Observational studyJournal of the American Medical Informatics Association : JAMIA2018
Association between workarounds and medication administration errors in bar-code-assisted medication administration in hospitals.
Observational study in Journal of the American Medical Informatics Association : JAMIA, 2018. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 25 papers, 2 of them syntheses that pooled it.
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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.
Neither the registry nor the abstract names a trial number. If this is a trial report, that itself is worth knowing.
Who cites it
25 citing papers in PubMed, 2 syntheses or guidelines pooled it, 63 citations in OpenAlex.
- Pooled it
- A systematic literature review on strategies to avoid look-alike errors of labels.European journal of clinical pharmacology · 2018Pooled it
- The Influence of Nurse Staffing and Workload on Medication Administration Errors: A Scoping Review.Journal of advanced nursing · 2026Article
- Automated dispensing cabinets and nurse-related medication errors in inpatient settings: A systematic review.Exploratory research in clinical and social pharmacy · 2026Review
- Impact of barcode medication administration on patient safety in UK hospital settings: protocol for a mixed-methods realist evaluation.BMJ open · 2025Article
- "I know I shouldn't but …" the inevitable tension of using workarounds to be a "good nurse".Frontiers in health services · 2025Article
- Nexus of Quality Use of Medicines, Pharmacists' Activities, and the Emergency Department: A Narrative Review.Pharmacy (Basel, Switzerland) · 2024Review
- Detecting clinical medication errors with AI enabled wearable cameras.NPJ digital medicine · 2024Article
- Clinical and economic impact of medication administration errors among neonates in neonatal intensive care units.PloS one · 2024Observational
- Pharmacy practice in hospital settings in GCC countries: Dispensing and administration.Saudi pharmaceutical journal : SPJ : the official publication of the Saudi Pharmaceutical Society · 2023Article
- Development and validation of a risk prediction model for medication administration errors among neonates in the neonatal intensive care unit: a study protocol.BMJ paediatrics open · 2023Article
- Prevalence and determinants of medication administration errors in clinical wards: A two-centre prospective observational study.Journal of clinical nursing · 2023Observational
- Safety implications of different forms of understaffing among nurses during the COVID-19 pandemic.Journal of advanced nursing · 2022Article
- Barcode medication administration technology use in hospital practice: a mixed-methods observational study of policy deviations.BMJ quality & safety · 2021Observational
- Effect of automated unit dose dispensing with barcode scanning on medication administration errors: an uncontrolled before-and-after study.International journal for quality in health care : journal of the International Society for Quality in Health Care · 2021Article
- Developing an immersive virtual reality medication administration scenario using the nominal group technique.Nurse education in practice · 2021Article
- Factors associated with workarounds in barcode-assisted medication administration in hospitals.Journal of clinical nursing · 2020Observational
- An overview of clinical decision support systems: benefits, risks, and strategies for success.NPJ digital medicine · 2020Review
- Detection and Remediation of Misidentification Errors in Radiology Examination Ordering.Applied clinical informatics · 2020Article
- Implementation and Effectiveness of a Bar Code-Based Transfusion Management System for Transfusion Safety in a Tertiary Hospital: Retrospective Quality Improvement Study.JMIR medical informatics · 2019Article
Corrections and comments
PubMed lists nothing against this paper. Absence here is not a guarantee, only a check that was made.
Authors and funding
15 authors at 7 institutions in 2 countries.
Funding
No grant is acknowledged in the PubMed record.
Abstract
Objective: To study the association of workarounds with medication administration errors using barcode-assisted medication administration (BCMA), and to determine the frequency and types of workarounds and medication administration errors. Materials and Methods: A prospective observational study in Dutch hospitals using BCMA to administer medication. Direct observation was used to collect data. Primary outcome measure was the proportion of medication administrations with one or more medication administration errors. Secondary outcome was the frequency and types of workarounds and medication administration errors. Univariate and multivariate multilevel logistic regression analysis were used to assess the association between workarounds and medication administration errors. Descriptive statistics were used for the secondary outcomes. Results: We included 5793 medication administrations for 1230 inpatients. Workarounds were associated with medication administration errors (adjusted odds ratio 3.06 [95% CI: 2.49-3.78]). Most commonly, procedural workarounds were observed, such as not scanning at all (36%), not scanning patients because they did not wear a wristband (28%), incorrect medication scanning, multiple medication scanning, and ignoring alert signals (11%). Common types of medication administration errors were omissions (78%), administration of non-ordered drugs (8.0%), and wrong doses given (6.0%). Discussion: Workarounds are associated with medication administration errors in hospitals using BCMA. These data suggest that BCMA needs more post-implementation evaluation if it is to achieve the intended benefits for medication safety. Conclusion: In hospitals using barcode-assisted medication administration, workarounds occurred in 66% of medication administrations and were associated with large numbers of medication administration errors.
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