Patient safety has been a growing concern in healthcare since the Institute of Medicine (IOM) published their now infamous “To Err Is Human: Building a Safer Health System“ report in November 1999.¹ The report basically states that between 45,000 and 98,000 patients die each year in healthcare systems secondary to medical error. Unfortunately medication errors play a significant role in the problem. Not only is the cost to human life and livelihood devastating, the financial implications are staggering as well. Depending on which study you reference the numbers could run into the billions of dollars.

Let’s face it, medications are dangerous and can be potentially fatal when given incorrectly. This is especially true for chemotherapy, which has a long history of causing serious injury when prepared incorrectly.² And because the healthcare industry has recognized the dangers associated with medication administration, there have been many proposed solutions for reducing errors. Black-Box warnings, Sound-Alike-Look-Alike-Drug separation, high-alert medication differentiation, special storage precautions, colored labels, etc are all approaches to decrease medication dispensing and administration errors. However, all these solutions have a fatal flaw, and that is that they rely on human intervention.

Because humans are inherently bad at always being right we’ve developed technology that can help keep us from doing harm to our patients. One such technology is bar-code medication administration (BCMA). When used properly BCMA is an effective means to prevent medication administration errors. The addition of bar-code verification at the point-of-care has the potential to significantly increase patient safety.

However, published research since the original To Err Is Human report has not been encouraging as healthcare continues to struggle with medication errors.^3,4 This has led several organizations such as the American Society of Health-System Pharmacists (ASHP) to develop guidelines encouraging pharmacies to utilize a bar-code medication administration systems. “Use of the BCMA system should be universal within the health system. To the fullest extent feasible, every patient, care provider, and medication should receive a unique identifier, and that identifier should be used not only to verify care prescribed for a patient but also to document every significant step in the medication-use process.”⁵ I happen to agree with ASHP’s statement.

With that said a majority of acute care pharmacies have yet to implement any type of BCMA system.⁶ The reasons cited for the slow adoption include barriers to change, difficulties with implementation and lack of both financial and labor resources. It’s unfortunate that something that has been shown to decrease medication errors and save lives^7,8,9 is sitting on the back burner of many project plans in healthcare systems across the country. When you consider that BCMA has the potential to save individual healthcare systems millions of dollars¹⁰ it becomes a mystery why more hospitals have yet to adopt such a simple technology.

We all look for simple solutions to big problems, and BCMA provides such an opportunity. Of course not everyone believes that BCMA is everything it’s cracked up to be, but the evidence to support such a position is lacking. While some studies have demonstrated issues with the use of BCMA systems, none have demonstrated that BCMA fails to benefit patient safety.^11,12

Of all the technology implementations I’ve been a part of inside the hospital, BCMA was not the most difficult. I’m not saying implementing BCMA is a cinch, but to me it’s a no-brainer.

References

1. Linda T. Kohn, Janet M. Corrigan, and Molla S. Donaldson, Editors; Committee on Quality of Health Care in America, Institute of Medicine. To Err Is Human: Building a Safer Health System. Washington, D.C.: The National Academies Press; 2000.
2. Walsh KE, Dodd KS, Seetharaman K, et al. Medication errors among adults and children with cancer in the outpatient setting. J. Clin. Oncol. 2009;27(6):891-896.
3. Leape LL, Berwick DM. Five Years After To Err Is Human. JAMA: The Journal of the American Medical Association. 2005;293(19):2384 -2390.
4. 10 years after “To Err is Human”: An RCA of Patient Safety Research?: Slide Presentation from the AHRQ 2008 Annual Conference (Text Version). Available at: http://www.ahrq.gov/about/annualmtg08/090908slides/Pronovost.htm [Accessed February 28, 2011].
5. ASHP Statement on Bar-Code-Enabled Medication Administration Technology. American Journal of Health-System Pharmacy. 2009;66(6):588 -590.
6. Pedersen CA, Schneider PJ, Scheckelhoff DJ. ASHP national survey of pharmacy practice in hospital settings: Monitoring and patient education—2009. American Journal of Health-System Pharmacy. 2010;67(7):542 -558.
7. Lawton G, Shields A. Bar-code verification of medication administration in a small hospital. American Journal of Health-System Pharmacy. 2005;62(22):2413 -2415.
8. Larrabee S, Brown M. Recognizing the institutional benefits of bar-code point-of-care technology. Jt Comm J Qual Saf. 2003;29(7):345-353.
9. Poon EG, Keohane CA, Yoon CS, et al. Effect of Bar-Code Technology on the Safety of Medication Administration. N Engl J Med. 2010;262:1698-1707
10. Maviglia SM, Yoo JY, Franz C, et al. Cost-Benefit Analysis of a Hospital Pharmacy Bar Code Solution. Arch Intern Med. 2007;167(8):788-794.
11. Miller DF, Fortier CR, Garrison KL. Bar Code Medication Administration Technology: Characterization of High-Alert Medication Triggers and Clinician Workarounds. Ann Pharmacother. 2011;45(2):162-168.
12. Koppel R, Wetterneck T, Telles JL, Karsh B. Workarounds to Barcode Medication Administration Systems: Their Occurrences, Causes, and Threats to Patient Safety. Journal of the American Medical Informatics Association. 2008;15(4):408 -423.