Should Hospitals Install Bar Coding or CPOE First?

Robert Wachter is widely regarded as a leading figure in the modern
patient safety

movement. Together with Dr. Lee Goldman, he coined the
term "hospitalist" in an influential 1996 essay in The New England
Journal of Medicine. His most recent book, Understanding Patient
Safety, (McGraw-Hill, 2008) examines the factors that have contributed
to what is often described as "an epidemic" facing American hospitals.
His posts appear semi-regularly on THCB and on his own blog "Wachter’s World

This is one of the most commonly asked questions in IT World, and my
answer has always been “CPOE first” – largely because that has always
been David Bates’s (the world’s leading IT/safety researcher) answer. But I’ve changed my mind. Here’s why.

Before I start, I promised
that I’d let you know if I ever blogged on a topic in which I have a
financial conflict of interest. On this, I do: I serve as a paid member
of the Scientific Advisory Board of IntelliDOT, a company that makes a
stand-alone bar coding system. If that freaks you out, stop reading.
But recognize that if you had asked me the “bar coding or computerized
provider order entry?” question last week, I would have answered “CPOE”.

because the evidence supporting CPOE is substantially stronger than the
evidence for bar coding. For example, a search of “CPOE” on AHRQ
Patient Safety Network (AHRQ PSNet) turns up several studies (for example, here and here) demonstrating substantial reductions in serious medication errors, and one documenting an impressive return-on-investment for CPOE. Although we
and others have noted that this evidence can be challenged for its lack
of generalizability (most of it came from studying the Brigham’s
home-grown CPOE system, not the commercial systems that the rest of us
are buying) and its impact on proxy outcomes (error rates) rather than
on true patient harm, these are mostly quibbles: a good CPOE system
does appear to decrease errors at the prescribing phase. Which makes

The literature supporting bar coding is wimpier. The only rigorous study of bar coding I can find is one
showing impressive safety gains after implementation of a bar coding
system – in the clinical pharmacy, not at the point of care. In fact, a
search of PSNet looking at the efficacy of bar coding turns up more
studies showing unintended consequences and mischief – including a
wonderful paper
written for our Quality Grand Round series involving a case in which
two patients (one a diabetic, the other not) ended up with each others’
wrist bands through an ED mix-up. Patient B would have gotten a
(probably fatal) slug of insulin for a sky-high blood sugar (drawn from
patient A, who was wearing B’s bracelet) had an alert doc not overheard
a nurse telling a colleague that she was going into Patient B’s room to
give him his insulin. Other papers
have made the point that clunky bar coding systems can lead to nurse
workarounds that subvert the safety features. Clearly, these systems
are not panaceas, and – like CPOE (see here and here) – they can easily be undermined by bad design and inattention to human factors.

This week, I had the pleasure of giving a keynote speech at a national bar coding conference, a quirky affair called the “unSummit”,
run by two charming bar coding evangelists, Mark Neuenschwander and
Jamie Kelly. Mark, in particular, is an unusual guy: a former minister
– no Reverend Wright jokes, please – who has a preacher’s passion for
bar coding. At the unSummit, I gave a big picture patient safety talk
to the 400 bar coding groupies, and then focused on why the uptake of
bar coding by American hospitals has been so painfully slow. “If you’re
a hospital, there are certain things you have to do, like passing JCAHO
and doing anything CMS tells you to do,” I explained. “So you’re
competing for limited bandwidth against a bunch of other non-mandatory
safety-oriented interventions: teamwork training, simulation, rapid
response teams, preventing diagnostic errors, and CPOE. Right now, bar
coding lacks the evidence to win that competition.”

But on my
flight home, I started thinking about the big, high profile errors I’ve
heard about in the last year or two, both at UCSF and nationally. And I
had an epiphany. Or maybe it was the turbulence. But here goes.

UCSF Medical Center (which has a very good paperless chart but neither
CPOE nor bar coding; the former is slated to launch soon, with bar
coding to follow), virtually every terrible medication error case I can
recall in the past couple of years involved a nurse administering a
medicine. And talk about “the business case for safety”: these days,
really nasty errors get reported to the state health department, whose
dour investigators come swooping in, turning over every rock in the
building and threatening to shut you down if they find one glitch too
many. Believe me, this is not fun. Nor cheap.

Then I began thinking about the People Magazine/60 Minutes-type errors over the past few years – Linda McDougal‘s unnecessary mastectomy because of a path lab mix-up, Dennis Quaid’s twins‘ massive heparin overdose, the fatal error in Madison
in which a nurse infused an epidural anesthetic intravenously into a
pregnant woman. It hadn’t dawned on me previously, but all of these
cases represent identification errors that probably would have been
prevented by a decent bar coding system.

Thinking about this
drumbeat of tragedies, I tried to recall a major medication error in
the last few years that would have been prevented by CPOE… and I
couldn’t. Not that there aren’t any, but it does seem like today’s
Oh-My-God-How-Could-This-Happen med errors are now disproportionately
administration, not prescribing, mistakes.

What is going on? I
suspect that some of the prescribing errors that CPOE can prevent are
now avoided because so many docs are using handheld prescribing aids
like Epocrates, and because Joint Commission regs, such as banning high
risk abbreviations like “10U insulin” and “qd”, are eliminating some of
the worst offenders. Moreover, with everybody now on their toes about
medication safety, an errant prescription has many downstream
opportunities (pharmacist, nurse, even patient or family) to be caught
before it kills.

On the other hand, there is generally nothing
that stands between the busy nurse who makes a dose calculation error
or confuses a vial of heparin for insulin – and tragedy. The nurse has
only one chance to get it right, and no safety net if she gets it
wrong. Add to this the effects of the nursing shortage (busier nurses,
more temps, more young grads), patients on more and more complex meds,
fuller hospitals… and you inch ever closer to disaster.

Why did
CPOE gain so much more momentum than bar coding over the past decade?
Here’s my theory: because it involves physicians. Think back to the
early days of clinical IT. Many of the movers and shakers were
physician-informaticists, and they had to sell the case for change (and
considerable investment) to their fellow physicians if there was to be
any hope of their hospital taking the IT leap. It is logical that they
would have deemed prescribing errors to be the main culprit: those are
the ones that they themselves had committed and witnessed. As for
public demand, doctor’s handwriting has been fodder for Jay Leno jokes
for decades. Have you ever heard a stand-up comic prattle about the
nurse who gave a patient the wrong med?

In other words,
medication administration errors (and laboratory/pathology specimen
errors) tend to be out-of-sight, out-of-mind to physicians and the
public. Moreover, they involve assembly-line processes and simple
execution (no pun), all kinda boring. As for bar coding, how exciting
could something be when they’ve had it at the checkout counter at
Safeway for decades?. And so, despite their importance, administration
errors (which represented more than one-third of all med errors in Bates’s seminal study)
were largely ignored… by researchers, by early IT adopter healthcare
systems (the VA is an exception but for some reason didn’t focus on
studying this intervention), by physicians, and by the public. And
nurses, I think, have been ambivalent about bar coding – hopeful that
it might prevent mistakes but worried that it would create workflow

So CPOE became the darling of the healthcare IT set,
winning all the accolades and getting most of the push. And since bar
coding is much less expensive than CPOE, there wasn’t as much corporate
energy put into developing systems and promoting them.

Now, I
could be wrong about this. After all, whatever the reasons, the fact
remains that bar coding has not been researched very much or very well.
But, with all the medication administration errors I’m hearing about,
this is now an area in which I am willing to relax my evidence standards
a bit – it is beginning to seem like the equivalent of barricading the
cockpit doors after 9/11, a “relatively” low cost, low complexity (at
least when compared with CPOE) and commonsensical intervention that can
potentially save a lot of victims – both patients and nurses.

A few weeks ago on NBC’s Today Show, Dennis Quaid discussed (the first half of this clip is on his kids’ medication error, the last half on his new movie; it is
morning television, after all, and they have to sell soap) his new
foundation, set up to prevent the kinds of errors that nearly killed
his twins. “We’re going to concentrate on one thing at a time: bedside
bar coding… A lot of times patients end up getting the next door
neighbor’s medicine… nurses are so overworked… and mistakes occur.”
Quaid noted that he was suing the heparin drug manufacturer but had not
yet decided whether to sue the hospital, Cedars-Sinai. “Isn’t the
hospital going to institute [bar coding]?” asked host Meredith Vieira.
“They have not said they’re going to as of yet,” said Quaid, clearly
implying that he might soon remove his high-priced lawyers’ muzzles.

the last person to argue for health policy by Hollywood heartthrobs,
but I think that similar cases are occurring all-too-often out of the
klieg lights, and that many of them can probably be prevented. The
question is whether we wait for better evidence and better systems. I’m
pretty sure that our friends at Cedars-Sinai wish they hadn’t.

Ultimately, of course, we need both bar coding and
CPOE, and we need rigorous studies looking at what works and what
doesn’t. But you have to start somewhere. Even though the evidence
continues to trail, based on what I know today, if I was a hospital
ready to get into the IT game, I’d go with bar coding first.

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10 replies »


  2. In response to Matt’s question:
    So John, what level of proof do you need that BCMA – when implemented well – would prevent medication administration errors?
    How about even a single observational study that shows the benefits of BCMA?
    There is only one published in AJHP; and that was suspect b/c BCMA was one of many medication admin reorg interventions and the role of BCMA was unclear.
    I did see a very well done study funded by a BCMA company that showed zero benefit. The study was not submitted for publication; go figure.

  3. I am a nurse and actually see cpoe and bar-coding having equal import. The chicken scratch the nurses have to decipher is frightening and wastes already precious time. Theoreticaly barcoding is hard to argue against till you put it in the real world.I have been using the emar format for approximately a year and a half and find it extremely frustating for one simple reason….the system acts like any other computer with glitches outages dead zones frozen screens. I am not excusing nurses for bypassing the safety net at times but when these computers crash during codes or somebody has to wait an hour for a pain med because it is backed up in the pharmacy queue what are we to do? We are in a midst of a technological explosion but I am not sure every new advancement should become the gold standard without some serious reevaluation after it has been in use. We have fallen in love with technology but it doesn’t always love us back. Just some thoughts from somebody in the trenches.

  4. There are some established problems with bedside barcode reading of linear barcodes. 2D eliminate that but the reader is more expensive, so they seem to get avoided. (2D is used on meds, however, because of data density, linear barcodes simply get longer as they encode more info — so the label gets larger — and some objects don’t support having large labels applied to them.)
    As to the correlation record of medication to patient, that can be solved with higher density barcodes, the 2D variety, which also don’t have the nightmare reading problems that the linear barcode has.
    At the bedside, the patient’s safety isn’t helped by CPOE. CPOE’s job is over by then. A better barcode system can, however.
    Fascinating discussion!

  5. BCMA can be implemented without fully-operational CPOE.
    Usually, BCMA pairs implementation of “Electronic Medication Administration Record” (eMAR) with item-specific identification (bar-coding).

  6. ….. but surely to reap the benefits of barcoding, it needs to go in at least alongside CPOE (or at least a simulation of). If the barcodes from patient and medication are intended to match, then there must be an electronic record of what medication each patient is supposed to receive. How to get that record without CPOE?

  7. So John, what level of proof do you need that BCMA – when implemented well – would prevent medication administration errors?

  8. Until the science in in, I opt for good science over public relations. CPOE has a LOT more science.

  9. “I’m the last person to argue for health policy by Hollywood heartthrobs…”
    But it’s also very astute of you not to dismiss their experience either, just because it doesn’t come with standard error bars.
    I also listened to the Quaids (on 60 minutes), and found their story compelling, but your thoughtful analysis helps put it into context.
    And yes, the AHRQ data can’t come soon enough.

  10. Thank you for the excellent post, Dr. Wachter!
    In addition to PSNet, AHRQ runs the National Resource Center for Health IT (www.healthit.ahrq.gov) as the public face of its Health IT Program.
    AHRQ has funded eleven organizations in a variety of care settings in implementing bar-coded medication administration projects and exploring the effects of BCMA on health care quality, safety, cost, and other outcomes.
    While the projects described are not yet complete, some key “lessons learned” have emerged from the grantees’ experiences in implementing BCMA.
    Here’s a link, including “emerging lessons” and information on the grantees’ projects: http://healthit.ahrq.gov/portal/server.pt?open=514&objID=5562&mode=2&holderDisplayURL=http://prodportallb.ahrq.gov:7087/publishedcontent/publish/communities/a_e/ahrq_funded_projects/test_emerging_lessons/health_briefing_04182008081321/bar_coded_medication_administration.html

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