Flaws with Bar-coded Technology

It was found that the urgencies of care and the ingenuity of nurses to cope with these shortcomings have the unintended consequences of creating other medication errors. The study also illustrates how adjustments to workflow and the technology can reduce the risk of these errors and states that four of the study hospitals reduced the number of overrides by following the recommendations.

Close to a half-million instances where nurses and other staff scanned patients and medications were examined at five hospitals. The scientists also participated in implementation meetings, and conducted scores of interviews with pharmacists, nurses, and IT leaders.

The researchers found a high proportion of scans involved nurses overriding the technology with workarounds to compensate for difficulties with the barcode systems. Nurses scanning the barcode on the medication or the patient’s ID bracelet overrode the technology for 4.2 per cent of patients charted and for 10.3 per cent of medications charted.

31 “causes” of problems were found. These causes included: unreadable medication-barcodes (crinkled, smudged, torn, missing); malfunctioning scanners; unreadable patient-ID-wristbands (chewed, soaked, missing); non-barcoded-medications; medications in distant refrigerators, lost wireless connectivity; and emergencies.

The workarounds of the nurses consisted of, for example, affixing extra copies of patient barcodes on desks, scanning machines, supply room, and doorjambs, as well as carrying several pre-scanned patient’s medications on one tray. Ross Koppel, of the University of Pennsylvania School of Medicine, said: “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.”

MEDICA.de; Source: University of Pennsylvania School of Medicine