Cedars-Sinai Study Finds ICU Nurses + Barcode Scanners Help Prevent Potential Patient Harm

A new study published in The Joint Commission Journal on Quality and Patient Safety (JQPS) finds that bedside nurses, often supported by barcode medication scanning technology, are a critical line of defense in preventing potential patient harm from near-miss events in intensive care units (ICUs).

Researchers at Cedars-Sinai in Los Angeles analyzed 288 near misses reported in 2024 from inpatient critical care units across the health system. Near misses are incidents that have the potential to cause harm but do not actually reach the patient. Although they are often underreported, they occur more frequently than actual harm events and provide a rich source of information about vulnerabilities in care.

Lead author Tara Cohen, PhD, a research scientist and associate professor in the Jim and Eleanor Randall Department of Surgery at Cedars-Sinai, said, “Nurses’ actions included following up on irregular orders, conducting routine medication safety checks and facilitating communication among care teams. Their clinical judgment, experience and adherence to safety routines were instrumental in identifying potential threats before they reached patients.”

Study Findings

Using a human factors approach, the investigators mapped out 396 contributing factors associated with the near-miss events and examined which safeguards ultimately intercepted them. Nurses were the most frequent source of intervention, accounting for 41% of near-miss recoveries.

“Patient safety is of the utmost importance to our team,” said Cristina R. Ferrone, MD, chair of the Department of Surgery at Cedars-Sinai. She emphasized that systematically studying near-miss situations is essential to understanding how to prevent similar events from escalating into actual harm and to maintaining high standards of care.

Technology also played an important supporting role. Barcode medication scanners were involved in 31% of interventions and helped catch issues such as an incorrect drug, dose, or patient before administration. Equipment or machines accounted for 1% of interventions, while in 15% of near-miss cases, the specific source of the successful intervention could not be identified.

Leadership Reacts

Leaders at The Joint Commission, which publishes JQPS, praised the work as an example of how health systems can learn from events that never result in actual harm but reveal systemic weaknesses. 

Elizabeth Mort, MD, MPH, vice president and chief medical officer at The Joint Commission and editor-in-chief of the journal, noted that nursing “stands at the heart of patient care” and that nurses’ presence at the bedside, combined with the adoption of technologies like barcode scanning, is integral to quality and safety. She said that understanding how both staff and technology function as safeguards allows health care leaders to design stronger, more resilient systems.

Cedars-Sinai President and CEO Peter L. Slavin, MD, said the findings underscore the importance of empowering frontline professionals—particularly nurses—to speak up, question, and intervene whenever they identify potential risk. He also highlighted the role of tools such as barcode scanning in closing safety gaps and supporting teams in preventing adverse events before they occur.

The study’s authors and institutional leaders framed near-miss reporting and analysis as a cornerstone of continuous quality improvement. By closely examining what goes wrong—and how it is caught in time—health systems can inspire new technology solutions, refine workflows, and build safer, more resilient care environments for patients in ICUs and beyond.

🤔Nurses, does your hospital use medication barcode scanning? Share your thoughts below. 

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