L. Blair Heath--HIM

L. Blair Heath--HIM

August 31, 2006

Computerization Can Create Safety Hazards: A Bar-Coding Near Miss

The article by Clement McDonald, MD discusses the positives and negatives of computer-based physician order entry (CPOE). The CPOE uses a bar-coding system. The author describes a few cases in which there were serious mistakes using the bar-coding system. The misidentification of patients led to serious problems and misdiagnoses after admission.
The author attempts to point out that although computerized systems can be beneficial, we need to continue to closely monitor a patient and “double check” everything in order to ensure patient safety. The author is trying to show that this bar-coding system can be a positive thing, but we do not need to rely on it 100%. There is always room for error. McDonald also states that the best defense against error is a doctor who knows his/her patient well. I agree with the author. I think there is a good description of both the pros and cons of the CPOE. The author goes into details of several different errors that can occur during patient care. In the first case the author described, there was the error of switching the 2 bracelets during admission. The nurse did not notice that Mr. D’s 2 wristbands differed. Results were downloaded onto the wrong record because of the switched identification. The clerk, after noticing the error, did not personally confirm that the error had been resolved before further damage.
The patients name, admission date, birthday, doctor’s name, and patient number are all listed on the patient wristband. The quality of the data on the wristband is very good. It is accurate, current, and comprehensive which are comparable to the AHIMA characteristics.
The author promotes redundancy as a way to prevent errors. The tradeoff is that there is less time for direct patient care, but the safety of the patient is maintained. It is important to reduce the risk of misidentification as much as possible. Redundancy is a good way to reduce the risk of errors. I think for the most part the errors that occurred were systemic. Most of the time there was no “double checking”. The error that the clerk did not follow through after she realized the mistake was a random error.
The article goes into detail the continual need for humans to double check things. We put too much “faith” into computers. Although computers are very beneficial to the medical world, we do not need to lose sight that there is room for error. This article was very interesting to me. I am sure it would be a wake-up call to many professionals that are involved in hospital care.