Immediate steps toward patient safety: one health system explains how bar-code point-of-care technology offered a means to reduce medication errors that can be implemented relatively easily while pursuing more complex, long-term solutions

Healthcare Financial Management, Feb, 2004 by Van R. Johnson, John Hummel, Terance Kinninger, Russell F. Lewis

Ever since the Institute of Medicine (IOM) issued its groundbreaking report To Err Is Human: Building a Safer Health System in December 1999, patient safety has been a major concern for the nation's healthcare system. A recent study found that a leading cause of anxiety for patients is suffering a medication error during their hospital stay. (a)

Evidence suggests that in some cases this fear may be justified. Researchers in another study who observed nurses delivering medications to patients in 36 healthcare facilities in the greater Atlanta and Denver metropolitan areas came up with some startling findings: almost one in five medications were given erroneously, and 7 percent of these mistakes were potentially harmful. (b)

Investigators at Harvard found that most medication errors occur when a physician inaccurately ordered a medication (39 percent) or when a nurse mistakenly administered a drug (38 percent). (c) More important, the Harvard study also reported an often-overlooked finding: almost one-half of all inaccurate physician orders are intercepted, predominantly by nurses, before these mistakes reach the patient. By contrast, only 2 percent of errors nurses make when administering a medication are intercepted, making the risk of error far greater at the patient's bedside.

In July 2002, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) cited the need to reduce medication errors as a top priority. Healthcare executives ranked implementing patient-safety information technology as one of their leading initiatives for 2003. (d)

A Bar-Code Solution

Of the tools that are available today for reducing medication errors, one of the most effective is a new bedside technology called bar-code point-of-care (BPOC) technology. Bar codes have been used in most U.S. industries since the 1920s and are applied routinely to improve hospital inventory, supply, and charge capture.

One hospital system that has used BPOC technology successfully to link patients with the right medication is the U.S. Veterans Administration Medical Centers (VAMC). Using BPOC, the VAMC was able to reduce error rates in one facility by 86 percent. (e) The VAMC's success inspired HHS secretary Tommy Thompson to propose that all hospital medications contain a linear bar-code label within three years. (f) So far, excluding the VAMC, only 1.5 percent of all U.S. hospitals use BPOC to link patients with their correct medications. (g)

In 2003, JCAHO established six national patient safety goals, the first of which is to improve the accuracy of patient identification whenever administering medications or blood products--a core functionality of a BPOC system's technology. In addition, a bar-code system can help healthcare organizations meet JCAHO medication-use standards and satisfy requirements related to error reporting for process improvement.

Sutter Health's Patient-Safety Initiative

Based on the foregoing considerations, administrators at Sacramento, Calif.-based Sutter Health undertook a patient-safety initiative to minimize medication errors, including implementation of a BPOC system. Following recommendations of the IOM, the National Quality Forum, and the Leapfrog Group, Sutter Health began its initiative by installing a computerized physician order entry (CPOE) system to prevent physician errors in prescribing medications.

Although Sutter Health was convinced of the benefits of CPOE, the health system also recognized its inherent complexities and limitations. For example, CPOE would require significant human and capital outlays--the one-time cost of implementing a commercially available CPOE system in a 500-bed hospital can he as much as $7.9 million, with ongoing costs approaching $1.3 million. (h) Other challenges include a lengthy implementation time frame, risk of incomplete implementation due to limited user acceptance, and inherent restriction of error reduction at the front end of the medication process.

These concerns provided the impetus for Sutter Health's adoption of BPOC. In accordance with the findings of the Harvard study cited previously, Sutter Health's administrators acknowledged that even if CPOE were to completely eliminate errors from physicians' orders, without a bedside solution, nurses could still execute these "perfect" orders on the wrong patients. Therefore, to minimize medication errors where they were most likely to occur, Sutter Health decided to pursue BPOC simultaneously with CPOE.

From a business perspective, Sutter Health's administrative decision makers determined that implementing BPOC immediately was compelling because it would cost a fraction of a CPOE system, would be highly effective at reducing medication errors, and could be implemented in a hospital in only six to nine months. This rapid implementation time would allow the organization to achieve immediate bedside safety while the longer CPOE implementation process was being completed.

BPOC System Features

BPOC systems range in sophistication from simple "five rights checkers" (right patient, right drug, right route, right dose, and right time) to systems that offer clinical decision support and address all types of common and undesirable bedside occurrences.