Patient death tied to lack of proper escalation process for barcode scanning failures.

https://psnet.ahrq.gov/issue/patient-death-tied-lack-proper-escalation-process-barcode-scanning-failures Lack of experience with distinct processes and products can lay the foundation for mistakes. This article examines an instance when a colonoscopy preparation product was switched with a dialysis fluid, a barcoding system didn’t recognize the substitution, and a patient died. Barcode identification, solution availability and staffing improvements are discussed to minimize opportunities for the systemic failures contributing to harm.