ASHP Best Practices Award Mortar and Pestle
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Creating a Safer Environment for Medication Administration Utilizing Barcode Technology and Medication Observation Methodology

Richard D. Paoletti, M.B.A., R.Ph., Tina M. Suess, R.N., Michael G. Lesko, D.O., Alfred A. Feroli, M.S., R.Ph., James A. Kennel, Pharm.D., Joye M. Mahler, Timothy Sauders


Lancaster General Hospital
Lancaster, Pennsylvania



The purpose of this project was to systematically decrease adverse medication events through utilization of observation methodology and deployment of an electronic medication administration record (EMAR) and barcode point-of-care (BPOC) verification system.

Description of the Program

Direct observation technique was utilized to provide a consistent and reliable approach to data collection prior to and post implementation of changes to the medication use process. The EMAR and BPOC system was implemented to minimize administration-phase errors associated with the hospital's handwritten, non-pharmacy generated, five-day medication administration record. An extensive amount of work occurred in pharmacy, nursing and information services relating to system design and deployment. Implementation was systematically deployed by one nursing unit beginning in August, 2003 with full implementation on all inpatient units by July, 2004.

Experience with the Program

Implementation of the EMAR and BPOC system has provided significant enhancements to the medication administration process. Post implementation data demonstrated a 54% reduction (p=0.045) in medication errors. By utilizing system reports, this program has significantly enhanced the ability to capture valuable data related to medication administration and compliance with established medication administration processes. The Prevented Medication Error Report displays warning notices to the nurse (and/or provider) administering medication resulting in the nurse stopping the process of medication administration. The Possible Medication Error Report is used to identify nurses who are not utilizing the BPOC system correctly. One of the most important aspects of this medication safety initiative is the ongoing, systematic, direct observation of medication administration on nursing units. The direct observation accuracy rate prior to BPOC was 86.5%; after BPOC implementation, the accuracy rate rose to 97%. A multidisciplinary, collaborative approach and a common goal were instrumental in selecting and effectively implementing the tools that would enable our team to accomplish a 54% reduction of medication administration errors and provide a safer environment for our patients.


Implementation of this technology has served only as the beginning to achieving better patient care through enhanced medication safety. The combination of an EMAR and BPOC system to reduce medication administration errors coupled with the measurement of error rates through direct observation techniques has made this initiative a tremendous success.

The true impact of this initiative will continue to be measured for years to come as more initiatives and procedures are created in response to the data gleaned from utilization of this system.

View a pdf of the poster from the Midyear Meeting (3.8mb).