Medication errors in hospitals pose a significant threat to patient safety and contribute substantially to healthcare costs. Between 2005 and 2007, these errors cost Medicare over $6.9 billion, tragically resulting in more than 92,000 preventable in-hospital deaths. Medication administration mistakes are particularly prevalent, affecting an estimated 1.5 million individuals annually. This alarming situation has driven US healthcare facilities to aggressively adopt technology-driven solutions, with barcode scanning emerging as a pivotal tool in enhancing medication safety protocols.
Recognizing the severity of the issue, hospitals across the nation are implementing robust patient safety programs centered around health information technology (HIT). Computerized Prescriber Order Entry (CPOE) systems have been instrumental in minimizing drug-related errors by automatically flagging potential drug interactions and allergies. Building upon this foundation, barcode scanning is gaining traction as another critical electronic capability. Dr. Stuart Levine, an informatics specialist at the Institute for Safe Medication Practices (ISMP), emphasizes the broad applicability of barcode technology throughout a patient’s hospital journey, from the pharmacy to the point of care, to significantly mitigate medication error risks. He highlights that over half of hospital-related harm occurs at the point of care, underscoring the importance of barcode scanning in ensuring medication accuracy right at the patient’s bedside.
The integration of barcode scanning with other safety measures represents a paradigm shift in hospital drug safety strategies. J. Lyle Bootman, Co-chair of the IMNA and Dean and Professor at the University of Arizona College of Pharmacy, advocates for equipping healthcare providers with the necessary tools and data to ensure the safest possible drug prescription, dispensing, and administration processes, ultimately aiming for optimal patient care and outcomes with every medication.
This article delves into the successful implementation of barcode scanning systems at four prominent US healthcare facilities: HCA Virginia Health System, CHRISTUS St. Patrick Hospital, the Veterans Health Administration, and the Henry Ford Health System, showcasing diverse approaches and impactful results in leveraging this technology for enhanced patient safety.
The Cornerstone of Medication Safety: The 4 R’s
Hospital administrators are guided by the fundamental “4 R’s of medication safety”: ensuring the right dose of the right medication is administered to the right patient at the right time. Historically, achieving these objectives has been hampered by various hospital inefficiencies, including misinterpreted orders, transcription errors, communication gaps, drug misidentification, inadequate dose verification, drug-stocking issues, and a lack of standardized procedures. These vulnerabilities underscore the critical need for technology-driven solutions like barcode scanning to streamline processes and minimize human error.
Barcode Scanning Adoption: Case Studies in Enhanced Safety
HCA Virginia Health System: Embracing a Closed-Loop Medication Management
HCA Virginia Health System, like many others, grappled with the challenges of medication errors stemming from traditional hospital processes. In 2000, HCA leadership prioritized patient safety, committing to a HIT-driven medical safety strategy. Today, all 159 HCA hospitals utilize the MediTech information system, chosen for its capacity to facilitate a closed-loop medication management system.
MediTech’s comprehensive capabilities encompass CPOE, automated drug-dispensing cabinets, bar-coded medication administration, and smart intravenous (IV) pumps. This integrated system ensures a unified formulary, medication administration record (MAR), allergy record, and medication history, providing caregivers with real-time, consistent patient data for informed decision-making. Medication reconciliation and transitions across different hospital settings are also simplified, eliminating redundant data entry. Prescriptions are electronically transmitted to the inpatient pharmacy, enhancing efficiency and accuracy.
In 2002, HCA implemented MediTech’s Bedside Medication Verification (BMV) module, enabling point-of-care barcode scanning. When a medication order is processed by the pharmacy, the information is instantly updated in the patient’s Electronic Health Record (EHR). Pharmacists ensure every medication is bar-coded before leaving the pharmacy. At the bedside, nurses scan the barcode on the medication and the patient’s bar-coded identification bracelet. This verification process confirms the “4 R’s”—right patient, right drug, right dose, right time. Any discrepancy, such as administering medication prematurely, triggers an immediate system alert, preventing potential errors.
Noel Hodges, RPh, MBA, Division Director of Pharmacy Services at HCA Virginia, explains the system’s impact: “When a nurse scans the medication and the bar-code software realizes that the wrong patient is about to be given that medication, the medication cannot be dispensed. Before, odds were [that] the patient would have received the medication.” This highlights the system’s proactive error prevention capabilities.
CHRISTUS St. Patrick Hospital: Pharmacy-Driven Precision at the Bedside
CHRISTUS St. Patrick Hospital in Lake Charles, Louisiana, recognized the potential for severe consequences due to medication errors occurring at the patient bedside. This prompted a collaborative effort involving nursing, pharmacy, and information management to implement BMV.
Similar to HCA, CHRISTUS selected MediTech. Nurses at CHRISTUS utilize barcode scanners to scan the patient’s bar-coded arm band (Figures 1 and 2), which then displays the patient’s medication profile. Each medication barcode is subsequently scanned. If a medication is not listed on the patient’s profile, the system immediately warns the nurse, preventing administration errors.
Figure 1.
Figure 2.
Tamica Francois, LPN, BMV core team leader at CHRISTUS, emphasizes the pharmacy’s central role: “This is a completely pharmacy-driven process. The [pharmacists] input the time, dose, and patient, and there is no chance of deviating from the administration schedule.” The pharmacy dictates the medication schedule and parameters within the system, ensuring adherence to prescribed regimens.
Currently, three CHRISTUS hospitals employ BMV. While CHRISTUS lacked pre-BMV error tracking data due to manual processes, Ms. Francois anticipates a significant reduction in medication variances, projecting a decrease of 85% or greater with the automated system.
In-House Barcode Innovation: Tailored Systems for Unique Needs
While commercially available barcode systems offer robust solutions, some healthcare facilities opt for developing their own customized systems. This approach allows for greater flexibility in tailoring the system to specific hospital needs and seamless integration with existing departmental software.
Veterans Health Administration: A Nurse-Inspired, Nationally Scaled Solution
The Veterans Health Administration (VHA) embarked on developing its proprietary barcode system spurred by a simple observation. Inspired by a rental car employee using a handheld scanner, a VA nurse envisioned a similar application for patient and medication identification. Chris Tucker, RPh, VHA Director, recounts how a $50,000 VA startup grant catalyzed the development of a barcode system prototype. This real-time, wireless, point-of-care technology, featuring an integrated barcode scanner, was initially piloted in 22 nursing units within the VA’s Eastern Kansas Health Care System (Figure 3).
Figure 3.
This prototype served as the foundation for the VHA’s nationwide Bar Code Medication Administration (BCMA) system. BCMA’s primary function is to electronically validate medications and document medication administration. Each barcode scan on a medication order triggers system verification of the “5 Rights”: right patient, right drug, right dose, right time, and right route of administration, along with electronic documentation of administration.
BCMA was designed for seamless integration with the VA’s existing pharmacy and nursing software, fostering unprecedented collaboration between these departments, which historically operated somewhat independently in addressing medication delivery and administration challenges. Standardized order guidelines facilitated a more coordinated medication management process.
Ron Schneider, a pharmacist consultant at VHA, emphasizes the multidisciplinary collaboration critical to BCMA implementation, involving information management, nursing, and pharmacy specialists. He notes, “Understanding one another’s working conditions and collaborating our efforts improved the implementation process.”
Today, BCMA is implemented across all VA medical centers, demonstrating significant reductions in medication errors. Between 1993 and 2001, substantial improvements were observed across various error types (Table 1). In 2002, BCMA Version 2.0 was released, incorporating enhanced checks and balances for IV therapy. Future BCMA development aims to integrate with other clinical software, encompassing vital signs, nutrition, and lab results, for a more holistic patient information system.
Table 1.
Reported Error Rate per Total Doses of Medication Dispensed in the Veterans Health Administration
| Error Type | 1993 (%) | 2001 (%) | Improvement (%) |
|---|---|---|---|
| Wrong medication | 0.00371 | 0.00091 | 75.47 |
| Wrong dose | 0.00334 | 0.00127 | 61.97 |
| Wrong patient | 0.00138 | 0.00009 | 93.48 |
| Wrong time | 0.00143 | 0.00018 | 87.41 |
| Omission | 0.00917 | 0.00272 | 70.34 |
From Johnson CL, et al. J Healthcare Information Manage, 2002; 16(1):46–51. Reproduced with permission of the Healthcare Information and Management Systems Society.
Henry Ford Health System: Streamlining Lab Processes with Barcodes
At the Henry Ford Health System in Detroit, the surgical pathology laboratory pioneered barcode implementation. Dr. Richard J. Zarbo, Senior Vice President for Pathology and Laboratory Medicine, recognized the potential for improvement in the lab’s manual processes, which had remained largely unchanged for years.
“Everything we did was pencil- and paper-based, which opened the door for misidentifying lab specimens,” Dr. Zarbo explained. Driven by the principles of lean processing championed by Henry Ford, Dr. Zarbo and his team embarked on designing a barcode system five years prior to the original article’s publication to standardize workflow from specimen receipt to EHR integration.
The implemented system assigns a barcode to every specimen upon lab entry. This barcode links to the patient and specimen information within the laboratory information system (LIS). Technicians scan the barcode at each workstation throughout the analysis process, accessing necessary case information from the LIS. All work performed is then recorded directly into the patient’s EHR.
Dr. Zarbo highlights the transformative impact: “Our workstations now perform their work faster, the technicians are happier, and we can handle more content. Our former manual process was a non-value added [one], and I didn’t realize that until it went away.” Barcode implementation resulted in a remarkable 95% reduction in laboratory errors.
Dr. Zarbo clarifies that while their manual error rates were not initially high, the standardized workflow enabled by barcode technology significantly enhanced efficiency and reduced the potential for errors. He concludes, “It’s not bar coding that is the solution; it’s the standardized work flow. However, I do admit that having 95% fewer mistakes does help me sleep a lot better.”
National Push for Electronic Health Technology
Despite the clear benefits of barcode scanning in mitigating medical and medication errors, adoption rates in US hospitals remained relatively low at the time of the original article. A 2008 survey by the American Society of Health-System Pharmacists (ASHP) indicated that only 25% of hospital pharmacies utilized barcode medication administration systems. CPOE adoption was also limited to 12%, while automated drug-dispensing cabinets were more prevalent at 83%.
Dr. Levine advocates for universal barcode adoption, stating, “I would like to see that bar-code use percentage reach 100%. However, bar coding is only one technological strategy that will solve the medication error rate in this country. There needs to be a safety net formed by using all of the technology available to hospitals today.”
Recognizing the critical role of HIT, the federal government has made significant investments to accelerate its adoption. The American Recovery and Reinvestment Act allocated $19 billion to fund HIT initiatives, particularly emphasizing the expanded use of EHRs. An additional $1 billion was subsequently earmarked for HIT investment.
President Obama, in a speech at George Mason University, articulated the national imperative for health IT adoption: “To improve the quality of our health care while lowering its cost, we will make the immediate investments necessary to ensure that, within five years, all of America’s medical records are computerized. This will cut waste, eliminate red tape, and reduce the need to repeat expensive medical tests. But it won’t save just billions of dollars and thousands of jobs; it will save lives by reducing the deadly but preventable medical errors that pervade our health care system.” This political emphasis further underscored the importance of barcode scanning and other HIT solutions in transforming healthcare delivery and enhancing patient safety across the US.
References
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[2] Institute of Medicine. Preventing Medication Errors. Washington, DC: National Academies Press; 2006.
[3] Bates DW, Spell N, Porter J, et al. Arch Intern Med. 1997;157:1613–1620.
[4] Johnson CL, Carlson J, Tucker CL, et al. J Healthcare Information Manage. 2002;16(1):46–51.
[5] Pedersen CA, Schneider PJ, Scheckler R. Am J Health-Syst Pharm. 2009;66:367–384.
[6] Obama B. Remarks at George Mason University, Fairfax, VA. 2009 Feb 9.
