challenges to evaluating the safety and appropriateness of a medication that has been ordered (IOM, 2001). Relative to the other points along the medication-use continuum, the administration process has the fewest safeguards and fewest support mechanisms, and it often relies on a single health care professional for perfection (Cohen, 2000; IOM, 2003, 2004b).
Several inpatient facilities are beginning to implement bar code medication administration systems to increase assurance that the five rights are being achieved (IOM, 2002; Patterson, 2003; FR, 2004b; Burke et al., 2005). The bar codes placed on unit doses of medications are encoded with the patient’s name, drug, dose, route, and time of administration. Bar code scanners (placed in each patient’s room) are linked to computerized databases containing the patient’s drug regimen. The database may be crosslinked to other health information systems, such as a patient identification master file, an order entry system, and/or the pharmacy database (FR, 2004b; Nicholas and Agius, 2005). The nurse scans the bar code on the medication package and the patient’s identification wristband, allowing the system to determine whether there is a match. Following a confirmation signal, the nurse administers the medication. If there is an alert, the nurse stops the process from going forward, preventing a potential medication error. Because medication administration is a high-volume activity, bar code medication administration systems can provide needed support to nurses during clinical care. They also generate data for the medication administration record (MAR).
Maintenance of an accurate MAR is essential to safety and quality of care (IOM, 2004b). This record serves as a log of all medication-related activities for each patient. Entries are made immediately after a dose has been administered to minimize errors of omission (Cohen, 2000). MARs also document that medications were given in a timely manner for the correct indications. Expanded records are usually reserved for high-risk drugs (e.g., anticoagulants, cardiac drugs, insulin) so as to record important variables affecting administration (e.g., international normalized ratio [INR], used to measure prothrombin time). All medications are typically documented consistently in one place for ease of reference by the team of health care providers that may be caring for a patient. The MAR also serves as a reference in the event of a medication error (Gladstone, 1995; Wakefield et al., 1999). In some cases, third-party payers have reviewed the MAR to look for inconsistencies and gaps in treatment and to find evidence for denying payment.
The types of errors associated with administration-related mortality include (1) dosing errors (40.9 percent, 36.4 percent of which were overdoses); (2) incorrect drug (16 percent); and (3) incorrect route (9.5 percent) (Phillips et al., 2001). Causes of administration errors include miscommunications, miscalculations, workload/staffing problems, interruptions, rapid