Workarounds to Barcode Medication Administration Systems¶
Koppel, R., Wetterneck, T., Telles, J. L., & Karsh, B. (2008). Workarounds to Barcode Medication Administration Systems: Their Occurrences, Causes, and Threats to Patient Safety. Journal of the American Medical Informatics Association, 15(4), 408-423.
Cited by¶
2 citations across 2 artifacts.
Each citation links to the sentence it supports in the citing article.
Primes¶
- Bypassed Safeguard
- The canonical case — four engineered safeguards on a chemical storage tank, each bypassed in enacted practice for a locally rational reason, each locally invisible because nothing had yet gone wrong, so that when the runaway reaction came the designed-safeguard count was four and the enacted-safeguard count was zero — recurs with the same signature in a rogue-trader case where seven internal controls were each bypassed through a tolerated workaround, in a nuclear near-miss where direct inspection was bypassed in favour of mistrusted remote indicators, and in routine hospital barcode-scanning bypass when scanners fail and overrides become standard.
This sourceDocuments BCMA scan bypass under timed-med-pass production pressure and the workarounds nurses adopt.
- The canonical case — four engineered safeguards on a chemical storage tank, each bypassed in enacted practice for a locally rational reason, each locally invisible because nothing had yet gone wrong, so that when the runaway reaction came the designed-safeguard count was four and the enacted-safeguard count was zero — recurs with the same signature in a rogue-trader case where seven internal controls were each bypassed through a tolerated workaround, in a nuclear near-miss where direct inspection was bypassed in favour of mistrusted remote indicators, and in routine hospital barcode-scanning bypass when scanners fail and overrides become standard.
- Procedure-Work Mismatch
- In hospital nursing, an electronic medication-administration system prescribes a barcode-scan workflow: scan patient wristband, scan medication, confirm match, administer.
This sourceDocuments the barcode-scan medication workflow and the workarounds (batch-scanning, taped barcodes) nurses use to bridge it.
- In hospital nursing, an electronic medication-administration system prescribes a barcode-scan workflow: scan patient wristband, scan medication, confirm match, administer.
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