 |
 |
|
Home |
Current Issue |
Past Issues |
In the Clinic |
ACP Journal Club |
CME |
Collections |
Audio/Video |
Mobile |
Subscribe |
Tools |
Help |
ACP Online
|
| |||||||||||||||||||||||||||||||||||||||||||
4 April 2006 | Volume 144 Issue 7 | Pages 510-516
Increasing numbers of hospitals are implementing bar-coding systems to prevent errors in patient identification. In the present case, a diabetic patient admitted to a teaching hospital was mistakenly given the bar-coded identification wristband of another patient who was admitted at the same time. When a laboratory result that documented the diabetic patient's severe hyperglycemia was entered into the other patient's electronic medical record, the latter patient seemed to have a very high glucose level and was almost given what could have been a fatal dose of insulin. This near miss shows that computer systems, although having the potential to improve safety, may create new kinds of errors if not accompanied by well-designed, well-implemented cross-check processes and a culture of safety. Moreover, computer systems may have the pernicious effect of weakening human vigilance, removing an important safety protection. Researchers should continue to study real-world implementation of computerized systems to understand their benefits and potential harms, and administrators and providers should seek ways to anticipate these harms and mitigate them.
Author and Article Information
From Regenstrief Institute, Indianapolis, Indiana.
Grant Support: This work was supported by grant G08 LM008232 from the National Library of Medicine and grant 510040784 from the Indiana Twenty-First Century Research and Technology Fund. Funding for the Quality Grand Rounds series is supported by the California HealthCare Foundation as part of its Quality Initiative.
Potential Financial Conflicts of Interest: None disclosed.
Requests for Single Reprints: Clement J. McDonald, MD, Regenstrief Institute, 1050 Wishard Boulevard, Indianapolis, IN 46202; e-mail, cmcdonald{at}regenstrief.org. IMPROVING PATIENT CARE
QUALITY GRAND ROUNDS
Series Editors: Robert M. Wachter, MD; Kaveh G. Shojania, MD; Sanjay Saint, MD, MPH; Amy J. Markowitz, JD; and Mark Smith, MD, MBA
Improving Patient Care is a special section within Annals supported in part by the U.S. Department of Health and Human Services (HHS) Agency for Healthcare Research and Quality (AHRQ). The opinions expressed in this article are those of the authors and do not represent the position or endorsement of AHRQ or HHS.
Funding for the Quality Grand Rounds series is supported by the California Health Care Foundation as part of its Quality Initiative. The authors are supported by general institutional funds.
Computerization Can Create Safety Hazards: A Bar-Coding Near Miss
Related articles in Annals:
This article has been cited by other articles:
|
|
 |
|
  R. Koppel, T. Wetterneck, J. L. Telles, and B.-T. Karsh Workarounds to Barcode Medication Administration Systems: Their Occurrences, Causes, and Threats to Patient Safety J. Am. Med. Inform. Assoc., July 1, 2008; 15(4): 408 - 423. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 V. Lichtner, S. Wilson, and J. R. Galliers The challenging nature of patient identifiers: an ethnographic study of patient identification at a London walk-in centre Health Informatics Journal, June 1, 2008; 14(2): 141 - 150. [Abstract] [PDF]
|
|
|
|
|
|
J. M. Walker, P. Carayon, N. Leveson, R. A. Paulus, J. Tooker, H. Chin, A. Bothe Jr., and W. F. Stewart EHR Safety: The Way Forward to Safe and Effective Systems J. Am. Med. Inform. Assoc., May 1, 2008; 15(3): 272 - 277. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 K. E. Walsh, C. P. Landrigan, W. G. Adams, R. J. Vinci, J. B. Chessare, M. R. Cooper, P. M. Hebert, E. G. Schainker, T. J. McLaughlin, and H. Bauchner Effect of Computer Order Entry on Prevention of Serious Medication Errors in Hospitalized Children Pediatrics, March 1, 2008; 121(3): e421 - e427. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 C. D. Mahoney, C. M. Berard-Collins, R. Coleman, J. F. Amaral, and C. M. Cotter Effects of an integrated clinical information system on medication safety in a multi-hospital setting Am. J. Health Syst. Pharm., September 15, 2007; 64(18): 1969 - 1977. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
M. I. Harrison, R. Koppel, and S. Bar-Lev Unintended Consequences of Information Technologies in Health Care An Interactive Sociotechnical Analysis J. Am. Med. Inform. Assoc., September 1, 2007; 14(5): 542 - 549. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 J. C. Crosson, P. A. Ohman-Strickland, K. A. Hahn, B. DiCicco-Bloom, E. Shaw, A. J. Orzano, and B. F. Crabtree Electronic Medical Records and Diabetes Quality of Care: Results From a Sample of Family Medicine Practices Ann. Fam. Med, May 1, 2007; 5(3): 209 - 215. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
J. P. Weiner, T. Kfuri, K. Chan, and J. B. Fowles "e-Iatrogenesis": The Most Critical Unintended Consequence of CPOE and other HIT J. Am. Med. Inform. Assoc., May 1, 2007; 14(3): 387 - 388. [Full Text] [PDF]
|
|
|
|
 |
|
 E. B. Milbrandt, A. Ishizaka, and D. C. Angus Update in Critical Care 2006 Am. J. Respir. Crit. Care Med., April 1, 2007; 175(7): 638 - 648. [Full Text] [PDF]
|
|
|
|
 |
|
 R. M. Wachter, K. G. Shojania, A. J. Markowitz, M. Smith, and S. Saint Quality grand rounds: the case for patient safety. Ann Intern Med, October 17, 2006; 145(8): 629 - 630. [Full Text] [PDF]
|
|
|
|
|
|
E. C. Wu and N. Shah Corporate strategies for computerization. Ann Intern Med, September 5, 2006; 145(5): 395 - 395. [Full Text] [PDF]
|
|
|
|
|
|
Correction: Computerization Can Create Safety Hazards: A Bar-Coding Near Miss Ann Intern Med, August 1, 2006; 145(3): 235 - 235. [Full Text] [PDF]
|
|
|
|
 |
|
 R. M. Wachter Expected and Unanticipated Consequences of the Quality and Information Technology Revolutions JAMA, June 21, 2006; 295(23): 2780 - 2783. [Full Text] [PDF]
|
|
Read all Rapid Responses
Article
