Computerization Can Create Safety Hazards: A Bar-Coding Near Miss
Abstract
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.
Article and Author Information
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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.
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Potential Financial Conflicts of Interest: None disclosed.
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Requests for Single Reprints: Clement J. McDonald, MD, Regenstrief Institute, 1050 Wishard Boulevard, Indianapolis, IN 46202; e-mail, cmcdonald{at}regenstrief.org.
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