Patient misidentifications caused by errors in standard bar code technology.

Area of Science:

• Healthcare technology
• Patient safety
• Medical device performance

Background:

• Bar code technology is widely used in healthcare to reduce transcription errors.
• However, linear bar code systems are not infallible and can lead to patient misidentification.
• This study investigates errors in bar code scanning for point-of-care glucose testing.

Purpose of the Study:

• Identify sources of bar code decoding errors during point-of-care glucose testing.
• Determine factors contributing to incorrect patient identifiers.
• Develop solutions to prevent these patient safety risks.

Main Methods:

• Misread wristband bar codes were identified and rescanned using five different scanner models.
• Bar codes were reprinted for control comparisons.
• Error rates were calculated for each bar code-scanner pair, and data integrity checks were performed.

Main Results:

• A single bar code generated up to three incorrect patient identifiers.
• Sources of error included minor bar code imperfections, scanner resolution issues, and suboptimal bar code orientation.
• The Roche ACCU-CHEK® glucometer exhibited the highest error rate; internal checks failed to detect these errors.

Conclusions:

• Bar code scanning errors can result in patient misidentification, with severe implications for patient records.
• These findings impact point-of-care testing, medication administration, and transfusion systems.
• Manufacturers should improve equipment specifications and consider alternatives to linear bar codes for enhanced patient safety.