Barcode Technology Flaws Put Some Patients at Risk

THURSDAY July 3, 2008 -- 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.

Posted: July 2008


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