Effectiveness of a barcode medication administration system in reducing preventable adverse drug events in a neonatal intensive care unit: a prospective cohort study.

Journal Article (Journal Article)

OBJECTIVE: Patients are at risk of harm from medication errors. Barcode medication administration (BCMA) systems are recommended to mitigate preventable adverse drug events (ADEs). Our hypothesis was that a BCMA system would reduce preventable ADEs by 45% in a neonatal intensive care unit. STUDY DESIGN: We conducted a prospective, observational, cohort study of a BCMA system intervention in a neonatal intensive care unit. Participants were admitted neonates during 50 weeks. Medication errors and potential or preventable ADEs were detected by a daily structured audit of each subject's medical record, with assignment of an event as a preventable ADE made by blinded assessors. The generalized estimating equation method was used in modeling the targeted, preventable ADE rate with covariates. RESULTS: A total of 92,398 medication doses were administered to 958 subjects. The generalized estimating equation method yielded a relative risk of preventable ADE when the system was implemented of 0.53 (95% confidence limits 0.29 to 0.91, P = .04), adjusted for log(10)doses of medication/subject/day, a significant predictive covariate (P < .001), as well as for birth weight, sex, Caucasian race, birth cohort number, and nursing hours/subject/day. CONCLUSION: The BCMA system reduced the risk of targeted, preventable ADEs by 47%, controlling for the number of medication doses/subject/day, an important risk exposure.

Full Text

Duke Authors

Cited Authors

  • Morriss, FH; Abramowitz, PW; Nelson, SP; Milavetz, G; Michael, SL; Gordon, SN; Pendergast, JF; Cook, EF

Published Date

  • March 2009

Published In

Volume / Issue

  • 154 / 3

Start / End Page

  • 363 - 368.e1

PubMed ID

  • 18823912

Electronic International Standard Serial Number (EISSN)

  • 1097-6833

Digital Object Identifier (DOI)

  • 10.1016/j.jpeds.2008.08.025


  • eng

Conference Location

  • United States