Paper Writing
JANUARY 2018, VOL. 45 NO. 1 ONCOLOGY NURSING FORUM E1ONF.ONS.ORG
Impact of a Barcode
Medication Administration
System on Patient Safety
Marta Macias, RN, PhD, Francisco A. Bernabeu-Andreu, PhD, Ignacio Arribas, MD, PhD,
Fatima Navarro, MD, and Gema Baldominos, PhD
T he process of medication administra-tion is the last stage during which a barrier can be erected to prevent an error from reaching the patient. The study and implementation of strate-
gies for error prevention are considered to be prior-
ities by health organizations. Studies of medication
administration errors (MAEs) report an incidence
of about 7%20%, and 8% when wrong-time errors,
or errors related to the medication administration
schedule, are excluded (Berdot et al., 2012; Keers, Wil-
liams, Cooke, & Ashcroft, 2013).
The type of medication is important when eval-
uating the characteristics of errors; health strategies
and policies are focused on medications defined as
high risk (Saedder, Brock, Nielsen, Bonnerup, & Lisby,
2014). Antineoplastic agents are considered to be high-
risk medications because of their narrow therapeutic
range and high toxicity (ASHP Council on Professional
Affairs, 2002). In a study analyzing the causes of death
because of medication errors, antineoplastic medi-
cations were found to be the most common agents
involved (McCarthy, Tuiskula, Driscoll, & Davis, 2017).
The incidence of MAEs in chemotherapy administration
ranges from 0.04% (Ford, Killebrew, Fugitt, Jacobsen,
& Prystas, 2006) to 18.8% (Walsh et al., 2009). The
incidence of MAEs in the outpatient setting range from
0.68% (Len Villar, Aranda Garca, Tobaruela Soto, &
Iranzo Fernndez, 2008) to 7.1% (Walsh et al., 2009) in
the adult population. The outpatient oncology setting
is considered to be a priority when reinforcing patient
safety (Goldspiel, DeChristoforo, & Hoffman, 2015;
Len Villar et al., 2008).
Barcode medication administration (BCMA) is rec-
ommended for the prevention of MAEs (Lefkowitz,
Cheiken, & Barnhart, 1991; Neuenschwander et al.,
2003) because it allows nurses to verify the five rights
of medication administration (i.e., patient, drug, time,
route, and dose). Observational studies on BCMA tech-
nology reported a decrease in the incidence of MAEs,
OBJECTIVES: To determine the impact of barcode
medication administration (BCMA) on the incidence
of medication administration errors among patients
in an onco-hematology day hospital and to identify
the characteristics of medication errors in that
setting.
SAMPLE & SETTING: 715 patients treated in the
onco-hematology day unit at the Prncipe de Asturias
University Hospital in Madrid, Spain.
METHODS & VARIABLES: A between-groups,
pre-/postintervention study was conducted.
Administration errors observed in patients with solid
tumors (intervention group) were compared with
those in patients with hematologic cancer (control
group) before and after the introduction of BCMA.
Error incidence, type, and severity were assessed, as
was length of stay for treatment.
RESULTS: Use of a BCMA system reduced the
incidence and severity of errors in medication
administration in the onco-hematology day hospital.
IMPLICATIONS FOR NURSING: BCMA is a useful
technology to check the five rights of medication
administration in the onco-hematology day hospital
and could help nurses increase the time spent on
direct patient care activities.
KEYWORDSoutpatient care; medication errors;
barcode medication administration
ONF, 45(1), E1E13.
DOI10.1188/18.ONF.E1-E13
E2 ONCOLOGY NURSING FORUM JANUARY 2018, VOL. 45 NO. 1 ONF.ONS.ORG
ranging from 23% (Helmons, Wargel, & Daniels, 2009)
to 56% (DeYoung, Vanderkooi, & Barletta, 2009).
When wrong-time errors were excluded, the percent-
age of errors ranged from 41% (Poon et al., 2010) to 81%
(Bonkowski et al., 2013). Little evidence exists regard-
ing the impact of this intervention on the severity of
errors (Hassink, Jansen, & Helmons, 2012). An import-
ant aspect to consider is the effect that BCMA devices
have on the time nurses need to administer medica-
tion; to date, no study has observed any variations in
time (Franklin, OGrady, Donyai, Jacklin, & Barber,
2007; Tsai, Sun, & Taur, 2010).
In addition, little evidence exists related to the fre-
quency and type of MAEs in oncology, particularly in
the outpatient setting (Strudwick et al., 2017); assess-
ment of the use of information and communication
technology in this area to improve patient safety is
also limited. In the case of BCMA systems, the advan-
tages achieved in other populations and clinical units
have been applied to the oncology setting (Bubalo
et al., 2014). The diversity of criteria used to define
medication errors and error types, the disparity of
the methods used to detect them, and the variety of
settings justify the need for this study (Hassink et al.,
TABLE 1. Types of Medication Administration Errors in the Onco-Hematology Day Hospital
New Classification Observations and Changes Made
Wrong medication: Dispensation/administration of a
medication different than the prescribed
The subcategory wrong prescription was not included.
No definition of transcription is provided.
Omission of a dose or medication: Not administering
a prescribed dose (patients refusing medication were
excluded)
The current authors only considered medication or dose
omissions.
Wrong dose (higher, lower, extra) No observations
Wrong date The current authors renamed the category wrong time of
administration to wrong date.
Wrong pharmacy dose No observations
Wrong preparation/handling/packaging/labeling No observations
Wrong administration technique No observations
Wrong route No observations
Wrong infusion rate No changes were made in this category. The infusion rate
was checked for each drug with the drug sheet and the
hospitals protocols. The current authors considered a rate
of 20% plus or minus of the advised infusion rate to be
correct.
Wrong patient No observations
Insufficient drug monitoring: Absence of clinical review The absence of analytical controls subcategory was
excluded.
Deteriorated medication (including expired drug, incorrect
preservation)
No observations
Wrong order of administration of antineoplastic
treatment
New category proposed by the current studys research
group
Other types (not included in the rest of the categories) No observations
Note. The Ruiz-Jarabo 2000 work group classifies 18 types of error. The categories wrong storage, wrong length of admin-
istration, not applicable, and patients noncompliance were not considered. The rest of the categories were included.
Note. Based on information from Grupo Ruiz-Jarabo 2000 (2008).
JANUARY 2018, VOL. 45 NO. 1 ONCOLOGY NURSING FORUM E3ONF.ONS.ORG
2012). The aim of this study was to assess the impact
of BCMA on the incidence of MAEs, types of errors,
patient risk, and time spent administering medication
to onco-hematology patients in the day hospital.
Methods
An MAE (Keers et al., 2013) was defined as noncon-
cordance between the medication administration
performed and any of the following options: doctors
prescription, official administration instructions
according to the protocol of the center, or the admin-
istration instructions from the manufacturer. Also
taken into account were nonconcordance errors
between the doctors prescription and the dispen-
sation or transcription of the medication by the
pharmacy department.
In this study, the current authors used the adapted
version of the classification of type of medication
errors as defined by the Ruiz-Jarabo 2000 work
group (Grupo Ruiz-Jarabo 2000, 2008) (see Table 1).
Of the 14 types of error proposed, 7 could be influ-
enced by the BCMA system: wrong medication, dose
or medication omission, incorrect dose, wrong date
of treatment, wrong route of administration, wrong
patient, and wrong order of medication administra-
tion. The potential severity of each error was assessed
on a scale from 1 (no severity) to 5 (catastrophic).
The degree of severity resulting from the errors
was assessed according to the index of the National
Coordinating Council for Medication Error Reporting
and Prevention. The length of stay for treatment was
also measured.
Setting and Sample
A pre-/postintervention study was conducted in the
onco-hematology day unit of the Prncipe de Asturias
University Hospital from January 2011 to May 2012.
Twenty patients were admitted to the day hospi-
tal. BCMA and computerized physician order entry
(CPOE) were implemented for the intervention
group, made up of patients with solid tumors.
MAEs observed in patients with solid tumors
(intervention group, N = 627) were compared with
those observed in patients with hematologic cancer
(control group, N = 88). About 30,000 medication
administrations are performed annually in this ward.
Sixty-three patients were excluded from the study for
various reasons: (a) adverse drug reaction leading to
the interruption of therapy administration (interven-
tion, n = 7; control, n = 1); (b) incomplete observer
records of the drugs administration because of lack
of time (intervention, n = 17; control, n = 8); and (c)
technical issues during BCMA implementation in the
intervention group (n = 30).
Training was given to an interprofessional team
of professionals from the quality, pharmacy, infor-
mation, and technology departments, as well as from
the biomedical research foundation and the day
unit. Nurses received two training sessions on the
management of the BCMA system, which was then
implemented in phases. Systematic assessment of
the implementation was performed throughout the
process.
This study was approved by the Prncipe de Asturias
University Hospitals ethics committee in clinical
research. Informed consent was obtained from the
nurses who were involved in the study because of their
medication preparation and administration duties.
Patients were assigned correlative numbers, and the
anonymized patient data were included in a database.
Data Collection Procedure
The observation technique described by Barker, Flynn,
and Pepper (2002) and by Dean and Barber (2001)
was used to detect MAEs. To avoid nurses modify-
ing their actions because they were being observed
during the BCMA process, they were told that the
observer was there to monitor the performance of
the medication distribution system. Observations
were carried out during the Monday to Friday nurs-
ing shift (from 8 am to 7:30 pm) starting one month
before the introduction of the BCMA system and
ending one month afterward. According to the power
analysis conducted, a sample size of 1,994 observa-
tions (997 in the preimplementation period and 997
in the postimplementation period) would be required
to detect a difference in the MAE rate of 4.2% with
80% power and 95% confidence interval (CI). The
preintervention phase was conducted 10 months
before implementation of the BCMA system, and
postintervention observations took place 6 months
after BCMA implementation.
Study observers were selected and trained during
a workshop; the group of observers consisted of four
pharmacy students, six pharmacists, and one nurse.
To prepare for the observation, the observers studied
the standard operating procedures and the applica-
ble drug administration procedures of the setting.
Observers were trained to detect and classify errors.
For this reason, a written observational protocol was
established. Each observer carried out pilot observa-
tions that were supervised by one of the researchers for
one week to become familiar with the BCMA system.
Pilot observations were discussed with the research
E4 ONCOLOGY NURSING FORUM JANUARY 2018, VOL. 45 NO. 1 ONF.ONS.ORG
team, and pilot data were discarded. In practice, the
observer accompanied the nurse who administered
the medication using the BCMA system and observed
the administration of each dose of medication to the
patient. The observer was instructed to record each
of the nurses actions while administering medica-
tion to patients. These observation records were then
compared with the prescribed medication and with
available medication protocols in the ward to identify
MAEs. If the observer became aware of a potentially
TABLE 2. Characteristics of Medication Administration Before and After Implementing the BCMA System
Solid Tumor (Intervention) Hematology (Control)
Before BCMA After BCMA Before BCMA After BCMA
Characteristic n N % n N % n N % n N %
Medication administration
Total number of OEs 1,281 2,912 44 1,272 2,912 44 141 2,912 5 218 2,912 7
Supportive drug OEs 842 2,912 29 767 2,912 26 89 2,912 3 139 2,912 5
Antineoplastic OEs 439 2,912 15 505 2,912 17 52 2,912 2 79 2,912 3
Medication prescription
Manual 199 304 65 40 40 100 48 48 100
Electronic 105 304 35 323 323 100
Number of OEs by route
IV 1,157 1,281 90 1,205 1,272 95
IV minibag (< 100 ml) 785 1,281 61 750 1,272 59
IV large volume (> 100 ml) 366 1,281 29 455 1,272 36
IV bolus dose 6 1,281 1
Oral 110 1,281 9 52 1,272 4
Subcutaneous 14 1,281 1 13 1,272 1
Intrathecal
Intramuscular 2 1,272 < 1
Patientsa
Overall 304 715 43 323 715 45 40 715 6 48 715 7
Women 167 304 55 196 323 61 23 40 58 24 48 50
Solid Tumor (Intervention) Hematology (Control)
Before BCMA After BCMA Before BCMA After BCMA
Characteristic n N % n N % n N % n N %
Age (years)b
Younger than 25 298 320 1 38 3 3 45 7
2534 6 298 2 3 320 < 1 1 38 3 45
3544 23 298 8 52 320 16 1 38 3 1 45 2
4554 66 298 22 51 320 16 8 38 21 3 45 7
5564 109 298 37 93 320 29 9 38 24 18 45 40
65 or older 94 298 32 121 320 38 18 38 47 20 45 44
a The median number of patients per day was 20.2 for the intervention group and 2.8 for the control group.
b For the intervention group, the median age was 59.16 years (SD = 10.61, range = 3284) before BCMA and 59.51 years (SD = 12.52, range =
3087) after BCMA. For the control group, the median age was 60.87 years (SD = 13.29, range = 1979) before BCMA and 62.16 years (SD =
15.25, range = 1887) after BCMA.
BCMAbarcode medication administration; OEopportunity for error (the sum of observed administrations and omitted medications)
Note. Because of rounding, percentages may not total 100.
JANUARY 2018, VOL. 45 NO. 1 ONCOLOGY NURSING FORUM E5ONF.ONS.ORG
serious error, the observer was instructed to intervene
for ethical reasons. These data were included in the
study if the serious error reached the patient.
Calibrated chronometers were used to measure
patients total length of stay in the onco-hematology
day unit and the time to administer each medication.
In both study periods, nursing staff included four
nurses with similar working conditions (number of
patients attended to and medications administered).
These four nurses attended to the two patient study
groups (intervention and control) in the same setting.
A maximum of three nurses were present during each
round of medication administration, and one nurse
was present from 47:30 pm.
To assess the degree of severity resulting from
errors, a panel of experts, which consisted of a doctor
specializing in oncology, a pharmacist, and a nurse,
was engaged. The actual degree of severity of the
MAEs was assessed with data obtained from medical
records. Information taken from the administration
instructions of the manufacturer and from UpToDate
were used to assess the potential severity of MAEs.
When no evidence was available, the authors relied on
the consensus criteria of the panel of experts.
Data Analysis
Information from the observations of the medication
administration process was entered into a comput-
erized database by one person. Absolute and relative
frequencies of the MAEs were calculated and com-
pared to determine the number of errors observed
before and after implementation of the BCMA
system. The chi-square test or the Fishers exact test
(as appropriate), odds ratio (OR), and relative error
reduction were used for this purpose. These analy-
ses were performed in the intervention and control
groups. When appropriate, 95% CIs were calculated
for further accuracy. For the comparison of quanti-
tative variables before and after the intervention, the
paired Students t test was used when the variable
followed a normal distribution, whereas the Mann
Whitney U test or the Wilcoxon signed-rank test was
used when it did not. In all cases, a p value of less than
0.05 was considered to be statistically significant. The
power of the study reached 91%. Data analysis was
performed using IBM SPSS Statistics, version 20.0;
EpiData, version 4.1; and GraphPad Prism, version 7.0.
Results
A total of 2,912 medication administrations were
observed (including omissions) in 715 patients (627 in
the intervention group and 88 in the control group).
The number of observations of medication administra-
tions in the intervention group was similar before and
after the intervention (1,281 versus 1,272, respectively).
The number of observations was smaller in the control
group because of the reduced number of patients who
attended per day (141 before the intervention versus 218
after the intervention). Patients received a large number
of different medications, including antineoplastic
agents, drugs for comorbid illness, and medications
for supportive care and for complications related to
antineoplastic therapy. These were all observed and
included in the study. Medications have been sepa-
rated into two main groups: antineoplastic agents and
supportive drugs. In all study groups, supportive drugs
stood out as the most frequently used medications
compared to antineoplastic agents. Concerning the
route of administration, most medications were admin-
istered via IV. Table 2 shows the overall characteristics
of the medications observed and the characteristics of
the patients to whom they were administered.
Frequency and Type of Errors
The most relevant result from this study is that, when
attention is paid exclusively to the type of errors that
could be influenced by the intervention, the BCMA
system reduced the incidence of these errors by 85%
(see Table 3). Research shows that the most frequently
reported antineoplastic MAE is wrong dose, followed
by dose omission (Ford et al., 2006; Gandhi et al.,
2005; Len Villar et al., 2008; Rinke, Shore, Morlock,
Hicks, & Miller, 2007; Serrano-Fabi, Albert-Mar,
Almenar-Cubells, & Jimnez-Torres, 2010). However,
the most frequent error in the intervention group
during both periods was the rate of infusion. Among
other possible causes, the current authors observed
that infusion pumps were not systematically used for
either supportive drugs or photosensitive antineo-
plastic medications. This type of error, although not
sensitive to the intervention, set off a series of actions
for improvement in the current authors hospital. Few
studies have assessed this error (Dhamija, Kapoor, &
Juneja, 2014; Franklin et al., 2007). The second most
frequent error in this study was the order of admin-
istration; the current authors found one study that
also reports this error as frequent (Ulas et al., 2015).
The third most frequent error during both study peri-
ods in the current study was the wrong technique of
administration; nearly all the errors of this type were
associated with the administration of paclitaxel.
The incidence of MAEs during the study was 39%
(number of MAEs out of number of opportunities for
error; this refers to both study groups and all types of
E6 ONCOLOGY NURSING FORUM JANUARY 2018, VOL. 45 NO. 1 ONF.ONS.ORG
MAEs), and about 6% of medications accumulated more
than one error. The incidence of MAEs sensitive to the
BCMA system (or not able to be influenced by the BCMA
system) in the intervention group was 16%. Following
the intervention, a significant relative reduction of about
2% occurred. In the control group, a significant increase
was noted in the incidence of MAEs, from 18% before the
intervention to 39% after the intervention.
With the implementation of the BCMA system, the
authors observed a significant relative reduction in
the following types of error in the intervention group:
wrong medication, administration omission, wrong
dose, and wrong order of administration. An increase
in frequency of errors relating to technique of admin-
istration and rate of infusion was noted (see Table 4).
However, these are not influenced by the BCMA system.
Severity
The severity of MAEs was assessed in the intervention
group, with a focus on those sensitive to BCMA imple-
mentation, and from two perspectives: the potential
severity of the error and the actual consequences for
the patient. Regarding potential severity of errors, all
categories experienced a reduction in the number of
errors, except in the mild category, and showed sta-
tistically significant differences in moderate potential
TABLE 3. MAEs and Types of Errors Influenced by BCMA System in Patients With Solid Tumors (Intervention Group)
Before BCMA After BCMA Relative Change in ROE
Variable n N % n N % % 95% CI OR 95% CI p
Intervention group
MAEs 595 1,281 46 459 1,272 36 22 [23.4, 21.2] 1.54 [1.31, 1.8] < 0.001 Excluding infusion rate errors 259 1,281 20 126 1,272 10 51 [54, 48.1] 2.3 [1.83, 2.9] < 0.001 Control group MAEs 91 141 65 152 218 70 8 [4.6, 12.7] 0.79 [0.5, 1.24] 0.3 Excluding infusion rate errors 41 141 29 77 218 35 21 [12.7, 33.3] 0.75 [0.47, 1.18] 0.22 Errors influenced by BCMA 25 141 18 86 218 39 223 [178.6, 184.7] 0.33 [0.2, 0.55] 0.0012 Type of error influ- enced by BCMA Errors influenced by BCMA 206 1,281 16 31 1,272 2 85 [88.6, 81.3] 0.13 [0.09, 0.19] < 0.001 Pharmacy tran- scription errorsa 19 1,281 2 1 1,272 < 1 93 [99.7, 81.3] 0.05 [0.01, 0.39] < 0.001 Wrong medicationa 6 1,281 1 2 1,272 < 1 60 [88.2, 45.1] 0.33 [0.07, 1.66] 0.159 Medication administration omission a 14 1,281 1 1 1,272 < 1 91 [99.6, 76.3] 0.07 [0.01, 0.54] 0.008 Wrong dose (higher) 7 1,281 1 100 0.008 Wrong dose (lower) 8 1,281 1 100 0.004 Extra dose Wrong datea 2 1,281 < 1 100 0.16 Wrong routea 8 1,281 1 6 1,272 1 17 [37, 16.4] 0.75 [0.26, 2.18] 0.6 Wrong patienta Wrong ordera 142 1,281 11 21 1,272 2 86 [89.2, 80.6] 0.13 [0.08, 0.21] < 0.001 a n refers to number of MAEs, whereas N is number of opportunities for error. BCMAbarcode medication administration; CIconfidence interval; MAEmedication administration error; ORodds ratio; ROErate of error JANUARY 2018, VOL. 45 NO. 1 ONCOLOGY NURSING FORUM E7ONF.ONS.ORG severity (see Table 5). The no-severity category (55%) was the most frequent in the period before BCMA implementation, whereas the mild category (61%) was the most frequent in the period after BCMA implementation. No errors were rated in the highest severity category after BCMA implementation. Regarding the actual consequences for patients, only four errors (2%) caused mild harm to the patient in the period before BCMA implementation. Most errors were classified into the reached the patient but caused no harm category, which was the only one to increase after the intervention. A nonsignificant reduction of errors was observed in both categories in which errors had an impact on patients, with no cases observed after the intervention. Length of Stay for Treatment Administration When analyzing the impact of the intervention on average length of stay for treatment, no statistically significant differences were found. In the interven- tion group, the average length of stay was 166 minutes before the intervention and 160 minutes after the intervention. In the control group, the average length of stay was 167 minutes before the intervention and 155 minutes after the intervention. Discussion The implementation of a BCMA system for patients with solid tumors was associated with an 85% relative reduction of MAEs. No statistically significant differ- ences were observed in the control group. The current authors estimated that 3,200 potential MAEs per year could be prevented in the studied setting. As Bubalo et al. (2014) stated, these results are relevant because of the lack of studies focusing on these types of treat- ments. In their review of the impact of BCMA systems, Leung et al. (2015) emphasized the limited knowledge of these systems within the outpatient treatment TABLE 4. MAEs in Patients With Solid Tumors Before and After BCMA Before BCMA After BCMA Relative Change in ROE Type of errora n % n % % 95% CI OR 95% CI p Wrong medication 32 5 3 1 89 [96.4, 74.8] 8.64 [2.63, 28.4] < 0.001 Pharmacy dispensation 7 1 100 0.02 Pharmacy transcription 19 3 1 < 1 94 [99.7, 75.7] 15.1 [2.01, 113.28] < 0.001 Administration 6 1 2 < 1 60 [85.7, 28.4] 2.75 [0.55, 13.68] < 0.47 Omission 15 3 2 < 1 84 [96.4, 62.1] 6.91 [1.34, 25.97] 0.006 Pharmacy transcription 1 < 1 1 < 1 100 [29.03, 50] 1 Pharmacy dispensation Administration 14 2 1 < 1 91 [99.5, 69.3] 11.04 [1.45, 84.24] 0.003 Wrong dose 15 3 100 < 0.001 Higher 7 1 100 0.02 Lower 8 1 100 0.012 Extra Wrong date 2 < 1 100 0.5 Wrong pharmaceutical form Wrong preparation/handling/ packaging/labeling 8 1 4 1 39 [60.34, 15.9] 0.56 Wrong administration technique 53 9 91 20 123 [10.7, 141.4] 0.4 [0.27, 0.57] 0.001 Wrong route 8 1 6 1 [17.24, 7.22] 0.95 Wrong infusion rate 317 53 332 72 36 [33.2, 38.3] 0.44 [0.34, 0.57] < 0.001 Wrong patient Wrong drug monitoring 2 < 1 100 0.5 Deteriorated medication 1 < 1 100 Wrong order 142 24 21 5 81 [86.1, 74.9] 6.54 [4.06, 10.53] < 0.001 a Number of errors out of total number of MAEs (N = 595 MAEs before BCMA; N = 459 MAES after BCMA) BCMAbarcode medication administration; CIconfidence interval; MAEmedication administration error; OEopportunity for error; ORodds ratio; ROErate of error E8 ONCOLOGY NURSING FORUM JANUARY 2018, VOL. 45 NO. 1 ONF.ONS.ORG setting. Only one study (Seibert, Maddox, Flynn, & Williams, 2014) uses a methodology similar to the present study. It too measured the impact of BCMA in a day hospital; although the data on incidence of MAEs are not comparable, Seibert et al. (2014) did not observe a significant reduction of errors after BCMA implementation. The authors stated that a manual double-checking procedure was performed before the BCMA system was implemented, which may justify their findings (Seibert et al., 2014). Most medications were administered via IV, which limits potential comparisons with similar studies. Only Helmons et al. (2009) clearly specified the routes of administration, and in their study, the oral route was the most frequently used. In the current study, observations were mainly performed by pharmacists; in other studies, observa- tions were carried out by pharmacists (Bonkowski et al., 2013; Franklin et al., 2007), nurses (Paoletti et al., 2007; Poon et al., 2010; Skibinski, White, Lin, Dong, & Wu, 2007), or a combination of both (Cochran & Haynatzki, 2013; DeYoung et al., 2009; Seibert et al., 2014). Future research should take into account the profile and training of observers; an interprofessional group of observers could improve the quality of the data obtained. No current gold standard has been established with regard to the duration of the observation period. In the current study, the observation period extended to more than one month, with uninterrupted observations for 11 hours per day. In other studies, the observation period varied from four hours (Serrano-Fabi et al., 2010) to seven months (Seibert et al., 2014). Although the use of control groups is highly rec- ommended to avoid potential random errors (Hassink et al., 2012), only one study has been conducted com- paring an intervention group with a control group, as the current study does; however, the context is not the same (Paoletti et al., 2007). Paoletti et al. (2007) observed an increase in the number of errors in the control group after the intervention. In addition, in a systematic review of 42 pre-/postintervention stud- ies on patient safety, the authors found that none included a control group to assess the effectiveness TABLE 5. Severity of MAEs in Patients with Solid Tumors Influenced by BCMA Before BCMA (N = 206)a After BCMA (N = 31)a Variable n % n % p Severity description A. Potential B. Did not reach the patient 19 9 3 10 0.8 C. Reached the patient but caused no harm 144 70 28 90 0.77 D. Reached the patient and required monitoring 2 1 0.54 E. May have contributed to or resulted in temporary harm to the patient and required intervention 2 1 0.54 F. May have contributed to or resulted in temporary harm to the patient and required initial or prolonged hospitalization G. May have contributed to or resulted in permanent harm to the patient H. Required intervention necessary to sustain the patients life I. May have contributed to or resulted in death of the patient Not evaluated 39 19 Severity of potential description No severity 113 55 12 39 0.33 Mild 48 23 19 61 0.003 Moderate 29 14 0.038 Severe 16 8 0.12 Life-threatening a N refers to total number of MAEs influenced by BCMA BCMAbarcode medication administration; MAEmedication administration error JANUARY 2018, VOL. 45 NO. 1 ONCOLOGY NURSING FORUM E9ONF.ONS.ORG of the interventions (Acheampong, Anto, & Koffuor, 2014). Incidence of Medication Administration Errors Results from the current study show a reduction of 85% in the incidence of medication errorsa finding that is in line with prior evidence, where a reduction of as much as 80% of the errors is reported after implementation of a BCMA system (Bonkowski et al., 2013; Leung et al., 2015). However, the literature regarding the impact of BCMA systems shows contra- dictory results. The incidence of all MAEs in this study was higher than that observed in other studies with sim- ilar methodology (Bonkowski et al., 2013; Cochran & Haynatzki, 2013; Franklin et al., 2007; Hardmeier, Tsourounis, Moore, Abbott, & Guglielmo, 2014; Helmons et al., 2009; Morriss, Abramowitz, Carmen, & Wallis, 2009; Paoletti et al., 2007; Poon et al., 2010; Seibert et al., 2014; Skibinski et al., 2007) where the incidence of MAEs ranged from 7%25% in the period before BCMA implementation and from 2%21% in the period after. When selecting errors sensitive to the BCMA system in the intervention group, the inci- dence was 16%. These differences can be explained by the peculiarities of the study setting, the complex management of the medications used, and the study design. Among study variables, those related to the type of error were decisive to compare different stud- ies results. The frequency of administration error (related to time) was assessed in many studies and had a high incidence in comparison to other errors; the current authors could not consider it because each patient in this study received only one dose of medication per treatment. The current study pro- vides unprecedented evidence of the high error rate in the incorrect medication infusion rate, which is a relevant finding because this type of MAE was not sensitive to BCMA implementation. Future research should be aimed at the reduction of incorrect medica- tion infusion rates, given the potential adverse effect on patients safety. A validated classification system for types of medication errors would be necessary to compare results. Types of Error in Medication Administration The current authors findings on types of error are noteworthy, given the current lack of research and error assessment in the field of medication adminis- tration. These results provide information on MAEs in oncology treatments that are specific to the out- patient setting. The types of error most frequently analyzed in similar studies are wrong medication, wrong dose, wrong route of administration, wrong time, and dose omission. Wrong order of admin- istration is a unique type of error associated with antineoplastic treatments, which was included for the first time in the current study. Regarding the impact of BCMA on errors sensitive to these systems, results from other studies are not at all homogeneous. In some studies, administration omission errors decreased the most after imple- menting the BCMA system (Franklin et al., 2007;
