In 2001, Carilion Clinic implemented medication barcode scanning at its Roanoke Memorial facility, a 628-bed tertiary care hospital. In 2006, with a scan compliance of 82%, a near-miss sentinel event involving a preventable medication error re-energized an institutional commitment to a "Culture of Safety." Multifaceted problems with our medication barcode technology created a forced override of the system to ensure timely medication administration, resulting in a loss of safety checks for 15% (1,500 per day) of the medication administrations.
A multiprofessional team comprised of nursing, pharmacy, human resources, quality management and technical services was formalized. Early commitment to "whatever it takes to do the right thing for the patient" was embraced. Each step in the medication administration process was reviewed. Solutions were identified and implemented systematically in stages to measure their impact. Process changes culminated in a required second licensed verification for all overrides. Compliance with the utilization of the barcode system rose from 82% in September 2006 to 98% in May 2007 with all units exceeding the 90% compliance target. Projected annual total medication errors avoided rose 42% at a calculated cost avoidance of more than $2.8 million. Targeted education demonstrated the largest improvement in compliance and emphasized system-wide disclosure of the sentinel error, a sense of urgency to patients and the effects on our patients, families and community.
Using the theme, "We're OVERRUN with Thanks!" the success of the project was celebrated with the team presenting cakes and plaques to the nursing units. Technology, such as barcode scanning, provides a significant opportunity to reduce medication administration risk; however, it does not replace the need for safe practice. We learned that, as institutions adopt complex, costly technologies to deliver safer care, success rests on integrated approaches that enhance work processes while emphasizing professional responsibility to patient safety.
