Computerization can create safety hazards: a bar-coding near miss.
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.
Regenstrief Institute, Indianapolis, Indiana.
Clement J
CJ
McDonald
D000369:Aged, 80 and over; D001330:Electronic Data Processing; D006784:Hospitals, Teaching / Q000592:standards; D006801:Humans; D008297:Male; D016347:Medical Records Systems, Computerized; D008508:Medication Errors / Q000517:prevention & control; D005791:Patient Care / Q000592:standards*; D010355:Patient Identification Systems / Q000379:methods* / Q000592:standards*; D014481:United States