Medication Administration and Information Technology

  • Catherine Garger
  • Carol Matlin
  • George R. Kim
  • Robert E. Miller
Part of the Health Informatics book series (HI)


Medication administration is the final step in the medication delivery cycle before a prescribed drug reaches a patient. In ambulatory settings, the patient, or in the case of children, the parent or guardian is responsible for accepting prescribed medications from the pharmacist and following directions regarding direct administration of drug doses. In inpatient settings, it is principally the bedside nurse who administers prescribed medications. A study of inpatient settings suggests that interventions by pediatric clinical pharmacists, while effective for intercepting prescribing errors, may be ineffective in intercepting harmful administration errors.1


Medication Administration Administration Error Computerize Patient Record System Medication Administration Record Medication Administration Error 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


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  1. 1.
    Wang JK, Herzog NS, Kaushal R, Park C, Mochizuki C, Weingarten SR. Prevention of pediatric medication errors by hospital pharmacists and the potential benefit of computerized physician order entry. Pediatrics. 2007;119(1):e77–e85.PubMedCrossRefGoogle Scholar
  2. 2.
    Institute for Safe Medical Practices (ISMP). ISMP's List of High-Alert Medications; 2007. Available at: Accessed December 21, 2008.
  3. 3.
    Vanitha V, Narasimhan KL. Intravenous breast milk administration-a rare accident. Indian Pediatr. 2006;43(9):827.PubMedGoogle Scholar
  4. 4.
    Warner B, Sapsford A. Misappropriated human milk: fantasy, fear, and fact regarding infectious risk. Newborn Infant Nurs Rev. 2004;4(1):56–61.CrossRefGoogle Scholar
  5. 5.
    Martínez-Costa C, Silvestre MD, López MC, Plaza A, Miranda M, Guijarro R. Effects of refrigeration on the bactericidal activity of human milk: a preliminary study. J Pediatr Gastroenterol Nutr. 2007;45(2):275–277.PubMedCrossRefGoogle Scholar
  6. 6.
    Hanna N, Ahmed K, Anwar M, Petrova A, Hiatt M, Hegyi T. Effect of storage on breast milk antioxidant activity. Arch Dis Child Fetal Neonatal Ed. 2004;89(6):F518–F520.PubMedCrossRefGoogle Scholar
  7. 7.
    Cochran GL, Jones KJ, Brockman J, Skinner A, Hicks RW. Errors prevented by and associated with bar-code medication administration systems. Jt Comm J Qual Patient Saf. 2007;33(5):293–301, 245.PubMedGoogle Scholar
  8. 8.
    Snijders C, van Lingen RA, Molendijk A, Fetter WP. Incidents and errors in neonatal intensive care: a review of the literature. Arch Dis Child Fetal Neonatal Ed. 2007;92(5):F391–F398.PubMedCrossRefGoogle Scholar
  9. 9.
    Bridge L. Reducing the risk of wrong route errors. Paediatr Nurs. 2007;19(6):33–35.PubMedGoogle Scholar
  10. 10.
    Ryan CA, Mohammad I, Murphy B. Normal neurologic and developmental outcome after an accidental intravenous infusion of expressed breast milk in a neonate. Pediatrics. 2006;117(1):236–238.PubMedCrossRefGoogle Scholar
  11. 11.
    Gray JE, Suresh G, Ursprung R, et al. Patient misidentification in the neonatal intensive care unit: quantification of risk. Pediatrics. 2006;117(1):e43–e47.PubMedCrossRefGoogle Scholar
  12. 12.
    Howanitz PJ, Renner SW, Walsh MK. Continuous wristband monitoring over 2 years decreases identification errors: a College of American Pathologists Q-Tracks Study. Arch Pathol Lab Med. 2002;126(7):809–815.PubMedGoogle Scholar
  13. 13.
    Drenckpohl D, Bowers L, Cooper H. Use of the six sigma methodology to reduce incidence of breast milk administration errors in the NICU. Neonatal Netw. 2007;26(3):161–166.PubMedGoogle Scholar
  14. 14.
    Wikipedia. Radio-Frequency Identification; 2007. Available at: Accessed December 21, 2008.
  15. 15.
    Grey M. Tracking with RFID. Brigham and Women's is keeping tabs on expensive equipment and valuable devices with the help of an indoor positioning system. Healthc Inform. 2007;24(11):25–27.Google Scholar
  16. 16.
    Levine M, Adida B, Mandl K, Kohane I, Halamka J. What are the benefits and risks of fitting patients with radiofrequency identification devices. PLoS Med. 2007;4(11):e322.PubMedCrossRefGoogle Scholar
  17. 17.
    Sade RM, American Medical Association Council on Ethical and Judicial Affairs. Radio Frequency ID Devices in Humans. American Medical Association; 2007. Available at: Accessed December 21, 2008.
  18. 18.
    Anastos JP. The ambient experience in pediatric radiology. J Radiol Nurs. 2007; 26(2):50–55.CrossRefGoogle Scholar
  19. 19.
    Campbell BC, Anastos J. Can CT scans be ‘fun’? Innovative CT suite gives children greater control over the environment to ease their fears. Healthc Exec. 2006;21(1):36–37.PubMedGoogle Scholar
  20. 20.
    The Joint Commission. Root causes: practical approaches for preventing infant abductions. Jt Comm Persp Patient Saf. 2003;3(10):7–8.Google Scholar
  21. 21.
    Miller RS. Preventing infant abduction in the hospital. Nursing. 2007;37(10):20, 22.PubMedGoogle Scholar
  22. 22.
    Vanderveen T. Smart Pumps: Advanced Capabilities and Continuous Quality Improvement. Patient Safety and Quality Healthcare; 2007. Available at: Accessed December 21, 2008.
  23. 23.
    Syed S, Paul JE, Hueftlein M, Kampf M, McLean RF. Morphine overdose from error propagation on an acute pain service. Can J Anaesth. 2006;53(6):586–590.PubMedCrossRefGoogle Scholar
  24. 24.
    Steffen M, von Hintzenstern U, Obermayer A. Critical infusion incident caused by incorrect use of a patient-controlled analgesia pump. Anaesthesiol Reanim. 2002;27(4):107–110.PubMedGoogle Scholar
  25. 25.
    Elannaz A, Chaumeron A, Viel E, Ripart J. Morphine overdose due to cumulative errors leading to ACP pump dysfunction. Ann Fr Anesth Reanim. 2004;23(11):1073–1075.PubMedGoogle Scholar
  26. 26.
    Vicente KJ, Kada-Bekhaled K, Hillel G, Cassano A, Orser BA. Programming errors contribute to death from patient-controlled analgesia: case report and estimate of probability. Can J Anaesth. 2003;50(4):328–332.PubMedCrossRefGoogle Scholar
  27. 27.
    Doyle DJ, Vicente KJ. Electrical short circuit as a possible cause of death in patients on PCA machines: report on an opiate overdose and a possible preventive remedy. Anesthesiology. 2001;94(5):940.PubMedCrossRefGoogle Scholar
  28. 28.
    Rothschild JM, Keohane CA, Cook EF, et al. A controlled trial of smart infusion pumps to improve medication safety in critically ill patients. Crit Care Med. 2005;33(3):533–540.PubMedCrossRefGoogle Scholar
  29. 29.
    Larsen GY, Parker HB, Cash J, O'Connell M, Grant MC. Standard drug concentrations and smart-pump technology reduce continuous-medication-infusion errors in pediatric patients. Pediatrics. 2005 July;116(1):e21–e25.PubMedCrossRefGoogle Scholar
  30. 30.
    Conroy S, Sweis D, Planner C, Yeung V, Collier J, Haines L, Wong IC. Interventions to reduce dosing errors in children: a systematic review of the literature. Drug Saf. 2007;30(12):1111–1125.PubMedCrossRefGoogle Scholar
  31. 31.
    Eisenhauer LA, Hurley AC, Dolan N. Nurses' reported thinking during medication administration. J Nurs Scholarsh. 2007;39(1):82–87.PubMedCrossRefGoogle Scholar
  32. 32.
    Hurley AC, Bane A, Fotakis S, et al. Nurses' satisfaction with medication administration point-of-care technology. J Nurs Adm. 2007;37(7–8):343–349.PubMedGoogle Scholar
  33. 33.
    Vogelsmeier AA, Halbesleben JR, Scott-Cawiezell JR. Technology implementation and workarounds in the nursing home. J Am Med Inform Assoc. 2008;15(1):114–119.PubMedCrossRefGoogle Scholar
  34. 34.
    Larrabee S, Brown MM. Recognizing the institutional benefits of bar-code point-of-care technology. Jt Comm J Qual Saf. 2003;29(7):345–353.PubMedGoogle Scholar
  35. 35.
    Franklin BD, O'Grady K, Donyai P, Jacklin A, Barber N. The impact of a closed-loop electronic prescribing and administration system on prescribing errors, administration errors and staff time: a before-and-after study. Qual Saf Health Care. 2007;16(4):279–284.PubMedCrossRefGoogle Scholar
  36. 36.
    Wideman MV, Whittler ME, Anderson TM. Barcode Medication Administration: Lessons Learned from an Intensive Care Unit Implementation. Advances in Patient Safety: From Research to Implementation. Vo l 3, AHRQ Publication Nos. 050021 (1–4). Agency for Healthcare Research and Quality, Rockville, MD; 2005: 437–451. Available at: http://www. Accessed December 21, 2008.
  37. 37.
    Kirkley D, Stein M. Nurses and clinical technology: sources of resistance and strategies for acceptance. Nurs Econ. 2004;22(4):195, 216–222.Google Scholar
  38. 38.
    Kim GR, Miller MR, Ardolino MA, Smith JE, Lee DC, Lehmann CU. Capture and classification of problems during CPOE deployment in an academic pediatric center. AMIA Annu Symp Proc. 2007:414–417.Google Scholar
  39. 39.
    Wakefield BJ, Uden-Holman T, Wakefield DS. Development and Validation of the Medication Administration Error Reporting Survey. Advances in Patient Safety: From Research to Implementation. Volumes 4, AHRQ Publication Nos. 050021 (1–4). Agency for Healthcare Research and Quality, Rockville, MD; 2005. Available at: Accessed December 21, 2008.
  40. 40.
    Keatings M, Martin M, McCallum A, Lewis J. Medical errors: understanding the parent's perspective. Pediatr Clin North Am. 2006;53(6):1079–1089.PubMedCrossRefGoogle Scholar
  41. 41.
    Bayley KB, Savitz LA, Rodriguez G, Gillanders W, Stoner S. Barriers Associated with Medication Information Handoffs. Advances in Patient Safety: From Research to Implementation. Volumes 3, AHRQ Publication Nos. 050021 (1–4). February 2005. Agency for Healthcare Research and Quality, Rockville, MD; 2005. Available at: http://www.ncbi. Accessed December 21, 2008.
  42. 42.
    Rinke ML, Shore AD, Morlock L, Hicks RW, Miller MR. Characteristics of pediatric chemotherapy medication errors in a national error reporting database. Cancer. 2007;110(1): 186–195.PubMedCrossRefGoogle Scholar
  43. 43.
    United States Department of Veteran Affairs. Veterans Health Information Systems and Technology Architecture (VistA) Monograph; 2006. Available at: Accessed December 21, 2008.
  44. 44.
    Patterson ES, Cool RI, Render ML. Improving patient safety by identifying side effects from introducing bar coding in medication administration. J Am Med Inform Assoc. 2002;9:540–553.PubMedCrossRefGoogle Scholar
  45. 45.
    Mills PD, Neily J, Mims E, Burkhardt ME, Bagian J. Improving the bar-coded medication administration system at the Department of Veterans Affairs. Am J Health Syst Pharm. 2006;63(15):1442–1447.PubMedCrossRefGoogle Scholar
  46. 46.
    Young D. Pittsburgh hospital combines RFID, bar codes to improve safety. Am J Health Syst Pharm. 2006;63(24):2431, 2435.PubMedCrossRefGoogle Scholar
  47. 47.
    Shogan MG. Emergency management plan for newborn abduction. J Obstet Gynecol Neonatal Nurs. 2002;31(3):340–346.PubMedCrossRefGoogle Scholar
  48. 48.
    Sullivan L. RFID System Prevented A Possible Infant Abduction. Information Week; 2005. Available at: Accessed December 21, 2008.
  49. 49.
    Cesario SK. Selecting an infant security system. AWHONN Lifelines. 2003;7(3):236–242.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2009

Authors and Affiliations

  • Catherine Garger
    • 1
  • Carol Matlin
    • 1
  • George R. Kim
    • Robert E. Miller
      • 2
    1. 1.The Johns Hopkins Children's CenterBaltimore
    2. 2.Director of Pathology InformaticsJohns Hopkins University School of MedicineBaltimore

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