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The Pennsylvania Patient Safety Authority (PPSA) is citing an increase in healthcare facilities reporting patient safety events associated with barcode medication administration (BCMA).
Pennsylvania healthcare facilities increasingly have reported patient safety events associated with BCMA, a technology used to prevent medication-administration errors, says Ellen S. Deutsch, MD, medical director for the Pennsylvania Patient Safety Authority.
Of the 1,309 events related to BCMA processes that occurred from 2005 through 2016, 453 were “near misses” and 857 reached the patient, including six that resulted in patient harm and one resulting in a patient’s death.
“The likelihood of the right patient, receiving the right medication, at the right dose, at the right time increases when barcode medication administration processes have been properly vetted for deficiencies,” Deutsch said recently in a statement announcing the data.
PPSA identified a statewide increase of near-miss BCMA events over the 12-year period, occurring at each point of the medication management process. Most involved administering medication, and others involved dispensing, prescribing, and transcribing errors.
The PPSA analysis has identified what appeared to be intentional barcode scans of the wrong patient, apparently the result of workarounds that staff employed to pursue better efficiency. Difficulty accessing records also resulted in wrong-patient selections, and lack of internet connectivity led to additional staff workarounds.
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