Through a chance conversation with her brother-in-law last year, Jeanne Fortier, RN, Vice President of Clinical Services at MDI Hospital, helped identify a technological innovation that has greatly enhanced the Hospital’s ability to ensure patient safety.
In May of 2004, the Hospital took a big step in its ongoing effort to implement an electronic medical records system by employing bar codes to safeguard patients from medication errors. However, because it was designed more for grocery stores than hospitals, the bar code technology supplied by the Hospital’s software vendor simply did not work.
The bar codes containing identifying information were printed onto a patient wristband and on medication labels ordered for the patient. At the bedside, nurses scanned the bar codes on the wristbands and medications with a hand held device connected to a mobile computer. Software checked to ensure that the right patient received the right dose of the right drug at the right time via the right route – a patient safety standard known as the “Five Rights.”
However, the scanners and bar code used by the Hospital did not work consistently on the small round surface of a patient’s wrist or on the medication packets and bottles. “We’re committed to patient safety and adherence to the Five Rights,” said Fortier. “But the bar code and scanner system we had did not work in the healthcare environment, which prevented us from accessing the safety features of our patient software.”
MDI Hospital was not alone in its struggle to use bar codes as part of its patient safety program. Reports show that only 10% of hospitals nationwide have implemented bar code technology.
After a few months, the bar code scanners at MDI Hospital were turned off and the nurses had to enter medication data manually, which meant they had to rely on their own expertise to prevent medication errors. “Our nurses have an excellent track record when it comes to patient safety,” explained Fortier. “But with more patients needing more medications, the potential for errors has increased in recent years. The software was designed to provide an additional tool for our nurses to ensure patient safety, but without a functioning bar code and scanner, it doesn’t work.”
Then in the spring of 2005, Fortier had a conversation with her sister’s husband, Don Flynn, Vice President of Hand Held Products, a New York-based company specializing in data collection solutions. “We talked about the fact that we had been using bar codes and they weren’t working,” explained Fortier. “Don explained that his company might have a solution.”
Flynn mentioned state-of-the-art technology developed by his company that employs a code known as the Aztec 2D matrix code. When printed, the code resembles square dots on a square grid, versus the series of straight lines of a traditional bar code.
Developed in the last decade for the manufacturing and gaming industries, the Aztec 2D code provides more information in a smaller space than a linear bar code. The smaller space allows the code to be printed multiple times, which greatly increases the chances of a good scan on the uneven surfaces of a patient wristband.
Combined with a new, more effective scanner, also developed by Hand Held Products, the new technology provided the solution the Hospital was looking for. “Our nurses can now consistently get a good scan on the wristband and medication packets and bottles, which allows them to take advantage of the safety features our patient software provides,” explained Fortier.