Medication safety improves after implementation of positive patient identification

Abstract

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.

Keywords: Patient safety; computerized provider order entry; harm scores; informatics; pharmacy; positive patient identification.

Fig. 1

Dispensing errors per million doses, calendar year 2007-2009. In the five quarters prior to intervention, medication errors reaching patients averaged 2.53 per million (dark color), with 23.94 „near misses“ per million (light color). The pilot program occured during the Q2 of 2008, with roll-out to critical care units and hospital wide in Q3 of 2008. In the five quarters post-intervention, near misses remained at 23.5/million, but medication errors reaching the patient decreased to 0.69 per million doses, a 73% decrease (p<0.05).