MPA | Pharmacy News

By Cherie Woodhams, R.Ph., IT lead analyst, Bronson Healthcare Group, Kalamazoo

The Leapfrog Group is a national nonprofit organization trying to improve the quality and safety of healthcare in the United States. The group collects and reports hospital performance through a survey hospitals complete. The survey asks questions related to computerized physician order entry systems (CPOE), surgery, maternity care, intensive care unit (ICU) physician staffing, safe practices, patient safety errors, medication safety and pediatric care.

Two of these measurements where organizations are falling short is to complete barcode medication administration (BCMA) and have processes and structures in place to prevent workarounds.1

The standard is for organizations to:

  • Implement a BCMA system in 100 percent of the hospital’s adult and pediatric medical and/or surgical units, obstetric units and medical intensive care units (adult, pediatric and neonatal).
  • Scan both the patient barcode (usually a wristband with barcode) and the medication bar codes 95 percent of the time during bedside medication administrations in the above listed units.
  • Use a BCMA system that includes the seven best practice clinical decision support (CDS) elements listed below:
    • Vital sign check.
    • Patient specific allergy check during BCMA.
    • Second nurse check when needed.
    • Wrong time (early/later warnings).
    • Wrong dose.
    • Wrong patient.
    • Wrong medication.
  • Implement all five best practice processes and structures to prevent workarounds of the BCMA system including:
    • A formal committee to oversee BCMA use.
    • Backup systems for hardware failures.
    • A help desk to respond to BCMA issues in real-time.
    • Conducting real-time observations of staff using the BCMA system.
    • Engaging with nursing leadership on BCMA usage.

Of the seven CDS elements for BCMA, the majority of hospitals are missing a built in vital sign check during BCMA. There are also deficiencies in monitoring and preventing workarounds.

Ideas on how to improve meeting the CDS standard include, but are not limited to:

  • Create required documentation of vital sign checks during medication administration of a list of medications approved by each facility if the vital signs have not been documented within so many hours from administration.
  • Display vital signs in the electronic medication administration workflow for easy access during medication administration.

Due to deficits in discouraging workarounds of the BCMA process, the Leapfrog Group will be implementing additional criteria for the next survey cycle with a meets standard of meeting six out of the eight criteria.2 These additional criteria include:

  • In the past 12 months, used the data and information to implement quality improvement projects that have focused on improving the hospital’s BCMA performance OR in the past 12 months, used the data and information to monitor a previously implemented quality improvement project focused on improving the hospital’s BCMA performance.
  • In the past 12 months, evaluated the results of the quality improvement projects and validated that these projects have resulted in higher adherence to the hospital’s standard medication administration process OR in the past 12 months, evaluated the results of the quality improvement projects and demonstrated continued adherence to the hospital’s standard medication administration process.
  • Talked to end users about the resolution of any system deficiencies and/or problems that may have contributed to the workarounds.

What is your organization doing to improve these two measurements? Post your response or request access to Michigan Society of Health-System Pharmacists IT List Serve if you don’t already have access at, then post your response.


  1. The Leapfrog Group. New Report on Bar Code Medication Administration Finds Virtually All Hospitals Have the Technology, but Lack Requirements to Deploy it Effectively. PR Newswire website. Published April 12, 2018. Accessed October 29, 2018.
  2. The Leapfrog Group. Planned Updates to the Leapfrog Hospital Safety Grade Methodology: Request for Public Comment. Hospital Safety Grade website. Accessed October 29, 2018.

Bookmark and Share  

Search for
Pharmacy News