Error Alert
Institute for Safe Medication Practices, Horsham, PA
Barcode scanning medication containers during the dispensing process is an important way patients can be protected from errors. It serves as an automated double check to verify that the drug product and strength selected from storage matches what has been entered into the patient’s profile in the pharmacy’s computer system. However, the Institute for Safe Medication Practices (ISMP) continues to receive reports in which barcode scanning was not implemented within the pharmacy, barcode scanning was bypassed, or only one manufacturer container was scanned when multiple containers are required to fill a prescription.
For example, a patient was supposed to receive lamotrigine extended-release 200 mg tablets; however, she actually received a mix of manufacturer bottles for lamotrigine extended-release 200 mg tablets and lamotrigine extended-release 300 mg tablets. She discovered the error when she opened a bottle of lamotrigine extended-release 300 mg tablets and noticed they looked different than what she normally received. At first, she thought they may have been 200 mg tablets from a different generic manufacturer, but after reviewing the container label she realized that they were 300 mg tablets.
It is easy to see how these bottles could be confused despite the different shading used on the bottom of the labels and around the drug strength. The drug name and other information on the principal display panels are formatted similarly. Also, the drug strength is printed to the right of the drug name, around the curve of the bottle. This increases the risk that the strength may be missed when looking at multiple bottles at the same time. However, if the barcode on each manufacturer container had been scanned, it is likely that this error would never have progressed to the verification stage, much less reached the patient.
Similarly, ISMP has received multiple reports of mix-ups involving fluticasone propionate aerosol metered-dose inhalers and fluticasone propionate nasal spray. In most of these reports, fluticasone metered-dose inhalers were ordered, but the nasal spray product was dispensed. Sometimes this was due to the wrong formulation being selected during order entry. But in other cases, the wrong product was retrieved from the pharmacy shelf, resulting in pharmacy labels with directions for the metered-dose inhaler (e.g., inhale 2 puffs into the lungs twice a day) being affixed to the nasal spray product by mistake. One report indicated that the product’s barcode was not scanned during production, thereby missing an opportunity to catch the error.
To help prevent the types of errors described above, all pharmacies should consistently utilize barcode scanning during the dispensing process and scan each bottle used to fill a prescription, including each manufacturer bottle that may be dispensed to a patient. Identify an individual or team to track and review data from the pharmacy and barcode scanning system, including the percentage of medications with an unreadable barcode, scanning compliance rates, and bypassed or acknowledged alerts. Use these data to identify and address any barriers to using the technology safely and effectively.
At the point of sale, open the bag and have the patient check what has been dispensed to make sure it is correct. In fact, one of the fluticasone-related reports indicated that the error was caught while counseling the patient, as they were expecting a metered-dose inhaler instead of a nasal spray. ■