Barcodes In Healthcare
In a study published in the journal Anesthesiology in which researchers examined surgical procedures at Massachusetts General Hospital during 2013—2014, it was found that almost half of those surgeries involved a drug dosing mishap. Over one-third of them caused patient injury, including three life-threatening mistakes, although no deaths actually resulted.
Operating rooms are particularly prone to dosing errors because the time for pharmacists and nurses to verify medications is very limited, a problem which is compounded by the fact that many syringe-delivered medications are unmarked and are clear liquids that are visually undifferentiated.
During an operation, typically about 10 medications are administered. The study found that an error of some kind was made in about 50% of operations.
While the study is alarming, to say the least, this type of data has never been formally collected before, so the only basis of comparison is with
anecdotal reporting, which health care professionals admit has always been underreported. It is doubly alarming, however, since the study was conducted at Massachusetts General Hospital, considered to be one of the best hospitals in the US.
Operating Room Environments
Is it unreasonable to expect that operating room drugs be labeled and scanned as they are in bedside dosing situations? Is the OR environment too fast-paced for this basic, simple safeguard? Probably in some cases; probably not in all cases. Massachusetts General has a barcoded syringe labeling system in place but was not being used when most of the detected errors occurred.
The good news is that studies like this are now being conducted more widely, so data is being compiled often for the first time. While the data will be shocking at first, the availability of the data will enable changes to take place including studies to determine where better safeguards can be implemented.
Tajal Gandhu, President and CEO of the National Patient Safety Foundation said, “Boy, we still have a lot of work to do, (but) if it happens at Mass General, it can happen anywhere.”
