Table 2

Organisational policy deviations with barcode medication administration and their connection to potential medication errors

Types of policy deviations*NExamples and descriptionsPotential medication errors
Medication not dispensed; obtained and given during observation55Nurse did not check for omission of dispensing before administration round start even though some medications (eg, parenteral injectables) were not expected to be found in the COW at allOmission
Medication not dispensed; not given during observation†25
Barcode label missing70Dispensed tablets without a barcode label, or without primary packagingWrong medication
Wrong dose
Wrong dose dispensed†30Dispensed whole blister pack instead of one tablet (correct dose)Wrong dose
Scanning failure26Barcode on the medication was not readable for the scannerWrong medication
Wrong dose
Wrong route
Barcode label not attached13Barcode label was in the patient drawer but not attached to the medication
Nurses stored expired labels for future administrations to save time from printing new labels
Wrong medication
Wrong medication dispensed†11Dispensed extended-release tablet instead of tablet
Dispensed sound-alike medication, for example, Lescol instead of Losec
Dispensed 2 g Cloxacillin intravenous bag from the storage room instead of 1 g
Errors discovered by scanning in eMAR
Wrong medication
COW deviations due to recent changes in the eMAR7Antithrombotic medication was dispensed in the patient drawer, nurse removed it during administration due to the patient being scheduled for surgery that dayContraindication
Wrong drug
Wrong route
Medication placed in the wrong compartment in the drawer5During dispensing, medication prescribed for morning administration was placed in the compartment in the patient drawer assigned for evening administrationWrong medication
Omission or wrong time
Wrong room number on patient drawer3The patient changed the room, but the room number on the patient drawer was not changedWrong patient
Wrong label attached1Attached ‘metoprolol’ label on a generic substitute Bloxazoc (metoprolol) unit dose. Revealed after failure with scanning the labelWrong medication
Wrong dose
Patients’ own medication stored in the patient room24We observed deviation of this policy for 24 of total 25 patients’ own medications (96%)Wrong dose
Wrong medication
  • *The number of deviations refers to one deviation of the same type per patient even if more deviations of same type exist with one patient, for example, if one patient had wrong dose dispensed for two medications, this was counted as one deviation.

  • †Deviations which also classify as actual medication errors.

  • COW, computer on wheels; eMAR, electronic Medication Administration Record.