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

• HIT Description: Bar code technology for pharmacy dispensing More info...
  
• Purpose of Study: evaluate the impact of the implementation of bar code technology in a hospital pharmacy on rates od dispensing errors and potential adverse drug events
  
• Years of study: 2003
  
• Study Design: pre-post
  
• Outcomes: impact on patient safety
  

• Settings: pharmacy of a 735-bed tertiary care academic medical center with approximately 5.9 million dose of medications dispensed/year
• Intervention: Before and after measurement of target and non-target rates of dispensing errors and potential adverse drug events. Target dispensing errors are those that bar coding is designed to prevent and target ADEs are dispensing errors that can harm patients.
• Evaluation Method: pharmacist-observer evaluated for dispensing errors; physician reviewed chart and supplemental information to determine potential ADEs
• Description: bar code conversion process required establishing a dedicate repackaging center to affix a bar code if the manufacturer had not done so; redesigned dispensing system into 3 configurations with 2 requiring scanning of all doses and 1 requiring one-time scanning if several doses of the same medication were being dispensed.
• Quality of Care and Patient Safety Outcome: Rates of target potential ADEs and all potential ADEs decreased by 74% and 63%, respectively. Relative rates of dispensing errors decreased by 93-96% for dispensing configurations requiring scanning of all doses. The configuration that did not require scanning of all doses had only a 60% relative rate reduction and an increased incidence of target potential ADEs.