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J Am Med Inform Assoc. 2002 Sep-Oct;9(5):540-53.

Improving patient safety by identifying side effects from introducing bar coding in medication administration.

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Ohio State University, Columbus, Ohio, USA.



In addition to providing new capabilities, the introduction of technology in complex, sociotechnical systems, such as health care and aviation, can have unanticipated side effects on technical, social, and organizational dimensions. To identify potential accidents in the making, the authors looked for side effects from a natural experiment, the implementation of bar code medication administration (BCMA), a technology designed to reduce adverse drug events (ADEs).


Cross-sectional observational study of medication passes before (21 hours of observation of 7 nurses at 1 hospital) and after (60 hours of observation of 26 nurses at 3 hospitals) BCMA implementation.


Detailed, handwritten field notes of targeted ethnographic observations of in situ nurse-BCMA interactions were iteratively analyzed using process tracing and five conceptual frameworks.


Ethnographic observations distilled into 67 nurse-BCMA interactions were classified into 12 categories. We identified five negative side effects after BCMA implementation: (1) nurses confused by automated removal of medications by BCMA, (2) degraded coordination between nurses and physicians, (3) nurses dropping activities to reduce workload during busy periods, (4) increased prioritization of monitored activities during goal conflicts, and (5) decreased ability to deviate from routine sequences.


These side effects might create new paths to ADEs. We recommend design revisions, modification of organizational policies, and "best practices" training that could potentially minimize or eliminate these side effects before they contribute to adverse outcomes.

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