Failure to Plan, Failure to Rollout: Bar Code Medication Verification Failure

A community hospital implemented a bar code medication verification (BMV) system to improve tracking of medications and support safe medication administration. In addition to the software for BMV, hospital administrators purchased laptop computers stationed atop wheeled carts, or workstations on wheels, and medication bar code scanners. Medication errors were made, the same medication errors the BMV system was supposed to correct. Medications were kept in a med room that housed a dispensing machine. Nurses had to enter their username and personal identification number, choose the patient, choose the medication, remove it, and sign out. Although against policy, nurses routinely did this with controlled medications because in the paper system if a nurse forgot to sign off the medicine, someone could sign and cosign it so the record was kept properly. BMV programs are sophisticated, complex systems that are supposed to increase the safety of patients and decrease errors in medication administration.