When Health and Human Services Secretary Tommy G. Thompson announced the recent Food and Drug Administration's Final Rule for Bar Coding on Human Drugs and Biological Products, it became one more significant step toward reducing the potential for medication errors.
As little as forty to fifty years ago, many viewed medication errors as incompetence on the part of the individual making the error. Those individuals making the error were often fired, with no attempt made to look for the root cause of the error. Sometimes, the errors were repeated because systems and conditions were not considered as factors contributing to the reason for the error.
At one time, when nurses still wore white caps, the Director of Nursing took away the cap of the nurse who made the error and placed it on the top of a file cabinet for all to see until an appropriate amount of time had passed during which the nurse was embarrassed and shamed. In these examples, the individuals most likely only learned not to report any future error they may have made.
As the impact of systems thinking has emerged in the understanding of medication errors, health care has made big leaps on the entire continuum of medication ordering, transcription, and administration. Implementation of methods to reduce medication errors often depends on the ability of the organization's leadership to do so and on the sophistication of their information technology system.
Bar coding will help prevent medication errors by providing a method for scanning the medication being administered and also scanning the patient's bar code to see if the right patient is getting the right drug in the right dose at the right time. The degree of implementation of the bar coding system depends in part on the amount of information technology that exists in the organization. The Healthcare Information and Management Systems Society Bar Coding Fact Sheet reports that point-of-care, unit-of-use bar coding that is part of an information system with embedded decision support will require significant investment (and) sustained industry support will be required.1
Implementations of this magnitude, impact the quality of care not only through reducing potential errors. With more accurate documentation and the ability to track practitioners who may make an error along the medication ordering, transcription, and administration continuum, learning interventions can readily be available. In the Department of Health and Human Services News Release announcing the final rule for bar coding, examples were cited of instances where widespread adoption of advanced information systems[horizontal ellipsis]in some hospitals[horizontal ellipsis]have reduced medication error rates by as much as 85 percent, and in a study at a Veterans Affairs Medical Center that employed a bar coding scanning system, 5.7 million doses of medication were administered to patients with no medication errors.2
The potential for impacting quality of patient care through the use of bar coding is evident. However, this is only one step toward achieving the vision set forth in the 1999 and 2001 reports from the Institute of Medicine. It will take continued vigilance and work on the part of all professions and professional groups to reduce the human and economic cost of medical errors. This is a great beginning.
SueEllen Pinkerton RN, PhD, FAAN
Editor-in-Chief
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