Study: Low-Tech Solutions Might Minimize Medical Errors

To stem ongoing and dangerous, often deadly and certainly, costly, <"">medical mistakes, researchers are looking at basic, low-tech solutions, such as implementing a color-coding system.  Anesthesiologists at Penn State Hershey, in simulated emergency room (ER) situations, tested such a system in which standardizing and color-coding medication labels were used.  The system could significantly decrease costly and potentially harmful medication errors.  The study will be presented this weekend at the annual meeting of the American Society of Anesthesiologists in Orlando, Florida.

Imitating ER situations, volunteer anesthesiologists, residents, and nurses drew medications with different colored labels.  When the label color on the syringe matched the label color on the medication bottle, fewer near-mistakes occurred compared to when there was no color match.  When peel-off labels were removed from the medication bottle and placed on the syringe to be used, errors were reduced and fewer commands were skipped.  “Many ‘high-tech’ solutions have been suggested, including use of bar codes, radiofrequency identification for medications, and computerized medication administration processes,” researcher Dr. Elizabeth H. Sinz, of the department of anesthesiology at Penn State Hershey, said in a news release issued by the society.  “But, besides their high costs, all of these methods have flaws that may produce as many errors as they eliminate.  Furthermore, these solutions are often impractical for fast-paced situations in operating rooms or during emergencies,” she said, adding, “Simple systems, such as the color-coding methods used in our study, are more reliable and useable than complex systems,” she said.

In July we reported on a study—led by Ross Koppel, Ph.D of the University of Pennsylvania (HUP) School of Medicine—that revealed how patient medication errors were linked to hospital technology flaws.  The research revealed how hospital nurses use bar-coded technology that matches patients with their medication, showing that both the technology design and its implementation—often relied upon as a “cure-all” for medication administration errors—is flawed and can increase the likelihood of some errors.  Even worse, it seems that “the urgencies of care” and creative attempts to cope with the problems have caused other medication errors.  The group found 31 “causes” of problems resulting in workarounds, including:  “Unreadable medication-barcodes (crinkled, smudged, torn, missing, covered by another label); malfunctioning scanners; unreadable or missing patient-ID-wristbands (chewed, soaked, missing); non-barcoded-medications; medications in distant refrigerators; lost wireless connectivity; problems with patients in contact isolation; and emergencies.”

There are some of the 1.5 million adverse drug reactions annually that are caused by medication mistakes that, in turn, cost the health care industry about $3.5 billion each year.  On average, hospital patients are subject to one medication administration error daily, according to the Institute of Medicine; in hospitals, medication administration accounts for 26% to 32% of adult patient medication errors.  Koppel emphasized, “It’s not that staff are lazy or careless, it’s that the system does not work as well as it should.  If the refrigerated medication is two floors and a long hallway away, you’re not going to wheel your 87-year-old patient to the fridge.  You make a copy of her barcode.  And while you do that, you help another two patients who also need refrigerated medications.”

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