Technology and Safety: National Patient Safety Goals and Barcoding


March / April 2009
Technology and Safety

National Patient Safety Goals and Barcoding

Indiana newborns are mistakenly given adult doses of Heparin. A 33-year-old New York woman undergoes a double mastectomy intended for someone else. A 67-year-old California man dies when he receives blood meant for another patient.

As someone who expects to be a patient some day, I’m a believer in The Joint Commission’s National Patient Safety Goals (NPSGs). The first goal of the 2009 version expects hospitals to “improve the accuracy of [patient] identification.”

In the NPSG’s preface, The Joint Commission (TJC) warns of a clear and present danger: “Wrong-patient errors occur in virtually all aspects of diagnosis and treatment.” From medication errors alone, over 7,000 lives are lost each year — more than 20 times the number of US troops lost last year in Iraq. Add another half-million patients who are injured by medication mistakes. This says nothing about other types of wrong-patient errors.

When caregivers stick us with needles, collect specimens, wheel us off to surgery, or send pieces of us to pathology, we’d prefer they not mix us up with other patients.

NPSGs have two things in common with the Ten Commandments. First, as NBC’s Ted Koppel has noted, “What Moses brought down from Mt. Sinai were not the Ten Suggestions.” Anyone who has had their feet held to the fire of a Joint Commission Survey understands that the goals are more than suggestions.

Second, TJC’s first goal is a granular application of “Thou shalt not kill” and “Thou shalt not steal” — perhaps our favorite commandments we want our neighbors to keep so they don’t take our lives or rob us of our health.

TJC explains, “The Goals highlight problematic areas in healthcare and describe evidence and expert-based solutions to these problems.”

While patients should be encouraged by the first NPSG, we also have reason to be troubled that it has been the number-one goal for 8 years running — not goal two or seven but number one. Former Secretary of State, John Foster Dulles’ 50-year-old advice comes to mind: “The measure of success is not whether you have a tough problem to deal with, but whether it’s the same problem you had last year.”

Recently, TJC announced that no new NPSGs will be developed for 2010, citing the fact that “the field is struggling to meet some of the current NPSGs” — not the least of which is improving positive-patient identification.

Elements of Performance
So what’s a hospital to do? For starters, give attention to the NPSG’s Elements of Performance against which hospitals are tested. Acceptable performance requires caregivers to use two patient identifiers “prior to any specimen collection, medication administration, transfusion, or treatment.” The two identifiers are to include examining patient wristbands, having patients state their names, and/or engaging family members when patients are unable to respond. The performance elements also clearly state that the “patient’s room number or physical location is not used as an identifier.”

A few years ago, a woman in a Falls Church, Virginia, hospital swapped beds with the other patient in her room so she could be nearer the window. A technician mistakenly took a blood sample from the roommate, resulting in the woman’s death after receiving the wrong type of blood during surgery (Associated Press, 2003).

In 2006, Health and Human Services adopted the National Quality Forum’s language when declaring that transfusion errors are “never events” — errors that should never happen (CMS, 2006). Thus, it is not surprising that the Elements of Performance for the first goal adds a layer of expectations for handling blood. Not only do transfusions require that two identifiers be used to accurately match the patient to the product but also that two qualified caregivers be involved in the identification process. TJC offers one caveat: “If two individuals are not available, an automated identification technology (for example, barcoding) may be used in place of one of the individuals.”

This is the first time that “barcoding” has been included in the goals. TJC had previously entertained including barcoding at the point of care (BPOC) when their Potential 2008 NPSGs called for hospitals to “investigate and initiate planning for the use of positive-ID technology.” However, the language was dropped before the final goals were released.

Three years earlier, the Proposed 2005 Goals were even more definitive, requiring hospitals to implement barcoding by January 1, 2007. Most of us felt this was too ambitious. But had the barcoding requirement made it into the final goals, we would be much closer to 100% BPOC adoption level rather than 24%, where we are at today. At the same time, we would have realized significant progress “to improve the accuracy of patient identification.”

It is arguable that nothing is having or could have a greater impact on helping hospitals conquer the first goal than BPOC technologies. Brigham and Women’s Hospital’s (BWH) Adverse Drug Event Prevention Study showed that because 61% of serious medication errors occur after the ordering stage, a more complete solution was needed to close serious gaps in the dispensing process and at points of administration. So the BWH implemented barcode-verification technology throughout the rest of the med-use process — from preparation to distribution, dispensing, and finally to all points of administration. The outcomes proved impressive: 1) Dispensing errors have been reduced by 85%, avoiding about 6,000 potential adverse-drug events per year; 2) 7,300 wrong drug/wrong patient administration errors are being intercepted per month.

As a result, BWH’s Director of Pharmacy Bill Churchill believes that “barcoding at the point of care is the single most important medication safety technology that will help us achieve the goal of declaring victory over medication errors.”

In reporting on the positive impact of barcoding on nursing care, Fran Turisco and Jared Rhoads (2008) remind us that medication administration is the last opportunity to catch errors created during the many steps of the medication use process. They add, “Any changes in this step to reduce errors will have an immediate impact on patient safety.”

One of my hospital clients, intent on complying with TJC’s first goal, is tackling a master plan that calls for applying barcode labeling and point-of-care verification scanning to:

  • All patients
  • Anything collected from patients (e.g., specimens, mother’s milk, blood, stem cells, vital signs, information, etc.)
  • Anything administered to patients (e.g., medications, IVs, chemo, TPNs, breast milk, blood, bone marrow, meals, etc.)
  • Any procedure performed with patients (radiation, diagnostic imaging, surgery, implants, physical therapy, etc.)

The hospital understands it’s not realistic to apply all BPOC measures at once, so it has prioritized and is sequencing implementations. Hospitals with less comprehensive plans are discovering that implementing any one BPOC application is a gateway activity. Once they realize the benefits, they soon find themselves eager to implement another.

Successful BPOC hospitals treat technology for what it is — a tool intended to assist but not replace their caregivers. Perhaps it is helpful to think of BPOC being to patient safety what traffic lights are to highway safety. Lights do not replace the need for alert drivers. Even when lights are green, safe drivers look both directions before proceeding through intersections. BPOC technology may make it less likely for caregivers to do the wrong things and more likely for them to do the right things, but it does not replace the need for users to be fully alert at all intersections of care.

BPOC hospitals must anticipate and mitigate work-arounds. The fine for blowing through a red light in California is $351 for a first-time offense and increases with each additional infraction, to say nothing of lives lost in accidents. The penalties for blowing through a BPOC stop may cost patients’ lives and/or caregivers’ careers — not to mention hospital fines and injured reputations in the community.

“While barcoding is the right technology,” says Churchill, “it needs to be used the right way.”

Wrong-patient errors are indeed a tough problem, but given the experience of hospitals that have implemented BPOC, caregivers and patients need not experience the same problems year after year. While it is not known if the next round of NPSGs will include BPOC, no one need wait to “improve the accuracy of patient identification.” Barcode technology is ready.

Mark Neuenschwander is president of The Neuenschwander Company and cofounder of The unSUMMIT for Bedside Barcoding. He may be contacted at


Associated Press. (2003, Augusts 30). Patient dies after getting wrong blood. Charleston Gazette.

CMS. (2006, May 18). Eliminating serious, preventable, and costly medical errors — never events. Available at

The Joint Commission. 2005 National Patient Safety Goals. Available at

The Joint Commission. Facts about the National Patient Safety Goals: Updates on activities for 2009. Available at

Turisco, F. & Rhoads, J. (2008, December). Equipped for efficiency: Improving nursing care through technology. Available at