Errors prevented by and associated with bar-code medication administration systems

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Cochran GL, Jones KJ, Brockman J, Skinner A, Hicks RW. Errors prevented by and associated with bar-code medication administration systems. Jt Comm J Qual Patient Saf. 2007 May;33(5):293-301, 245.


Bar-code medication administration (BCMA) technology is the method of placing readable bar-codes onto all medication. The bar-code encodes the National Drug Code (NDC) – name of drug company labeling the package for sale, name of the drug and its dose, and type of packaging. Hospitalized patients also receive a bar-code on their hospital bracelet, to assure positive patient identification. The purpose of this study is binary. It strives to uncover errors prevented by BCMA, as well as those errors associated as a result of BCMA systems.


Data from reports of errors submitted to MEDMARX, a national database of voluntarily reported errors, was used for this study.

Study Selection

From June-August 2006, error reports were studied that had been retrieved using a free-text search of variations of the phrase “bar code”, that had been submitted from January 1, 2000 to December 31, 2005. 2,783 reports, from 65 hospitals were retrieved. Eighty-percent of those reports had been submitted by one institution and had been excluded from the study. Thirty-one error reports, received from clinical and ambulatory care sites were retrieved, however, are also not included in this study. The remaining 515 error reports were then broken down into two categories: 1) errors prevented by BCMA and 2) those errors associated with BCMA.


Seventy reports were found where BCMA prevented an error; 445 reports were found where an error was a result of BCMA.


The 70 reports of errors prevented by BCMA, were found to have been prevented during either the dispensing or administration phases of medication disbursement. Within those categories, the reports were then filtered further into one of the following groups: Incorrect medication dispensed, Incorrect dose dispensed, Stocking or Storage of errors, Early Dose Warning, No Drug Order. The 445 reports of errors as a result of BCMA were broken down into three categories: Near Miss, Nonharmful, Harmful. These reports occurred due to one of the following reasons: Mislabeling of medication with incorrect bar code, Lack of bar code, Inability to scan bar code, Override of error warning, Bar code not scanned, Workarounds, Wrong patient, System not available, miscellaneous. The highest number of errors was due to mislabeling, with lack of bar code, inability to scan bar code, and staff workarounds coming in closely behind, respectively.


BCMA can be used to assist in the prevention of errors occurring during drug disbursement, however, as research has shown, can not be relied on solely to eliminate errors. In order for BCMA to be advantageous, it needs to be joined, by an alert, trained set of eyes. As found in the study, more errors were reported as a result of BCMA, rather than prevented by. BCMA alone is not fool-proof. It is not effective unless used in accordance with proper human execution. Facilities should make it a high priority to ensure that all employees/staff are fully trained on the usage of BCMA. Manufacturers can assist in the elimination of errors caused by BCMA by the availability of bar-codes on unit dose medication.