Manic for medication safety: bar codes and drug information databases are helping to reduce medication errors.(Patient Safety)(Cover story)

The tragic deaths last September of three premature newborns who were mistakenly given an adult dose of heparin in an Indianapolis hospital did more than just make headlines. It also served as a stark reminder that too few healthcare organizations have in place adequate safeguards that can prevent medication errors.

Those who give more than lip service to issues of patient safety know that they not only have to invest in new technologies, but they also need to regularly review and update their policies and procedures pertaining to the ordering and distribution of medications. While errors can occur at any point along the route, from the physician's initial order, to the filling of carts in the pharmacy, to the administration of reeds by nurses at the bedside, it is at the point of care that clinicians can establish a last line of defense.

Not surprisingly, implementation of bar-code technology at the bedside is proving to be an effective way to reduce most medication errors. "The benefit is that it's at the end of the pipeline and most likely is going to catch everything coming down that pipeline," says Jim Douglas, R.N., clinical systems administrator at Northern Michigan Hospital in Petoskey, Mich. Douglas says that in 2006 alone, the hospital reduced medication errors by 5,744 and prevented 400 serious medical errors, including two that would most likely have been fatal. Since beginning the implementation of the Cerner Bridge Medication Administration point-of-care technology in 1998, more than 21,000 medication errors and a total of five fatalities have been avoided.

Bar Coding for Safety

At 243 beds, Northern Michigan Hospital has about 120 physicians with privileges, 450 registered nurses and 15 pharmacists. But as is the case with most hospitals, the hand-off of patient information during a normal shift change can be sketchy at best. To ensure that nurses coming on to the floor are apprised of each patient's status and any medications already administered, the Joint Commission on Accreditation of Healthcare Organizations mandated hospitals establish standards for effective shift transfer communication.

One of the most serious oversights has always involved …