Date of Award

Spring 2015

Project Type


Program or Major

Nursing Practice

Degree Name


First Advisor

Pamela DiNapoli

Second Advisor

Gene Harkless

Third Advisor

Mercedes Fleming


It has been reported by members of The Institute of Medicine that a patient is at risk for one medication administration error per day when hospitalized, thus prevention of medication administration errors is a priority patient safety goal. One recommendation to reduce the prevalence of medication administration errors is the use of barcoded medication administration (BCMA) systems. While there are many benefits to BCMA, there are also issues with existing systems. Suboptimal BCMA design and implementation has resulted in medication administration workarounds. A hospital located in southern New Hampshire, implemented a Knowledge Based Medication Administration (KBMA) system in January 2014. Shortly after implementation, inefficiencies within the system were identified, resulting in KBMA nursing workarounds.

The aim of this program evaluation quality improvement project using mixed methods was to identify the system’s issues, and processes resulting in workarounds to find solutions that optimize the KBMA system and ensure patient safety. Override drug scan tracking reports were monitored for specific KBMA nurse workarounds during four phases from January 2014 to December 10, 2014. Simultaneously structured observations of registered nurses using KBMA (N = 52) were conducted over a three-month period. System process changes and educational interventions were provided during the first three phases and withdrawn during the fourth phase. During the evaluation period, there was an overall decrease in KBMA workaround totals from (N = 12, 231) in Phase 1, to (N = 5,321) in Phase 4.