Barcode Technology Flaws Put Some Patients at Risk (HealthDay)

THURSDAY, July 3 (HealthDay News) -- Flaws in the design andimplementation of barcode systems designed to match hospital patients withthe right dose of the right medication can increase the risk of certainmedication errors, according to a study that looked at the use of thesystem in five U.S. hospitals.

The first-of-its-kind study looked at almost half a million instanceswhere nurses and other staff scanned patients and medications. In aremarkably high percentage of instances, nurses overrode the technology inorder to compensate for awkward or inconvenient aspects of the barcodesystems. Nurses scanning the barcode on the medication or the patient's ID bracelet overrode the system for 4.2 percent of patients charted and 10.3percent of medications charted.

The researchers identified 31 causes of system problems that prompted"workarounds" by nurses. These included: unreadable medication barcodes(crinkled, smudged, torn, missing, covered by another label);malfunctioning scanners; unreadable or missing patient ID wristbands;non-barcoded medications; medications in distant refrigerators; lostwireless connectivity; problems with patients in contact isolation, andemergencies.

Workarounds used by nurses included: affixing extra copies of patientID barcodes on desks, scanning machines, clipboards, supply rooms, anddoorjambs, as well as carrying several pre-scanned patient medications onone tray.

"It's not that staff are lazy or careless, it's that the system doesnot work as well as it should. If the refrigerated medication is twofloors and a long hallway away, you're not going to wheel your 87-year-oldpatient to the fridge. You make a copy of her barcode. And while you dothat, you help another two patients who also need refrigeratedmedications," study leader Ross Koppel, of the University of PennsylvaniaSchool of Medicine, said in a prepared statement.

"Bar-coding is still under development," he noted. "Administrators andvendors may expect it to be fool-proof, but users know it's not. It's avery promising technology that still requires constant refining andcareful observation of on-the-floor workflow to get it right."

Koppel emphasized that barcode systems do prevent medication errors andsave lives. Identifying problems with the systems and mitigatingworkarounds can make them even more effective. In their study, Koppel andhis colleagues made a number of recommendations, and four of the hospitalsin the study dramatically reduced the number of workarounds by followingthese recommendations.

The study was published in the July/August issue of the Journal ofthe American Medical Informatics Association.

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