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.
Supported in partVerified against the work's full text
Koppel et al. document barcode-scanning workarounds and overrides when scanners or barcodes fail, but cover none of the other cases or the shared-signature argument.
“workarounds 6 and 7 are efforts to administer medications when confronting problematic patient or medication barcodes and/or when scanners fail.”
- 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.
Supported in partVerified against the work's full text
Koppel and colleagues set out the workflow such systems require of nurses: scan an ID badge to reach the system, obtain the medication, check its label against the electronic medication administration record, “scan medication barcodes”, scan the patient's wristband barcode, administer, and document the administration. That prescribed sequence of scans preceding administration is the workflow the sentence describes. The work lists the medication barcode scanned before the wristband, the reverse of the sentence's order, and names no separate confirm-match step apart from the system's own checking function.
“BCMAs require that users: (1) scan their ID badges to access BCMAs, (2) obtain medications from supply areas, (3) check medication labels against the BCMA eMAR”
- 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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