Medication dispensing errors and potential adverse drug events before and after implementing bar code technology in the pharmacy

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Poon EG, Cina JL, Churchill W, Patel N, Featherstone E, Rothschild JM, Keohane CA, Whittemore AD, Bates DW, Gandhi TK.

As stated by Poon and colleagues medication errors in hospitals are common, and dispensing errors made in the pharmacy contribute considerably to these errors. Because only one third of the dispensing errors are intercepted by nurses before medication administration, it is important to improve the dispensing process in the pharmacy to reduce such errors in the first place. According to authors bar code technology could be used as effective in preventing dispensing errors in the pharmacy of the hospital.

A study was conducted in hospital pharmacy which included a pre-barcode evaluation and a post-barcode evaluation of pharmacy’s dispensing error output. The results of this study clearly states that overall, the rates of target potential ADEs and all potential ADEs decreased by 74% and 63%, respectively. Of the 3 configurations of bar code technology studied, the 2 configurations that required staff to scan all doses had a 93% to 96% relative reduction in the incidence of target dispensing errors and 86% to 97% relative reduction in the incidence of potential ADEs. However, the configuration that did not require scanning of every dose had only a 60% relative reduction in the incidence of target dispensing errors and an increased (by 2.4-fold) incidence of target potential ADEs. There were several potentially life-threatening ADEs involving intravenous dopamine and intravenous heparin in that configuration.

In conclusion Poon and colleagues outlined two policy implications of their study’s results. First, the results affirm the decision by the FDA to require that all medications used in the hospital setting have a bar code at the unit dose level. This requirement may reduce the need for smaller hospitals to build their own medication repackaging centers. Second, the findings of the study are an example of how particular configurations of Health Information Technology seem to substantially improve patient safety, and they lend support to the recent investment in HIT at the regional and federal levels.

Nick Nepochatov