Advocacy White Paper
Bar Coding for Patient Safety
The Institute of Medicine’s Quality Chasm report has crystallized attention on the human and
economic cost of medical errors. Causes and thus remediation of medical errors is complex.
Elimination of reliance on oral and handwritten communication along with minimizing transcription,
translation, and interpretation are common elements of remediation.
Bar codes to enable self, or auto identification of medical items, patients, and staff are integral to
many of solutions to the medical errors problem. In August 2001, the Federation of American
Hospitals (FAH) announced their resolution on patient safety and reduction of medical errors that
included a specific call for standardized machine readable bar coding on single unit dose packaging.
The National Coordinating Council for Medication Error Reporting (NCCMERP) and the
American Society of Health-System Pharmacists (ASHP) publicly called for the FDA to mandate
bar codes down to the immediate unit-of-use package on all medication packages. In May, HHS
Secretary Tommy Thompson testified to the benefits of bar coding as a “simple technology …
everyone has seen at the grocery store.” His estimate of the benefit from broad use of bar coding
was $11 billion dollars in supply chain costs alone.
With apparent consensus on a shared vision for the use of bar coding in health care, it’s worth
considering why this “simple technology” that has been part of everyday life for nearly four decades
has not already become commonplace in health care. In fact, bar coding is quite common in health
care materials management. It is at the point of care that bar coding is rarely used.
The lack of everyday point of care use of bar codes is a chicken-and-egg problem. Manufacturers
are not labeling (each) units-of-use with bar codes because they are not required to do so by
regulation or market forces. Health care software vendors haven’t built point-of-care bar c