Raising the safety bar

In the retail world, bar coding has been around for ages. It has been slower to arrive in health care, but this technology is finally starting to gain traction as one of the ways hospitals can improve medication safety.

Here in Willmar, Rice Memorial Hospital joined the bar-coding team last week, implementing bar-coded medication administration at the patient bedside.

Many improvements in patient safety are more or less invisible to the public. Not so with bar coding, which patients and families are bound to notice. How it works: Before handing out a pill or hanging an IV solution, nurses will be using a handheld scanner to check the bar code on the patient’s wrist ID and the bar code for each medication to ensure everything matches – right patient, right medication, right dose, right route, right time. If something is wrong, an alert will pop up – yellow, for instance, if the pill is the correct medication but only one pill was scanned when the full dose requires two, and red if the medication is wrong, meant for another patient or some other glitch indicating it shouldn’t be administered.

Medication errors are a big deal. Far and away, the largest number of adverse events in U.S. hospitals involve medication mistakes. Although accurate figures are hard to come by, a report put together a few years ago by the Institute of Medicine estimates that each person who’s hospitalized is at risk of one medication error per day. Other statistics suggest that medication-related adverse events occur in anywhere from 1 percent to 10 percent of all hospital stays. (These statistics don’t even include errors that take place in outpatient pharmacies, nursing homes or other settings.)

When they do take place, these errors can be devastating. At the very least, they can lead to severe effects and require medical intervention, as happened in the case of actor Dennis Quaid’s infant twins, who in 2007 mistakenly received a 1,000-fold overdose of heparin, a blood thinner for preventing clots. And some medication errors are fatal, a lesson underscored with the story of Betsy Lehman, who was being treated for breast cancer and died in 1994 of a lethal chemotherapy overdose.

Getting at the root cause of medication errors is not easy. Mistakes can happen at almost any point in the process. Sometimes the physician mistakenly writes down the wrong dose. Sometimes the pharmacy misreads a handwritten prescription. Sometimes a pharmacist dispenses the wrong drug or the wrong dose. Sometimes a nurse mistakenly picks up the wrong drug, or administers it to the wrong patient. On top of this, health care professionals are surrounded by a busy, distracting environment that increases their risk of basic human error.

Increasingly, the industry has been turning to technology to standardize these processes and reduce the likelihood of certain types of errors. In this context, bar coding makes a lot of sense. The technology is reliable. It’s automated, with less room for human error. Given that errors involving the actual administration of a medication are among the most challenging to prevent, bar coding also offers that final double-check at the bedside, where the process is especially vulnerable.

When you think about it, it’s a little surprising that bar coding hasn’t caught on sooner in health care. Rice Memorial Hospital in fact is among a minority of hospitals where this technology has been introduced.

Bar coding, however, is not as simple as it sounds. When the U.S. Agency for Healthcare Research and Quality reviewed some of the research it has funded on bar coding, it found all kinds of obstacles. In some cases, hospitals bought bar code scanners that turned out to be incompatible with many of the bar codes being used. At many hospitals the workload actually increased because many drugs didn’t come with bar codes or had to be repackaged into unit doses. There’s also the issue of training the staff, providing tech support and having bedside nurses adapt to a significant change in their routine.

This isn’t the kind of change that happens overnight. At Rice Hospital, for instance, the planning process started way back last fall. The fact that Rice has been using an electronic medication administration record and automated dispensing cabinets for the past two years gave it a head start on the introduction of bar coding. Nevertheless, it takes a lot of work to implement this kind of initiative. Information-gathering, evaluation and tweaking of the system will probably continue for many months.

None of us should expect bar coding to be the total answer to medication safety. It’s just one piece in the overall picture. As with any technology, it’s only as good as the humans who design it and the humans who use it. Will mistakes continue to happen in spite of bar coding? More than likely they will. But it’s to be hoped there will be far fewer of them, and that this particular point in the medication administration continuum will become demonstrably less vulnerable to error.

West Central Tribune photo by Anne Polta

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