"Are we there yet?" Ten persistent hazards and inefficiencies with the use of medication administration technology from the perspective of practicing nurses

J Am Med Inform Assoc. 2023 Apr 19;30(5):809-818. doi: 10.1093/jamia/ocad031.


Objectives: (1) Characterize persistent hazards and inefficiencies in inpatient medication administration; (2) Explore cognitive attributes of medication administration tasks; and (3) Discuss strategies to reduce medication administration technology-related hazards.

Materials and methods: Interviews were conducted with 32 nurses practicing at 2 urban, eastern and western US health systems. Qualitative analysis using inductive and deductive coding included consensus discussion, iterative review, and coding structure revision. We abstracted hazards and inefficiencies through the lens of risks to patient safety and the cognitive perception-action cycle (PAC).

Results: Persistent safety hazards and inefficiencies related to MAT organized around the PAC cycle included: (1) Compatibility constraints create information silos; (2) Missing action cues; (3) Intermittent communication flow between safety monitoring systems and nurses; (4) Occlusion of important alerts by other, less helpful alerts; (5) Dispersed information: Information required for tasks is not collocated; (6) Inconsistent data organization: Mismatch of the display and the user's mental model; (7) Hidden medication administration technologies (MAT) limitations: Inaccurate beliefs about MAT functionality contribute to overreliance on the technology; (8) Software rigidity causes workarounds; (9) Cumbersome dependencies between technology and the physical environment; and (10) Technology breakdowns require adaptive actions.

Discussion: Errors might persist in medication administration despite successful Bar Code Medication Administration and Electronic Medication Administration Record deployment for reducing errors. Opportunities to improve MAT require a deeper understanding of high-level reasoning in medication administration, including control over the information space, collaboration tools, and decision support.

Conclusion: Future medication administration technology should consider a deeper understanding of nursing knowledge work for medication administration.

Keywords: BCMA; cognitive support systems; health information technology design; medication administration record; patient safety; perception-action cycle.

Publication types

  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • Communication
  • Electronic Data Processing
  • Humans
  • Medication Errors* / prevention & control
  • Medication Systems, Hospital
  • Patient Safety*
  • Pharmaceutical Preparations


  • Pharmaceutical Preparations