Improving the bar-coded medication administration system at the Department of Veterans Affairs

Medication errors account for significant patient morbidity and mortality1,–3 as well as legal, operational, and patient care costs.4,5 Common causes of these errors, such as lack of knowledge about a drug, lack of information about a patient, rule violations, and transcription errors, have been described.6,7 The system failures that frequently lead to medication errors may be prevented at the level of the event, where workplace design issues predominate,8 and at the organizational level, where policies that inadvertently promote the risk for failure are primary.9 The interdependent processes in medication-use systems typify the situation where the risk of failure increases with a task’s complexity.10 Several anecdotal reports have indicated that bar-coding systems successfully lower medication administration errors in Veterans Affairs (VA) medical centers11 and other medical systems.12,–15 Nevertheless, within VA, there have been significant negative effects since introducing the bar-coded medication administration (BCMA) system.16 More generally, VA discovered that introducing new technology to complex medical systems, while beneficial, also presents new challenges.17