Pediatric medication administration errors and workflow following implementation of a bar code medication...

Area of Science:

• Pediatric Patient Safety
• Health Informatics
• Medication Administration Safety

Background:

• Bar Code Medication Administration (BCMA) systems are crucial for reducing medication errors.
• Understanding workarounds and actual error rates is essential for improving patient safety.

Purpose of the Study:

• To measure the frequency and types of medication administration errors (MAEs).
• To assess compliance with medication administration safety processes.
• To identify BCMA workarounds and compare direct observation findings with incident reports.

Main Methods:

• Direct observation of nursing staff administering medications on pediatric and neonatal units.
• Comparison of observed data with medication administration-related incident reports (IRs).
• Analysis of compliance with six institutional medication administration safety processes.

Main Results:

• A 5% frequency of medication errors was observed.
• Compliance with safety processes averaged 86%, with significant variability.
• Three common BCMA workarounds were identified, including bypassing patient identification and premature charting.

Conclusions:

• Direct observation identified a low frequency of MAEs post-BCMA implementation.
• Incident reporting captured different MAEs than direct observation.
• Utilizing both direct observation and incident reporting is recommended for a comprehensive understanding of MAEs.