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FDA may require bar codes on all medications
AHRQ announces two online patient safety resources
Thirteen dead in Connecticut nursing home fire

Patient Safety Monitor Alert, March 11, 2003

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FDA MAY REQUIRE BAR CODES ON ALL MEDICATIONS

Health care staff intrigued by the nifty bar-coded medication systems some hospitals use to reduce medical errors may soon use the technology at their own organizations. The Food and Drug Administration (FDA) plans to require bar codes on every dispensed drug, Tommy G. Thompson, secretary of the Department of Health and Human Services said at a press breakfast last week, according to the Washington Post.

The system allows a nurse to match the bar-coded prescription label to a similar code on a patient's wrist band. A computer then alerts the nurse if the drug or dosage doesn't match the patient. "Nurses [will be able to] go home at night and feel so much more comfortable that they didn't give anything in error," said Michael Cohen, president of the Institute for Safe Medication Practices.

The bar-coding requirement will have to go through a period of public comment before it's fully implemented. Officials told the Post they plan to release further details of the proposed rule this week.

AHRQ LAUNCHES TWO ONLINE PATIENT SAFETY RESOURCES

Looking for evidence-based quality measures? Check out the Agency for Healthcare Research and Quality's (AHRQ) National Quality Measures Clearinghouse, a new Web site that allows you to search for measures by disease, treatment, age range, gender, and a variety of other topics. The clearinghouse also allows you to compare different measures side by side so you can determine which will best work for your organization, according to a press release from AHRQ. The organization will eventually incorporate the clearinghouse into a larger Web site.

Go to www.qualitymeasures.ahrq.gov to find the NQMC. Have measures other health care organizations may find useful? You can submit measures that meet the criteria found at www.qualitymeasures.ahrq.gov/contact/coninclusion.aspx to the AHRQ for consideration.

AHRQ also recently launched a Web-based, peer-reviewed medical journal. The new "AHRQ WebM&M (Morbidity and Mortality Rounds on the Web) will illustrate patient safety lessons learned from actual medical errors. Go to http://webmm.ahrq.gov to check out the journal.

THIRTEEN DEAD IN CONNECTICUT NURSING HOME FIRE

The death toll in the Feb. 26 Hartford, CT nursing home fire has risen to 13 people, the Associated Press (AP) reported earlier this week. Ten patients were initially killed in the blaze, and now three of the 23 people sent to the hospital for treatment have died.

A 23-year-old mentally ill patient told police that she started the fire at the Greenwood Health Center while "lying in bed and flicking a lighter," but authorities have not yet determined whether it was an accident or arson, according to the wire service.

During a later hearing to examine the issues surrounding the case, Senator Edith Prague (D) told the state's Select Committee on Aging that she will again seek legislation to separate psychiatric patients from the less-mobile elderly, the AP reported. Also during the hearing, the state's chief attorney criticized fire laws that exempted the nursing facility from sprinkler requirements, and others called for mandatory sprinkler legislation.

The facility, built in 1969, met all fire codes, according to an inspection. Although the facility had installed sprinklers in rooms containing oxygen tanks, none were required in the rest of the facility.

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