
tion schedule listed in each hospital’s
medication administration record
was used to determine whether a
dose was administered within the ac-
ceptable time frame.
Target errors were errors that
should have been prevented by the
BCMA system—wrong dose, wrong
form, extra dose, unauthorized drug,
and omission.
An opportunity for error is a mea-
sure used as the basic unit of data
in observational error studies.10 In
this study, opportunity for error was
defined as any dose that was ordered
and either administered or omitted.
Any administered dose was desig-
nated as either correct or incorrect
(error or no error), which meant the
error rate could not exceed 100%.
211
 PRACTICE REPORTS  Barcode technology
The total opportunities for error
was the combined total of the num-
ber of doses given plus the number of
omissions.
Total errors was defined as the
total of all errors that were observed,
including omission, unauthorized
drug, extra dose, and wrong route,
form, technique, dose, or time.
Accuracy rate was the percentage
of doses administered correctly and
calculated as follows: (total opportu-
nities for error – total errors)/(total
opportunities for error × 100).
Observed doses were those for
which the observer witnessed both
nursing preparation (e.g., drawing
up medication from vial) and ad-
ministration of the medication to the
patient.10
Electronic scanning was the proc-
ess of using an electronic device to
read a medication barcode and inter-
pret data using software to validate
medication accuracy against defined
information such as patient identi-
fication, medication identification,
and medication strength while docu-
menting the actual administration
and defined variables such as nurse
name, date, and time.
An averted event was defined as a
near-miss event, meaning that an er-
ror occurred but was intercepted, pre-
venting it from reaching the patient.
Data analysis. Observer reports
were reviewed by the research phar-
macist to ensure that error defini-
tions had been applied accurately.
Any questionable error was discussed
by the observer and the research
pharmacist or with the AU MEDS
specialist to determine if the error
was actually an error and the issue
was resolved. Data from the emer-
gency department and outpatient
oncology unit of hospital 1 were
not included in the calculation of
changes in target errors because of
important differences between these
and other units in the drug distribu-
tion system.
Chi-square analysis with Yates
correction was used to compare
212 Am J Health-Syst Pharm—Vol 71 Feb 1, 2014
phases 1 and 3 to determine whether
the BCMA-eMAR system was as-
sociated with accurate medication
administration in each patient care
unit.
The a priori level of significance
was 0.05. The level of power achieved
was calculated, with a goal of 0.80;
small-effect sample size20 was used
to conservatively assess the effect of
the BCMA-eMAR system. Confi-
dence intervals were calculated for
all means.
Data not collected by direct ob-
servation. When a nurse scanned
a medication before administering
it, one of the following warnings
could have appeared on the com-
puter screen: medication is not on
current eMAR, medication is for a
different patient, abnormal labora-
tory test results, or allergy. At this
point, the nurse can decide not to
administer the medication. When the
nurse was warned before medication
administration and decided not to
administer the medication, this was
considered an averted event. When
a potential error was intercepted by
the system after the nurse scanned
the medication or the patient’s
wristband, the BCMA-eMAR system
recorded the event and tabulated the
number of times the nurse decided to
administer or not administer a dose
of medication.
Voluntarily reported data were
recorded for five time periods: three
before BCMA-eMAR implementa-
tion and two after BCMA-eMAR
implementation. The voluntary
reporting process was performed
using a Web-based reporting and
analysis software system (Quantros
Safety Event Manager, version 5.13,
Milpitas, CA). This system allowed
the reporter to provide a narra-
tive description of the event and
included specific fields for record-
ing the date and time of the event,
patient-specific demographics, loca-
tion, type of error or event, cause,
name of medication, severity of error
or harm, and strategies to prevent
reccurrence. The software provided a
number of search and reporting op-
tions that permitted the tabulation of
recorded data.
Results
Medication administration ac-
curacy. The total opportunities for
error and the accuracy rates by pa-
tient care unit during phases 1 and
3 are listed in Table 1. Electronic
scanning percentages exceeded 90%
during phase 3. The occurrence rates
for all error types are shown in Table
2. The overall accuracy rate at hos-
pital 1 changed significantly, from
89% in phase 1 to 90% in phase
3 (p = 0.0015). If wrong-time er-
rors are excluded, the accuracy rate
improved from 92% in phase 1 to
96% in phase 3 (p = 0.000008). The
overall accuracy rate did not change
significantly from phase 1 to phase
3 at hospital 2; when wrong-time
errors were excluded from consid-
eration, the accuracy rate improved
from 93% in phase 1 to 96% in phase
3 (p = 0.015).
Target-error analysis. The results
of the target-error analysis in study
phases 1 and 3 were compared (Table
2). The number of target errors at
both facilities did decrease from
phase 1 to phase 3; for hospital 1,
this analysis was performed with
the emergency department and out-
patient oncology units excluded, as
these were considered special interest
units.
Special care units. The medica-
tion accuracy rate decreased signifi-
cantly after BCMA implementation
in the ICU at hospital 2 (accuracy
rate, 94% and 83% in phases 1 and 3,
respectively; p = 0.004). The analysis
showed a large increase in technique
errors (e.g., failure to use a filter
straw to remove medication contents
from an ampul, failure to have the
patient rinse his or her mouth after
using an inhaler)—1 in phase 1 and
13 in phase 3.
The accuracy rate for hospital 1’s
outpatient oncology unit remained
 PRACTICE REPORTS  Barcode technology

Table 1.
Total Opportunities for Error and Accuracy Rate Before (Phase 1) and After (Phase 3) Implementation
of BCMA with Electronic MARa
Accuracy Rate
Total Opportunities Accuracy Excluding Wrong-Time
Unit and Study Phase for Error Rate (%) Errors (%)
Hospital 1
 Medical–surgical
  Phase 1 534 88 93
  Phase 3 101 93 96
 Telemetry
  Phase 1 310 94 94
  Phase 3 161 88b 94
 Rehabilitation
  Phase 1 531 86 90
  Phase 3 744 85 94c
 Emergency
  Phase 1 205 86 87
  Phase 3 237 95d 99e
  Inpatient oncology
  Phase 1 310 89 94
  Phase 3 87 94 98
  Outpatient oncology
  Phase 1 202 97 97
  Phase 3 247 97 98g
   Total
    Phase 1 2092 89 92
    Phase 3 1577 90d 96f
Hospital 2
 Medical–surgical
  Phase 1 569 89 94
  Phase 3 129 92 93
 Telemetry
  Phase 1 465 89 93
  Phase 3 254 89 98g
 Rehabilitation
  Phase 1 692 87 92
  Phase 3 325 94h 97i
  Intensive care
  Phase 1 335 94 96
  Phase 3 65 83c 88j
   Total
    Phase 1 2061 89 93
    Phase 3 773 91 96k
a
Chi-square analysis with Yates correction was conducted for comparisons between phases 1 and 3 in the same study units. BCMA = barcode-assisted medication
administration, MAR = medication administration record.
b
p = 0.04.
c
p = 0.004.
d
p = 0.0015.
e
p = 0.000002.
f
p = 0.000008.
g
p = 0.006.
h
p = 0.0005.
i
p = 0.002.
j
p = 0.003.
k
p = 0.015.

Am J Health-Syst Pharm—Vol 71 Feb 1, 2014 213

 PRACTICE REPORTS  Barcode technology

fairly consistent, even when wrong-

Excludes the emergency department and outpatient oncology unit because of differences in their drug distribution systems. The exclusion was for target errors only. With the exclusions, there were 115 total target errors and
time errors were excluded. Because

Wrong
Route

0
9

0
9

0
1
most chemotherapy and support
Types of Errors Observed in Study Hospitals Before (Phase 1) and After (Phase 3) Implementation of Barcode-Assisted Medication medications administered are for a
single dose, wrong-time errors are
Other Errors
not as relevant in this unit as in other

Technique
Wrong
practice settings. The accuracy rate

36
13

13
11

45
13
increased from 97% in phase 1 to

There were 92 total target errors and 1969 no-error doses during phase 1 and 17 total target errors and 756 no-error doses during phase 3 (p = 0.002, chi-square analysis with Yates correction).
98% in phase 3. In this unit, there
were a total of 4 errors in phase 3, in-
cluding 2 technique errors involving
the administration rate of support
Wrong
Time

67
94

66
83

86
36
medications (not chemotherapy), 1
unauthorized-drug error involving a
support medication that was not in-
dicated on the physician’s order, and

1570 no-target error doses during phase 1 and 37 total target errors and 1056 no-error doses during phase 3 (p = 0.0001, chi-square analysis with Yates correction).
Omission

1 wrong dose involving a support

71
22

69
19

54
6
medication.
In the emergency department at
hospital 1, the accuracy rate increased
from 86% to 95% (p = 0.0015) from
Unauthorized

phase 1 to phase 3. When wrong-

time errors were excluded, the ac-
Drug

6
3

6
2

7
2

curacy rate improved—from 87% to

99% (p = 0.000002). The number of
wrong-dose errors decreased from 8
to 0 in phase 3.
Target Errors

Errors averted by BCMA-eMAR

and voluntarily reported errors. As
Extra
Dose
Administration with Electronic Medication Administration Record

4
1

4
1

7
0

demonstrated in the observational

Hospital 2—all unitsb

data, some of the medication er-

rors identified were not detected
or prevented by BCMA-eMAR.
Electronic data collected from the
Wrong
Form

BCMA-eMAR system and volun-

4
0

4
0

4
0
Hospital 1­—all units

tarily reported data were compared

with the data obtained via direct
observation.
Table 3 shows the number of
Wrong

doses of medication administered

Dose

40
16

32
15

20
9

in the study hospitals, the number

of errors reported in the voluntary
reporting system, the number of ob-
served errors during the study for all
observation periods, and the number
of events averted by BCMA-eMAR
Hospital 1—units excludeda

on the observational units. Medica-

tion errors consistently declined after
Study Phase

BCMA-eMAR was implemented,

with the number of doses adminis-
tered showing little change (Figure
  Phase 1
  Phase 3

  Phase 1
  Phase 3

  Phase 1
  Phase 3

1). The number of averted events far

Table 2.

exceeded both voluntarily reported

and directly observed medication er-
b
a

214 Am J Health-Syst Pharm—Vol 71 Feb 1, 2014

 PRACTICE REPORTS  Barcode technology

Table 3.
Errors Reported Voluntarily and Detected by Direct Observation Before and After Implementation
of Barcode-Assisted Medication Administration (BCMA)
No. No. Errors No. Errors
Total No. Voluntarily Observed Averted by
Doses Reported No. BCMA Directly in BCMA in Study
Date Range Givena Errorsa Units Studied Study Units Units
Before BCMA
  Dec 2006–Mar 2007 663,785 101 4 451 NA
  Dec 2007–Mar 2008 697,830 81 2 87 NA
  Jan–May 2008 907,441 73 4 152 NA
After BCMA
  Feb–May 2009 724,068 26 8 182 1,121
  Sep 2010–Dec 2010 671,834 33 4 58 1,234
a
For all units (not just study units) of both study hospitals combined. NA = not applicable.

Figure 1. Number of medication errors occurring in hospital 1 (A) and hospital 2 (B) after implementation of barcode-assisted medication
administration with electronic medication administration record. Bars represent doses administered.

A 250000 35
31
29 30
No. Doses Administered

200000
24 25
22

No. Errors
150000 20
18
15 16 16
15
16 16 15
100000 12
16 11 11 12 11 11
14 13
12 10
50000 10 9 9 10
8 7 8 8
7 5

0 0
Dec
Jan 07
Feb
Mar
Dec
Jan
Feb
Mar
Apr
May
Feb
Mar 09
Apr
May
Sep
Oct
Nov
Dec
11 Jan
Feb
Mar
Apr
May
Jun
Jul
Aug

Oct

Dec
Sep

Nov

B 250000
37
40

33 35
No. Doses Administered

200000
30

25
No. Errors

150000
24 19 20
20 17
16
100000 20 14 15 14 14 15
11 12 12 11 12
15
9 9 10
8
50000 9
8 7 5
6 6
3 4 4 3
0 0
Dec
Jan 07
Feb
Mar
Dec
Jan 08
Feb
Mar
Apr
May
Feb
Mar 09
Apr
May
Sep
Oct
Nov
Dec
11 Jan
Feb
Mar
Apr
May
Jun
Jul
Aug

Oct

Dec
Sep

Nov

No. errors
Trend line

Am J Health-Syst Pharm—Vol 71 Feb 1, 2014 215

 PRACTICE REPORTS  Barcode technology
rors. The majority of averted events
were related to abnormal labora-
tory results, in which case the nurse
chose to withhold the dose based
on the laboratory test results. There
was a general decline in voluntarily
reported errors over the entire study
period even though the number of
administered doses remained fairly
constant.
Discussion
The results of this study demon-
strated that BCMA-eMAR was as-
sociated with significant reductions
in target errors. In addition, many
adverse events associated with giving
a medication when a patient had a
contraindicating laboratory test re-
sult may have been averted by using
BCMA-eMAR.
Improvements in medication
accuracy rates were seen in adult
inpatient units. These changes were
greater when wrong-time errors were
eliminated from the comparisons. All
of the patient care units studied were
high-volume medication administra-
tion environments. Results from the
medical–surgical and rehabilitation
units from both hospitals were simi-
lar. However, the accuracy rate, when
wrong-time errors were excluded,
in the telemetry unit of hospital 2
improved significantly, but there was
no change in the telemetry unit of
hospital 1. There was a difference in
the number of beds in these units (38
beds versus 14 beds, respectively). In
addition, patients in the telemetry
unit of hospital 1 were predomi-
nantly medical–cardiology patients,
while patients in the telemetry unit
of hospital 2 were a mixture of
postprocedure interventional pa-
tients, including patients who had
undergone angioplasty or coronary
artery bypass graft surgery as well as
medical–cardiology patients. Final-
ly, patients in the telemetry unit in
hospital 1 had a longer mean length
of stay than did those in hospital 2.
In addition to observations in
adult inpatient units, this study eval-
216 Am J Health-Syst Pharm—Vol 71 Feb 1, 2014
uated BCMA-eMAR in three special
care environments. The number of
medication errors in the emergency
department, most of which were
technique errors, significantly de-
creased from phase 1 to phase 3 (p =
0.0015; when excluding wrong-time
errors, p = 0.000002). However, there
were no reductions in accuracy rates
in the outpatient oncology infusion
clinic (hospital 1) and the ICU (hos-
pital 2). The outpatient oncology
infusion clinic incorporates multiple
double checks with nurses and phar-
macists, which likely explains the
high accuracy rates before and after
BCMA-eMAR implementation. The
increase in observed errors in the ICU
was the result of multiple medication
technique misadventures. Technique
errors are not typically identified and
prevented using BCMA. In this case,
education of the nursing staff is key
to ensuring that staff members un-
derstand the relationships between
medication dosage forms, clinical
effects, and routes of administra-
tion. An institution may implement
pop-up reminders on the eMAR to
remind nurses of proper medication-
handling techniques.
The use of BCMA-eMAR was
accompanied by a reduction in the
number of voluntarily reported
medication errors. BCMA-eMAR
and direct observation are more ef-
fective than voluntary reporting pro-
grams for intercepting and recording
errors and preventing them from
reaching patients. Voluntary report-
ing is typically rich in detail and often
allows a more thorough analysis of
events, possibly resulting in substan-
tive improvement opportunities.
Direct observation of medication
administration successfully identifies
medication errors but requires more
resources to perform. BCMA-eMAR
systems electronically capture events
and provide reports that can be
used to develop improvement plans.
When used together, these systems
provide rich information for process
improvements.
Some medication errors may not
be prevented by the use of BCMA-
eMAR, such as prescribing the
wrong medication for a condition,
failing to appropriately tailor the
dosage for the patient, prescribing
the wrong route of administration,
failing to implement an order, and
failing to change an i.v. fluid or initi-
ate new medications when an order
is changed. If a medication order
is incorrectly entered on a patient’s
profile by a pharmacist, a nurse re-
viewing the order must detect the
error or the BCMA-eMAR system
will allow the wrong medication to
be administered. BCMA-eMAR does
not prevent a medication that should
be administered intravenously from
being administered orally. I.V. pump
programming errors will not be
prevented by BCMA-eMAR unless
barcode technology is used to man-
age i.v. pump manipulations.
The observational data collected
revealed a large number of wrong-
time medication administration
errors despite the liberal two-hour
administration window. While these
errors may have less importance in
some cases, they may be critical in
certain patients, such as those who
have diabetes mellitus and may have
had their meal but whose insulin was
delayed or given too early, result-
ing in blood sugar abnormalities.
BCMA-eMAR made little difference
in improving the timeliness of medi-
cation administration in the two
hospitals studied. In fact, wrong-time
errors increased in hospital 1 but
decreased in hospital 2 after BCMA-
eMAR implementation.
Importantly, this study found that
BCMA-eMAR did not introduce new
types of errors into the medication
administration process. Although
nurses initially believed that a re-
quirement to scan barcodes on medi-
cations, patients, and themselves
would dramatically slow the medica-
tion administration process, this ef-
fect was not observed as they became
efficient with the use of the system.

The results of this study expand
and further support the positive
effects and limitations of BCMA
on reducing medication errors. In
addition, this study included obser-
vations from patient care units for
which there are no other data in the
literature (emergency department,
ICU, and oncology) and provided
comparative data from different
methodologies of gathering medi-
cation errors (voluntarily reported
versus directly observed).
Conclusion
Implementation of BCMA-
eMAR in two hospitals was associat-
ed with significant increases in total
medication accuracy rates in most
study units and did not introduce
new types of error into the medica-
tion administration process. Accu-
racy rates further improved when
wrong-time errors were excluded
from analysis. The frequency of er-
rors preventable by BCMA-eMAR
decreased significantly in both hos-
pitals after implementation of that
technology. BCMA-eMAR and di-
rect observation were more effective
than voluntary reporting programs
at intercepting and recording errors
and preventing them from reaching
patients.
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Appendix—Error category definitions
Unauthorized drug: Administration of a dose
of medication that was not ordered for the
patient; may also be referred to as an unau-
thorized or wrong-drug error.
Extra dose: Any dose given in excess of the total
number of times ordered by the physician,
such as a dose given on the basis of an ex-
pired order, after a drug has been discontin-
ued, or after a drug has been put on hold. If
a physician ordered a drug to be given every
morning and the nurse gave it in the evening,
the error is placed in this category.
Omission: Failure to give an ordered dose. If the
patient refuses the medication, an opportu-
nity for error is not counted if the nurse re-
sponsible for administering the dose tried to
give it. If no attempt was made to administer
the dose, then an omission error is counted.
Doses withheld according to policies calling
for the withholding of medication doses,
such as nothing by mouth before surgery, are
not counted as errors or opportunities for
errors. The observer will detect omissions by
comparing the medications administered at a
given time with doses that should have been
given at that time based on the prescriber’s
written orders.
Wrong route: Medication administered to a
patient using a different route than ordered
(e.g., oral administration of a drug ordered
for intramuscular use). Also included in this
category are doses given in the wrong site,
such as the right eye instead of the left eye.
Wrong form: The administration of a dose in a
different form than ordered by the physician
when the physician specified or implied a
specific dose form. Giving a tablet when
a suspension was ordered is an example.
If one of the following dosage forms is
crushed, a wrong-form error is counted:
extended-release products, enteric-coated
drugs, sublingual medications, and efferves-
cent tablets.
Wrong technique: An incorrect or omitted ac-
tion by the nurse during the preparation or
administration of a dose that does not result
in another type of error. For example, if the
wrong rate of infusion is used and the patient
receives the correct dose, a wrong-technique
error has occurred. If a heart rate is not
measured prior to drug administration, a
wrong-technique error has occurred. If the
heart rate is measured and the rate is too low
for the dose to be given but the nurse still
administers the drug, an extra-dose error
has occurred
Wrong dose: Any dose that contained the wrong
number of preformed dosage units (such as
tablets) or is, in the judgment of the observer,
±17% the correct oral dosage. In judging
dosage, measuring devices and graduations
217
 PRACTICE REPORTS  Barcode technology

are those provided for routine use by the

institution: graduations on the syringe for
injections, on medicine cups for oral liquids,
and drops for the dropper provided. Any
dose of an injectable product that is ±10%
or more of the correct dosage is considered
an error of this type. Wrong-dose errors are
counted for ointments, topical solutions, and
similar medications when the dose is quan-
titatively specified by the physician (e.g., in
inches of ointment).
Wrong time: Administration of a dose more than
60 minutes before or after the scheduled ad-
ministration time, unless there is a valid rea-
son. Valid reasons include situations where
the physician has ordered that the patient
not consume anything by mouth, the patient
is off the floor for a diagnostic test, or in
surgery. As-needed doses should be adminis-
tered only as frequently as ordered—the time
of the previous dose’s administration should
be determined from the medication adminis-
tration record. The first dose given according
to the standard administration schedule is
considered to establish that the schedule and
subsequent doses on the same day can then
be examined for wrong-time errors.

218 Am J Health-Syst Pharm—Vol 71 Feb 1, 2014