uu.seUppsala University Publications
Change search
ReferencesLink to record
Permanent link

Direct link
Pediatric Medication Administration Errors and Workflow Following Implementation of a Bar Code Medication Administration System
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Pharmacy, Department of Pharmacy.
Show others and affiliations
2014 (English)In: JOURNAL FOR HEALTHCARE QUALITY, ISSN 1062-2551, Vol. 36, no 4, 54-63 p.Article in journal (Refereed) Published
Abstract [en]

Direct observation was used to detect medication errors and Bar Code Medication Administration (BCMA) workarounds on two pediatric units and one neonatal unit at UCSF Benioff Children's Hospital. The study (1) measured the frequency of nursing medication administration-related errors, (2) characterized the types of medication errors, (3) assessed compliance with the institution's six medication administration safety processes, and (4) identified observed workarounds following BCMA implementation. The results of the direct observation were compared to medication administration-related incident reports (IRs) for the same period. The frequency of medication errors was 5% for the three units. Compliance with the process measures was achieved 86% of the time (range 23-100%). Seven medication administration-related IRs were submitted during the same observation period. Three BCMA workarounds were identified; (1) failure to visually confirm patient's identification, (2) failure to compare the medication to the electronic medication administration record at least twice before administration, and (3) charting administration of medication before actual administration. The direct observation methodology identified a low frequency of medication administration errors (MAEs) consistent with post-BCMA implementation. The incident reporting system identified different MAEs than direct observation suggesting that both methods should be used to better characterize the scope of MAEs.

Place, publisher, year, edition, pages
2014. Vol. 36, no 4, 54-63 p.
Keyword [en]
error/adverse, event/incident, classification, systems/near, misses/error, medication safety, performance, improvement/quality, improvement performance, improvement models, reporting
National Category
Health Care Service and Management, Health Policy and Services and Health Economy
URN: urn:nbn:se:uu:diva-245564DOI: 10.1111/jhq.12071ISI: 000348450800005PubMedID: 25041604OAI: oai:DiVA.org:uu-245564DiVA: diva2:791373
Available from: 2015-02-27 Created: 2015-02-26 Last updated: 2015-02-27Bibliographically approved

Open Access in DiVA

No full text

Other links

Publisher's full textPubMed
By organisation
Department of Pharmacy
Health Care Service and Management, Health Policy and Services and Health Economy

Search outside of DiVA

GoogleGoogle Scholar
The number of downloads is the sum of all downloads of full texts. It may include eg previous versions that are now no longer available

Altmetric score

Total: 183 hits
ReferencesLink to record
Permanent link

Direct link