When barcode technology is used in medication administration, it significantly reduces the risk of medication errors.1 But the technology must be used correctly for the safety feature to work. According to the Patient Safety Network, part of the Agency for Healthcare Research and Quality, nurses frequently use workarounds to solve barcode medication administration problems and these "workarounds were associated with a threefold higher risk of medication error" in a recent study.2 In May, the Institute for Safe Medication Practices reported the case of a nurse who used a barcode workaround that lead to a patient injury when she mistakenly administered heparin instead of norepinephrine to a critically ill, septic older adult.3 The nurse had requested new infusion bags of both norepinephrine and heparin to replace current infusions that were running low, with the norepinephrine bag being almost empty. They were dispensed via a pneumatic tube system. The nurse accidentally brought the heparin into the patient's room instead of the norepinephrine. When she attempted to scan the heparin label, thinking it was norepinephrine, the barcode would not scan because the label was smudged from alcohol-based hand sanitizer. As a workaround, the nurse scanned the label of the already infusing norepinephrine (referred to as proxy scanning of the barcode), and hung the bag of heparin, infusing it at the norepinephrine rate. The patient experienced cardiac arrest, and despite stabilization died two days later.

For safe practice, nurses should never use an infusion from the pharmacy with a smudged barcode or label and should avoid proxy scanning of barcodes. Other instances of unsafe nursing practice due to using safety workarounds and suggestions for safe practice can be found in the June and July installments of Drug Watch.

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