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DOI: 10.4338/ACI-2010-02-RA-0011
Medication Safety Improves after Implementation of Positive Patient Identification
Publikationsverlauf
received:
17. Februar 2010
accepted:
10. Juni 2010
Publikationsdatum:
16. Dezember 2017 (online)
![](https://www.thieme-connect.de/media/10.1055-s-00035026/201003/lookinside/thumbnails/10-4338-aci-2010-02-ra-0011-1.jpg)
Summary
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.
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