Affiliations: [a] Department of Regulatory Science, Hokkaido University Graduate School of Medicine, Sapporo, Japan | [b] Division of Medical information planning, Hokkaido University Hospital, Sapporo, Japan | [c] Department of Biostatistics, Hokkaido University Graduate School of Medicine, Sapporo, Japan | [d] Division of Hospital Safety Management, Hokkaido University Hospital, Sapporo, Japan
Correspondence:
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Corresponding author: Yasuyuki Nasuhara, Hokkaido University Hospital Division of Hospital Safety Management, North 14, West 5, Kita-ku, Sapporo, 060-8648, Japan. Tel.: +81 11 706 7030; Fax: +81 11 706 6996; E-mail:[email protected]
Abstract:
BACKGROUND: Bar-code technology, used for verification of patients and their
medication, could prevent medication errors in clinical practice. OBJECTIVE: Retrospective analysis of electronically stored medical error
reports was conducted in a university hospital. METHODS: The number of reported medication errors of injected drugs,
including wrong drug administration and administration to the wrong patient, was compared
before and after implementation of the bar-code verification system for
inpatient care. RESULTS: A total of 2867 error reports associated with injection drugs were
extracted. Wrong patient errors decreased significantly after implementation
of the bar-code verification system (17.4/year vs. 4.5/year, p< 0.05),
although wrong drug errors did not decrease sufficiently (24.2/year vs.
20.3/year). The source of medication errors due to wrong drugs was drug
preparation in hospital wards. CONCLUSION: Bar-code medication administration is effective for prevention
of wrong patient errors. However, ordinary bar-code verification systems are
limited in their ability to prevent incorrect drug preparation in hospital
wards.
