ABSTRACT
Bar code medication administration was added 9 months after the electronic health records was implemented. The pharmacy created a “catch-up schedule” so that all medications would be given at standard times unless otherwise ordered. Nursing staff were never provided a computerized display equivalent to the paper medication administration record (MAR), although one had been created for physician use after complaints were received. Instead, nurses needed to check multiple screens to find when the last dose was actually administered. Assessment of the future state workflow should have identified potential risks and points of failure for the new medication system. Task management within the product is poorly designed, as both pharmacy and nursing staff members need to go through multiple screens to administer each medication, and charting when a drug is not given is even more difficult. Unless the medication can be administered through the full MAR screen, it only creates another place the nurses need to look for information.
