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Study of Nurse Workarounds in a Hospital Using Bar Code Medication Administration System

Rack, Laurie L. DNP, RN, NEA-BC; Dudjak, Linda A. PhD, RN; Wolf, Gail A. PhD, RN, FAAN

doi: 10.1097/NCQ.0b013e318240a854

This study analyzed registered nurse workarounds in an academic medical center using bar code medication administration technology. Nurse focus groups and a survey were used to determine the frequency and potential causes of workarounds. More than half of the nurses surveyed indicated that they administered medications without scanning the patient or medications during the last shift worked. Benefits of this study include considerations when implementing bar code medication administration technology that may minimize the development of these workarounds in practice.

Presbyterian Hospital, University of Pittsburgh Medical Center (Dr Rack); and School of Nursing (Drs Dudjak and Wolf), University of Pittsburgh, Pittsburgh, Pennsylvania.

Correspondence: Laurie L. Rack, DNP, RN, NEA-BC, Presbyterian Hospital, University of Pittsburgh Medical Center, 200 Lothrop St, Pittsburgh, PA 15213 (

The authors declare no conflict of interest.

Accepted for publication: November 7, 2011

Published online before print: December 28, 2011.

© 2012 Lippincott Williams & Wilkins, Inc.