I already have the barcode on the ampoule, is it possible to improve this?
A large number of ampoules have always had a linear barcode.
But now, we have several medicines in barcoded vials. data matrix (two-dimensional barcode) and what do these barcodes add to us? They add the batch number and expiration date to the data we already have, as well as a very low error rate.
So far, we have only good news!
However, safety needs to be improved as we have high error rates compared to other industrial sectors.
In Brazil, we have some large companies that are adept at Six Sigma (is a set of practices originally developed by Motorola to systematically improve processes by eliminating defects:
- Consul (appliances)
- Braskem (chemical and petrochemical)
- Brahma (drinks)
- Gerdau (steel mill)
- Fiat (cars) among many others.
We can say that there are less than 3,4 errors per million procedures and/or products.
In the healthcare sector, we are still far from achieving a low rate, with 10% of cases resulting in an adverse event and 50% of these could be preventable. Corresponding to 5000 errors in every million, on the other hand, other industries are 1470 times more efficient.
Disregarding airlines, since there are 9000 lost luggage cases per million, almost twice as many errors as in the healthcare sector. Transporting luggage without errors does not seem as complex an activity as modern medicine.
Among the many strategies to achieve a level of safety is the duplication of controls, because in a hospital at the end of the process, the person administering the medication is not a robot, but a human being. Who suffers from stress, work overload, personal concerns and distractions like any other human being.
Let's go... if you've already warned someone once, tell them again, help them with more warnings so that they can keep their attention focused. For example, how many times have you made a mistake, gotten distracted while making coffee at home, or reversed the order of the process?
So, through effective barcode (CB) control on a hospital bed, we can conclude that everything is fine. However, this does not solve the whole problem.
If you have CB control at the patient's bedside, you can electronically check the correct medication, if the patient has a bracelet with CB, you can control the correct patient.
But, let's look at the 05 Right :
- Right medicine
- Right patient
- Correct route of administration
- Right moment
- Right dose
Would it help…
…the nurse reads the name of the medication correctly and without difficulty? That she be encouraged to read the patient’s name, so that the medication packaging is corrupted only where it is marked? Did this professional study for four long years to learn how to administer medication and not just beep at the CB?
… inform and advise on the medication packaging of the correct route and speed of administration?
… inform that the medication is High Surveillance (HAM)? Or that it can cause a fall and that the bed rail would have to be raised to avoid the fall (which is 3 times more likely than an adverse event)?
… should the medicine be diluted before being administered?
…indicate that the medicine may cause an allergic reaction?
…indicate that this medicine should not be chewed or crushed?
… indicate that the medication causes dizziness and warn that the patient should stay in bed for a longer period?
…should a certain medicine not be administered to women? Or should it not be administered during breastfeeding?
…indicate that a medication should be administered at a specific time?
All this information and alerts are lost when you decide that there is no need to be redundant. When you conclude that just the information about the correct medication with the barcode on the vial is enough.
The database that the Opuspac delivers free of charge to its customers, has 2000 registered medicines with 200 mini leaflets with alerts and warnings, which automatically prints on the back of the packaging that will be administered at the bedside, aiming at patient safety.
