While such technology is pivotal to reducing errors, too often, healthcare leaders mistakenly believe that the immediate effects of automation alone will ensure the safety of their medication systems. Early adopters of the newest technology have reported significant barriers to successful implementation, new sources of error, and major infrastructure changes that have been necessary to accommodate the technology. Further, while new technology always introduces the opportunity for unanticipated errors, some vendors have marketed their products without sufficient testing or the ability to fully implement it on site. As a result, frustrated practitioners have taken shortcuts or added complexity to the medication system to circumvent or cure technology problems.
Some examples follow.
Furthermore, in these cases, the bar code may not match the dose ordered and administered. Also, if a drug is prescribed or entered into the pharmacy computer in error, bar code systems will only help to get the wrong drug to the correct patient or the ordered drug to the wrong patient. As a result, prescribers may bypass the order entry process totally and encourage nurses, pharmacists, or unit secretaries to enter written or verbal drug orders. Some CPOE systems are separate from the pharmacy system, which requires double entry of all orders. Also, the MAR that is generated from the CPOE system may be used without pharmacy review.