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I've been thinking about babies, bar codes, and bathwater.
Twenty years ago, I made the obligatory pilgrimage with my five kids to Chuck
E. Cheese's. Ugh. A few months ago, I made my second and final visit--this
time with my grandson. Two noteworthy changes: Chuck E's token-gobbling
entertainment technology has been upgraded, and he's installed a Kid-Check
security system with the commitment: "Everyone that comes together, leaves
together." On the way in, whole families are now stamped with unique
identifiers in invisible ink. On the way out, stamps are black-lighted to
ensure all children belong to the adults with whom they are departing. This is
not your father's Chuck E. Cheese.
Similar, though more sophisticated, technologies are being utilized in
hospitals to ensure infants belong to the adults with whom they are leaving.
To prevent abductions, newborns are tagged with radio-frequency identification
(RFID) bracelets or anklets, which trigger alarms and even lock doors when
unauthorized persons attempt to remove babies from secured areas. Beyond
newborns, a good case could be made for hospitals tagging older children. In a
UK hospital this past June, a woman nearly succeeded in kidnapping a
9-month-old from a pediatrics unit.
Our first son (adopted) used to tell people he was abducted. Not all babies
who leave hospitals with the wrong parents are kidnapped. In some cases, staff
confuses one baby's identity with another's. In March, two
newborns were unintentionally switched in an Illinois hospital after they
were circumcised. One boy was sent home with the wrong woman, while his mother
remained in the hospital. Half a day later, the staff realized what had
happened thought it might be a good idea to ask the family to return the child
and pick up their own. DNA testing confirmed who belonged to whom. Thank God,
the error was caught. This is not always the case.
Recently, two 57-year old women, who were born in a tiny rural Oregon hospital
on 3 May 1952 (both hairless and weighing six pounds), met for the first time.
Turns out, their mothers had not left with the daughters they had carried into
labor. Because of the
mix-up, each had been raised by the other's parents. Fortunately, the
women (who refer to themselves as "twisters") and their parents have forged a
bond in spite of the hospital's error. Nevertheless, ponder their losses.
Positive ID technologies are important for stays as well as departures,
helping to ensure that whatever is done is done with the right persons.
Utilizing bar-code-enabled patient/process/product identification before milk
collection, feedings, medication administrations, blood transfusions, specimen
collections, and vital-sign monitoring prevents errors from reaching both
mothers and children.
At a Brooklyn hospital in January, two mothers (each with the first initial
"S" and last name "Brown") were confused, and one of their children was taken
to the wrong mother for his
first feeding. Matching the infant's and mom's bar-coded bracelets could
have prevented this error. Systems like
LacTrack incorporate
bar-code labeling of expressed milk at the point of collection as well as
verification scanning of mother's milk and/or manufactured formula at the
point of feeding. Systems like
TotGuard
not only issue infant RFID tags for security purposes but also mothers' RFID
tags for pairing purposes. When babies are handed to mothers, their radio
signals interrogate each other and audibly confirm or deny a match.
It's critical that these child-protection technologies be used properly. A few
weeks ago, in Hong Kong's Queen Elizabeth Hospital, two infants were
mixed up and breast-fed by the wrong mothers for four days. Staff had
confused the children in the process of applying bar-coded ID bands. I know
someone will use this story to float arguments against the efficacy of bar
coding. But I'd argue the hospital had a process rather than a technology
problem. Not unlike four of the five Chuck E. Cheeses in the San Antonio area.
In November of last year, a local television station with hidden cameras was
able to get children through each restaurant's security check with the wrong
adults. However, just because a good technology was used in a poor manner is
no reason to throw the baby out with the bathwater. Did I just say that?
Anyway, fail-safe processes must be designed and enforced for bar-code tagging
babies and mothers just as they are for bar-code labeling medications. (See:
I've Been Thinking About
Verifying Bar Codes on Wristbands). A single bar-coded ID band should be
printed for each newborn, then verified, applied, and tested for accurate
mapping to its mother's--all before either leaves the delivery room. Why not
print a matching label for the baby's bed at the same time? Scanning can
verify that the right baby is being placed in the right crib, the same way
it's being used to verify that drugs are being stored in and retrieved from
the correct compartments (See: I've
been thinking about positive product ID).
One Sunday in 1988 BC (before cellular), we took two cars to church. Upon
arriving home, only four of the five kids were with us. Our missing child
hadn't been abducted. His parents had failed to communicate. So much for No
Child Left Behind. Hey, at least we left him at church. Could have been Chuck
E. Cheese's. In any case, you should know that we revisited and refined some
processes.
What do you think?
Mark Neuenschwander a.k.a. Noosh
mark@hospitalrx.com
http://twitter.com/hospitalrx
Now for some news...
- Free Webinar - Pharmacy Face-Off: BCMA vs. CPOE, Which Comes First?
Pharmacy OneSource is hosting a free webinar debate on September 23rd at
noon Eastern time. John Poikonen takes on Steven Rough in the first
"pharmacy face-off." These pharmacists will debate on Bar Code Medication
Administration or Computerized Physician Order Entry and which should be
implemented first.
Register today!
- Fatal or serious NHS medication errors double in two years
Of the 72,482 incidents known to have occurred that year, 82 per cent were
made in the administration or dispensing of medicines by nurses or
pharmacists, rather than in the prescription of drugs by doctors. Source:
timesonline.co.uk
- Join the bar-code point-of-care discussion
Free membership:
pointofcareforum.com
- McKesson to market another robot--this one for IVs
Exclusive five-year strategic partnership with McKesson for Health Robotics'
CytoCare Robot. Source:
TradingMarkets.com
- Another California hospital scanning bar codes at the bedside
Up in Tri-City's intensive care unit, registered nurse Anna Duenas uses the
new scanning system daily. She said she appreciates the convenience of the
new system, because the computer logs each drug she enters without her
having to leave a patient's room and enter in information into a computer
manually.
An added benefit: The new system provides confirmation for patients who
might not remember getting their medications. "Sometimes if a patient feels
maybe they didn't get their medications, you have the record right there,
and you can show them that they did get it," she said. "It's a backup both
ways." Source:
NCTimes.com
- YouTube: The Nation's First Paperless Hospital
Lakeside Hospital Omaha, NE Secretary Sebelius tours the nation's first
paperless hospital. Source:
YouTube.com
- Cancer sufferer dies after getting wrong blood
Staff at a Merseyside hospital made a "catalogue of errors" when they gave a
cancer sufferer the wrong blood, an inquest concluded. Source:
liverpoolecho.co.uk
- Another hospital launches medication barcode verification
Patients at Hill Country Memorial Hospital can be comforted knowing that as
of July their medications are verified by computer before they are
administered--as part of the Bedside Medication Verification (BMV) system.
Source: Mason
County News
- Paper: Nurses Don't Hate Change
Survey of nurses in a neonatal intensive care unit regarding the
implementation, use and effectiveness of a bar code medication
administration system.
Forty-six nurses (median age < 30 years) completed a 30-item questionnaire.
Most nurses reported comfort using the system within two weeks. Source:
Longwoods.com
- Paper: Enhancing Transfusion Safety with an Innovative Bar-Code-Based
Tracking System
In an effort to reduce transfusion errors, a novel, comprehensive,
computerized wireless bar-code-based tracking system for matching patients,
blood samples and blood products was created and deployed at a major
academic medical centre. Source:
Longwoods.com
- Safer software nets Kiwi firm big bucks
Auckland health technology firm SaferSleep is dreaming of a US$60 million
payday after breaking into the lucrative British market. The company uses
bar-code technology for administering aesthesia to patients. Source:
Manawatu Standard
- Parents say wrong drug led to brain-damaged baby
A Florida hospital mistakenly gave a pregnant woman a drug commonly used to
speed up labor, causing her to give birth two months early and severely
injuring the baby, according to a lawsuit. Source:
Miami
Herald
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