2006/04/04 by Clement J. McDonald · 2 citations
Health Professions · Medicine · Psychology · #Electronic Health Records Systems #Medical Coding and Health Information #Healthcare Technology and Patient Monitoring #Medicine #Patient safety #Coding (social sciences) #Medical emergency #Human error #Near miss #Vigilance (psychology) #Identification (biology) #Intensive care medicine #Risk analysis (engineering) #Health care #Reliability engineering #Cognitive psychology #Psychology
paper · doi:10.7326/0003-4819-144-7-200604040-00010
openalex publication_date 2006/04/04 · openalex created_date 2025/10/10 · openalex updated_date 2026/07/31
Increasing numbers of hospitals are implementing bar-coding systems to prevent errors in patient identification. In the present case, a diabetic patient admitted to a teaching hospital was mistakenly given the bar-coded identification wristband of another patient who was admitted at the same time. When a laboratory result that documented the diabetic patient's severe hyperglycemia was entered into the other patient's electronic medical record, the latter patient seemed to have a very high glucose level and was almost given what could have been a fatal dose of insulin. This near miss shows that computer systems, although having the potential to improve safety, may create new kinds of errors if not accompanied by well-designed, well-implemented cross-check processes and a culture of safety. Moreover, computer systems may have the pernicious effect of weakening human vigilance, removing an important safety protection. Researchers should continue to study real-world implementation of computerized systems to understand their benefits and potential harms, and administrators and providers should seek ways to anticipate these harms and mitigate them.