Observational studyBMJ quality & safety2021
Barcode medication administration technology use in hospital practice: a mixed-methods observational study of policy deviations.
Observational study in BMJ quality & safety, 2021. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 24 papers, 2 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
24 citing papers in PubMed, 2 syntheses or guidelines pooled it.
- Nurses' Adherence to Double-Checking: A Systematic Review of Influencing Factors, Improvement Strategies, and Their Effectiveness.International nursing review · 2026Pooled it
- Assessing the Effectiveness of Interventions Implemented by Nurses to Reduce Medication Administration Errors in Hospitalised Acute Adult Patient Settings: Systematic Review and Meta-Analysis.Journal of clinical nursing · 2026Pooled it
- Factors contributing to medication safety incidents observed by community pharmacists - a content analysis of incident reports.Exploratory research in clinical and social pharmacy · 2026Article
- Use of Information Technology to Mitigate Protocol Deviations in Clinical Research: A Quality Improvement Project.Therapeutic innovation & regulatory science · 2026Article
- "It's Not Just a System Error": A Qualitative Study of Nurses' Perspectives on Medication Safety in Saudi Hospitals.Healthcare (Basel, Switzerland) · 2026Article
- Associations Between Interruptions and Medication Administration Errors Among Nurses in Hospital Settings: A Scoping Review of Quantitative Studies.Journal of advanced nursing · 2026Article
- Traceability and Anti-Counterfeiting in Agri-Food Supply Chains: A Review of RFID, IoT, Blockchain, and AI Technologies.Sensors (Basel, Switzerland) · 2026Review
- Beyond the 'Go-Live': why context matters in EHR implementations.BMJ health & care informatics · 2026Article
- Article
- Impact of barcode medication administration on patient safety in UK hospital settings: protocol for a mixed-methods realist evaluation.BMJ open · 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 Hybrid Artificial Intelligence Approach for Down Syndrome Risk Prediction in First Trimester Screening.Diagnostics (Basel, Switzerland) · 2025Article
- Medication safety analysis of elderly inpatients based on improved functional resonance analysis method (FRAM): a mixed methods study.Scientific reports · 2025Article
- Do healthcare professionals work around safety standards, and should we be worried? A scoping review.BMJ quality & safety · 2025Article
- A SEIPS-Based Analysis to Understand Safety Culture During Postpartum Hemorrhage.Healthcare (Basel, Switzerland) · 2025Article
- Barcode medication administration system use and safety implications: a data-driven longitudinal study supported by clinical observation.BMJ health & care informatics · 2025Article
- Accurate Medical Vial Identification Through Mixed Reality: A HoloLens 2 Implementation.Electronics · 2024Article
- Application of a Human Factors and Systems Engineering Approach to Explore Care Transitions of Sepsis Survivors From Hospital to Home Health Care.Human factors · 2024Article
- Enhancing neurosurgical navigation operation flow management through personal digital assistant technology: a prospective cohort study.Frontiers in public health · 2024Article
- Designing Human-Centered AI to Prevent Medication Dispensing Errors: Focus Group Study With Pharmacists.JMIR formative research · 2023Article
Corrections and comments
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Authors and funding
4 authors.
Funding
No grant is acknowledged in the PubMed record.
Abstract
introductionBarcode medication administration (BCMA) can, if poorly implemented, cause disrupted workflow, increased workload and cause medication errors. Further exploration is needed of the causes of BCMA policy deviations.
objectiveTo gain an insight into nurses' use of barcode technology during medication dispensing and administration; to record the number and type of BCMA policy deviations, and to investigate their causes.
methodsWe conducted a prospective, mixed-methods study. Medication administration rounds on two hospital wards were observed using a digital tool and field notes. The SEIPS (Systems Engineering Initiative for Patient Safety) model was used to analyse the data.
resultsWe observed 44 nurses administering 884 medications to 213 patients. We identified BCMA policy deviations for more than half of the observations; these related to the level of tasks, organisation, technology, environment and nurses. Task-related policy deviations occurred with 140 patients (66%) during dispensing and 152 patients (71%) during administration. Organisational deviations included failure to scan 29% of medications and 20% of patient's wristbands. Policy deviations also arose due to technological factors (eg, low laptop battery, system freezing), as well as environmental factors (eg, medication room location, patient drawer size). Most deviations were caused by policies that interfere with proper and safe BCMA use and suboptimal technology design.
conclusionOur findings indicate that adaptations of the work system are needed, particularly in relation to policies and technology, to optimise the use of BCMA by nurses during medication dispensing and administration. These adaptations should lead to enhanced patient safety, as the absolute goal with BCMA implementation.
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Registered trials
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