The Missing Scan, Barcoding at the Point of Dispense

Posted on August 28, 2015

By: Chris Miller, Product Manager

We see it over and over on a regular basis, death caused by medication errors. A July 2014 press release from U.S. Senator Barbra Boxer estimates each year “between 210,000 and 440,000 Americans die as a result of preventable errors in hospitals”1, which leads to an estimated $19.5 Billion, yes with a capital “B” for Billions, in costs to hospitals. Hospitals are scrambling to institute new safeguards, from distraction-free zones to nurse servers, and various other methods. While in theory, these practices are beneficial, are they really addressing the safety issues, or are they merely masking them?

Don’t get me wrong, I am not criticizing the methods by which hospitals are implementing safety; I don’t think that there can be enough procedures implemented to remove distractions from nurses or pharmacy workers. As a product manager for an automated dispensing cabinet (ADC), I have been to a number of customer sites that simply refuse to implement one of the most common methods of safety that can be implemented when dispensing medications: barcoding scanning on dispense. Countless discussions with nurses have revealed a common opinion that scanning a barcode when a medication is dispensed adds an unnecessary step of validation, and that it is just the same process as scanning the medication at the bedside. However, the fact of the matter is that these are two distinctly differing events.

Why is it that bread at the local grocery store has more barcode check points than medications dispensed from an automated machine? Put yourself in the patient’s bed. What reaction would you have if your nurse came into your room to give you your medication and scanned the wrong medication only to say, “I’ll be right back…” then rushed out of your room to retrieve the correct medication?   Your first response would be, “new nurse please!”

Nurses are busy; I get it. In fact, statistics show that clinicians spend less time seeing more patients a day than ever before. With such a busy work load, it is no wonder that nurses are distracted. So, why shouldn’t the discipline of barcode scanning be implemented along with other safety measures that ensure that nurses are slowing down at the critical care points, such as dispensing medications for patients? When a nurse scans a medication at the ADC on dispense, that nurse is validating the medication that was just dispensed versus the medication that was requested, which provides immediate feedback on an incorrect medication scan prior to moving on in the dispensing and administrating processes.   This is an entirely different validation from the scan on administration, which is providing the final validation that the patient who is scanned is receiving the right medication, right dose, for the right time and right route, all at the bedside. A one-second scan at the ADC of each medication dispensed does not lengthen the amount of time it takes to dispense medications by any significance. A nurse picks and holds the medication under a scanner for 1 second, then moves on. However, the amount of time a nurse takes to return to the ADC once the incorrect medication has been discovered and then return to the patient with the new medication, can add up.

While simple measures like scanning on dispense and BCMA are valuable and have shown to decrease medication errors by as much as 86%2, it does not prevent every medication error, especially if the error occurred early on in the upstream filling process or labeling process; however, the barcode on dispense is an invaluable scan that provides just one more opportunity to catch a medication error. That missing scan could save a life and a good nurse a job.



Boxer Releases Updated Report on Medical Errors

According to Researchers, Between 210,000 and 440,000 People Die Every Year from Errors in Hospitals that Could Have Been Prevented

Thursday, July 3rd 2014



Medication Errors Occurring with the Use of Bar-Code Administration Technology

Pa Patient Saf Advis 2008 Dec;5(4):122-6.

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