Computerization can create safety hazards: a bar-coding near miss

Ann Intern Med. 2006 Apr 4;144(7):510-6. doi: 10.7326/0003-4819-144-7-200604040-00010.


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.

Publication types

  • Clinical Conference
  • Research Support, N.I.H., Extramural
  • Research Support, Non-U.S. Gov't
  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • Aged, 80 and over
  • Electronic Data Processing*
  • Hospitals, Teaching / standards
  • Humans
  • Male
  • Medical Records Systems, Computerized
  • Medication Errors* / prevention & control
  • Patient Care / standards*
  • Patient Identification Systems / methods*
  • Patient Identification Systems / standards*
  • United States