Implementation of Bar-Code Medication Administration to Reduce Patient Harm

Mayo Clin Proc Innov Qual Outcomes. 2018 Nov 26;2(4):342-351. doi: 10.1016/j.mayocpiqo.2018.09.001. eCollection 2018 Dec.


Objective: To assess the impact of implementing bar-code medication administration (BCMA) technology on the rate of medication administration errors in the inpatient setting, specifically those that affect the patient and result in harm.

Patients and methods: Implementation of the new technology began in September 2008 in a staged rollout of 4 or 5 units at a time in 11 separate waves. All corresponding medication administrations and voluntarily reported medication-related adverse events from March 1, 2007, through September 30, 2013, were included for analyses. Adherence to the use of BCMA technology and the number of adverse events were tracked and compared across the preimplementation period through follow-up. Actual errors, not potential errors, were included in the analysis.

Results: After the BCMA technology was introduced, reported medication administration errors decreased by 43.5%. More importantly, the rate of harmful medication errors decreased from 0.65 per 100,000 medications preintervention to 0.29 per 100,000 medications postintervention. This resulted in a 55.4% decrease in actual patient harm events. None of the errors at category E or higher was caused by BCMA factors.

Conclusion: Consistent use of BCMA technology improves patient safety by decreasing the number of patients harmed by medication administration errors.

Keywords: ADE, adverse drug event; BCMA, bar-code medication administration; ITSA, interrupted time series analysis.