1. Auto Identification: A Panacea for Patient safety
and Traceability in Healthcare
This paper was presented at IIHMR National conference on “Healthcare
in 2020: Opportunities and challenges before public health, hospital
and pharmaceutical”. Nov 11, 2006. by (Dr. Nitin Verma)
Healthcare is an industry in transition and as such is struggling to understand
the effective use of technology in supporting its future state. Patient safety
concerns, desired improve clinical outcome and regulatory requirements are
creating demand for more traceability in the Healthcare industry than ever before.
In July 2004, a shocking report revealed the fact that 195,000 people die in US
hospitals due to likely preventable errors. This number is nearly double and
alarmingly higher than the IOM (Institute of Medicine) report that claimed that
nearly 98000 people die in US Healthcare institutions due to medically
preventable errors. Most future improvements in health care may not come from
better medicine, but from improved systems engineering. Both Bar coding and
RFID technologies, neither "new" in the sense of being recent developments, are
vying for acceptance in the healthcare arena. Both of these technologies are
delivering traceability and improving the patient safety while actually enhancing
efficiency and profitability. They perform the similar function but using
significantly different approach.
This paper will document the
• Various aspects of patient life cycle where Bar coding/ RFID technology
are Contributing.
• Brief description of various automatic identification system used in
Healthcare
• RFID Overview

2. Contribution of Auto Identification Technologies in
Healthcare
Bar coding technology has existed and been widely used in many industries since
the mid- 1970's. Historically, bar coding has been viewed by the healthcare
industry as strictly a logistics tool, meant to organize and automate inventory
management. However, recent reports of the high rate of medical error and the
ever-increasing costs of healthcare delivery have begun to change this perception.
Now it seems, the use of bar codes has as much to do with safety and quality
assurance as it does with automation and cost containment. For the ease of
discussion this paper will divide the contribution of bar Coding in to Clinical and
Non Clinical Applications.
Clinical Applications
One of the paramount concerns of a hospitalized patient is to ensure that his five
(5) patient’s rights are met and well taken care. With the regulations requiring
pharmaceutical companies to incorporate bar coding onto drug labels, the onus
has shifted to hospitals to begin investing in the technology infrastructure. It will
help them to provide the desired patient safety and thus reduced medical errors.
The clinical application where bar coding has contributed significantly can be
discussed under the following
Medication Administration Verification
In a classical scenario, the physician writes a prescription either manually or eRX.
These orders are then sent to the pharmacy by
1. Interphase – in case of eRX using the integrated clinical information and
the Pharmacy information system.
2. Pneumatic tube and
3. Human career
The pharmacist then fills the orders and sends them back to the requesting
location. These orders are then placed either in the automated drug dispensing
devices or in patient bin on the medication cart. Many of the times the nurse
would meticulously follow the physician’s order. She will dispense the
medication and record it in patient’s medical record. However 20% of the time the
1
nurse makes a mistake according to a study conducted by the IOM. Although
using different methodologies two studies arrived at the similar figure, attributing
the cost of a single Adverse medical event in a hospitalized patient between
2,3
$2013-$2595. In a paperless hospital before dispensing medication, the nurse
would first scan her employee ID which has a bar code then enters the password
followed by scanning the patient’s wrist band containing bar code. The nurse

3. then scans the bar coded medication which automatically records the mediation
details in the patient’s medical record.
Blood Transfusion Verification
Blood transfusion errors have long been a source of concern for hospitals and
clinics. The blood-handling process at many healthcare facilities contains a
number of manual steps, which can introduce human error. The most common
occurrence of the error is the incorrect labeling of samples taken either by blood
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specialists or other staff. A study by Sharma et al has shown that nearly 80% of
blood transfusion errors are related to bedside errors or labeling errors, and that
blood bank errors account for approximately 13 % of errors. The primary cause of
labeling errors is either confusion or overwriting of the patient’s hospital ID
number. Within the blood bank, errors are caused by human factors, cross-
checking errors, and mistakes by staff that is performing multiple roles
simultaneously.
With the use of bar coding technology, the nurse enters the system by scanning
his or her name badge and entering a secure password. The nurse then scans the
patient’s wristband, and responds to a series of electronically displayed prompts,
scans the blood product, the blood product. This verifies the patient’s blood type,
the blood unit number, and expiration date. If all prompts are accurately executed,
the nurse is directed to start the blood transfusion. On the other hand if any of the
prompts are inaccurately executed (e.g., the patient’s wristband identification
number does not match the patient identification number on the blood product
bag), an alert is generated. Bedside bar coding systems used in transfusion have
resulted in 100 percent accurate patient identification and are recommended by
industry experts.
Laboratory specimen identification
Because the lab investigation guides the physician’s decision and care, they are
the most frequent investigation performed on a hospitalized patient. Collecting
blood specimen is akin to the blood transfusion not only in terms of process but
also the kind of errors occurs in both the process are almost similar. The physician
orders a test and the phlebotomist/Nurse verifies the physician’s order, identified
the patient, draws the sample and placed in the appropriate container and then
labels it. Then the specimen is transported to the lab via human career or
pneumatic tube. Using Bar Coding through the Specimen Identification system
can help healthcare institutions not only meeting the regulatory requirement
concerning the patient safety and reducing medical errors but also meeting their
own institution’s regulatory requirement.
Before a phlebotomist begins hi sward round for collection of specimen,
collection list information which gets transmitted to the Lab Information System
(LIS) by the Clinical Information System (CIS) is downloaded to a hand-held bar
code reading terminal that stores each patient’s name, hospital number, lab

4. accession number, and test order. While in the patient’s room to make the draw,
the phlebotomist scans the patient’s bar-coded ID wristband to verify identity and
test order match. Once back in the lab, the phlebotomist uploads the information
from the terminal to the LIS, giving the lab accurate collection data that includes
positive patient ID, phlebotomist ID, time of collection, and time of receipt in the
lab. This information is finally sent back to the CIS. Errors and processing time
both are minimized simultaneously and patient safety is enhanced.
Respiratory therapy
Respiration therapy is again akin to the medication ordering, where physician
writes a prescription. This prescription goes to the pharmacy either via interphase
between pharmacy information systems or through the human carrier. The
pharmacist fills the order and sends it back to the requesting location. The
workflow of a therapist usually includes delivering medications to a number of
patients in a defined geographical region of the hospital. The patient that are
assigned to a therapist may have several medication prescribed. The registered
respiratory therapist carries these medications with them when they begin their
round. It is not unusual for a therapist to carry 15-20 different medication vials at
one time. It is like either inviting a problem or a an accident waiting to happen
“though it is preventable”
With the use of Bar Coding technology, the flow would be similar to the
Medication Administration Verification, where a respiratory therapist first scans
his employee ID bearing a bar code. Then the therapist scans the patient’s wrist
band. The scanning of patient’s wrist band displays the prescribed medication
order and the direction for use by the pharmacist. The therapist then confirms the
physician’s orders on his chart with the orders displayed on the Bar Code at Point
of Care (BPOC). Once the medication has been administered to the patient the
therapist confirms the transactions in the BPOC system which goes to various
ancillary departments like Billing etc.
Dietary Management
Bar coding is playing an important role even in the dietary management. Dietary
management system completely automates the three major functions performed in
the Dietary department of the hospital— maintenance of patient records,
manipulation of individual patient menus, and management of prescribed
nourishments/ supplements. A generous amount of statistical information is also
derived from the data maintained in the System and is made available for clinical
and management use
In a usual process of diet management, the physician’s recommended diet
requests goes to the kitchen either through a human career or an interphase
between the clinical information system and the Diet management system. These
orders gets printed, prepared in the hospital kitchen and there verified by the

5. dietician and then delivered to the patients. Considering a scenario of Dietary
Management in Hepatic Encephalopathy, where Protein restriction is part of
treatment with 20 g protein/day and, with clinical recovery, 10 g increments are
introduced every 3-5 days, as tolerated by the patient, to a limit of 0.8-1.0 g/kg
5
body weight . This is usually considered sufficient to achieve a positive nitrogen
balance. This practice continues despite evidence showing that patients with
stable cirrhosis have a higher protein requirement than normal. Now visualize a
case of Acute Hepatic Encephalopathy where increasing protein intake may
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worsen the condition in 35% of patients . Use of branched chain amino acids may
improve nitrogen balance but without producing any clinical improvement in the
encephalopathy. There are several scenarios where a tray can be exchanged
between two patients of same name, location etc and imagine how disastrous it
can be?
With Bar Coding and using a BPOC product, the chances of these kinds of errors
can be reduced significantly. With Bar coded food tray delivery, the attendant first
scan his/her employee ID badge bearing a bar code then enters a unique password
to enter the diet management system. The attendant scans the patient wrist band
bar code which enables the patient’s diet profile and the bar code from the tray.
Successful match prompt pops up when there is a complete match for the
attendant, patient and tray’s bar codes.
In Vitro Fertilization
In 20023, two proud and relieved parents, Mr. and Mrs. Andrews, saw their
newborn twins for the first time, conceived after 15 long year and difficult course
of IVF treatment. At last it all seemed worthwhile except the babies were of mixed
race, while both parents were white. It was a shock for them. They were
undergoing IVF Treatment at a very reputed infertility clinic in Chicago. The IVF
clinic blundered and used the wrong sperm to fertilize Mrs. A's eggs. The child's
biological father was Mr. B, a man the couple had never met and who with his
partner was also trying for a family using IVF.
All this happened in spite of “Double Witness” A mechanism where the clinical
Embryologist is required to ask a colleague to witness and document every
procedure in which an error can occur. But with more than 25-30- procedure
during each round of IVF make it very labor intensive and still leave the room for
human error. Similar accidents have happened in the UK, Netherlands and rest of
the globe.
With use of RFID, the procedure can become almost full proof. The sperm and
related eggs are tagged with RFID a tag ensuring the resulting embryo is
transferred to the correct mother. If Clinical embryologist/lab personnel try to use
the wrong samples by bringing sperm and eggs from different couples into the

6. same work area, for example, the system automatically sounds an audio and
visual alarm thus eliminating the human error.
Non-Clinical Applications
Tracking
Any article in hospital setting that can be identified using numeric or alpha
numeric codes can be tracked using bar code technology. Bar coding is currently
used in the tracking of material management, Central Sterile Service Department
(CSSD), Medical Record Department (MRD) and clinically in the areas of
Pharmacy, Laboratory and Radiology. However the technology is entering in to
new areas everyday to improve patient safety and efficiency.
Validation
Is the cognitive process of establishing the truth about anything. In Healthcare it is
an effective method of ensuring quality and patient safety. It ensures that a
process has been completed or can be completed because required supply/drug etc
is available in stock. The most important function of validation in hospital is to
ensure that the patient being treated is in fact the right patient. Similarly the
medication being administered or is yet to be administered is the right medication
and that too at the right time in right dose.
Inventory Control
Healthcare institutions across the globe are struggling to perform a tedious
activity of Inventory Control. Whether it is surgical, medical or supply for lab,
radiology or pharmacy, the inventory is always managed in a combination of
centralized and decentralized fashion. The consumable inventory is maintained at
decentralized locations in OPD/Wards/Theatres and then at the central location to
support these decentralized locations. Bar coding and RFID is helping, not only in
supervising the utilization structure of a supply and thus lowering the inventory
level at a decentralized location which has much higher inventory than its
consumption but also helps in managing these diffused consumable supply.
As Hodge explains, "A hospital that has 500 beds might have 95 IV pumps. Those
pumps have to go through preventive maintenance every 6 months. If you ask
them where all their IV pumps are, 50% of the time they won't know where 30%
of the pumps are. They won't know when the last time they were maintained. If
they're not maintained, when they go to use them and the readings are not
correct, it could potentially hurt a patient." 7

7. Automatic Identification systems
Barcode Systems
The technology of creating and reading these "zebra stripes" have held their own
against other identification systems in past 20 years. The barcode is a binary code
comprising a line and spaces arranged in a parallel configuration. They are
arranged according to a predetermined pattern and represent data elements that
refer to an associated symbol. The sequence, made up of wide and narrow lines
and spaces can be interpreted numerically and alphanumerically. It is read by
optical laser scanning, i.e. by the different reflection of a laser beam from the
black bars and white gaps. However, despite being identical in their physical
design, there are considerable differences between the code layouts in the
approximately ten different barcode types currently in use:
Optical Character Recognition
Optical character recognition, usually abbreviated to OCR, involves computer
software designed to translate images of typewritten text (usually captured by a
scanner) into machine-editable text, or to translate pictures of characters into a
standard encoding scheme representing them in ASCII or Unicode. OCR began
as a field in artificial intelligence.
Biometric procedure
Biometric is defined as the science of counting and (body) measurement
procedure involving living beings. In the context of identification systems,
biometry is the general term for all procedures that identify people by comparing
unmistakable and individual physical characteristics. Biometric procedures most
common in use are voice identification, finger printing and hand printing and less
commonly retina or iris identification
Voice Identification: With rapid advancement in healthcare technology,
voice identification in user identification is gaining acceptance. The
sophisticated equipment converts the spoken words in to digital signals for
evaluation by the identification software.
Finger printing procedure (Dactyloscopy): The most mature, most
widely accepted and therefore most often used biometric technology is
fingerprint recognition. In the healthcare environment fingerprint
biometrics is used to protect the security and confidentiality of electronic
health information, control and manage physical access rights to
authorized rooms etc

8. Smart Card
A Smart Card is a credit sized plastic card with a special type of integrated chip
embedded in it. The integrated chip holds information in electronic form. They
are 'smart' because they control who accesses this information and how i.e. read
only, update
Memory cards
In memory cards the memory component is called EEPROM, which is accessed
using a sequential logic. It can also incorporates the security algorithms i.e.
stream ciphering.
Microprocessor cards
They contain a microprocessor which is connected to a segmented memory as the
name suggests. They are primarily used in security sensitive application
RFID Overview
RFID systems are closely related to smart cards, where data is stored on an
electronic data carrying device - the transponder. However unlike the smart cards,
the power supply to the data carrying device and the data exchange between the
data carrying device and the reader are achieved using magnetic and electro
magnetic fields.
What is RFID?
RFID (Radio Frequency Identification) is a method of identifying unique items
using radio waves. Typical RFID systems are made up of 2 major components:
transponder or the tag and the interrogator or the reader. The tags are usually
applied to items, often as part of an adhesive bar code label. Tags can also be
included in more durable enclosures and in ID cards or wrist bands. The
interrogator or reader can be standalone unit or integrated with a mobile computer
for handheld use.
How RFID Works
RFID systems works according to one of two basic procedures: full duple
(FDX)/half duplex (HDX) systems and sequential systems (SEQ).
In FDX and HDX system the transponder’s response is broadcast when the
reader’ RF field is switched on. Because the transponder’s signal to the receiver
antenna can be extremely week in comparison with the signals from the reader
itself, appropriate transmission policies must be used to differentiate

9. transponder’s signal from that of the reader. In practice the data transfer from
transponder to reader takes place using load modulation.
In contrast, sequential procedure employs a system whereby the fields from the
reader is switched off briefly at regular interval. These gaps are recognized by the
transponders and used for sending data from the transponder to the reader
Various features of RFID
Feature Attribute
Operation Type FDX SEQ
Data Quantity > 1 bit 1 bit EAS
Programmable Yes No
Data Carrier’s IC SAW
Operating
Principle
Sequence State Machine µP
Power Supply Battery Passive
Frequency range LF RF Microwave
Data Transfer, Sub harmonic Back scatter/Load Other
Transponder→ modulation
reader
Response 1/n-fold 1:1 Various
Frequency
One very important feature of RFID system is the power supply to the
transponder. Passive transponder does not have their own power supply, and
therefore all power required for the operation of a passive transponder must be
drawn from the (electrical/magnetic) field of the reader. In contrast, Active
transponder incorporates a battery which supply all or part of a power the power
for the operation. Another important characteristic of the RFID systems is the
operating frequency and the resulting range of the system. The different
transmission frequency is classified in to three basic ranges. Low Frequency
(125/134 KHz) – LF: Most commonly used for access control, and asset tracking.
High Frequency (13.56 MHz) – HF: Used where medium data rate and read
ranges are required. Ultra High Frequency (850 MHz to 950 MHz and 2.4 GHz
to 2.5 GHz) – UHF: Offers the longest read ranges and high reading speeds.
A further subdivision of RFID systems according to range allows to differentiate
between close coupling (0-1cm), remote coupling (0-1m), and long range (>1m)
systems. The different procedure for sending data from transponder back to the
reader can be classified in to three (3) groups:

10. 1. the use of reflection or backscatter (the frequency of the reflected wave
corresponds with the transmission frequency of the reader → frequency
ratio 1:1)
2. Load modulation (the reader’s field is influenced by the transponder →
frequency ratio 1:1)
3. The use of subharmonics (1/n fold) and the generation of harmonic waves
(n-fold) in the transponder.

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Safer Health System. National Academy Press. Washington, DC. 1999.
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patients: Excess length of stay, extra cost and attributal mortality. JAMA 1997,
277. 310-306.
3. 3. Bates DW; Spell N; Cullen DJ; et al The cost of adverse events in hospitalized
patients. JAMA 1997, 277. 307-
4. 1R.R. Sharma, S.Kumar, and S.K. Agnihotri. “Sources of Preventable Errors
Related to Transfusion.” Vox Sanguinis 2001 81, 37-41.
5. Andres T. Hepatic encephalopathy. In: Bircher J, Benhamou P, McIntyre N,
Rizzeto M, Rodés J, eds. Oxford textbook of clinical hepatology. 2nd ed. Oxford:
Oxford University Press, 1999:765-783
6. Riordan SM, Williams R. Treatment of hepatic encephalopathy. N Engl J Med
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7. Automatic Identification, By Judith M. Inglesby, RN MN; Tom Inglesby
(http://www.psqh.com/sepoct05/barcodingrfid2.html )