Barcoding for Patient Safety
This paper examined the positive and negative aspects of Barcoding practices in hospitals to enhance patient safety. It has been found that medical errors widely prevalent and frequent can be avoided by such automated measures as barcoding. The few objections are downtime issues and costs involved. While the downtime time problem is common to all the other industries which the healthcare sector can learn from as to how to overcome such situations, values are found to be outweighed by benefits. Moreover, financial incentives to implement barcoding are in place. Further, costs should not be an excuse for life-saving issues. Overall, the positive features make the negative ones diminutive.
The U.S. is losing over $ 37 billion each year due to medical errors even though the nation spends about $ 1.6 trillion on healthcare and incurs an avoidable expenditure of $ 300 billion each year spent on poor treatment outcomes. Medical error is the eighth leading cause of death, killing between 44,000 and 98,000 Americans each year, a rate higher than the mortality rates from vehicle accidents, breast cancer, and AIDS attributed to 43,458, 42,297, and 16,516 deaths each year respectively. The sad news is that majority of medical errors are preventable. Medical errors occur either due to the non-completion of a planned action or planning wrongly to accomplish the desired objective about the patient. Medical errors are categorized as diagnostic, treatment-related, preventative, and others. (Jacquelyn & Frederick.G, 2006).
In light of the above scenario, this paper seeks to examine how high technology could prevent medical errors. The technology used for barcoding products and services of other industries than healthcare is now a familiar place. In the healthcare sector, pharmaceutical products have recently been mandated by the FDA to carry barcodes. Labeling drugs must now include a barcode containing the National Drug Code meant for each type of medication. This has been made mandatory with effect from 2006. If barcodes are applied in hospitals, a nurse would scan his/her bar code, bar code of the medication and that of the patient and send information wirelessly to the computer the software in which would verify whether the correct medication is being administered to the right patient at the right time by generating a warning or approval as the case may be. The barcodes are applied to ‘patient ID bands, medications, and vials of blood and transfusion bags.’ This technology gains significance, given the fact that 35 % of the medication errors happen at the administration stage. Further analysis of the error incidence shows that 21 % of mistakes due to dose omission, 4 % due to the wrong patient, 4 % due to incorrect time, and 1 % due to the wrong route could be prevented (Hoyt, Sutton, & Yoshihashi, 2008).
The use of the technology will be examined in greater detail in the following pages to test the hypothesis of this paper set as;
Although some research has identified faults in the health care industries through barcode technology, Barcode-Enabled Point-of-Care, or Bedside Point-of-Care (BPOC) systems, its use offers benefits that are invaluable for providing safe, high-quality in-patient or out-patient hospital care.
Bar-code Technology and the History of its Development
The U.S.A. had its first barcoding system applied in Cincinnati at a supermarket 40 years ago when there were no printing and scanning techniques. The inexpensive printed tags and printing devices subsequently introduced made the barcode operations economical, and hence the barcoding practice came to be adopted in commercial establishments. Scanning technology essential for barcoding also aided its fast development, though belated development of feasible scanning systems delayed the early adoption of barcoding. There are different barcode technologies: one-dimensional (1D), also known as linear barcodes, two dimensional (2D), and three dimensional (3D) to cater to different user needs. These were developed along with several barcode symbologies having unique characteristics to meet specific needs. Today, various barcode technologies meeting the diverse user needs have become part and parcel of daily life. The barcode technology involving automatic identification and data capture has its origin traceable to the early 1800s as reading aids for the blind. The different types of automatic identification and data capture are optical character recognition (OCR), radio frequency identification (RFID), magnetic stripe technology apart from barcode technology. Each type has its advantages and disadvantages. Barcoding is a method of printing information in a machine-readable format and is the least expensive. The current form of barcode technology having a data recognition pattern was developed in the 1950s or earlier with the advent of data entry methods by computers. Two graduates from Drexel Institute of Technology, Norman J Woodland and Bernard Silver, obtained patents in 1952 to invent what was called “a bull’s eye” composed of concentric circles rather than straight-line bars as they are today. The bull’s eye was the first format of a linear barcode. Although Woodland’s original design was of narrow and vertical lines, it was redesigned as concentric circles to facilitate omnidirectional scanning. Later in 1962, David Collins and Chris Kapsambelis at Sylvania/GTE developed a barcode scanner system known as KarTrak. (Kato, Tan, & Chai, 2010). It was “an optic scanning system that illuminated a barcode made of horizontal bars of reflective red, white and blue tape on a non-reflective background” (Kato, Tan, & Chai, 2010, p. 13). This enabled introduction of color elements in barcoding specially developed to meet the needs of railroad research people for solving their problem of collecting owner and serial number information from moving railroad cars (Kato, Tan, & Chai, 2010, p. 13). The barcode scanning equipment was introduced by Collins in 1968. This led to the use of barcoding in General Motors in 1972 for identifying engines and axles. The primary purpose of barcoding when it was introduced in the USA in the 1960s and 1970s was to reduce human errors and to enable efficient processing of data. (Kato, Tan, & Chai, 2010). Thus ” the substitution error rate of the 1D barcode is much less than an experienced manual operator’s rate, which is about one substitution error per 300 characters entered” (Kato, Tan, & Chai, 2010, p. 13). The requirements of retailers, wholesalers, and grocery manufacturers compelled the development and adoption of standardized barcodes in the U.S.A. The barcoding “enabled retail stores to register data on each product at the point of sale (POS) and obtain real-time information on products” (Kato, Tan, & Chai, 2010, p. 13).
Barcoding in Health Care
Barcodes enhanced by information technology can address errors by scanning medication and the patient’s wristbands or ID bands at the point of care (POC) just before administration. The ‘5 rights’ to be ensured by the barcode-enabled prevention of medication errors are “the right patient, right drug, right dose, right route, and the right time.” The flow-chart in figure 1 explains the process of ‘barcoded medication administration’ (BCMA) technology (Cummings, Ratko, & Matuszewski, 2005).
The BCMA technology depicted in the figure above consists of hardware and software that include machines meant for generating barcode printouts of patients’ wristbands and medication packages at the pharmacy, and barcode scanners connected to computers placed at the patient’s location. Besides, there are wireless communication networks connecting the portable computers at the bedside and a centralized processor, software applications installed on the server to process the incoming information and return data to the computers at the bedside. There are also interfaces connecting server/software and hospital databases from the pharmacy information system and admission discharge transfer (ADT) system (Cummings, Ratko, & Matuszewski, 2005). In a hospital setting, the barcoding controlled medication administration at the bedside is preceded by nurses scanning their employee ID barcode along with that of the barcode imprinted on the patient’s wrist band and barcode on each medication package. The linear barcode (1-D), which is the most commonly used for medications, contains the 10 digit National Drug Code (NDC) number meant to identify manufacturer, product, and package size. A hospital is also free to adopt a smaller code to identify the coded item in a broader description. On the other hand, a 2-Dimensional barcode can accommodate more details, such as the batch number and the expiry date of the medication. More than one type of barcode can be used, as seen in figure 2 below (Cummings, Ratko, & Matuszewski, 2005).
BCMA was implemented at a small 300-bed community hospital. Piloting this project showed that it would reduce medication errors by 80% as there was a complimentary matching of patients and medication through the barcoding process (Sylevestor O & John R, 2008).
The electronic medication-administration system (eMar) on the line of the BCMA technology above facilitates automatic documentation of the administration of drugs by nurses through barcode scanning. This technology registers medication orders by electronic means from a physician’s order entry or pharmacy system, thus eliminating transcription errors from the traditional process of nurses collecting information of drugs to be administered from the transcriptions of the physicians’ medication orders. With the barcoding, the patient’s electronic record displays medication orders after being approved by the pharmacists. The system will also alert nurses on any medications overdue for any patients. The barcode eMAR serves as an additional layer of safety as the nurses have to scan the barcodes on the patient’s wrist band and the medication before administering the drugs to the patients. On the nurse’s scanning the said barcodes, the system verifies the pharmacist’s approval and patient’s identity and documents the administration of drugs or issues a warning in case of variations. The use of Bar-code eMAR technology ensures financial incentives under the American Recovery and Reinvestment Act 2009 by 2013 because of medication safety made possible by this technology and additional cost involved thereon. To test the eMAR system, a 9-month study was conducted in 2005 to determine the error rate at a 735-bed hospital. There had been 1.7 million medication orders and 5.9 million administrations from both the units that had used the barcode, and that had not combined. Oncology units were excluded since delays in clinical decisions due to complex dose regimens could not be harmonious with the workflow from the rest of the teams. The study reported a 41 % reduction in medication administration errors and a 51 % reduction in potential adverse drug events due to these errors. Errors in the timing of medication also registered a decrease of 27 %. Because of the introduction of barcode eMAR, this hospital is likely to prevent 95,000 adverse drug events, 270,000 late medications, and 50,000 adverse drug events due to transcription errors every year (Eric G, et al., 2010).
A study indicates that about 28 % adverse drug events are due to medication errors that can cause iatrogenic injuries, a well known common universal phenomenon but ‘costly and clinically important’ As these are preventable medication errors, a bedside point of care (BPOC) system such as above will be a permanent solution to avoid the mistakes (Mehta & Gogtay, 2005).
Cost and Benefit Analysis
The Bed-side Point of Care (BPOC) would not only include barcoding but also what the authors call failure mode effects analysis (FEMA), decision support systems (DSS) with real-time medical informatics, electronic medical records (EMR), computer physician order entry (CPOE), automated dispensing machines (ADM) and robotics as part of an integrated systems approach that was planned to be implemented by 2010. This approach expects to reduce medication errors drastically, besides lowering healthcare costs. The medication errors are not generally due to negligence or incompetency on the part of healthcare professionals. They are somewhat due to inherent in the systems approach, i.e., how the health system is organized and delivered. In a typical scenario of manual and semi-automatic environment, patient’s medical information is rarely available at one place in a hospital. There is more than one provider, department, and location involved, each keeping a patient’s medical records of its own. Even the patient does not have a comprehensive medical history on a real-time basis. It has been estimated that if 90 % of the hospitals adopt the above said emerging technologies as part of an integrated systems approach, it will result in a saving of $ 80 billion annually, i.e., $ 77 billion from enhanced efficiency and $ 4 billion from reduced medication errors and side effects. It would cost a total of $ 115 billion, i.e., $ 98 billion at the hands of hospitals and $17 billion at the hands of doctors. The costs could be recovered over time, and the resultants financial and safety benefits would significantly outweigh the costs. Brigham and Women’s and its sister hospital in Massachusetts, which implemented the above emerging technologies, has reported reduced overall medication errors by 81% and a saving of $ 10 million as 10 to1 payback on costs. (Jacquelyn & Frederick.G, 2006).
Slow Adoption of Barcoding in Hospitals
The slow adoption is attributed to the development of prototypes only during the mid-1990s, and barcoding in healthcare came to be widely recognized during the late 1990s. As per the survey by the American Society of Health-System Pharmacists (ASHP), only 1.1 % of the hospitals used barcoding in 1999. In 2002, it was 1.5 %. In 2003, it was found widely used by hospitals run by the Veterans Administration. The usage figure was predicted to climb to 5 % to 10 % shortly later (Cummings, Ratko, & Matuszewski, 2005).
Possible Challenges in Barcoding Practice
Although BCMA is crucial for safety, few obstacles likely to be faced by the healthcare industry are: Barcode label on patient or drug can contain printing errors; all drugs may not have the barcodes of the manufacturers, and all manufacturer code may not have been standardized and included in formulary databases; relabeling and repackaging of drugs will entail additional costs and be susceptible to new errors; users can circumvent key steps resulting in ignoring error safeguards; hospital computer interfaces can be problematic; barcode scanning adds to the nurses’ workload and interferes with their workflow both resulting in stress among them; barcode machines have to be robust, readily available and user-friendly (Cummings, Ratko, & Matuszewski, 2005).
The BCMA system is only a segment of the IT-enabled medication system. CPOE, eMARS, and smart pumps related to patient safety will soon make the IT-enabled medication system complete. RFID, already popular in inventory management, will quickly replace barcodes on wristbands, staff IDs, and drug packages. (Cummings, Ratko, & Matuszewski, 2005).
While medication error detection increases the efficiency of the hospital and enhances patient safety, there is a note of caution that with the electronic documentation of such errors, employers must take care to justify keeping hospital staff in employment despite such repetitive errors committed by particular nurses (Bobo, 2002).
Barcoding, which is cost-prohibitive, can be avoided by other cost-efficient methods. They include educating hospital staff on patient safety, standardizing, and continually reviewing protocols and separate protocols for high-risk medications. Instead of having to rely entirely on barcoding like technologies, hospitals can decide to change the practice of mixing, storing, prescribing, and delivering medicines. For example, concentrated potassium chloride, a lethal medication, is a source of causing deaths merely because of its storage inpatient care units. This chemical, which has caused 8-10 deaths, if removed from stock kept along with supply meant for patient care, can save calamities. Besides, pharmacists who are an invaluable source of hospital care cannot be attempted to be replaced by unit-dosing machines, which has not been proved as a safer mode of dispensing than through pharmacists (Trooskin, 2002).
Barcoding or any automated process for that matter is not a guarantee against medical errors due to the electronic systems’ vulnerability to viruses and downtime due to many factors such as loss and malfunctions of the interface, malfunctioning of software and hardware and upgrades. A first-ever study indicates that the most severe medication error occurred during the downtime eMARs. It also resulted in delayed access to patient records, which can adversely impact patient outcomes (Hanuscak, Szenibach, Seoane-Vazquez, Reichert, & McCluskey, 2009).
The above review of implementing barcoding technology in healthcare promises enhanced patient safety save a few shortcomings, which can be tolerated for benefits outweighing costs. Some objections are trivial. One complaint is the cost factor, which is already being addressed by the proposed statutory financial incentives to those who implement barcoding. Only when profit-motivated retailers and defense establishments insisted on barcoding for the apparent benefits despite costs, barcoding by the manufacturers and suppliers in other sectors became widely prevalent. Now they cannot only do without barcoding. It should be more so in the healthcare industry. Similarly, in healthcare, after some initial hiccups, barcoding should become popular, especially given the prospect of saving valuable lives by avoiding preventable medication errors and given the financial incentives being offered by the Government. As regards the downtime, healthcare is not alone. The healthcare industry should learn from other sectors, including different sectors such as space and defense establishment, regarding managing such situations. As said elsewhere, the barcode is meant to be an additional tier of safety and should be in conjunction with traditional practices. In life-saving issues, cost should not be an impediment. Thus this research finds justification of the hypothesis: Although some research has identified faults in the health care industries through the use of barcode technology, Barcode-Enabled Point-of-Care, or Bedside Point-of-Care (BPOC) systems, its use offers benefits that are invaluable for providing safe, high-quality in-patient or out-patient hospital care.
- Bobo, C. M. (2002). Avoid the pitfalls of progress. Nursing Management , 33 (12), 16,18,72.
- Cummings, J., Ratko, T., & Matuszewski, K. (2005, September/October). Barcoding to Enhance Patient Safety. Patient Safety & Quality Health Care .
- Eric G, P., Carol, K., Catherine S, Y., Matthew, D., Anne, B., Osnat, L.-k., et al. (2010). Effect of Bar-Code Technology on the Safety of Medication Administration. The New England Journal of Medicine , 362 (18), 1698-707.
- Hanuscak, T. L., Szenibach, S. L., Seoane-Vazquez, E., Reichert, B. J., & McCluskey, C. F. (2009). Evaluation of causes and frequency of medication errors during information technology downtime. American Journal of Health-System Pharmacy , 66 (12), 1119-1124.
- Hoyt, R. E., Sutton, M., & Yoshihashi, A. (2008). Medical Informatics: Practical Guide for the Health Care Professional 2008 (2nd p 215 ed.). ‘City not mentioned’: Lulu.com.
- Jacquelyn, C., & Frederick.G, C. (2006). Preventing Medication Errors in Hospitals through a Systems Approach and Technological Innovation: A Prescription for 2010. Hopsital Topics , 84 (4) 3-8.
- Kato, H., Tan, K. T., & Chai, D. (2010). Barcodes for Mobile Devices . Cambridge : Cambridge University Press.
- Mehta, S., & Gogtay, N. (2005). From the pen to the patient: Minimising medication errors. Journal of Postgraduate Medicine , 51 (1), 3-3-4.
- Sylevestor O, F., & John R, C. (2008). Medication Adminstration: The Implementation Process of Bar-Coding for Medication Adminstration to Enhance Medication Safety. Nursing Economics , 26 (3), 207-10.
- Trooskin, S. Z. (2002). Low-technology, cost-efficient strategies for reducing medication errors. American Journal of Infection Control , 30 (6), 351-54.