Brigham to adopt barcodes to cut errors

Brigham and Women's Hospital this month is rolling out supermarket-style barcodes on medications and patients' wristbands, one of the first US hospitals to adopt this common food industry technology to reduce overdoses and other dangerous medical errors.

The Harvard Medical School teaching hospital plans to use barcodes on all its medical and surgical floors by mid-July, and to complete implementation in the operating rooms, emergency department and obstetrics units by the end of 2006. The system will cost the hospital about $10 million on equipment and training for several thousand nurses to scan barcodes.

''This absolutely can prevent certain types of errors," said Fran Griffin, a director at the Institute for Healthcare Improvement, a Cambridge nonprofit group that helps hospitals improve care. ''When people are working in a high-stress, fast-paced environment, it's so easy to grab the wrong drug."

In its groundbreaking report ''To Err is Human," The Institute of Medicine, a nonprofit Washington policy group, five years ago estimated that hospital mistakes kill 44,000 to 98,000 Americans annually, and that about 7,000 of those deaths are attributable to medication errors.

Barcodes are designed to prevent nurses from accidentally giving the wrong drug or dose. The system requires a nurse to scan a barcode printed on the patient's identification bracelet, which is encoded with the names of his or her medications, doses and times of doses. The nurse then scans the barcode on the drug package to see if the information matches.

The system doesn't stop other errors, such as doctors prescribing the wrong drug. And, as hospitals are finding with other computerized error-prevention systems, technology sometimes introduces completely new mistakes into the system.

But health care specialists believe barcodes are one of a host of promising technologies hospitals are adopting to attack the problem of medical mistakes. The nation's Veterans Affairs hospitals began using barcodes three years ago, while Massachusetts General Hospital is experimenting with microchips that embed a patient's blood type in his or her wristband. The signal coming from the patient's wristband must match that of another chip attached to the blood bag.

Dr. Andy Whittemore, the Brigham's chief medical officer, said the Brigham expects barcodes to significantly reduce medication errors and near-misses at the hospital, which has openly reported its error rates and quality-improvement initiatives in national medical journals.

Dr. David Bates, who is chief of general medicine at the Brigham and who studies hospital errors, reviewed 10,070 medication orders for 379 patients, and discovered that the staff committed 530 medication errors. In another study he conducted, also published in 1995, Bates found that the earlier in the process an error occurs, the more likely someone will intercept it before it harms the patient. For instance, half of all errors committed by a doctor -- a physician ordering a drug to which the patient has a known allergy, for example -- were caught; none of the errors committed by nurses as they administered drugs were caught.

''That's why barcoding is so important," he said. ''There really is no one between the nurse and the patient."

Whittemore said that barcodes could have prevented an error that occurred at the hospital last week when a nurse gave two newborn boys a tenfold overdose of liquid Tylenol. Whittemore said the nurse drew up 4 cubic centimeters of the painkiller into a syringe instead of 0.4 ccs. Under the new barcoding system, which the hospital plans to install in the newborn nursery next year, the pharmacy will send syringes to patient floors already filled with specific doses of medicines, which will be encoded in each syringe's barcode. The nurse will then scan the barcode to make sure it matches the barcode on the baby's wristband.

Nancy Kruger, the Brigham's vice president of patient care services and chief nursing officer, said it's difficult to predict how much the system will cut the hospital's error rate, because sometimes technology unmasks new types of mistakes no one knew about. Technology also can introduce new errors. Doctors at the Hospital of the University of Pennsylvania, for example, recently identified 22 types of new mistakes they have made because of difficulty using computerized drug-ordering, such as forgetting to delete old medications when adding new ones.

On Monday of last week, nurses on the 14th floor of the Brigham's main tower were among the first to try out the new system. The nurses on the 30-bed unit give about 30 medications each per shift -- the highest volume in the hospital -- because their patients' illnesses are so complicated.

Nurse Lorna Holmes called up patient Lillian Dube's medication record on her portable laptop computer and saw that a doctor had prescribed 50 mg of the painkiller Darvon. Holmes pulled out a tiny package from a pill cart and scanned the drug's barcode with a portable scanner that looked like a cell phone. The computer flashed a written warning that the pill was 100 mg. Holmes knew the pills came in doses of 100 mg and planned to cut it in half.

Next, Holmes walked into Dube's room, asked her name to confirm her identity, and scanned the plastic band on her left wrist. Dube, 59, who was in the hospital for a heart valve replacement, said nurses explained the system to her that morning.

''This is a good idea," she said, ''especially if the patient is unconscious." Intravenous drugs can be given while a patient is asleep.

She said a nurse once brought her the wrong drug, but because Dube was awake, she knew it was a mistake and sent her back.

Another nurse using the new system called up a patient's record on her laptop computer. The record told her it was time to give the woman Isordil for chest pain and the antibiotic Flagyl. But when she retrieved the medications from the medication cart and scanned their barcodes, a yellow check mark failed to appear next to Flagyl on the computer. When the nurse looked more closely at the large silver package, she discovered she had picked out Reglan, an anti-nausea medicine. The barcode system had caught the error.

Until now, nurses have eyeballed medication labels to make sure they were giving patients what their doctor ordered, leaving room for human error.

Cost is a major obstacle for hospitals considering barcodes. Aside from the initial investment, Whittemore said, the Brigham eventually will spend about $1 million a year to maintain the system. Much of the expense goes toward labeling the medicines, because the drug industry prints barcodes on just half of the 6 million doses the Brigham uses annually, leaving the hospital to put barcodes on 3 million individual packages.

Nursing coordinator Anne Bane, said the hospital has had to work out a number of kinks. For instance, nurses who tested the system complained it took too long to scan patients' wristbands. So the company that makes the scanners cut the time to one second instead of 4 to 6 seconds. The hospital also found traditional barcodes took up too much room on patients' wristbands and compressed them into a one-inch square.

And, Bane said, the system will not prevent all errors. Hospital policy allows nurses to give medicines without scanning in emergencies, when the patient is so sick he or she needs medication immediately. But a nurse could choose not to scan a drug because she's busy, in effect overriding the system, and allowing an error to get through, incidents the hospital plans to track.

Besides, Bane said, a physician still can order the wrong medicine or a drug a patient is allergic to. ''The system can never replace a nurse," she said. ''The nurse must still use her brain and know why she is giving a particular drug to this patient."

Liz Kowalczyk can be reached at kowalczyk@globe.com.