Appl Clin Inform 2010; 01(03): 213-220
DOI: 10.4338/ACI-2010-02-RA-0011
Research Article
Schattauer GmbH

Medication Safety Improves after Implementation of Positive Patient Identification

T. Higgins
1  Clinical Informatics Baystate Medical Center, Springfield, MA
2  Critical Care Baystate Medical Center, Springfield, MA
,
M. Heelon
3  Pharmacy Baystate Medical Center, Springfield, MA
,
B. Siano
1  Clinical Informatics Baystate Medical Center, Springfield, MA
4  Patient Care Baystate Medical Center, Springfield, MA
,
L. Douglass
1  Clinical Informatics Baystate Medical Center, Springfield, MA
4  Patient Care Baystate Medical Center, Springfield, MA
,
P. Liebro
3  Pharmacy Baystate Medical Center, Springfield, MA
,
B. Spath
5  Information Services Baystate Medical Center, Springfield, MA
,
N. Kudler
1  Clinical Informatics Baystate Medical Center, Springfield, MA
,
G. Kerr
3  Pharmacy Baystate Medical Center, Springfield, MA
› Author Affiliations
Further Information

Correspondence to:

Thomas L. Higgins MD, MBA
Medical Director, Inpatient Informatics
Baystate Medical Center
759 Chestnut Street
Springfield, Massachusetts 01199
United States

Publication History

received: 17 February 2010

accepted: 10 June 2010

Publication Date:
16 December 2017 (online)

 

Summary

Objective: To report the incidence and severity of medication safety events before and after initiation of barcode scanning for positive patient identification (PPID) in a large teaching hospital.

Methods: Retrospective analysis of data from an existing safety reporting system with anonymous and non-punitive self-reporting. Medication safety events were categorized as “near-miss” (unsafe conditions or caught before reaching the patient) or reaching the patient, with requisite additional monitoring or treatment. Baseline and post-PPID implementation data on events per 1,000,000 drug administrations were compared by chi-square with p<0.05 considered significant.

Results: An average of 510,541 doses were dispensed each month in 2008. Total self-reported medication errors initially increased from 20 per million doses dispensed pre-barcoding (first quarter 2008) to 38 per million doses dispensed immediately post-intervention (last quarter 2008), but errors reaching the patient decreased from 3.26 per million to 0.8 per million despite the increase in “near-misses”. A number of process issues were identified and improved, including additional training and equipment, instituting ParX scanning when filling Pyxis machines, and lobbying for a manufacturing change in how bar codes were printed on bags of intravenous solutions to reduce scanning failures.

Conclusion: Introduction of barcoding of medications and patient wristbands reduced serious medication dispensing errors reaching the patient, but temporarily increased the number of “near-miss” situations reported. Overall patient safety improved with the barcoding and positive patient identification initiative. These results have been sustained during the 18 months following full implementation.


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Conflicts of interest

None of the authors report any conflicts of interest.


Correspondence to:

Thomas L. Higgins MD, MBA
Medical Director, Inpatient Informatics
Baystate Medical Center
759 Chestnut Street
Springfield, Massachusetts 01199
United States