Barcode Medication Administration Implementation in the FIAT Health System

Abstract

“Don’t you see? This won’t make a difference in the long run,” pleaded Dr. Target, the Medical Director of Information Services.

Dr. Target was attending a process review meeting and could tell she was not convincing anyone. She was at a root cause analysis meeting because of a medication error that she knew could have been prevented.

A physician had correctly written for 10 units of insulin to be given to a patient following correct JCAHO protocol and writing the number 10 without a trailing zero as well as the word “units” in clear legible writing.

Unfortunately, the unit clerk erroneously transcribed the order as 100 units to the paper Medication Administration Record (MAR). The patient consequently received 10 times the intended dose of insulin.

Dr. Target continued, “Have you ever been on the floors and seen all the tasks the clerks have to juggle? When a physician writes an order, the clerks must fax it to the pharmacy and then transcribe the medication order to the paper MAR. The person with the least clinical knowledge is responsible for setting up the patient’s MAR. Do you realize that while they are doing this, they are also answering the phone, jockeying for access to the chart and answering questions. It’s a wonder that this didn’t happen sooner.”