NURSING PATIENT CARE POLICY & PROCEDURE
June 1, 2015
April 28, 2017
Nursing Manual (Red)
Policy #: 10.19 AP
Title: Medication Administration Using
Barcode Scanning Technology (Adult and
To establish a safe, reliable and uniform method of administering and documenting
medication orders utilizing medication administration scanning technology.
Medication administration scanning technology will be used for the administration and
documentation of patient medication orders where the technology is available.
A. Barcode Medication Administration (BCMA) Scanning Technology
B. Patient identification - bar-coded wristband
C. Bar-coded Employee ID badge
A. BCMA Scanning Technology Storage and Care:
1. BCMA scanning technology should be returned to their designated storage areas
and plugged into a power source when not in use. Patient data will be protected
according to regulatory requirements and UWHC Hospital Administrative Policy
4.13, Using and Disclosing (or Releasing) Protected Health Information.
2. Mobile workstations and scanners are individually assigned to a given nursing unit
and are to be kept on that unit. Devices are not to be “loaned” to another unit.
Respiratory Care and Phlebotomy have been assigned scanners for departmental
3. The Care Team Leader, Senior Team Member or designee must account for all
mobile BCMA scanning technology at the end of each shift.
4. Problems with the functioning of BCMA scanning technology should be reported to
the Help Desk at 5-7777 at the time the problem is identified.
B. User Access
1. BCMA scanning technology users will be assigned a role and given security based
on job functions. (See UWHC Administrative Policy 1.02, UW Health Access to
Electronic Information Systems.)
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a. A user who forgets his/her photo ID badge with the barcode will not be
given a temporary code. That employee will need to manually enter
his/her user ID and password each time BCMA is used. Using another
person’s badge to sign on is not permitted.
b. If an employee loses his/her photo ID badge or the bar-code is unable to
be successfully scanned consult Photo ID Badges website on U-
Connect, for replacement procedures.
c. A user who forgets his/her password should notify the Help Desk at 5-
7777 to have the password reset.
C. Order Entry Verification
1. When an authorized clinician enters a medication order into Health Link, it
will appear on the BCMA device and in the Hyperspace eMAR in the “NEW”
tab. New medication orders will appear in appropriate tabs and will be flagged
with icons to alert the clinicians that the order has not been verified by
Pharmacy and/or Nursing.
2. If the order has been transcribed from a paper order sheet, the pharmacist and
nurse will verify the order entered in Health Link for accuracy against the
written order and the nurse will initial the appropriate column on the paper
order sheet. Discrepancies in order entry need to be communicated to the
3. If an order needs to be clarified, it should remain on the NEW list until
clarified with the pharmacist or provider. Once clarified, the order is to be re-
entered by the provider or entered as a verbal/telephone order by the receiving
4. If an order needs to be reentered, the original order that was incorrect will be
discontinued and a new order will be created, hence, there will be two orders
to be verified by the clinician. The original discontinued order and the
corrected new order.
a. Discontinued orders will be verified by the nurse or the respiratory
therapist for appropriateness to the patient prior to signing off the order.
Discontinued medication orders will display highlighted in gray on the e-
MAR for 36 hours. Any remaining overdue doses that have not been
documented against will remain on the due list in the MAR until
documented as given or omitted.
b. Respiratory Therapy will acknowledge and verify all respiratory therapy
medication orders prior to administering the first dose as above.
D. Barcode Medication Administration
1. Medications should not be given until they are ordered except in urgent or
emergent situations. See UW Health Clinical Policy 6.1.7, Management of
STAT Medications for Inpatient Units for more information about urgent or
2. See UW Health Clinical Policy 3.2.1, Patient Identification for patient
identification information. Medications may not be administered to a patient
without a bar-coded wristband in place except during emergency situations
and Health Link downtime.
3. The clinician documenting medication administration using BCMA is
expected to scan all medications and intravenous fluids prior to
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administration. Circumstances in which it is acceptable to administer
medications non-bar-coded include:
a. Medication that is not packaged with a barcode or the barcode present on
the package is not recognized.
b. Medication dispensed in a multi-dose container in which the barcode was on
the outside wrapper that has been discarded.
c. Medication that is from a patient’s own supply.
d. Medication administration documented during recovery from a system
downtime. (Refer to UW Health Clinical Policy 3.2.6, Inpatient Health
Link Downtime and Recovery.)
4. The clinician will use either Hyperspace e-MAR or scanning technology to
document medication administration in Health Link.
a. Medications should be taken in the original package to the bedside. If the
medication needs to be prepped prior to administration, the clinician should
retain the original package. The medication is to be administered after all
medications have been scanned and/or the package labels have been
checked to assure the right medication, dose, route, and scheduled
administration time have been selected, and that no warnings are present.
b. When a medication administration requires a witness, the witness will
verify the medication being prepared matches the order. Documentation of
this double check is done by the witness scanning his/her barcode and
entering his/her password. (Refer to UWHC Policy 8.33, High Alert
c. The administering nurse identifies the patient confirming the name, birth
date and/or medical record from the wristband as well as scanning the
patient’s wristband barcode prior to administering the medication.
d. The patient should be observed taking the medications and the
administration should be charted in Health Link as soon as possible after
administration is complete Do not leave medications at the bedside.
e. Medications that are omitted will be documented as such with an
appropriate reason for the omission selected.
5. Medications will remain on the DUE list until documented against. Medications
that are on the OVERDUE list must be reconciled before the offgoing nurse
leaves for the day. Communication should occur with the oncoming nurse
regarding the need to administer any medication remaining on the DUE list.
LATE medications should be documented when given, with the reason for late
6. PATIENT NOT PHYSICALLY PRESENT: In circumstances where, due to
emergent patient condition (e.g., emergently taken to OR), the medication was
not documented real time it is acceptable for the nurse who administered the
medication to later utilize the Patient ID Scan – Override function to allow for
complete and accurate documentation. The Patient ID Scan – Override function
will not be used for the convenience of staff in any other situation.
7. A medication should not be documented as OMITTED unless the decision has
been made that the patient will not receive that dose of the medication. When a
medication is charted as OMITTED it disappears from the DUE list. If a
medication is documented as OMITTED and the decision is later made to
administer the medication, the clinician will need to mark the medication as
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8. Administering medications dispensed on override:
a. The nurse administering the medication must review the patient allergies
and all other pertinent information prior to the administration of the
E. Special Considerations By Medication Type
1. Continuous IV Solutions have an initial due time, but do not have subsequent
scheduled due times. The RN is to document each time a new bag is hung.
a. The nurse should re-order the next infusion bag for continuous infusions at
least 2 hours prior to the time the next bag is needed. The request is placed
via Health Link medication messaging. If the medication is needed
urgently, the nurse should contact the unit pharmacist to initiate the STAT
medication dispensing process. In situations of Health Link downtime, the
nurse should notify the Central Pharmacy when the next bag will be needed.
2. Intermittent IVs will appear with scheduled due times. Orders that fall into
this category are IV boluses that are scheduled for a particular time, rate
changes for IVs that follow protocols (i.e. rate = 500 mL/hr starting at 2200
pre-transplant), chemotherapy, etc.
3. Total Parenteral Nutrition (TPN) solutions will appear with an initial
scheduled due time. Every bag of TPN is a new order and will require
verification of the components prior to administration.
4. Patient Controlled Analgesia (PCA) medications do not have subsequent
scheduled due times and will be handled as a PRN medication. The rate,
concentration and lockout information will be included in the Admin
Instructions when the order is entered.
a. For additional information, refer to UW Health Clinical Policy 6.1.2,
Intravenous Patient Controlled Analgesia (PCA) for Adult and Pediatric
5. High alert medications should be administered according UWHC Policy 8.33,
High Alert Medication Administration and UW Health Clinical Policy 6.1.1,
Chemotherapy Processes: Informed Consent, Ordering, Verification,
Administration, Documentation and Patient/Family Education. Medications that
require dual witness are flagged with !! on the MAR.
6. PRN medications- For orders that contain a range dose, the RN will scan the
medication where appropriate, and edit the dose field to document the
appropriate amount administered.
a. PRN medications that are obtained from the AcuDose Controlled Access
7. Heparinized saline/IV flushes- Refer to UW Health Flushing/Locking of
Venous Access Devices- Pediatric/Adult-Inpatient/Ambulatory Clinical
8. Multi-dose vials/containers and Metered Dose Inhalers when scanned will
enter the ordered dose unless the barcode contains the package dose, in which
case the user will receive an overdose warning. In either event, the dose field
must be entered to reflect the actual dose administered. Care must be taken to
maintain the packaging material and corresponding barcode label.
9. Notes to chart are to be documented non-barcoded with the action “Order
Noted” and do not require a barcode scan or patient wrist band scan. These
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notes are used to:
a. Communicate an alert; e.g., No Heparin, crush all meds, TPN rate
b. Communicate a required action/intervention; e.g., Warfarin dose
varies daily, Remove Patch, Draw Drug Level, Document Self
Administered Medication Program.
10. A Skin Test will be ordered as a panel which includes a medication
administration order to be documented in the MAR and a procedure order to
read the test. The reading of the test will be documented against the
F. Other Documentation Considerations
1. If not directly documented by the providers, medications administered
by another provider (e.g., attending physician or mid-level provider) are to
be documented as “Given” with a notation of the first name, last name and
credentials of the administering provider in comments.
2. Medications administered to patients in other treatment areas:
a. Paper Order: If medication administration was documented on paper,
it will not be re-entered in Health Link unless they are
b. Medication on Electronic MAR: If the medication was ordered
electronically and given while the patient was off the unit, the floor
nurse should chart the medication as “Documented in Another Care
Area”. This will remove the medication from the DUE or OVERDUE
3. Medications administered to patients by the unit RN while the patient is
off the unit should be recorded in the clinical record. If connection to the
wireless network is not possible while off the unit, when the patient returns to
the unit, the RN should document the administration as administered non-
barcoded and the administration time should be edited to accurately reflect
the date/ time of the administration.
4. Medications administered during code situations are to be documented
on the Resuscitation Record.
5. Medications administered by student nurses will be in accordance with
Nursing Administrative Policy 8.11, Student Clinical Practice of Nursing and
Advanced Practitioners at UW Health.
Refer to UW Health Clinical Policy 3.2.6, Inpatient Health Link Downtime
V. UWHC CROSS REFERENCES
A. UW Health Clinical Policy 3.2.1, Patient Identification
B. UW Health Clinical Policy 3.2.6, Inpatient Health Link Downtime and Recovery
C. UW Health Clinical Policy 6.1.7, Management of STAT Medications for Inpatient
D. UW Health Clinical Policy 6.1.2, Intravenous Patient Controlled Analgesia (PCA) for
Adult and Pediatric Patients
E. UW Health Clinical Policy 6.1.1, Chemotherapy Processes: Informed Consent,
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Ordering, Verification, Administration, Documentation and Patient/Family Education
F. UWHC Administrative Policy 1.02, UW Health Access to Electronic Information
G. UWHC Administrative Policy 4.13, Using and Disclosing (or Releasing) Protected
H. UWHC Administrative Policy 8.16, Patient Care Orders
I. UWHC Administrative Policy 8.17, Administration of Medications
J. UWHC Policy 8.30, Controlled Substance Control Systems in Patient Care Areas
K. UWHC Policy 8.33, High Alert Medication Administration
L. Nursing Administrative Policy 8.11, Student Clinical Practice of Nursing and
Advanced Practitioners at UW Health
M. Pharmacy Policy 14.4, AcuDose®-Rx
N. UW Health Flushing/Locking of Venous Access Devices- Pediatric/Adult-
Inpatient/Ambulatory Clinical Practice Guideline
O. U – Connect, Photo ID Badges website
VI. REVIEWED BY
Nursing Project Manager, Nursing Informatics
Nursing Patient Care Policy and Procedure Committee, June 2015
Beth Houlahan, DNP, RN, CENP
Senior Vice President, Chief Nurse Executive