On The Cover

Sonya Collins

About one in every 30 patients in health care experiences some type of medication-related harm, according to WHO. About one in four instances of this type of harm is severe or life-threatening. All told, it’s estimated that as much as half of the avoidable harm to patients in health care is related to medications.

Wherever there are humans involved in the medication process from prescribing to dispensing and administering, there is the potential for error. As technology provides increasingly more opportunities to automate and standardize medication therapy, it may also reduce errors and patient harm, but health systems must first embrace it.

“There’s a lot of technology already out there that could reduce medication errors and increase patient safety, but it isn’t being adopted,” says Rita Jew, PharmD, president of the Institute for Safe Medication Practices, in Plymouth Meeting, PA.

I.V. workflow management software

Sterile compounding of I.V. medications is a multistep process that brings with it multiple opportunities for human error in every step. I.V. workflow management software (IVWMS) automates and standardizes this complex process through barcode scanning, photo capture of volume, and gravity measurement to verify the accuracy of the medication, its formulation, and dose.

“There are safeguards in place at each step of the process, for example you take pictures of what you draw up so the pharmacist can check it,” Jew said. “You’re not just doing it all by memory or experience. The software prompts you to make sure you’re doing the right thing.”

Though the software has been commercially available since the early 2000s, uptake within health systems has been relatively slow. By 2020, some 15 years after IVWMS first came to market, just 21% of health systems were using it, according to an American Society of Health-System Pharmacists survey.

Some of the health systems less likely to adopt the software, Jew said, are smaller hospitals, many in rural areas, that may claim they don’t do enough sterile compounding to warrant the purchase of the expensive program.

“If you don’t do enough sterile compounding, if you don’t do it all the time,” Jew said, “then it’s even more important that you have technology to help ensure that the process is safe.”

Not only can IVWMS help reduce medication errors, but it can also give health systems a better read on its baseline weaknesses. The software will pick up on far more errors than clinicians typically observe and report, which can allow for systemic improvement in patient safety.

“It can provide ongoing records for auditing,” said Jacob Smith, PharmD, assistant director of medication safety and quality at Johns Hopkins Hospital and Health System in Baltimore. “We can pull data and see whether we are mis-preparing doses with a high frequency in certain areas or overriding alerts with higher frequency in certain areas.”

The software also helps improve efficiency, he adds, in that it can eliminate the need for a pharmacist to enter the clean room and perform checks on every medication.

ISMP recommended that IVWMS become a part of standard sterile compounding practice. Jew added that she’d like to see the software’s use extended to nonsterile compounding, as well.

Robotics

Beyond the automation and standardization that IVWMS provides, robotics can further reduce human intervention and thereby reduce the potential for human error in I.V. preparation.

“You have I.V. workflow management software and technology to assist with what the technician is doing, but the technician will never be as accurate as robotics,” said David Aguero, PharmD, director of medication systems and informatics, division of pharmaceutical services at St. Jude Children’s Research Hospital in Memphis, TN.

Depending on the system, robotic solutions can organize medications, monitor expiration dates, prepare prescriptions, control stock, and make replacement orders. They can count pills and bottles, label vials, store large quantities of drugs, and access patient data. They also help prevent cross-contamination by storing each drug in an individual cell. They simplify drug dispensing for nurses on the wards, as well.

Automation of these tasks not only reduces errors, which improves patient safety, but it also frees up nurses’ and pharmacists’ time, which can be redirected to patient care. Research has shown that robotic dispensing may also improve patient satisfaction because of its impact on wait times.

Studies that compare dispensing errors before and after the implementation of robotic systems have found that the technology reduces errors by large margins. In an October 1, 2022, study published online in the Journal of Pharmaceutical Health Care and Sciences, robotic technology in a small acute care hospital pharmacy that handles 500 daily prescriptions reduced prevented dispensing errors from 0.204% to 0.044% of all prescriptions filled and unprevented dispensing errors from 0.015% to 0.002%. Wrong strength and wrong drug errors, which can cause the most harm to patients, were nearly eliminated completely. Once again, when considering the result of this study, it’s important to note that automated systems are better at both preventing errors and counting them.

Despite the objective patient safety gains that robots may offer, it’s critical that pharmacies understand their limitations. They are controlled by software that can crash. They are ultimately installed, maintained, and overseen by humans, who inherently make mistakes.

“With every technology, people have to understand what it can and cannot do,” Jew said. “When you implement a new technology, do a failure mode and facts analysis, so that you can safeguard what the technology cannot safeguard.”

While costly robotic systems might not be appropriate for every hospital, such as small, lower resource facilities, large medical centers that do high-volume batching could benefit significantly from the automated systems.

In manual, high-volume batching, a human handles every dose. Even after a sterile sample is taken, there’s still the chance of a contaminated dose.

“A human could breach sterility unintentionally and never know it,” Jew said, “but with robots, as long as you clean it properly and do your validation testing, you can guarantee sterility.”

Robotic technology could be poised to make a paradigm-shifting impact in hospital pharmacy. “They’re getting stronger. As the price point continues to come down, I believe that these could be the next dispensing cabinets for health-system pharmacy,” Aguero said.

Expanded use of barcodes

Barcode medication administration (BCMA) systems may reduce medication errors by as much as 50% or even more. While the technology has been available for some 20 years, it’s still not universally employed. Some medication safety experts say health systems haven’t even scratched the surface when it comes to the impact that barcoding technology can have on patient safety.

As it stands, the most common use of BCMA is in the dispensing of sterile compounded drugs. But the technology could impact oral medications and nonsterile compounding, as well. To name just one option, BCMA could reduce or eliminate errors related to so-called “lookalike” and “sound-alike” medications.

“The next thing we need to do is expand barcoding to all of dispensing,” Jew said. There’s less use of barcoding for these other medications, she added, “because they are perceived to be lower risk.”

But scanning individual medications before they are administered to a patient is far from the only use of barcoding in health-system pharmacy, Smith said. He challenges pharmacies to consider the role that barcoding could play in monitoring every task involved in drug preparation, dispensing, and administration.

“Any step that can have a downstream safety impact on the patient, we want to think about barcoding it,” he said. “That means moving barcoded scanning into the pharmacy and making sure that every single dose that’s prepared, and at important steps in the preparation process, we’re giving ourselves additional electronic checks to monitor for common safety-prone steps in the process.”

Radio frequency identification tagging

Radio frequency identification (RFID) technology can fill gaps in areas where barcodes may fall short. For example, high-volume batching may require 25 vials of the same drug or ingredient. In a hospital that uses barcoding, policy may dictate that the pharmacist or technician scan each of the 25 vials individually. Similarly, barcode best practices would require that each individual vial be scanned when restocking an automatic dispensing cabinet.

Because this is a time-consuming task that slows down workflow, less safe workarounds evolve, such as scanning a single vial 25 times.

“But the risk is that you may have the right drug scanned once, but you may have another vial mixed in that doesn’t contain the right drug,” Jew said. “One barcode scan of one vial is not representative unless you have a whole unopened box of vials.”

Some RFID systems, on the other hand, do not require a physical, manual scan of each tag. As a technician, nurse, or pharmacist is working with the drugs, their identity is being registered more passively.

This technology is especially beneficial in crash carts and anesthesia trays, Jew noted. “It helps with improving accuracy and ensuring there’s no expired or recalled drugs in those trays.”

RFID technology may also come at a much lower upfront cost than, for example, an automated dispensing cabinet. “With RFID, you pay for the tags as you use them,” Aguero said, “compared to a potential multimillion-dollar upfront purchase.”

The barrier to widespread use of RFID technology across and throughout health systems then is not necessarily the cost, but the need to tag medications individually. It introduces a new opportunity for human error, and it adds significant labor to pharmacy workflow.

“We can improve patient safety when we remove those human touch points and purchase pre-tagged medications,” Aguero said.

There may be a missed opportunity for drug manufacturers or wholesalers to offer this as an added service. “The manufacturer can tag thousands of products at once on a service line, and wholesalers can assist with that, too,” Aguero said. “There need to be more vendors coming to the table offering that.”

Artificial intelligence

EHRs have caused medication error rates to plummet. But EHRs prompt pharmacists to check prescriptions against patient or drug information that may raise a red flag about the drug being dispensed. AI may assist health-system pharmacies in identifying another kind of error.

A study published in the March 2021 issue of JAMIA OpenJAMIA Open found that machine learning could use provider behaviors and characteristics, such as level of experience and number of patient interactions in the hour prior to prescribing a drug, to predict medication errors.

In a study published in the November 2023 issue of the Journal of the American College of Clinical Pharmacy, researchers used machine learning to link prescriptions for certain medications to diagnoses of specific GI conditions recorded in patient EHRs. When the drugs were ordered in the absence of diagnoses of those conditions, pharmacists were alerted to investigate the prescription.

AI has tremendous potential to quantify and slash medication errors, but experts stress that many of these uses are not yet ready for integration into standard clinical practice. Further, even when AI approaches are proven safe and effective for clinical use, clinicians will always need a deep understanding of the technology’s limitations.

“This is especially important with AI,” Jew said, “because it can give you wrong information and you might not even know.”

Bringing tech onto the team

No single technology alone can reduce all types of medication errors, but combined they stand to significantly reduce errors that humans may easily miss. They can also help free up human health care workers to do more of what no machine can do: provide direct, compassionate care to the patient. ■