Medication Safety

The number of medications has grown an astonishing 500% in the past decade. Today, more than 17,000 trade and generic pharmaceuticals are marketed in North America. As a result, the number of medication errors in hospitals and care centers across the country has grown, making it the number one concern of patients who are hospitalized.

Where do medication errors occur most in hospitals across the country?

• 39% in ordering
• 12% in transcribing
• 11% in preparing
• 38% in administering

Why do medication errors occur?

• Wrong drug
• Wrong Dose
• Similar names
• Similar labeling/packaging
• Transcription error
• Omission error

Physicians, nurses and pharmacists must keep pace with every one of these new drugs, learning about allergic reactions, adverse drug effects and more.

What Eden Is Doing To Improve Safety?

Eden Medical Center has taken a significant leap forward to help protect patients from medication errors. Through advanced computerized bar coding – the same technology used for decades on everything from food packaging to concert tickets – physicians and nurses can track drug orders and make the delivery of patient medications even safer.

This patient-safety technology, known as the electronic Medication Administration Program (eMap), helps prevent errors by linking the bar code technology with electronic patient medication profiles.

“The technology provides an extra layer of safety, which is always a concern of the patient-care team as they manage patient medications,” said Eden Medical Center Pharmacy Services Clinical Coordinator Larry Poon, Pharm. D. “A tremendous amount of resources has been devoted to analyzing, designing and testing the system and procedures. This is truly a collaborative effort of the physicians, nurses, pharmacists and information technologists.”

How It Works

Today, every patient wears a wristband with his or her name on it as well as a simple bar code.

A computer bar code on each patient’s identification bracelet is used to match and monitor the medication ordered by the doctor. Before administering medications, nurses and other caregivers scan a bar code on the patient’s wristband, on the nurses’ own identification badge, and on the medications using a hand-held device. A bedside computer integrates these bar codes with medical databases to provide patient-specific information. Through immediate feedback on the computer screen, the bedside nurse will be alerted to any potential errors and other critical information that could prevent adverse drug effects.

The system is designed to achieve the “five rights”:

• Right patient
• Right drug
• Right dose
• Right time
• Right route of administration

Here is a step by step look at the process:

1. A bar code is on each patient’s personalized wristband, the nurse’s ID badge and the unit dose medication. The three codes are used to match and monitor the medication ordered by the doctor.
2. Before administering a medication, the nurse scans each of the three bar codes using a handheld device at the bedside.
3. A bedside computer will then “read” these bar codes into a software application that uses expert databases to ensure the right medication in the right dose is given to the right patient at the right time.
4. Immediately – through a message box on the computer screen – the nurse will be alerted to any potential errors and be given other critical information that could prevent potential adverse drug events.
5. At the click of a mouse, our nurses will have access to a tremendous amount of valuable, potentially lifesaving information.
6. It will also allow the health care team to track vital information about the patient’s current medications, conditions and drug interactions and allergies.
7. It alerts the healthcare provider to possible problems: allergies, maximum daily dose, look-alike/sound-alike drugs and high-risk drugs.

Ahead of the Industry

Sutter Health is the first health care network in Northern California to use this advanced technology. Sutter Health announced its $50 million investment in new and advanced patent safety technology in August 2002. Eden and its fellow Sutter Health affiliates are the first hospitals in Northern California to use bar-coding technology. In fact, this technology is used in only 4% of hospitals in the country.