The supermarkets do it - so why can't
we raise the "bar" in health care?
From the July 25, 2001 issue
For many years, bar code technology has demonstrated its
power to improve productivity and accuracy in a variety of
diverse industries. As such, one would expect this technology
to spread quickly to health care to enhance patient safety.
Not so! A 1987 survey by the American Hospital Association
showed that bar codes were used most often in materials management,
not in clinical applications (Longe K. The status of bar codes
in hospitals: a survey report. Hospital Technology Series.
Chicago: AHA; 1989:8). Little has changed since then according
to 1435 hospitals that completed the 2000 ISMP Medication
Safety Self Assessment. While 43% of hospitals had discussed
the possibility of bar coded drug administration, only 2.5%
used this technology in some areas of the hospital, and less
than 1% had fully implemented it throughout the organization.
Likewise, just 2% of hospitals used bar coding technology
to dispense most medications throughout the organization.
What's the problem with applying bar code technology in medicine,
and specifically to the medication use process? The catch
lies largely with the pharmaceutical industry's apparent unwillingness
to adopt a universal bar code standard and apply a bar code
consistently to the immediate container of all medications,
including unit dose packages. Further complicating the issue,
there is an extended lag time between the launch of new medications
and their availability (if ever) in unit dose packaging. And
sadly, unit dose packaging for some established products has
been discontinued and this trend appears to be increasing.
At this point, hospitals that employ bar code technology must
repackage many medications and relabel each with a bar code.
This can only be done at considerable cost in manpower and/or
automated repackaging equipment. Further, error risk is increased
because doses must be taken from their original container
As yet, the FDA has failed to issue a regulatory mandate
to print bar codes on all medication packages. But just this
month, the National Coordinating Council for Medication Error
Reporting and Prevention (NCCMERP) and the American Society
of Health-System Pharmacists (ASHP) publicly called for a
renewed effort in this regard. On the heels of an August 2000
conference with a wide variety of stakeholders, the NCCMERP
proposed the expeditious implementation of bar codes down
to the immediate unit-of-use package, and laid out guidelines
to standardize the data elements, format, location, and scope
of bar codes on packages (see www.nccmerp.org for details).
Likewise, ASHP sent a letter to Tommy Thompson, Secretary
of the Department of Health and Human Services, to press for
collaborative efforts to establish bar code regulations within
6 months, stressing that the FDA has both a mandate to protect
the public and the authority to require manufacturers to print
bar codes on their products (see www.ashp.org for details).
According to Henry Manasse, ASHP Executive Vice President
and CEO, ASHP has concluded that the pharmaceutical industry
is unlikely to apply bar codes to all sizes of containers
of drug products in a timely manner without a regulatory mandate
from the FDA. Manasse wrote, "The time for discussion is over,
and the time for substantive action has arrived."
We couldn't agree more. We estimate that there are about
one million hospitalized patients in the US who receive about
16 doses of medications daily (over 16,000,000 doses per day).
Assuming a very conservative 2% medication error rate, about
320,000 medication errors occur daily. Using data from Leape
et al (Systems analysis of adverse drug events. JAMA 1995;274:35-43),
over 100,000 errors occur during drug administration(38%)
and 35,000 during drug dispensing (11%). Using machine-readable
code may prevent most of these errors, including some that
cause death or permanent injury!
What will a fully realized bar code system in health care
bring us? For now, such knowledge is confined to the few who
are just beginning to demonstrate the enormous value of this
technology in clinical settings. But its slow adoption in
health care is clear evidence that it will not catch fire
until manufacturers are required to place uniform bar codes
on their products. Nevertheless, while we all join in support
of ASHP and NCCMERP in their push for bar code regulations,
hospitals must begin now to prepare for bar coding by gaining
familiarity with available technology and establishing comprehensive
unit-dose dispensing systems. Unless medications are dispensed
in patient-specific doses and in the most ready-to-use form,
bar code technology can offer only a partial solution - which
may well be no solution at all if, in the end, medications
frequently bypass the very system designed to ensure their