@article{10407,
  author = {Clement J. McDonald},
  title = {Computerization can create safety hazards: a bar-coding near miss.},
  abstract = {<p>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.</p>},
  year = {2006},
  journal = {Ann Intern Med},
  volume = {144},
  pages = {510-6},
  month = {04/2006},
  issn = {1539-3704},
  language = {eng},
}