ArticleJournal of the American Medical Informatics Association : JAMIA
Workarounds to barcode medication administration systems: their occurrences, causes, and threats to patient safety.
Article in Journal of the American Medical Informatics Association : JAMIA. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 175 papers, 6 of them syntheses that pooled it.
What it found
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The abstract states no effect estimate the extractor could read, or names no intervention and outcome on the map, so this paper lights no cell and moves no belief. It is still indexed, cited and linked below.
The trial behind it
Trials whose registry record cites this paper, or whose number appears in the abstract. A trial that started after this paper was published is citing it as background, not reporting it.
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Who cites it
175 citing papers in PubMed, 6 syntheses or guidelines pooled it, 685 citations in OpenAlex.
- The influence of electronic health record design on usability and medication safety: systematic review.BMC health services research · 2025Pooled it
- A Systematic Review of Quantitative Methods for Evaluating Electronic Medication Administration Record and Bar-Coded Medication Administration Usability.Applied clinical informatics · 2023Pooled it
- Pooled it
- A systematic review of the impact of health information technology on nurses' time.Journal of the American Medical Informatics Association : JAMIA · 2020Pooled it
- Impact of interventions designed to reduce medication administration errors in hospitals: a systematic review.Drug safety · 2014Pooled it
- The impact of mobile handheld technology on hospital physicians' work practices and patient care: a systematic review.Journal of the American Medical Informatics Association : JAMIAPooled it
- Examining Care Planning Efficiency and Clinical Decision Support Adoption in a System Tailoring to Nurses' Graph Literacy: National, Web-Based Randomized Controlled Trial.Journal of medical Internet research · 2023Trial
- Older adults' satisfaction with a medication dispensing device in home care.Informatics for health & social care · 2013Trial
- "Most of what I do is a workaround now": Clinician Use of Workarounds Following an EHR Transition.Journal of general internal medicine · 2026Article
- Raman Analysis of RNA Nucleotide Strands From SARS-CoV-2 Variants and Subvariants: A Step Forward in the Definition of "Raman Genome".Advanced science (Weinheim, Baden-Wurttemberg, Germany) · 2026Article
- Understanding the Limits of Patient Safety Classification Systems for Health Information Technology-Related Incidents.JMIR human factors · 2026Article
- Does System Choice Matter? Influence of Hospital Information Systems on Digital Maturity.Journal of medical systems · 2026Article
- Facilitators and barriers in using barcode technology to ensure safe medication dispensing, preparation, and administration in a children's hospital: a focus group study for clinical pharmacists.International journal of clinical pharmacy · 2026Article
- Automated dispensing cabinets and nurse-related medication errors in inpatient settings: A systematic review.Exploratory research in clinical and social pharmacy · 2026Review
- Evaluating the implementation of a hospital-internal digital supply chain system over 5 years using a logic model framework.Frontiers in digital health · 2026Article
- Impact of barcode medication administration on patient safety in UK hospital settings: protocol for a mixed-methods realist evaluation.BMJ open · 2025Article
- The impact of inpatient medication administration technologies on nursing autonomy and practice: a meta-ethnographic synthesis of the qualitative literature.Journal of the American Medical Informatics Association : JAMIA · 2025Article
- Facilitators and Barriers Associated With the Use of Barcode Technologies in Drug Preparation and Administration in Hospital Settings-A Narrative Review of Qualitative Studies.Journal of patient safety · 2025Article
- A systematic review of clinicians' acceptance and use of clinical decision support systems over time.NPJ digital medicine · 2025Article
- Patients' Perceptions of Artificial Intelligence Acceptance, Challenges, and Use in Medical Care: Qualitative Study.Journal of medical Internet research · 2025Article
115 more citing papers are in PubMed but not listed here.
Corrections and comments
PubMed lists nothing against this paper. Absence here is not a guarantee, only a check that was made.
Authors and funding
4 authors at 3 institutions in 1 country.
Funding
Abstract
The authors develop a typology of clinicians' workarounds when using barcoded medication administration (BCMA) systems. Authors then identify the causes and possible consequences of each workaround. The BCMAs usually consist of handheld devices for scanning machine-readable barcodes on patients and medications. They also interface with electronic medication administration records. Ideally, BCMAs help confirm the five "rights" of medication administration: right patient, drug, dose, route, and time. While BCMAs are reported to reduce medication administration errors--the least likely medication error to be intercepted--these claims have not been clearly demonstrated. The authors studied BCMA use at five hospitals by: (1) observing and shadowing nurses using BCMAs at two hospitals, (2) interviewing staff and hospital leaders at five hospitals, (3) participating in BCMA staff meetings, (4) participating in one hospital's failure-mode-and-effects analyses, (5) analyzing BCMA override log data. The authors identified 15 types of workarounds, including, for example, affixing patient identification barcodes to computer carts, scanners, doorjambs, or nurses' belt rings; carrying several patients' prescanned medications on carts. The authors identified 31 types of causes of workarounds, such as unreadable medication barcodes (crinkled, smudged, torn, missing, covered by another label); malfunctioning scanners; unreadable or missing patient identification wristbands (chewed, soaked, missing); nonbarcoded medications; failing batteries; uncertain wireless connectivity; emergencies. The authors found nurses overrode BCMA alerts for 4.2% of patients charted and for 10.3% of medications charted. Possible consequences of the workarounds include wrong administration of medications, wrong doses, wrong times, and wrong formulations. Shortcomings in BCMAs' design, implementation, and workflow integration encourage workarounds. Integrating BCMAs within real-world clinical workflows requires attention to in situ use to ensure safety features' correct use.
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What OpenQuestion holds
Registered trials
Read under generation 80e0d062 · epoch 390. Bibliography from PubMed, PubMed Central and OpenAlex; grants from NIH RePORTER; trial links from ClinicalTrials.gov; estimates, votes and beliefs from the OpenQuestion graph.