Are pharmacy labels your workflow crutch?

Posted on June 23, 2017

By Beth Richter, Pharmacist Consultant

For many years, pharmacy workflow and medication dispensing have been driven by paper: paper in the form of a label.  Labels are used for everything and for good reason.  There are labels for the little baggie of medications so you know where it’s going, labels for pre-filled syringes to identify contents, expiration date and lot number, labels on IV bags to identify contents, flow rates, etc.  Labels are undoubtedly a very important aspect to the pharmacy practice.  The first class I ever took in pharmacy school, my professor said “the first lesson in pharmacy was to document everything; if you don’t document it, it didn’t happen!”

Just like working in a laboratory, it’s very important to label all your bottles, beakers and vials because mixing the wrong ingredients together can be very dangerous.  Improper labeling reared its ugly head at my home recently.  My husband is a chemical engineer and  “wannabe” farmer.  He had some fine looking little seedlings growing in our basement in early spring (grow light and all).  One day, he approached the little guys with a spray bottle to give them a drink of water.  As he finished spraying I heard the yelling start; he had inadvertently sprayed them with citric acid!  He knew it was citric acid because the smell hit him and he remembered that he’d put citric acid in this bottle for another reason a few weeks ago for another purpose but forgot to label it.  The little seedlings were dead in 2 days.

Labeling the contents of syringes, bags, bottles, etc. in a pharmacy is critically important.  Let’s focus on dispensing labels for a minute.  Health system pharmacies spend loads of time managing the contents and whereabouts of dispensing labels.  These are the labels that indicate the patient name, location with the facility, medication name, dose, dosage form, directions, expiration date, etc.  While most of these are all fundamentally necessary on a label, what about the directions, are directions needed on the dispensing label in a health system?

Pharmacies implement complex automation systems that aid in barcode generation and label printing however many pharmacies still choose to use their pharmacy information system label instead of the labels generated from their automation solution.  These pharmacies spend countless hours juggling these labels throughout the day.  Pharmacy automation systems are designed to make pharmacies safer and more efficient.  One safety feature designed into these systems is the ability print a dispensing label upon the correct scan of a product.   The software is designed to help the user apply the correct label to the correct product.  Picture this: a pharmacy technician is standing at a carousel about to pick 5 different patients’ first-dose orders.  The carousel guides the technician through the picking process; rotates to the first patient’s medication, medication is picked from the carousel, medication is scanned, label is printed, technician applies the label to the product.  There are zero opportunities for error here.  Here’s another scenario that I see today in some pharmacies: a pharmacy technician brings 5 labels that were printed from the pharmacy information system over to a carousel and is standing there about to pick 5 different patient’s first-dose orders.  The carousel guides the technician through the picking process: rotates to the first patient’s medication, medication is picked, medication is scanned, technician looks through the 5 labels in their hands to find the correct label, medication is labeled.  There are four opportunities for error here.

When I see this process occur in a pharmacy, I always ask “why are you using the pharmacy information system label v/s the carousel label?”  I’m always told “because the PIS label has more information on it for the nurses” i.e. directions are more complete.  The Electronic Health Record (EHR) technology available today in health systems supports and targets the use of the Electronic Medication Administration Record (eMAR); making the directions on the pharmacy label entirely unimportant.  Physicians change patient orders routinely throughout the day.  The health system’s EHR can capture those changes real-time and constantly update the eMAR for the precise up-to-date medications, dosages, and direction changes.  The eMAR is the nurse’s roadmap; not the pharmacy label.  What happens when the pharmacy dispenses a medication that was previously ordered twice daily and now the directions have changed to once daily based on renal function results?  The medication was dispensed correctly and the dosage is the same but those directions have now changed.  The nurse must rely on the eMAR for those changes and not the pharmacy label.  Applying a label with all the medication directions only enables antiquated nursing behavior and may lead to administration errors if a nurse administers a medication according to old directions printed on the label.  Nurses should rely on the eMAR, never the pharmacy label.  If the directions are not on the label at all, they have no choice but to turn to the eMAR.  Pharmacy labels should help steer nursing to administer based on the correct record of truth: the eMAR.  Pharmacies should fully utilize rather than work-around the patient safety features and efficiency gains that their pharmacy automation provides.

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