II. Dispensing Errors - Cause and Prevention
We have analyzed
dispensing errors in community and ambulatory pharmacies to
determine how systems can be applied to prevent them. We
have been engaged for some time in funding independent research
to find out how to absolutely minimize dispensing errors.
Some of these studies are soon to be published.
The most basic
dispensing errors are:
-
Prescription
filled with wrong drug.
-
Prescription
filled with wrong strength.
-
Wrong prescription
label or auxiliary labels omitted.
An insurance
company has reported that more than 80% of claims against
pharmacists in the community and ambulatory practice settings
arise from these basic mistakes. (Source: Baker, Kenneth R.,
Pharmacists Mutual Claims Study 1989-1997, Speech, National
Association of Chain Drug Stores.)
Automated dispensing
systems depend on drug product barcodes to prevent errors
in both robotic and manual prescription dispensing processes.
I will describe these processes below in some detail. Appendix
A depicts these processes in actual operation.
1. Most prescriptions
are filled using countable tablets and capsules. In robotic
dispensing of countable tablets and capsules, they are poured
into the robot’s dispensing cell and then automatically counted
out into prescription vials by the robot as needed.
a. When
refilling the dispensing cell, the barcode on the drug
product (stock bottle) is scanned and matched to the bar
code on the cell. A picture of the tablet or capsule is
displayed for further verification.
b. Prescriptions
are then transmitted to the robot and queued for dispensing.
c. The robot
verifies the barcode on the dispensing cell before it counts
out the drug.
d. Then
the robot counts the tablets or capsules into the vial.
e. Next
the robot prints and applies the prescription label. The
label contains a barcode, a picture of the drug, descriptive
information regarding the drug and auxiliary labels.
f. The operator
scans the label barcode and the system displays an image
of the drug for final verification by a pharmacist.
There are
more than 2,000 systems of this type in use today. Pharmacists
using these systems have claimed that it is almost impossible
to dispense the wrong drug or strength, or attach the wrong
label.
“I could
tell immediately that with the barcode technology, the
SP 200 would improve our error rate. The time-saving features
of the ScriptPro system are evident as well.”
President, Brewton Medical Center Pharmacy,
Brewton, AL
With bar
code scanning, the SP 200 is virtually foolproof. It is
extremely accurate on making sure the patient gets the right
drug.”
Director of Pharmacy, San Joaquin General
Hospital, French Camp, CA
2. Prescriptions
that are not filled using countable tablets and capsules
are typically filled using prepackaged items such as inhalers,
birth control packs, etc. These are often called "unit-of-use
medications" or "patient packs." In robotic
dispensing of patient packs, they are presented to the robot
and automatically stored. They are then picked by the robot
for dispensing as needed.
a. When
presenting a patient pack to the robot for storage, the
barcode on the drug product (patient pack) is scanned. This identifies the drug to the robot so that it can be
stored and tracked automatically.
b. Prescriptions are then transmitted to the robot and queued
for dispensing.
c. The robot then picks the patient pack for dispensing.
d. The operator then scans the barcode on the patient
pack, again verifying its identification.
e. Next the robot prints the prescription label and presents
it to the operator for application to the patient pack. The label contains a barcode identifying the drug, a
picture of the drug, descriptive information regarding
the drug and auxiliary labels.
f. The operator scans the label barcode and the system
displays an image of the drug for final verification by
a pharmacist.
The robotic
systems described above support efficient and accurate dispensing
of most prescription drugs. There are also systems that
support the manual dispensing of prescriptions. These systems
use the barcode labels on drug products as well to prevent
basic dispensing errors.
3. For manual
dispensing, the prescriptions are queued on the screen at
a prescription filling station. The operator uses the station
to manually fill and label the prescriptions.
a. The screen
display shows the operator which prescriptions are to be
filled.
b. The operator fills a prescription by picking the required
drug product and scanning its barcode at the station. The filling is aborted unless the barcode scan confirms
that the correct drug product has been selected.
c. The station then prints the prescription label and presents
it to the operator for application to the drug product. The label contains a barcode, a picture of the drug, descriptive
information regarding the drug and auxiliary labels.
d. The operator scans the label barcode and the system
displays an image of the drug for final verification by
a pharmacist.
There are other
dispensing errors that can occur:
Wrong prescription
in bag provided to patient.
-
Wrong bag
provided to patient.
-
Failure
to provide all prescriptions.
-
Failure
to provide counseling to patient.
Again, bar
codes are used to prevent errors:
a. The station
prints a barcode label for the bag that is to be given
to the patient. This barcode is unique and associates
all prescriptions for the patient with the bag.
b. Barcodes on prescription labels are then matched to
the barcode on the bag. The bag is not considered complete
until all prescriptions for the patient have been scanned
and matched.
2. When providing
the bag to the patient.
a. Patient
presents card (or other document) with identifying barcode.
b. Scan of patient card prompts display of bag(s) to be
provided.
c. Bag labels are scanned for match to patient.
d. Patient is prompted to obtain counseling and sign for
receipt of prescription via electronic signature device.
These systems
prevent errors by controlling and tracking every step in the
dispensing process. They record every action, every drug
product and every person involved. Barcodes form the electronic
chain that holds the system together. The electronic chain
runs:
-
from the
drug product barcode
-
to
the prescription label barcode
-
to
the prescription bag barcode
-
-
to
the electronic signature of the patient that confirms receipt
of the prescription and counseling
Attached to every
link in the chain is the barcode of the person responsible
for that step. The final link is the patient's own signature.
Reports and inquiries are available to track the entire dispensing
process.
The first link
in the chain is the drug product barcode. Without that link,
there can be no complete chain.
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