News | May 12, 2008

Hospitals Look to Bar Coding to Address Medication Safety

May 13, 2008 - Healthcare experts across the country are encouraging hospitals to adopt bedside bar coding to reduce harmful medication errors, according to a survey conducted at The unSummit for Bedside Bar Coding Conference April 30 - May 2 in Austin, TX.

Bar code verification of medications in hospitals has been shown to help reduce medication errors, which harm an estimated 400,000 patients each year, including one in 15 pediatric patients. Until now, the debate over which solution best addresses medication error has long favored computerized physician order entry (CPOE) over bar code point-of-care technology (BPOC). This view is shifting. Despite the documented effectiveness of CPOE in peer-reviewed literature, a series of recent high-profile medication errors including the heparin overdose of actor Dennis Quaid's newborn twins, has drawn patient safety leadership to focus on patient bedsides rather than the physician�s prescription pad.

More than 400 pharmacists, nurses, informaticists and technology vendors gathered for The unSUMMIT for Bedside Bar Coding, a conference dedicated solely to bedside bar-coding technology. During the two and a half days, more than 40 speakers from 20 hospitals and industry experts reported results from extensive BPOC use, illustrating common hang-ups as well as sharing their means of success.

Robert Wachter, M.D., professor and associate chairman of the University of California San Francisco Department of Medicine and chief of medical staff at UCSF Medical Center, wrote in his blog Wachter's World that he couldn't recall a major medication error that would have been prevented by CPOE.

"Not that there aren't any, but it does seem like today's 'oh-my-God-how-could-this-happen' med errors are now disproportionately administration, not prescribing, mistakes," he said.

As a result, Wachter, the pioneer of hospitalist medicine, is now saying, "based on what I know today, if I was a hospital ready to get into the IT game, I'd go with bar coding first."

Among them, nurse Julie Thao who in 2006 faced criminal charges for a fatal medication error and Dr. Charles Denham, founder and chairman of the nonprofit medical research organization, Texas Medical Institute of Technology, shared a stirring account of a nursing career lost to a preventable error highlighting the "other victim" of medication error. Manisha Shah, director of patient safety for the world's largest private operator of healthcare facilities, Hospital Corporation of America (HCA), unveiled the results of three years of BPOC data across 180 hospitals. Anne Bane, RN, and Tom Cooley, RPh., MBA of Brigham and Women's Hospital, which has been the epicenter of both CPOE and bar-coding research, co-presented the unintended consequences of BPOC so other hospitals might avoid their mistakes.

Since The unSUMMIT's initiation in 2005 when estimated adoption rates lagged in fewer than 10 percent of hospitals, proponents of bar coding have seen numbers double, according to a survey published in the American Journal of Health-System Pharmacists. A confluence of factors appears to be moving hospitals toward widespread adoption.

The unSUMMIT co-founder, Jamie Kelly said although the past rate of BPOC adoption has been slow, the support provided by Dr. Wachter, The Quaid Foundation, the unSUMMIT speakers and the more than 900 unSUMMIT attendees over the past three years, has the potential to establish bar coding as the standard of care in the coming years.

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