Every day BCMAs save lives and stop errors, says Dr. Koppel, and the published study documents thousands of medication errors avoided via these systems. In addition, the article also lists many recommendations for identifying the problems and mitigating workarounds. Four of the study hospitals reduced the number of overrides dramatically by following these recommendations.

"The causes of workarounds are neither rare nor secret," added Koppel. "They are hidden in plain sight, obscured by, among other things, a blind faith in technology and the urgent needs of patient care. Clever as they are, workarounds are the unintended consequence of a technology in need of continuing and in situ evaluation."

Professor Ross Koppel's research on healthcare information technology (HIT) came to national prominence a few years ago with a JAMA article on medication errors associated with computerized physician order entry systems (CPOE). But he has published widely on HIT, noting its many benefits as well as its problems. In the same July/August issue of JAMIA, in fact, he is also the first author on a paper that presents a way of using CPOE to detect and prevent medication errors - a decidedly pro-CPOE piece. Koppel remarked, "Many vendors and their supporters mistakenly believe I'm some sort of Luddite. That's the exact opposite of my position. I view these technologies as vital; that's why we must make them work to help clinicians and patients. Right now, the vendors and true believers focus on marketing HIT, and attack any criticisms as anti-technology. That's the worst way to improve these essential tools."

This study challenges assumptions of how these increasingly popular bar-coded medication administration systems are actually used in hospital practice. "It is not enough to tell the staff to "do it right", concludes Koppel, "rather repeated examinations and corrections of the technologies in actual use will help optimize their roles in preventing medication error and enhancing patient safety."

As noted, HUP does not use barcode medication administration systems, but requires staff to manually check identifiers to correctly match patient and medication. When HUP implements a medication barcode system, it will incorporate the findings from this research.

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Article adapted by Medical News Today from original press release.
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PENN Medicine is a $3.5 billion enterprise dedicated to the related missions of medical education, biomedical research, and excellence in patient care. PENN Medicine consists of the University of Pennsylvania School of Medicine (founded in 1765 as the nation's first medical school) and the University of Pennsylvania Health System.

Penn's School of Medicine is currently ranked #4 in the nation in U.S.News %26 World Report's survey of top research-oriented medical schools; and, according to most recent data from the National Institutes of Health, received over $379 million in NIH research funds in the 2006 fiscal year. Supporting 1,400 fulltime faculty and 700 students, the School of Medicine is recognized worldwide for its superior education and training of the next generation of physician-scientists and leaders of academic medicine.

Source: Marc Kaplan
University of Pennsylvania School of Medicine Article End