Author(s) Information

Mary LangFollow

Streaming Media

Name of Corresponding Author

Mary Lang

Credentials of Corresponding Author


Name of Faculty Advisor

K. Bobay PhD, RN, NEA-BC, FAAN

Nature and scope of the project

Thousands of medication errors occur each year to the detriment of patient care and at an enormous cost to healthcare systems. Subsequently, these healthcare organizations have been challenged to improve their delivery models.

Synthesis and analysis of supporting literature

One innovation used to decrease medication administration errors is the bar-coded medication administration (BCMA) system. However, despite, the BCMA improvements, research has shown that workarounds and the human factors involved in the BCMA systems continue to lead to errors. Since safe medication administration remains a key factor for patient care, this project focuses on the BCMA system and aims to increase mindfulness of the five rights of medication administration for nurses.

Project implementation

In this project, the evidence-based practice bundle utilizes engagement of staff with an emphasis on medication safety culture, huddles and teamwork, and mindfulness. Interprofessional relationships and teamwork between nurses, pharmacy and physicians are essential to support and improve patient outcomes. Education sessions and several initiatives, such as teamwork and mindfulness practice, will be fostered. In addition, there is administrative support for a few frontline nurses to be in the role of clinical nurse medication safety champions. Lastly, encouraging the staff to report medication errors that did not occur but were identified as defects in the systems.

Evaluation criteria

The results will be compared from the pre and post results looking at nurses identifying the five rights of medication administration, nurses’ perception of ease of BCMA, unit staffs’ perception of patient safety culture, and level of engagement.


Staff’s perception of feedback loops about patient safety concerns will be evaluated. In addition, the communication between pharmacy and frontline staff with regard to BCMA will be talked about in the post discussion groups. Lastly, there will be an increase in the number of identified good catches.


Further study of medication administration with respect to safe medication administration using the five rights, teamwork, and mindfulness practice will be conducted. Nurse medication champions will have the opportunity to continue as a resource for other nurses, and as a role model for other units. Lastly that safe medication administration will continue to be practiced and any good catches or near misses placed in the reporting system.



Improving Bar-Code Medication Administration with Mindfulness and Teamwork