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Director of Pharmacy
James C Garrelts
Manager, Clinical Pharmacy Services
Wesley Medical Center
Medication errors and adverse drug events (ADEs) have received a great deal of attention in recent years, following the 1999 Institute of Medicine report entitled To Err is Human: Building a Safer Healthcare System. Leape and associates(1) carefully evaluated 334 medication errors, finding that 39% were related to problems with prescribing and 38% involved medication administration at the bedside. While pharmacists and nurses caught about half of the ordering errors before they reached the patient, only 2% of errors involving administration were caught. Thus, medication administration is the most dangerous part of the medication use cycle.
Barker et al(2) evaluated medication errors using the observation method in 36 facilities of varying size. They found that 19% of doses were administered in error. Omission errors accounted for 30% of all errors, wrong dose for 17% and unauthorised drug for 4%. A physician panel judged that 7% of the errors represented potential ADEs. Thus it is clear that medication administration errors occur frequently and put patients at risk for ADEs.
Recently, barcode technology at the point of care (BPOC) has been utilised to reduce medication administration errors. BPOC requires that the nurse scan a barcode on the patients wristband to establish patient identification, followed by a scan of the medication barcode to verify that the correct medication is being administered to that patient at the right time. Because each dose of medication must have a useable barcode, the pharmacy department can utilise the barcode to minimise the risk of medication dispensing errors. A barrier to BPOC is that only 30–50% of medication doses have a useable barcode when received from the manufacturer. Therefore, the pharmacy must often incorporate a barcode in order to support the important safety advantages of BPOC.
BPOC systems are not yet widely used, although acceptance appears to be increasing in the USA. A survey of 500 US hospitals in 2002 found that only 1.5% utilised BPOC.(3) By 2004, BPOC was being used in 4.4% of hospitals, and this percentage increased to 9.4% in 2005 (16% in hospitals over 100 beds).(4,5)
Barcodes have been utilised in hospital pharmacy for quite some time, although usually in a limited role.(6–12) Meyer and coworkers(12) found an absolute time-saving of 1.52 seconds per dose for dispensing activities using a barcode system. Brigham and Women’s Hospital recently reported that utilisation of barcode scanning reduced pharmacy dispensing errors by 84%.(13) Ragan and colleagues(14) found a 96% reduction in pharmacy dispensing errors. This was coupled with a 20% time-savings when retrieving doses to be dispensed, from 0.61 to 0.49 minutes per retrieval. Other benefits accrued from using a barcode system included a reduction in the amount of time spent creating a daily pharmacy resupply order (from four hours to one hour) and a 7% improvement in inventory turnover (from 10.8 to 11.5 inventory turns). The number of times that the pharmacy experienced a stock-out and had to obtain a medication urgently fell from 16 to four times per month.
One of the biggest challenges facing pharmacy when considering implementation of a barcode system is the lack of manufacturer barcoding on products.(15) Because fewer than 50% of products are available in unit-dose form with a barcode, pharmacy departments must be able to repackage and incorporate a useable barcode. This commitment requires allocation of pharmacy technician time, along with availability of packaging and labelling equipment. A variety of options are available for packaging and inclusion of a barcode with the product. Some of the options include outsourcing, overwrapping, applying an extemporaneous barcode label and printing a barcode on the patient-identifying label. In many instances, a combination of packaging options will be the best solution.
It is important to realise that not all barcodes will be useable in a BPOC system. In the USA, manufacturer- provided barcodes have generally been based on the National Drug Code (NDC). Because multiple NDC formats have been permitted, there has been no standardisation of barcodes used on the NDC. Another frequently encountered issue is that the pharmacy often purchases a product from more than one supplier, based on availability. For instance, generic acetaminophen 325mg tablets may be purchased from supplier A for the first six months of the year. Based on inability to supply or because of an increase in price, the pharmacy may switch from supplier A to supplier B for the final six months of the year. Despite being the same generic product, suppliers A and B will each use a different NDC and barcode. The pharmacy must develop a method to identify and link both acetaminophen products for use in the BPOC system. Development of a unique identifier will also facilitate communication among other systems used in the pharmacy (eg, pharmacy information system, unit-dose packaging equipment, unit-based drug dispensing cabinets, drug wholesaler software or dispensing robot). Resources are available for a more detailed discussion of these issues.(14,15)
Several hospitals have described the benefits of BPOC. Puckett(16) reported a 71% reduction in reported medication errors following implementation of BPOC. The most frequently reduced errors were omitted doses (52%), wrong time (43%) and wrong drug being administered (33%). Coupling BPOC with an electronic medication administration record (eMAR) reduced nursing work, improved communication and scheduling of doses between pharmacy and nursing, and provided more accurate and timely billing. Thielke(17) implemented BPOC in a 28-bed haematology unit. Using the observation method, medication errors were reduced by 87%, with estimates that 11,518 errors per year were eliminated in this single unit. A survey also showed a 42% improvement in nurse satisfaction following implementation of the BPOC system. Larrabee and Brown(18) reported that their BPOC system detected and prevented approximately 100 medication errors (eg, “near misses”) for every error that would have occurred and been voluntarily reported prior to BPOC. Anderson and Wittwer(19) also found that BPOC greatly increased detection and prevention of “near miss” errors. They found a 44% decrease in medication errors, even though BPOC was only implemented in some parts of their hospital. Recently, BPOC has been shown to be feasible in small hospitals. Lawton and Shields(20) found that for all “near miss” medication errors detected and prevented, the most frequent categories were wrong dose (48%), no medication order (15%), wrong patient (15%) and wrong dosage form (11%). They estimated that the prevented errors could save an estimated $168,660 annually. Wright and Katz(21) reported that BPOC reduced medication errors by over 50% (preventing approximately 20 ADEs per day) in a large hospital setting that already utilised computerised prescriber order entry (CPOE). Sakowski and colleagues(22) evaluated a BPOC system in nine health-system hospitals. During a four-day sample period, they found documentation of 187 “near miss” errors prevented (1.1% of all scans). In an additional 477 instances, the clinician overrode a warning and continued with administration, resulting in a medication error. Finally, the Veterans Affairs system has been a leader in BPOC, reporting substantial reductions in both pharmacy dispensing and medication administration errors.(23)
With the advent of BPOC, some are now asking why profile-driven unit-based drug dispensing cabinets (DDCs) and robot technologies are needed. Why can’t medications be sent to nursing in “bushel baskets” and then let BPOC make sure that the correct medication is given to the patient? We are concerned about these reports because we believe that safeguards are needed at every step of the medication use process to reduce the occurrence of medication errors effectively.
That is why we offer a suite of products in our hospital, including profile-driven DDCs and BPOC, to reduce the chance of error as well as to increase efficiency and effectiveness at every step of the medication use process (ordering, transcription/order entry, preparation/dispensing and administration/documentation).
Medication administration remains the highest risk step in the medication use process. While there are many challenges to be addressed, institution of BPOC has been shown to produce substantial reductions in medication error rates.