Print “PDF version”
One of the many
factors contributing to the tragic NMBA (neuromuscular blocking agent) incident
we discussed in multiple columns was lack of barcoding capabilities in the PET
scanning suite (see our Patient Safety Tips of the Week for December 11, 2018 “Another
NMBA Accident”, February 12, 2019 “From
Tragedy to Travesty of Justice”, September
7, 2021 “The Vanderbilt Tragedy Gets
Uglier” and April 12,
2022 “A Healthcare Worker’s Worst
Fear”). Barcoding is
arguably our strongest medication safety intervention. But, like the hospital
in that incident, many hospitals have not expanded barcoding into those patient
care areas where patients may only temporarily visit, such as radiology suites.
ISMP recently reported results of a
survey it had done on implementation for its three new best practices released
in the 2022-2023 ISMP Targeted Medication Safety Best Practices for Hospitals (ISMP 2022). One of those best practices is expansion of barcoding
technology beyond inpatient care areas.
ISMP found that two-thirds to three-quarters of hospitals
reported full implementation of barcode technology in infusion clinics (76%),
post-anesthesia care units (73%), labor and delivery (72%), dialysis centers
(67%), emergency departments (65%), and perioperative holding areas (63%). But, lower levels of full implementation were reported in
radiology (31%), cardiac catheterization labs (23%), procedure rooms (16%), and
operating rooms (7%).
Our numerous columns on patient safety in the radiology
suite (or MRI or PET suite) point out that most of the issues are not directly
related to the imaging study being done. Rather, sick patients with multiple
vulnerabilities are spending time in those areas and problems related to their
ongoing medical interventions can occur while they are in those areas. They
often need to receive medications while in those areas and the lack of
barcoding capabilities there can lead to untoward events.
How is your facility doing on expanding use of barcoding
technology to those areas?
References:
ISMP (Institute for Safe Medication Practices). Survey Shows
Room for Improvement with Three New Best Practices for Hospitals. ISMP
Medication Safety Alert! Acute Care Edition 2022; 27(9): May 5, 2022
https://www.ismp.org/resources/survey-shows-room-improvement-three-new-best-practices-hospitals
Print “PDF version”
http://www.patientsafetysolutions.com/
What’s New in
the Patient Safety World Archive