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Medication Safety and Bar Codes: Not a Panacea?


Medication errors contribute substantially to unsafe hospital and ambulatory environments. The Institute of Medicine estimates that on average each hospitalized patient experiences 1 medication error per day.1

Medication errors contribute substantially to unsafe hospital and ambulatory environments. The Institute of Medicine estimates that on average each hospitalized patient experiences 1 medication error per day.1 Strategies to make the complicated process of medication administration less prone to error have included bar code systems, as I mention on page 665 of the article, “Unexplained Hypoglycemia: A Focused Approach to Finding the Cause,” in this issue.

The bar code system safely integrates the specific patient’s record with the prescribed drug and matches the patient with the correct drug, dose, route of administration, and timing interval. Previous studies have demonstrated that bar coding can reduce both dispensing and administration errors.2,3 However, medication safety has become such a complex issue that there is no quick, durable fix-not even bar code systems.


Recently, investigators discovered “workarounds” with the bar code system that can endanger patients’ safety.4 In the study, bar code systems sensed a problem with medication administration in about 4% of patients in the cohort, which accounted for approximately 10% of all the medications given. Rather than address the problem with the bar code sensor per se, working around the discrepancy saved valuable time. For example, a bar code “match” between a patient and a drug should be reviewed by a second person, usually a nurse, but this check and balance delays an often frenetic schedule. Or, the medication code might be scanned from the drug to be administered, but the patient’s code would not be. In those instances, it might be that the patient’s code on her wristband was damaged by body fluids or was inaccessible because she was sleeping.

What might happen as a result of the workaround? The wrong medication may be given to the patient and thus lead to a serious adverse event or even possibly death. In total, the investigators discovered 15 different workarounds, all with the potential to be associated with a medication error. The authors felt that the workflow usual in a busy hospital environment-the rush, stress, and contracted time frame-was likely to encourage timesaving workarounds.


Patient safety is a paramount issue and is part and parcel of the debate surrounding health care reform. Errors do not occur because of “bad” people but rather because good people are working in a flawed system. The costs underlying the present system are inflated by the complications of medication errors-mistakes that increase length of stay, lead to other disabilities, and fuel a litigious society. Medication safety is a substantive part of the safety debate. Even though bar codes are not a perfect answer, all of us should support their implementation along with other critical safety features (such as a pharmacist on rounds). But this study also cautions us not to rest easy with these efforts alone. There is still much to be done to ensure the safety of our patients.



1. Institute of Medicine. Preventing Medication Errors. Washington, DC:The National Academies Press; 2007.
2. Poon EG, Cina JL, Churchill W, et al. Medication dispensing errors andpotential adverse drug events before and after implementing bar code technologyin the pharmacy. Ann Intern Med. 2006;145:426-434.
3. Johnson CL, Carlson RA, Tucker CL, Willette C. Using BCMA software toimprove patient safety in Veterans Administration Medical Centers. J Healthc InfManag. 2002;16:46-51.
4. Koppel R, Wetterneck T, Telles JL, Karsh BT. Workarounds to barcode medicationadministration systems: their occurrences, causes, and threats to patientsafety. J Am Med Inform Assoc. 2008;15:408-423.

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