Wednesday, September 25, 2013

Bar-Code Scanners in the ED

Welcome to the Emergency Department of the Future.  Soft chimes play in the background.  Screaming children are appropriately muffled.  There is natural light and you can hear the ocean.  Patients and doctors alike are polite and respectful, and a benign happiness seems to radiate from all directions.  A young nurse wafts through the patient care areas with a handheld barcode scanner, verifying and dispensing medications in a timely and accurate fashion.

Everything about that vision is coming to your Emergency Department, everything except the chimes, the quiet, the politeness, and the happiness.  The bar-code scanners, however, perhaps.

This is a pre- and post- study from The Ohio State University regarding their use of handheld scanners for medication verification (BCMA).  Our hospital system uses these throughout the inpatient services to verify and provide decision-support for nurses at the final step of the medication delivery process.  However, given the chaotic nature of the Emergency Department, we have not yet implemented them in that environment.  Ohio State, on the other hand, has forged ahead – requiring all medication administrations be verified by bar-code scanner, excepting a small number of "emergency" medications that may be given via override.  They also excluded patients in their resuscitation areas from this requirement.

Across the 2,000 medication administrations observed in the pre- and post- implementation periods, there were reductions in essentially all types various drug administration errors, leading to 63/996 errors in pre- and 12/982 in the post-.  Therefore, these authors conclude – hurrah!

However, none of these errors were serious – and only one even met criteria for "possible temporary harm".  The majority of errors were "wrong dose", and involved sedatives, narcotics, and nausea medications the most.  Certainly, the potential for prevention of a significant drug event may be reduced with this system, but it would require much greater statistical power to detect such an effect.  These authors do not touch much upon any unintended consequences of their implementation – such as delays in treatment, changes in LOS, or qualitative frustration with the system.  A better accounting for these effects would assist in fully assessing the utility of this intervention in the Emergency Department.

"Effect of Barcode-assisted Medication Administration on Emergency Department Medication Errors"


  1. I just wanted to commend you on bringing to light the issue of barcode scanning in the emergency department on EM Lit of Note. I, for one, am not all impressed by the article at all.

    You bring up many points in your critique of the article that I see and experience firsthand everyday since barcode scanning went live in our ED: potential delays to treatment, physical space in the ED to allow for nurses to have mobile computers to facilitate scanning, network capability of the mobile computers in the ED (Internet access can be pretty shoddy in many EDs due to location), and errors embedded within the system of scanning in nurses taking extra steps to scan a medication. So often so, our nurses have many frustrations with the system, and they end up overriding scanning the medications altogether to prevent delays in treatment, which defeats the intent of the process. Even more so, nurses now seem so concerned about ensuring that the medication is scanned through the system that the sight of the bigger picture is lost. It is quite disappointing.

    I can see the role of barcode scanning on the inpatient units for patients who are admitted to the floors, as they may be on several daily medications, and with the nature of the floors, nurses are generally assigned less patients to care for at a time. Because of this, they have more time to scan the medications, along with the resources and space on the floors to allow for barcode scanning to work there. But the ED is a whole different world, with a workflow that is not all that predictable, and bar code scanning takes away from immediate and optimal patient care.

    1. I think the potential for patient care delay will always be there anytime new technology is introduced. The key is refinement of workflows and elimination of obstacles. This is how we have made it a success in our ED. The perceptions that other care areas have time and thus can bar-code scan is a presumptive statement. I would argue bar-code scanning has a place anywhere as long as med administration occur. It has consistently shown to have reduce occurrences of med errors even in the ED leading to optimal care.

      No question there are exceptions in which bar-code scanning should be excluded...Codes, Rapid Responses or Traumas. In all other scenarios, in my opinion, scanning should be utilized.


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