Medication administration errors may threaten patients’ safety and lead to negative health outcomes. When nurses administer and dispense medications to their patients, they should confirm the “five rights” of drug administration: “right patient, right medication, right dose, right route and right time” (Mulac et al., 2021, p. 1021). Therefore, the barcode medication administration (BCMA) system was developed to help nurses improve the process of drug administration and decrease medication errors. Although this system has some limitations and weaknesses, research shows that it can reduce the number of medication administration errors and improve patient health outcomes.
The aims of the review are to evaluate BCMA usage outcomes, identify the reasons for policy deviations involved in the process of BCMA, and examine the effect of BCMA on nurses’ satisfaction and patient outcomes. The literature review will also address the problems associated with the introduction of new technology in a clinical setting. Moreover, it will provide a brief comparison of the rate of medication errors before and after the implementation of BCMA. In this literature review, the strengths and weaknesses of the BCMA usage in the clinical environment and nurses’ reflections on this technology will be analyzed to answer the following question: What is the nurses’ satisfaction level with BCMA usage, and how is it connected to the reduction in medication errors? Finally, the review will help understand whether implementing the BCMA technology will decrease the number of medical mistakes.
Barcode Medication Administration (BCMA) and electronic Medication Administration Record (e-MAR) technologies are health information technologies aimed to minimize medical mistakes and enhance patient safety outcomes. Although BCMA technology has already existed for over two decades, hospitals and clinics have struggled to implement it within their clinical environment (Mulac et al., 2021). However, research showed that the implementation of BCMA and e-MAR could reduce medication errors significantly, improving patient outcomes and nurses’ satisfaction with the medication administration process (Naidu & Alicia, 2019). This literature review will focus on the experience of nurses from hospitals in Norway, Jordan, southern Taiwan, the University of Washington Medical Center, and other clinical settings. The target population who used this technology were registered nurses and other healthcare providers employed at the chosen hospitals for at least six months, able to administer drugs to their patients on a daily basis, and willing to participate in research.
The main difficulties nurses and other health care practitioners face are related to technological issues and nurses’ skills. Thus, nurses had to adjust to new technology, increasing their workload (Naidu & Alicia, 2019). Moreover, the new system had problems with hardware and software, had no access to Wi-Fi, refused to scan some labels and barcodes, and was hard to transport from one patient room to another (Darawad et al., 2019). On the other hand, those nurses who managed to adopt the new technology quickly reported the reduction of medical errors and increased work benefits (Lin et al., 2018). This literature review will focus on both advantages and disadvantages of BCMA technology and offer recommendations on improving patient outcomes with its help.
The subject of medication error reduction is important because it can help nurses decrease the number of errors and enhance health outcomes. According to Bowdle et al. (2018), in 2002-2003, there were 0.62% reports of errors and 0.23% reports of intercepted errors (p. 1338). In 2014, when BCMA was implemented, the number of errors associated with medication infusion decreased. Thus, there were 0.39% reports of mistakes and 0.075% reports of intercepted errors (Bowdle et al., 2018). One can see that the usage of BCMA was associated with a significant reduction of medical errors in the clinical environment. Nevertheless, to attain such good results, nurses should be able to understand how to improve their satisfaction with the use of this technology and how their satisfaction affects their patient outcomes.
This literature review involved a search using databases to include Medline, PubMed, CINAHL, and Cochrane Library. The PICO format was used to plan the investigation and identify the keywords to include patient safety, barcode medication administration, medication errors, nurses’ satisfaction, information system, and electronic medication record. These keywords were used because they facilitated search results. Since the focus of the literature review was on the barcode medication administration system and its effect on medication errors, patient outcomes, and nurses’ satisfaction, the chosen keywords made the search easier and more efficient.
Search criteria included articles that were qualitative, quantitative, and mixed-method studies. Since the main purpose of the review was to evaluate the effectiveness of the BCMA system, most articles reviewed were quantitative. However, nurses’ experience and satisfaction with the technology were also researched, so qualitative and mixed-method articles were searched to find this information. To be incorporated in this review, articles were required to be peer-reviewed and published between 2016 to 2021. University of Houston Victoria library was utilized as well as Google Scholar. Articles included had to be published in the English language. At the same time, the setting could be other than the United States since it was important to understand the impact of BCMA technology on medical errors worldwide.
Synthesis of the Evidence
The medication administration process is often associated with errors that can negatively affect patient health and safety outcomes. These errors may occur due to different factors, including difficulties with transcribing hand-written prescriptions, confusing patients and prescribed drugs, similar drug names, interruptions, workload, and others. To minimize these errors, many hospitals began introducing a barcode medication administration (BCMA) technology in their clinical environments. However, while this technology reduces medication administration errors, it is associated with policy deviations and nurses’ dissatisfaction. Therefore, healthcare workers and scientists began to study the main reasons for nurses’ dissatisfaction with the use of BCMA and how to address these reasons.
Five different studies were reviewed concerning the use of BCMA technology and its impact on nurses’ satisfaction, the reduction of medical errors, and the overall benefits and limitations of this system. All five studies concluded that BCMA could significantly decrease the number of medical mistakes (Mulac et al., 2021; Naidu & Alicia, 2019; Darawad et al., 2019; Lin et al., 2018; Browdle et al., 2018). However, in some studies, nurses’ satisfaction was higher (Lin et al., 2018; Darawad et al., 2019), while in other studies, nurses found BCMA less useful (Naidu & Alicia, 2019; Mulac et al., 2021). For example, in hospitals where nurses were taught how to use the BCMA system, their satisfaction level was higher, while in those organizations where the introduction process was omitted, the level of contentment was lower (Lin et al., 2018; Darawad et al., 2019). These and other discoveries can be seen in Appendix: Evidence Table.
A mixed-method study by Mulac et al. (2021) focused on the policy deviations associated with the usage of BCMA. Researchers found that the main causes of policy deviations were related to a complex dispensing process, unclear descriptions of policies, slow or too complicated BCMA procedures, and problems with technology (Mulac et al., 2021). Other researchers complement these findings, adding that nurses reported that the deviations occurred because BCMA was time-consuming, the device was hard to transport from room to room, Wi-Fi connection was slow, and some medication labels could not be scanned properly (Naidu & Alicia, 2019; Darawad et al., 2019; Lin et al., 2018). Jordanian nurses, for instance, reported that BCMA was a waste of time, and they could spend this time on patient care instead (Darawad et al., 2019). Still, most nurses agreed that if the technology-related problems were fixed, they would evaluate this system as useful.
At the same time, a quantitative study by Browdle et al. (2018) demonstrated that the numbers of medical errors and intercepted errors were reduced significantly after the implementation of the barcode-based safety system. Though, the limitation of this research is that it was conducted only by anesthesia providers, so it cannot be generalized and applied to all healthcare practitioners. In Lin et al.’s (2018) research, medication errors decreased from 405 to 314 after the implementation of BCMA. Likewise, Mulac et al. (2021) discovered that the new technology prevented the administration of wrong dispensed drugs for 5% of the clients.
Another benefit of the latest technology was the possibility to check the most relevant and recent medication information (Lin et al., 2018). Nurses did not need to look for the information in hand-written notes but could check it immediately. On the other hand, Mulac et al.’s (2021) study showed that nurses could not take for granted that their colleagues dispensed all medications correctly. They affirmed that manual confirmation of the medication administration was still needed to check the correctness of their fellow nurses’ work (Mulac et al., 2021). Nevertheless, the studies’ results cannot be generalized due to the small sample size and one study site.
Five reviewed studies concluded that nurses’ satisfaction with the use of BCMA was correlated with their computer skills and policy knowledge. Those nurses who received support and training before and during the BCMA system implementation reported higher contentment than those who did not receive any help (Naidu & Alicia, 2019; Darawad et al., 2019; Lin et al., 2018). The results of the studies demonstrate that nurses’ satisfaction can be improved through education, constant support, clear and specific policies, use of bar-coded and clearly labeled medications, better internet connection, effective communication between healthcare providers, and assistance with device transportation. Moreover, the reduction in medical errors was also associated with nurses’ satisfaction and, consequently, better patient safety. All studies agreed that BCMA was a useful technology that could reduce medication administration errors significantly.
At the same time, most of the reviewed studies have limitations. For instance, Mulac et al.’s (2021) study focuses on policy deviations instead of medication errors, so it is not easy to identify the impact of BCMA on patient safety. Naidu and Alicia (2019) conducted their study within an anonymous organization with limited sample size, and the nurses’ feedback might be affected by the supervision process. Similarly, researches by Darawad et al. (2019), Lin et al. (2018), and Browdle et al. (2018) were limited to a small sample of participants and a limited setting, which means that their results cannot be generalized. Further research is needed to replicate the study after the full implementation of BCMA technology in other hospitals across the world and compare the outcomes with the existing studies. Moreover, evaluating nurses’ experience of medication administration before using BCMA is also important since it can help understand whether nurses’ dissatisfaction with this device is biased or not.
Recommendations and Conclusions
Based on the literature review of five scholarly articles, one can conclude that nurses’ satisfaction with BCMA is positively correlated with their overall satisfaction and leads to the reduction in medical errors. If nurses are trained before the implementation of BCMA, receive constant support and supervision during this implementation, and have no problems with the Internet connection or barcode scanning process, their satisfaction level will increase. Consequently, if nurses are satisfied, they will make fewer mistakes and improve patient safety and health outcomes. Therefore, to increase nurses’ satisfaction with the BCMA process, healthcare institutions should provide them with training and support before implementing the new technology into the clinical setting. Another recommendation would be to solve the Internet-related issues, like the speed of the Internet connection, Wi-Fi connection, or various software bugs. Besides, communication between nurses and doctors about medication orders should also be improved. Medical establishments should also use only those medications labeled with clear and scannable barcodes.
Nurses should consider the following aspects of BCMA usage in order to follow the recommendations mentioned above. First, nurses should objectively assess their experience of using this technology. They should report any issues related to the difficulties in utilizing and transporting the device to their authorities. They should reflect on their perceptions of the technology and identify their personal barriers against its usage. It will help them better evaluate their skills and knowledge and attend training courses when needed. Moreover, if they do not receive appropriate education or support, they should demand it. Healthcare institutions should provide nurses with technology-specific policies and ensure that all workers comply with these policies and understand them clearly. Shared learning of BCMA usage between nurses in different clinical settings should be promoted to improve knowledge and staff motivation. Healthcare providers should recognize this technology as a part of their routine care standards and improve their computer skills if necessary.
The current research has some gaps and limitations that need to be addressed. The main gap of the observational study by Mulac et al. (2021) is that nurses were informed about the observation process. Thus, they could change their behavior while using BCMA technology, affecting the results of the observation. Moreover, most studies were limited to one study site, where nurses were responsible for administering medications. The results might be different for other organizations that use automated medication dispensing or are operated by pharmacies. In addition, the reviewed studies focused on nurses without the involvement of other specialists, like pharmacists and physicians. Their inclusion in research would add to the comprehension of the new technology implementation, helping develop new strategies to simplify the application and reduce the system’s drawbacks. Furthermore, the researchers examined the reasons for medical errors related to designated work process matters, while other reasons, like a human factor or nurses’ health condition, were ignored. Subsequently, further research is needed to understand the impact of BCMA on the reduction of medication errors, taking into account human-related factors that may affect these results. To conclude, it is important to address all these gaps to make future studies on the topic more informative, objective, and specific.
Bowdle, T. A., Jelacic, S., Nair, B., Togashi, K., Caine, K., Bussey, L., Kruger, C., Grieve, R., Grieve, D., Webster, C. S., & Merry, A. F. (2018). Facilitated self-reported anaesthetic medication errors before and after implementation of a safety bundle and barcode-based safety system. British Journal of Anaesthesia, 121(6), pp. 1338-1345. Web.
Darawad, M. W., Othman, E. H., & Alosta, M. R. (2019). Nurses’ satisfaction with barcode medication‐administration technology: Results of a cross‐sectional study. Nursing & health sciences, 21(4), pp. 461-469. Web.
Lin, J. C., Lee, T. T., & Mills, M. E. (2018). Evaluation of a barcode medication administration information system. CIN: Computers, Informatics, Nursing, 36(12), pp. 596-602. Web.
Mulac, A., Mathiesen, L., Taxis, K., & Granås, A. G. (2021). Barcode medication administration technology use in hospital practice: a mixed-methods observational study of policy deviations. BMJ quality & safety, 30(12), pp. 1021-1030. Web.
Naidu, M., & Alicia, Y. L. Y. (2019). Impact of bar-code medication administration and electronic medication administration record system in clinical practice for an effective medication administration process. Health, 11(05), p. 511. Web.
(list in-text citation)
|Purpose||Study Design (RCT, Qualitative, Quantitative, Mixed Method, Systematic Review, Practice Guideline) |
Include Level of Evidence (I through VIII)
|Population Description |
Sample Size (N=__ )
|Name and Description of Instrument(s) |
(Means of Collecting Data)
|(Bowdle et al., 2018)||Compares the rates of medical errors before and after implementation of a medication safety bundle, including barcode medication administration technology.||Quantitative |
Level VI: A single descriptive study.
|The number of anesthesia providers, including anesthesiologists and nurse anesthetists, is not given. The numbers of patients are: |
N = 11 709
N = 14 572
N = 24 264
|Anonymous medication error survey paper forms were submitted for every anesthesia record||Top 3 error types before the implementation of the BCMA system: |
After the introduction of the BCMA system, all these errors declined significantly (a 63% reduction in reported errors).
|(Darawad et al., 2019)||To examine the effect of introducing BCMA on nurses’ satisfaction and identify the relationship between nurses’ demographic variables and their perceived rating of BCMA and their satisfaction level with the use of this technology.||Quantitative |
Level VI: A single descriptive cross-sectional study
|Registered nurses working in Jordanian hospitals adopting BCMA technology. |
N = 207
|Self-reporting questionnaire included five items that had to be rated on a scale ranging from 0 to 10.||65% of participants reported BCMA improved their performance; 60% agreed that their productivity increased; 63% affirmed that BCMA enhanced job effectiveness; 54% perceived the system as useful, and 43% agreed that it was easy to use.|
|(Lin et al., 2018)||To evaluate BCMA system outcomes.||Quantitative |
Level VI: A single descriptive study
|Nurses from Taiwan, |
N = 232
|A questionnaire, composed of 27 items, included system quality, information quality, user satisfaction, and usage benefits.||After the implementation of the BCMA system, medication errors decreased from 405 to 314. The higher overall nurses’ satisfaction with the technology, the greater the usage benefits perceived by them.|
|(Mulac et al., 2021)||To understand how do nurses use the barcode technology while dispensing and administering medications; to trace the quantity and type of deviations that occur with BCMA policies, and to examine their causes.||Mixed-method study |
Level IV: case study
|Nurses from two medical wards (cardiac and geriatric intensive care) at a 700-bed hospital in Norway |
N = 44
|A digital observational tool (handheld tablets) was used to gather data from nurses||Researchers observed policy deviations that affected patient outcomes negatively. The main causes of deviations were related to unclear policy description, a complex dispensing process, suboptimal quality design, and a slow and difficult BCMA procedure.|
|(Naidu & Alicia, 2019)||To assess the BCMA and e-MAR usage outcomes, policies, processes, and clinical practices that affect nurses administering drugs in the clinical setting using the above-mentioned technologies.||Qualitative |
Level I: Evidence from systematic reviews of randomized control trials that have similar results
|After completing the systematic review, a pilot study with nursing staff and multidisciplinary doctors was initiated within an anonymous organization. |
N = 43
|Systematic review; survey||Although the use of BCMA and e-MAR may be complex and lead to delays in medication administration, these technologies can be effectively used once they are recognized as a part of a daily routine process.|