THURSDAY, July 3 (HealthDay News) -- Flaws in the design and
implementation of barcode systems designed to match hospital
patients with the right dose of the right medication can increase
the risk of certain medication errors, according to a study that
looked at the use of the system in five U.S. hospitals.
The first-of-its-kind study looked at almost half a million
instances where nurses and other staff scanned patients and
medications. In a remarkably high percentage of instances, nurses
overrode the technology in order to compensate for awkward or
inconvenient aspects of the barcode systems. Nurses scanning the
barcode on the medication or the patient's ID bracelet overrode the
system for 4.2 percent of patients charted and 10.3 percent of
medications charted.
The researchers identified 31 causes of system problems that
prompted "workarounds" by nurses. These included: unreadable
medication barcodes (crinkled, smudged, torn, missing, covered by
another label); malfunctioning scanners; unreadable or missing
patient ID wristbands; non-barcoded medications; medications in
distant refrigerators; lost wireless connectivity; problems with
patients in contact isolation, and emergencies.
Workarounds used by nurses included: affixing extra copies of
patient ID barcodes on desks, scanning machines, clipboards, supply
rooms, and doorjambs, as well as carrying several pre-scanned
patient medications on one tray.
"It's not that staff are lazy or careless, it's that the system
does not work as well as it should. If the refrigerated medication
is two floors and a long hallway away, you're not going to wheel
your 87-year-old patient to the fridge. You make a copy of her
barcode. And while you do that, you help another two patients who
also need refrigerated medications," study leader Ross Koppel, of
the University of Pennsylvania School of Medicine, said in a
prepared statement.
"Bar-coding is still under development," he noted.
"Administrators and vendors may expect it to be fool-proof, but
users know it's not. It's a very promising technology that still
requires constant refining and careful observation of on-the-floor
workflow to get it right."
Koppel emphasized that barcode systems do prevent medication
errors and save lives. Identifying problems with the systems and
mitigating workarounds can make them even more effective. In their
study, Koppel and his colleagues made a number of recommendations,
and four of the hospitals in the study dramatically reduced the
number of workarounds by following these recommendations.
The study was published in the July/August issue of the
Journal of the American Medical Informatics Association.
More information
The Institute for Safe Medication Practices has information for
consumers about
medication errors.
