Hospitals Take Lessons From Supermarkets

Ever since 1999, when the Institute of Medicine (IOM) published its landmark report on medical error, health care leaders have been bemoaning the sorry state of American medicine. Authors of the study, “To Err Is Human,” estimated that nearly 100,000 people die in American hospitals each year because of mistakes, many of which could be prevented.
The actual problem may be far worse. A more recent estimate pushes the death toll to nearly 200,000.
One of the biggest problems is medication blunders. Too often hospitalized patients receive the wrong drug or the wrong dose or the wrong combination of medicines. When Mrs. Jones is discharged from room 476 and Mr. Smith is given that bed, he may also get the medicine that was intended for her.
Other times a nurse may ask about a drug allergy but the information may not be highlighted on a patient’s chart. When an intern comes by the next day, she may not notice the drug allergy and may administer a life-threatening medicine.
Now, some hospitals are turning to the supermarket for technology that could prevent such common mistakes.
For decades, bar codes have been used to improve efficiency at check out and track sales and inventory. Look on a box of Cheerios or a jar of peanut butter and you will see the familiar thick and thin black lines that are instantly read by a scanner.
Bar codes on drugs will look quite similar, but the purpose is completely different. Instead of speeding check-out, medication codes should reduce the number of patients who get the wrong drug or the wrong dose.
The Veterans Administration has led the way in this effort. When a doctor orders a prescription, the order goes electronically to the pharmacy, where a bar code is generated and attached to the proper medicine.
Once the medicine gets to the patient’s room, the nurse matches the bar code on the medicine to one on the patient’s ID bracelet with a handheld scanner. The VA reports that this bar coding system has reduced the number of medication errors by 24 percent.
Why don’t more hospitals embrace this familiar technology? It is estimated that only about one hospital in 20 uses bar codes for verifying patient medications.
One reason may be cost. Partners, a big Boston health care system affiliated with Harvard Medical School, recently spent about $10 million on its bar code effort.
This big bill was deemed worthwhile because it has already cut drug dispensing errors in half. Analysts there calculate that 20 adverse drug events are prevented every day because of this technology.
Physicians involved in this effort conclude: “Although the ultimate goal is to protect patients, these measures also save on the bottom line, since the average adverse event costs an estimated $4,700 in extra hospital bills and ancillary services-excluding the cost of litigation.” (New England Journal of Medicine, July 28, 2005)
Until your hospital joins the 21st century and institutes bar coding and other safety measures, you and your family will need to be extremely vigilant whenever someone is hospitalized. Make sure your loved one is getting the right drug at the right time and in the right dose!