Probable causes to barcode medication administration policy deviations according to the SEIPS categories
| Probable cause | Example from observation/description | Data source |
| Tasks related | ||
| Scanning discarded during dispensing | Medications which were dispensed without scanning in the eMAR failed to scan during administration | Observational tool |
| Workflow not adopted to required tasks during administration | Nurse makes multiple runs back and forth to the medication room to retrieve not dispensed medications which interrupts the workflow and may affect patient safety | Observational tool Nurses’ comments |
| Suboptimal task performance | Voluminous medications (such as infusion bags, inhalers, eye drops) are routinely not scanned during dispensing because they are retrieved during administration | Observational tool Nurses’ comments |
| Organisational | ||
| Dispensing practices not adopted to nurse’s workload, resulted in normalising deviations | Manual labelling of medications during dispensing on ward was challenging to carry out without workarounds | Observational tool |
| Non-standardised dispensing process resulted in frequent deviations | Medication not barcode labelled; scanning failure; wrong dose dispensed; wrong medication dispensed; medication not dispensed; wrong label attached | Observational tool |
| Unclear procedures or task not assigned | Varying practice between the wards on updating the dispensed medications in the COW due to recent changes in the eMAR | Observational tool Nurses’ comments Field notes |
| Poor routines/not followed routines for changing the room number on patient drawer | Room number on patient drawer was another patient’s room number (Each patient drawer was labelled with room number and this was the first step in identifying the patient’s medications) | Observational tool |
| Unaware of hospital policies | Patient’s own medications stored in the patient room. Due to policy, patients’ own medication should be stored in the COW or the medication room | Observational tool |
| Technology | ||
| Poor charging routines or non-compliance with routine | The laptop battery was low either at the start or during administration | Observational tool |
| eMAR usability issues | Slow eMAR response and need for multiple clicking after scanning each medication | Field notes |
| The scanners were not wireless and limited the patient ID scanning | Nurse scanned medications prior to entering the patient room and administered medications while the COW was in the hallway, meaning that the patient ID wristband was not scanned | Field notes |
| Suboptimal COW design | Nurses often avoided to bring the bulky COW into the patient room when administering few or one single medication The COW design was cumbersome for the desired workflow of entering patient rooms during administration rounds The COW contained medications for all patients which combined with scanning not being used is a risk for patient safety | Field notes Nurses’ comments |
| Environmental | ||
| Medication room location affects task efficiency and time spent administering medications | The medication room was located far from the nursing station and most of the patient rooms. This resulted in slower administration and storage of random medications in the nursing station to avoid going back and forth to the medication room | Observational tool Field notes |
| Patient drawer size does not allow appropriate BCMA use | The small size patient drawer led to deviations such as not dispensing the medications because only small forms of oral medications and ampoules were dispensed in the patient drawer, whereas voluminous medications were retrieved during administration | Observational tool Field notes Nurses’ comments |
| Non-specific medication storage policy | Random single-unit doses stored on the desk in the nursing station or on the COWs and were obtained from here in case something was missing during administration. Unsafe practice as the single doses are easy to mix up when stored randomly on the COW during administration | Field notes |
| Nurse related | ||
| Non-standardised dispensing allows variations | Variations in performance between nurses and inconsistency in dispensing medications for the same nurse | Observational tool Field notes Nurses’ comments |
| BCMA slower than manual verification—leading to user dissatisfaction | Nurse did not use the BCMA at all during the whole medication round Nurse admitted to not using the BCMA on regular basis but used it during observation period | Observational tool Field notes Nurses’ comments |
BCMA, barcode medication administration; COW, computer on wheels; eMAR, electronic Medication Administration Record.