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Published on 1 September 2004

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Improving patient safety through automation


Christopher Thomsen
The Thomsen Group Inc
MedAccuracy LLC
The Thomsen Group Inc
Kansas City, MO

Since the 1960s, numerous studies have been conducted that provide irrefutable evidence that human beings make mistakes. The scope and magnitude of medication errors have been thoroughly recorded, analysed and published by leading research teams and support the fact that medication errors happen every day in every healthcare institution. In 1982, the American Journal of Hospital Pharmacy published a report measuring medication errors in nursing homes and small hospitals.(1) At that time, evidence gathered since the 1960s in hospitals in the USA, the UK and Canada depicted a medication error rate in hospitals of approximately one error per patient per day, excluding wrong-time errors. Up to that point, almost none of the information gained about medical and medication errors was shared with the general public, but a report in the Archives of Internal Medicine in 1996 indicated that patients were concerned and were becoming increasingly aware of their right to obtain and review their healthcare records. The report noted that 98% of all patients wanted to know when even a minor error was committed.

In 1999 the Institute of Medicine (IOM) publicly released the shocking yet important report “To err is human: building a safe health system”(2) and intensified the emphasis on the occurrence, clinical consequences and cost of adverse drug events (ADEs) in hospitals. For the first time, the IOM report shared the intimate details of the US healthcare system and noted that medication errors account for one out of 854 inpatient deaths and one out of 131 outpatient deaths. The Wall Street Journal brought additional attention to this matter when, in 2002, it published a research project depicting a medication error rate of 19% in a study conducted at 36 hospitals and skilled-nursing facilities.(3) Finally, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) recently reported that, of the 2,552 sentinel events reviewed by the commission since January 1995, medication errors (291, or 11.1% of the total) are in fourth place (out of 20) behind patient suicide (382 events), op/postop complication (330 events) and wrong-site surgery (310 events).

Causes for medication errors
According to the Institute for Safe Medication Practices (ISMP), medication errors are seldom the result of a single, isolated human error(4) and result from multiple small breakdowns in the systems for handling drugs. Such systems cross all professional boundaries and include patients themselves. For example, medication errors occur when patients neglect to tell their caregiver about all of the medications they take, including herbal remedies, over-the-counter drugs and nutritional supplements. In 1994, Betsy Allan Flynn noted that dispensing errors dramatically increase every half-hour as workload increases.(5) A study led by Lucian Leape and published in 1995 reported that 61% of ADEs occurred after the prescription order was written – that is, during the medication delivery and administration processes.(6) Conversely, 39% of the ADEs detected in the study were due to prescribing errors that occurred either in the pharmacy or in the physician’s office. This information tends to confirm the findings of the IOM 1999 report that called for systematic approaches to the prevention of medication errors and certainly compels one to suggest that technology and automation might help address and reduce medication errors.

Humans versus automation
Every year, billions of prescriptions are dispensed to patients in our hospitals and from our community pharmacies, and there is still no relief in sight in terms of the worldwide shortage of pharmacists. However, if we agree with the premise that “to err is human”, then adding more pharmacy staff is not necessarily the answer. David Watkinson (Watkinson Pharma Consultancy, UK) noted that while automation does not necessarily reduce process costs, it is likely to be the key to many future improvements.(7) If pharmacy does turn to automation for help, then we must ask at least two questions: “Where do we begin?” and “Can technology help reduce medication errors?”

Electronic prescribing
For nearly a decade, we have politely argued that the most critical point of the dispensing process is getting the prescription from the physician’s office correctly and legibly to the pharmacy, and to accomplish this task, computerised physician order entry (CPOE) seemed to be the most logical solution. The only problem is that, while it makes sense in terms of efficiency and safety, few doctors are prescribing electronically or using “true e-prescribing solutions” because so many prescriptions they write on handhelds are not electronically transmitted to pharmacies. However, recent figures indicate that less than 10% of practising US physicians write and transmit prescriptions electronically and that many prefer to print for the patient or fax directly to the pharmacy. In addition, while CPOE also makes sense in terms of patient safety, it is not infallible. Although CPOEs are designed to reduce errors due to poor handwriting, there are reports that new errors have been introduced because of physicians hitting the wrong key. Even so, handwriting-induced errors far outnumber “wrong key” errors.

Simple technology
Even the simplest technology can yield significant results. A 1991 a study on the illumination in pharmacies revealed that dispensing errors rates fell from 3.7% to 2.6% when illumination was increased from 102 to 146 foot-candles.(8) In addition, 66% of content errors are associated with tightly packed shelving.

Automated workflow systems
Robotic systems have been utilised extensively in  inpatient and outpatient pharmacies in the USA and in Europe to pick, count, label and dispense unit-of-use (patient packs), bulk oral solids, boxes, bottles or injectables for more than a decade. While we continue to debate over which business model is the best (centralised or decentralised), there really is no right or wrong answer so long as the technology helps reduce labour and increase efficiency.

But, whether the pharmacy is selecting, preparing and transporting medications to the nurse’s station, ward or bedside cabinet, or to the patient at the pharmacy window, the most important feature of any automated system must be dispensing accuracy. For this very reason, hospital pharmacies are now trying to install automated workflow systems. By utilising barcode scanning, onscreen drug images and even biometrics, automated workflow systems can track and manage every drug and every step of the process. In 2003 a study carried out at Auburn University indicated that simple prescription technologies such as barcodes and onscreen drug images could reduce medication errors by one full percentage point.(9) In November 2003, a Thomsen Group market research study revealed that 56% of US hospital pharmacies were using some type of automated workflow system; 65% of the respondents not using an automated workflow system noted that they were planning to implement such a system within the next two years.

Barcodes and scanning
Wrigley’s first placed a barcode on a stick of Juicy Fruit gum in 1974, and 30 years later the US Food and Drug Administration (FDA) proposed a rule that would require barcode labels on all human drugs and biologicals. Only recently has healthcare realised that this kind of technology allows for the tracking of all medications, from manufacturer to pharmacy to patient, and that it will have a positive impact on the problem of medication errors.

Barcode scanning, which is a critical component in nearly every automated dispensing system, is now moving beyond the pharmacy and to the patient’s bed. Bedside scanning, utilising handheld barcode scanning systems and bar-coded wristbands, promises to ensure that patient and medication are correctly identified before administration commences. While still in the early stages of deployment, acceptance by US hospitals is a first step, and bedside scanning is moving forward at a rapid pace.

Nevertheless, according to Matt Grissinger, a medication safety analyst from the ISMP, the technology can only be accurate when it is used correctly. The biggest impediment to maximising the usefulness of technology is the human being, who tries to outsmart the technology – or to use the system in a way in which it was not intended to be used. “People can work around technology,” he said, offering an example from the hospital side: “Rather than scan patient barcodes one at a time when administering medications, some time-pressed nurses could remove armbands from 10 patients for scanning,” he explained. Using the technology this way, the opportunity for error reverts – almost – to pre-technology days. As important as having the right technology is having the pharmacists and technicians buy in and want to do the right thing.” In the end, there is no perfect technology solution. There is, however, a logical sequence of technology and automation that, when properly integrated, can provide operational improvements and increased patient safety.


  1. Barker KN, Mikeal RL, Pearson RE, et al. Am J Hosp Pharm 1982;39:987-91.
  2. Institute of Medicine. To err is human: building a safer health system. Washington (DC): National Academy Press; 1999.
  3. Barker KN, Flynn EA, Pepper GA, et al. Arch Intern Med 2002;162:1897-903.
  4. Institute for Safe Medication Practices. ISMP’s focus on cooperation. ISMP informational packet; 2003.
  5. Allan EL. Relationships among facility design variables and medication errors in a pharmacy [PhD dissertation]. Auburn (AL): Auburn University; 1994.
  6. Leape LL, Bates DW, Cullen DJ, et al. JAMA 1995;274:35-43.
  7. Pike H. Pharm J 2003:271:655.
  8. Buchanan TL, Barker KN, Gibson JT, et al. Am J Hosp Pharm 1991;48:2137-45.
  9. Flynn EA, Barker KN, Carnahan BJ. J Am Pharm Assoc 2003:43:191-200.

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