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

Sutter Health had made a philosophical and financial commitment to promote patient safety with the most advanced technologies available. The organization therefore decided to implement a BPOC system that offered the highest level of sophistication, including:

* An electronic medication administration record

* On-line drug formulary

* Weight-based dose checking

* Allergy information

* Sound-Mike/look alike drug messages (Some medications have similar sounding names and/or similar looking appearances that can lead to confusion and errors. A sophisticated BPOC system will call attention to these similarities and caution the user to be certain the medication in hand is the appropriate medication to be given. For example, norCURon, a neuromuscular blocking agent, sounds like narCAN, an opiate antagonist.)

The system also offered the capability to check the safety of bedside activities beyond medications, including positive patient identification for blood transfusions and specimen tracking. This added capability provided a rationale for BPOC infrastructure costs beyond just reducing medication errors.

To minimize implementation risks, Sutter Health selected a vendor that already had a proven track record of implementing BPOC systems at dozens of hospitals. In addition, and perhaps most important, Sutter Health involved nursing staff in the product-selection process. Nurses who reviewed the product were enthusiastic about its workflow and capabilities, and strongly supported its use at the bedside, helping to ensure successful implementation.

Benefits of BPOC

Sutter Health's implementation of BPOC is proceeding rapidly according to expectations. Within nine months of the start of implementation, six Sutter Health hospitals were live on the BPOC system by the end of November 2003, and another four sites are in the early stages of implementation. The time devoted to working out corporate standards for the initial implementation sites has helped reduce implementation times at other sites. Sutter Health anticipates that BPOC will be implemented at all of its hospitals by the end of 2004 or early in 2005.

Sutter Health anticipates achieving numerous benefits with BPOC. The technology will not only immediately reduce bedside medication errors, but also substantially heighten awareness of near-misses. Understanding the type and circumstances of errors intercepted by BPOC will provide insight into potential systemic issues that cause the errors to occur. The resulting reduction in errors will produce a substantial financial benefit by reducing costs associated with medication errors.

Patient satisfaction. BPOC also will help alleviate patients' fear of medication errors because it involves a familiar and easily understandable technology. Patients will interact with the BPOC system as nurses scan their wristbands and medications at the bedside. They therefore will be able to witness the benefits of the technology firsthand, and be comforted with the intuitive recognition of the accuracy provided by bar codes.