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What’s New in the Patient Safety World

June 2022

Where Are You Barcoding?



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%).


The ISMP survey responses did identify multiple barriers to implementation of barcoding in these other areas. These included resource constraints, such as lack of scanners or lack of space, information technology issues, insufficient staffing (particularly pharmacists), and workflow issues such as one-step prescribing and administration and lack of electronic order entry. They also noted that some of the barriers were related to specific outpatient locations, such as concerns about sterility and inaccessible patients’ identification bands in the operating room, and concerns about metal objects and the absence of barcodes on radiopharmaceuticals in radiology.


ISMP is collaborating with a health system to describe how they achieved full implementation of this technology in their operating and procedure rooms and expects to publish an article on these within the next few months.


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?






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





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