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Chipping Away at Hospital Errors

Originally Published MPMN June 2004

EDITOR'S PAGE

Chipping Away at Hospital Errors

In 2002, a woman in St. Paul endured a double mastectomy to treat an aggressive form of breast cancer. Forty-eight hours later, her doctor told her that she had never had cancer at all. What was the cause of the misdiagnosis? A paperwork slip-up.

Last year, at Duke University Hospital, a 17-year-old girl was mistakenly given a heart and lungs that did not match her blood type. She later died, despite another transplant operation. 
This year in Sarasota, FL, physicians performed cardiac catheterization on the wrong person. Fortunately, the patient was not seriously harmed and went on to recover.

All of these incidents can be traced back to human error. And they are not isolated cases. According to a 1999 study by the Institute of Medicine, between 44,000 and 98,000 Americans die each year as a result of medical mistakes made while they are in the hospital. Countless others are harmed.

And the problem is not improving. A study of 36 hospitals in the Denver and Atlanta areas (Archives of Internal Medicine, September 9, 2002) revealed that medication errors were made in 19% of patient charts that were reviewed for discrepancies.

Clearly, hospitals and physicians have to do better. Fortunately, some medical device companies may have a solution. It's called radio-frequency identification (RFID). It is a technology that involves tags or chips that emit radio signals plus devices called readers that pick up the signal.

Precision Dynamics Corp., based in San Fernando, CA, offers the Smart Band RFID wristband system. It is a portable, dynamic database that carries patient information that can be updated during the patient's stay. 

According to the company, RFID helps to ensure that the "Five Rights of Medications Safety" are achieved. The product facilitates real-time confirmation of the right patient, right drug, right dose, right route, and right time. And unlike bar codes, RFID can be read through and around the human body, clothing, bed coverings, and nonmetallic materials. 

Innovision Research & Technology plc, based in the UK, also has an RFID technology. DataLabel tags measure less than 1 mm thick and can be embedded within devices of many sizes. They store all types of digitized data. 

"This technology offers enormous scope for preventing mistakes and minimizing costs [in the medical arena]," says the company's managing director Marc Borrett. "Not only could it help to prevent the reuse of single-use devices, but traceability of devices would become feasible. Devices used in particular procedures or with specific patients [could] be tracked and identified," he says.

Peter Provonost, MD, patient safety expert at Johns Hopkins Medical Institutions, champions the use of RFID. "If you think about it, that type of technology would improve patient safety and supply management." He goes on to say that it would ensure that the right patient is getting the right treatments and also that a new supply could be ordered immediately. 

Provonost emphasizes that standardization is critical in RFID in order to share information and to facilitate recordkeeping. And that's in the works. EPCglobal, a member-driven organization, is currently developing 
global standards. 

For more information about RFID, an introduction and basic overview of the technology and trends will be presented on Monday, June 14, during the MD&M East conference. Matt Ream, senior manager at RFID Systems, will talk about its role in medical device manufacturing and packaging. 

Susan Wallace, Managing Editor

Copyright ©2004 Medical Product Manufacturing News

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