Bar Coding: An Effective Strategy for Preventing Medication Errors

Medication safety is an ongoing challenge for hospitals, healthcare providers, and healthcare delivery systems. Medication errors in hospitals are common^1,2 and can lead to patient harm. A study by Leape and colleagues found that serious medication errors occurred most often in physician ordering (39%) and nurse administration (38%). The remaining 23% occurred during transcription (12%) and pharmacy dispensing (11%).³

Strategies are needed to reduce preventable adverse drug events (ADEs), and the implementation of healthcare information technology (HIT) has been touted as a promising strategy for preventing medication errors. Com put erized physician order entry (CPOE) has been shown to decrease serious medication errors by 55%.4 Bar code technology, which is widely adopted in industries outside of healthcare because of its ease of use and reliability, has been shown to prevent errors in dispensing drugs from the pharmacy.⁵ At the bedside, the use of bar code technology to verify a patient’s identity and the medication to be administered has been shown to be an effective strategy for preventing medication errors, and its use has been increasing. The US Department of Veterans Affairs, for example, pioneered the way by instituting a national bar coding program in 1999 in its hospital system.^6,7

Bar code medication verification at the bedside is usually implemented in conjunction with an electronic medication administration record (eMAR). This combination of technologies allows nurses to automatically document the administration of drugs by scanning their bar codes6 to ensure the correct medication is administered in the correct dose at the correct time to the correct patient. Because the eMAR imports drug orders electronically from the physician’s order entry or the pharmacy system, its implementation may reduce transcription errors.⁶

Bar code plus eMAR technology is not without its drawbacks. One study found that although medication management improved, the system studied was difficult to implement.⁸ Furthermore, other studies have highlighted certain unintended consequences of eMAR implementation, such as hospital staff relying too heavily on the technology, bypassing some of the hospital’s safety processes, or overriding the system’s alerts, thus increasing the risk for new errors.^9,10

Study examines efficacy and safety of bar code technology in hospital setting
Given the uncertainties with bar code plus eMAR technology, my colleagues and I at Brigham and Women’s Hospital evaluated its implementation in 35 adult medical, surgical, and intensive care units in our 735-bed tertiary academic medical center to assess its effects on administration and transcription errors, as well as associated potential ADEs.⁶

During the 9-month study, we compared 6723 medication administrations on patient units before the bar code plus eMAR technology was introduced with 7318 medication administrations after the technology was introduced. We also reviewed order transcriptions in both time frames.⁶

Results
Of the 1272 nontiming errors observed, 776 occurred in medication administration on units without the bar code plus eMAR system (an 11.5% error rate) compared with 495 such errors on units that used it (a 6.8% error rate), corresponding to a 41.4% relative reduction in errors (P <.001). The rate of potential ADEs (associated with nontiming errors) fell from 3.1% without the use of the bar code plus eMAR system to 1.6% with its use, representing a 50.8% relative reduction (P <.001). A 27.3% (P <.001) reduction was seen in the rate of timing errors in medication administration, but the rate of potential ADEs associated with timing errors did not differ significantly.⁶

Transcription errors also were reduced with the bar code plus eMAR system. Of the 3082 transcription orders reviewed, 1799 orders were on units without the technology. We found 110 transcription errors, of which 53 were potential ADEs, corresponding to 6.1 transcription errors and 2.9 potential ADEs per 100 medication orders transcribed. In the 1282 medication orders reviewed on units with the bar code plus eMAR system, transcription errors were completely eliminated.⁶

Clinical implications of bar code technology
This study demonstrates that bar code plus eMAR technology can be an important intervention to improve medication safety. Because the study hospital administers approximately 5.9 million doses of medications per year, use of the bar code plus eMAR is expected to prevent approximately 95,000 potential ADEs at the point of medication administration every year in this medical center. The electronicorder-entry system processed about 1.69 million medication orders during the study period. As a result, the system is also expected to prevent approximately 50,000 potential ADEs related to transcription errors.⁶

Whereas nurses and pharmacists often intercept errors made by physicians during the medication-ordering stage, errors made during the administration stage and, to a lesser extent, during the medication transcription stage often go undetected.3 This finding underscores the need for highly reliable strategies, such as bar code technology, to act as an additional safety component in medication administration and order transcription.⁶

Pharmacists’ role in dispensing medications is crucial in hospitals. The close integration of order-entry, pharmacy, and medication administration systems en - sures that nurses administer medications only after pharmacists have reviewed the orders, providing patients with the added benefit of the pharmacists’ clinical knowledge.⁶ Preventing trans cription errors is also vital. Factoring in the high number of doses administered and orders transcribed in acute care hospitals, implementation of a bar code plus eMAR system could significantly im prove medication safety.⁶

The results of this study were similar to Bates and colleagues’ findings on CPOE, which reduced serious medication errors at the ordering stage by more than 50%.⁴ Decision support embedded within CPOE systems is more likely to prevent errors that result from poor judgment, lack of knowledge, or incomplete clinical information when choosing a therapeutic plan. In contrast, a bar code plus eMAR system is more likely to prevent errors associated with memory lapses or mental slips in executing a therapeutic plan.⁶ My colleagues and I have suggested that these two technologies could play complementary roles in improving medication safety in acute care. More research is needed to determine which of these two technologies should be implemented first, if an organization has to make that choice.⁶

In the current study, the rate of medication administration errors fell significantly, but not all the errors were eliminated. We offer two possible reasons. Patient safety technology is effective if it is used as intended. Whereas the study hospital expended substantial resources in the training of end users, 20% of the drugs administered on units with the bar code plus eMAR technology were administered without the bar code scanning step during the study period. In addition, the study hospital used an early version of the software; several important improvements have been made since this study was conducted. In light of these issues, we recommend that deployment of HIT should be envisioned not as a single event in time but rather as an ongoing process that requires modifications and improvements.⁶

Multiple limitations of this study, however, warrant consideration. The study findings reflect the experience of one hospital that already has fully implemented CPOE for physicians and bar code verification for pharmacy staff. Hospitals considering implementation of a bar code plus eMAR technology without CPOE, pharmacy bar code verification, or both may observe a different outcome on the effect on administration errors. The study also examined potential ADEs, not actual ADEs. Furthermore, the study hospital worked closely with users and clinical leaders who were willing to support a significant change in workflow to improve the overall medication process.⁶ Healthcare organizations interested in using a bar code plus eMAR technology should take into account these factors and find strategies to implement the technology in the most cost-effective way.⁶

Bar code plus eMAR technology, in my opinion, improves medication safety by reducing administration and transcription errors, providing support for its inclusion as a 2013 criterion for meaningful use of HIT under the American Recovery and Reinvestment Act of 2009.

References

1. Brennan TA, Leape LL, Laird NM, et al. Incidence of adverse events and negligence in hospitalized patients: results of the Harvard Medical Practice Study I. N Engl J Med. 1991;324:370-376.
2. Bates DW, Cullen DJ, Laird N, et al. Incidence of adverse drug events and potential adverse drug events. Implications for prevention. ADE Prevention Study Group. JAMA. 1995;274:29-34.
3. Leape LL, Bates DW, Cullen CJ, et al. Systems analysis of adverse drug events. ADE Prevention Study Group. JAMA. 1995;274:35-43.
4. Bates DW, Leape LL, Cullen DJ, et al. Effect of computerized physician order entry and a team intervention on prevention of serious medication errors. JAMA. 1998;280:1311-1316.
5. Poon EG, Cina JL, Churchill W, et al. Medication dispensing errors and potential adverse drug events before and after implementing bar code technology in the pharmacy. Ann Intern Med. 2006;145:426-434.
6. Poon EG, Keohane CA, Yoon CS, et al. Effect of barcode technology on the safety of medication administration. N Engl J Med. 2010;362:1698-1707.
7. Wright AA, Katz IT. Bar coding for patient safety. N Engl J Med. 2005;353:329-331.
8. Puckett F. Medication-management component of a point-of-care information system. Am J Health Syst Pharm. 1995;52:1305-1309.
9. McDonald CJ. Computerization can create safety hazards: a bar-coding near miss. Ann Intern Med. 2006; 144:510-516.
10. Koppel R, Wetterneck T, Telles JL, Karsh BT. Workarounds to barcode medication administration systems: their occurrences, causes, and threats to patient safety. J Am Med Inform Assoc. 2008;15:408-423. Eileen Koutnik-Fotopoulos contributed to the preparation of this article.