Dangerous Waters
May 16, 2011 | In: I've Been Thinking
I’ve been thinking about sailboats, tug boats, and the technology needed for safely navigating medication-use waters.
Twenty years ago this month, American Journal of Health-System Pharmacy published an article by Gerald E. Meyer, entitled “The use of bar codes in inpatient drug distribution.” [1] His opening line helped trim my sails for the tack my work has taken these past 18 years:
“Professionals entrusted with the delivery and administration of pharmaceuticals have a fundamental responsibility to identify and implement interventions that will improve patient quality outcome measures…. These interventions include the timely and judicious use of therapeutic and technological advances.”
One year ago today (May 6, 2010), The New England Journal of Medicine published Brigham and Women’s research summarizing evidence that bar-code technology reduces medication administration errors.[2] Interestingly, within two weeks, AboutLawsuits.com posted a brief of the study. Intentionally or not, the site that provides news and information about personal injury lawsuits provokes a question: Do victims of medication errors, which could have been prevented with bar-code technology, have cause to file suit?
In the late 1920’s, a storm slammed the Jersey Shore causing two tugboats to lose the barges under their tow. The barge company sued the tugboat operators for negligence. They claimed the vessels were not seaworthy, citing their lack of radio sets with which captains could have picked up weather warnings and avoided danger.
I think it’s but a matter of time before a plaintiff sues a hospital for injury or wrongful death from a medication error, charging the hospital with negligence because it lacked technology with which caregivers could have picked up warnings and avoided danger.
Legendary Judge, Learned Hand, found the tug company liable for not having radios on board, even though, at the time, they were neither required nor commonplace for tugs.
In his summary, Hand observed that the whole tugboat industry may have “unduly lagged in the adoption of new and available devices.” He also explained that “the industry may never set its own tests. Courts must in the end say what is required;” then concluded, “There are precautions so imperative that even their universal disregard will not excuse their omission.”
Bar-code scanning is commonplace in our world. We meet it daily at brick-and-mortar points of sale, ballpark turnstiles, rental car returns, parking garages, airport security lines, boarding gates—to scratch the surface.
Furthermore, though not required, bar-code assisted medication administration (BCMA) technology is anything but an anomaly in today’s hospitals. A 2010 American Society of Health-System Pharmacists Survey[3] indicates that over one third (34.5 percent) of America’s hospitals have implemented this patient-safety technology.
I wonder how many of the remaining two-thirds imagine they are safe in the majority?
Bar-code point-of-care systems are designed and proven to intercept errors before they reach patients. Used properly, scanning prevents caregivers from misidentifying patients and mismatching them with the wrong drugs, blood, specimens, and numerous other treatments.
Losing cargo is one thing. Losing patients, another.
Can the hospital industry afford to unduly lag in the adoption of new and available devices? Sooner or later bar coding will be viewed as a precaution so imperative that even its widespread disregard will not excuse its omission?
I’m just saying.
What do you think?
Mark Neuenschwander a.k.a. Noosh
Copyright 2011 The Neuenschwander Company
[1] AJHP Vol 48 May 1991
[2] Effect of Bar-Code Technology on the Safety of Medication Administration, N ENGL J MED 362;18 nejm.org May 6, 2010
[3] ASHP national survey of pharmacy practice in hospital settings:Prescribing and transcribing—2010 Am J Health-Syst Pharm—Vol 68 Apr 15, 2011
3 Responses to Dangerous Waters
Bob Stein, Pharm.D., J.D.
May 19th, 2011 at 7:58 pm
Mark, very thought provoking. I’m not sure there’s an apt comparison between the tug operators’ choice not to equip their boats with radios and a hospital not (yet) using BCMA. Judge Hand noted “An adequate receiving set suitable for a coastwise tug can now be got at small cost and is reasonably reliable if kept up; obviously it is a source of great protection to their tows.”
The cost of a BCMA solution is much greater relative to the cost of a radio. In a later case, Judge Hand articulated a formula that factored the probability of injury with the extent of injury and balanced that against the burden of costs of alternate precautions against the injury and/or probability in determining whether the standard of care was breached. BCMA vs patient injury is arguably a much closer balance than the in the TJ Hooper case where the cost of alternative precautions were unquestionably small against the probability and extent of injury.
Thanks for reviving the joys of Torts class, Mark. 🙂
Al Erisman
May 21st, 2011 at 12:06 pm
Love the article. I was thinking about a similar thing when a friend who had surgery had to go back into the hospital because of post-operative infection. I wondered if the surgical team had used a check list–demonstrated to eliminate most post operative infection? And I wondered whether the hospital could be sued for not doing so?
Jerry Fahrni, Pharm.D.
May 25th, 2011 at 8:08 am
Bob – I don’t think Mark was actually saying that BCMA was dirt cheap. Rather I think he’s making a point about the healthcare industry’s failure to adopt a technology that’s a couple of decades old, not all that expensive in the scope of things, and readily available.
While you bring up an interesting point, I would argue that BCMA could potentially save tens of thousands of healthcare dollars, if not more, each year in avoided medication mishaps. I realize the savings are soft dollars and a difficult ROI to demonstrate, but it’s the same argument we use every day to justify “clinical pharmacists” on the units preventing med errors and improving patient care. The soft dollars associated with avoided ADRs and medication error avoidance is one of the difficulties in driving pharmacists out of the pharmacy and toward the patient bedside, i.e. justifying the cost to the bean counters.
It appears that the soft dollars in pharmacy are being used as sword or shield based on individual need; sword to get pharmacists on the floor, and shield when “BCMA vs patient injury is arguably a much closer balance than the in the TJ Hooper case where the cost of alternative precautions were unquestionably small against the probability and extent of injury”.
A couple of other things to consider regarding BCMA:
1) BCMA implementation is a fraction of the cost of CPOE implementation, which many facilities are choosing to do. Has CPOE demonstrated enough cost savings to justify the millions of dollars required for implementation? I don’t know the answer to that, but the healthcare industry appears to think CPOE is a must have regardless of the cost. I’m a fan of both, but think you more bang for your buck with BCMA.
2) BCMA is only the bedside component of barcoding. Barcoding technology can be utilized inside the physical pharmacy space to drive better inventory management, i.e. increase turns, decrease outdates and therefore waste, etc. This results in cost savings that can be shown on the budgetary bottom line.
Just some thoughts.