Medication Safety Improves after Implementation of Positive Patient Identification

Abstract

SummaryObjective: To report the incidence and severity of medication safety events before and after initiation of barcode scanning for positive patient identification (PPID) in a large teaching hospital. Methods: Retrospective analysis of data from an existing safety reporting system with anonymous and non-punitive self-reporting. Medication safety events were categorized as "near-miss" (unsafe conditions or caught before reaching the patient) or reaching the patient, with requisite additional monitoring or treatment. Baseline and post-PPID implementation data on events per 1,000,000 drug administrations were compared by chi-square with p<0.05 considered significant. Results: An average of 510,541 doses were dispensed each month in 2008. Total self-reported medication errors initially increased from 20 per million doses dispensed pre-barcoding (first quarter 2008) to 38 per million doses dispensed immediately post-intervention (last quarter 2008), but errors reaching the patient decreased from 3.26 per million to 0.8 per million despite the increase in "nearmisses". A number of process issues were identified and improved, including additional training and equipment, instituting ParX scanning when filling Pyxis machines, and lobbying for a manufacturing change in how bar codes were printed on bags of intravenous solutions to reduce scanning failures. Conclusion: Introduction of barcoding of medications and patient wristbands reduced serious medication dispensing errors reaching the patient, but temporarily increased the number of "near-miss" situations reported. Overall patient safety improved with the barcoding and positive patient identification initiative. These results have been sustained during the 18 months following full implementation. ObjectivesOur objective was to document the reduction in medication errors reaching patients after introduction of bar code scanning and positive patient identification in a large teaching hospital already using computerized provider order entry. Introduction of bar code scanning was associated with an unexpected increase in reported errors, so we further investigated the source of these error reports. We also report on the problems encountered and solutions deployed in implementing this practice change. MethodsThis study was conducted at Baystate Medical Center, a 655-bed general, acute care tertiary care teaching hospital. This study complies with the World Medical Association Declaration of Helsinki on Ethical Principles for Medical Research. As this study utilized de-identified data collected for quality improvement, it was not considered human subjects research and thus did not require Institutional Review Board approval. Data analyzed for this study were collected routinely for clinical care and quality improvement, and beyond introduction of bar-code scanning, clinical practice was not affected in any way by the study. Computerized Provider Order Entry (CPOE) was first initiated at Baystate in 1995 and transitioned from a legacy TDS Hospital Information System to Ce...

A Systematic Review of Quantitative Methods for Evaluating Electronic Medication Administration Record and Bar-Coded Medication Administration Usability

“…Integrating these medication administration technologies (MATs) into the inpatient workflow is linked with reducing medication errors. 1 2 3 4 However, poor usability of MAT can negatively impact provider workflow and have unintended consequences, resulting in patient safety risks. 5 6 A growing body of research shows the association between poor health information technology (health IT) usability and patient safety.…”

Integration of a Commercial Barcode-Assisted Medication Dispensing System in a Teaching Hospital

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