Bene fi ts of Barcode and Optical Technology in Pharmacy and Medicines Management
E- Commerce in Pharmacy
There is growing use of e-ordering and e-commerce in the pharmacy sector. While com- munity pharmacies have been placing orders electronically through their pharmacy sys- tems , via modem or e-fax, for some years, they have not had an automated means of processing the goods received and invoices, which has implications for stock control , especially in larger pharmacies. Furthermore, the ordering process for hospital pharmacies
186 7 Barcodes and Logistics
has been traditionally paper-based – with generation of paper orders, based on product usage data, faxing of the orders with postal con fi rmation, and then manual processing of goods received, and invoices sent to the fi nance department for payment.
The universal availability of machine-readable codes for medicines, together with electronic signatures/authorisation, brings with it the possibility of electronic ordering.
There have been a variety of approaches to electronic ordering, from standard elec- tronic data interchange (EDI) via a modem link, XML terminology , transmission of order data via an Excel fi le or use of standard messaging formats, such as the pharmacy messaging service (PMS) , which was developed for NHS purchasing in the UK.
Electronic ordering offers the following bene fi ts:
Reduction in number of
• ordering errors . The fi gure quoted from a study by DH CMU (NHS PASA) in the UK is that, if 90 % of orders are placed electronically, there will only be 5 % of ordering errors or exceptions.
Reduction in the cost of
• procurement administration
More streamlined procurement processes and improved timeliness of order
•
transmission
Greater transparency of the order process and ease of monitoring
•
The order items can be more easily matched to the invoiced items, to monitor
•
order ful fi lment and ensure accurate payments.
A number of wholesalers have developed electronic ordering systems, such as Medecator from AAH Pharmaceuticals. In the UK, the Luton and Dunstable Hospital installed the Windows-based Powergate e-commerce system [ 15 ] , which enabled the mapping of products from the pharmacy system to the supplier’s/wholesaler’s elec- tronic catalogue(s), usually using the EAN code , and ensured that electronic orders could be sent from the pharmacy system , and be fully readable by the supplier com- puter system. The order would then be ful fi lled and delivered with a concomitant elec- tronic invoice, which would enable electronic booking in of goods on the pharmacy system, and also electronic transfer of invoice data to the fi nance department. The e-ordering system enabled the department to improve stock pro fi ling, develop saving strategies for high-cost lines and released 10 h’ staff time from the purchasing process each week. The system also had a bene fi cial effect on relationships with wholesalers.
At the Greater Glasgow & Clyde NHS Board in Scotland, pharmacy automation was used together with electronic trading (wherever possible) to enable centralised procurement and distribution to hospital wards and departments across the region [ 16 ] . The centralisation of procurement led to some concerns from suppliers about the vis- ibility of the supply chain beyond the procurement hub. However, these concerns were addressed with appropriate information feeds from individual hospital sites, and build- ing up good relationships with wholesaler/supplier managers.
Reduction of Dispensing Errors
It is recognized that barcode scanning during the dispensing process has the poten- tial to reduce dispensing errors [ 17 ] . This may be done either in conjunction with
a pharmacy robot or as a stand-alone process with a barcode scanner linked to the pharmacy system. Nevertheless, there are various barriers to implementation of bar- code scanning for medicines veri fi cation in the dispensing process, especially if it is a stand-alone process relying on manual scanning by a member of staff.
These include:
Interruption of the usual pharmacy work fl ow.
•
Availability of the technology (many community pharmacy systems are not
•
con fi gured to use barcodes at the point of dispensing).
Staff training and engagement on the bene fi ts of using a barcode scanning
•
system.
Automated systems have the potential to reduce errors and manage risk at the supply end of the medicines use process. The UK Audit Commission’s “Spoonful of Sugar” report [ 18 ] , published in 2001, highlighted the potential of pharmacy automation to reduce dispensing error rates. Following on from that report, many hospital pharmacy departments constructed business cases to install automated dis- pensing systems ( pharmacy robots ), and to re-engineer pharmacy services. The operational aspects of these, and their relationship with EP systems, have been discussed in the previous chapter. A further study by Beard and Candlish at Sunderland [ 10 ] examined the extent to which an EP system could reduce the inci- dence of dispensing errors. An important general factor is that, because traditional dispensing is a manual process, error rates will to some extent be dependent on the number of staff present in a dispensary, and so dispensing error fi gures should be adjusted to take this into account, and be expressed as errors per member of staff.
The authors found that the use of the EP system for inpatient medicine ordering led to an dispensing error rate of 0.0029 errors per person, compared to 0.0045–0.0057 errors per person in other areas of the hospital. One of the pharmacies in the Trust used barcode product selection, which achieved a slightly lower dispensing error rate of 0.0022 errors per person. Due to the high ratio of staff to prescriptions, and the highly controlled environment, the lowest dispensing error rate was in the Trust’s chemotherapy manufacturing facility, where the authors calculated an error rate of zero.
Electronic Medicines Administration
As discussed in Chap. 3 , BCMA has the potential to reduce a signi fi cant proportion of medication errors relating to the administration of medicines. Furthermore, in conjunction with pharmacy robotics, barcodes can facilitate an end-to-end (closed loop) safe medication system [ 19 ] . Barcode technology has also been used by EP systems in order to reduce errors in the medication administration process on the ward. The patient’s wristband barcode is scanned prior to a medicine administra- tion event to con fi rm patient identity , and the barcode on the medicine is scanned to con fi rm the identity of the medicine to be administered. Medicines administra- tion with the assistance of barcodes to identify either the patient or the drug may
188 7 Barcodes and Logistics
contribute to reductions in levels of medicine administration errors at the point of administration.
The EP implementation at Charing Cross Hospital, London, UK [ 20 ] , used bar- code identi fi cation of patients. At each medicine administration event , the EP sys- tem required the patient’s barcode to be scanned, in order for the patient’s drawer on the electronic drug trolley to be released, so that the nurse could access the patient’s medication. This barcode patient identi fi cation function caused the percentage of occasions where the patient identity was not checked to be reduced from 82.6 to 18.9 %. However, system compliance was limited by practices such as sticking the patient’s barcode to their bedside cupboard, rather than to their wristband.
Poon et al. [ 21 ] conducted a study of 115,164 medicines administration events before implementation of barcode medicine administration, and 253,984 adminis- tration events after implementation. They found that target adverse events were reduced by 74 % and all adverse events were reduced by 63 %, and that the greater the proportion of doses scanned, the higher the error reduction rates possible. Nolen et al. [ 22 ] studied the use of barcode medicine administration (BCMA) in anaesthet- ics for cardiac surgery cases (n = 870). They found that the BCMA process increased the available information on peri-operative drug administration by 21.7 %, and the availability of drug cost data by 18.8 %. Furthermore, the time required to process the operating room anaesthesia record was reduced by 8 min per case, following full implementation of the system.
Miller et al. [ 23 ] has indicated that BCMA can reduce medication errors and improve patient safety. However, because the process of medicines administration by barcode scanning is potentially interruptive, there are various work-arounds (BCMA work- arounds ) that nurses and pharmacists may use to bypass the system. In a study of fi ve hospitals, Koppel et al. [ 24 ] have studied BCMA work-arounds and identi fi ed 15 work- arounds, with 31 causes of different types. Reasons for work-arounds [ 25 ] include:
Inability to scan medicines because a scanner is not available at the point of
•
medicines administration
Lack of awareness of the hospital’s BCMA process (bank/agency staff, but also
•
new staff and staff who are not usually involved with medicines administration) Shortage of time
•
Delay in computer response
•
Administration of a medicine prior to prescribing
•
McNulty et al. [ 26 ] discussed strategies for dealing with the problem of BCMA work-around. These include:
(a) encouraging a better culture of ownership of the system among nursing staff (b) improving the infrastructure to address known technical issues (e.g. wireless
black spots )
(c) an effective staff training programme , and better engagement of staff during the implementation period.
(d) greater use of “ hard stops ” in the system (i.e. ensuring that a medicine is not available for administration without following the procedure – e.g.
linking BCMA to electronic ward cabinets ). However, hard stops may be highly disruptive and implementers should consider the unintended consequences in each scenario.
The culture of ownership of the system is important and, while BCMA has the potential to resolve many medication errors at the point of administration, managers should remember that different staff groups with have different priorities with BCMA implementation [ 27 ] . Pharmacy staff will want to ensure that the stock and inventory is controlled, whereas nursing staff will want to ensure that the system is usable at the point of medicine administration.
There are potential barriers to the use of barcodes for medicine identi fi cation at the point of administration:
1. It is recognised that a proportion of medicinal products do not have barcodes [ 28 ] . This is especially the case with “ specials ”, parallel imports and some hos- pital manufactured products. There would need to an increase in the proportion of medicines that could be accurately identi fi ed by barcode for barcode medicine identi fi cation to be feasible in a variety of secondary care specialities.
2. Barcode medicine identi fi cation relies on original barcoded packs being used for medicine administration at ward level. While this may be the norm in some coun- tries, it is not routinely the case in the UK.
3. Barcode medicine identi fi cation on wards relies on the availability, con fi guration and scalability of the appropriate hardware
In the long term, the use of barcodes may also be limited by harmonisation issues and obsolescence, due to development of RFID (radio frequency identi fi cation) technology [ 4 ] .
The bene fi ts of improved operational ef fi ciency, together with patient safety fea- tures, drive additional economic bene fi ts. These include reduction in reworking and reordering, improved product availability, reduction in waste (expired medicines), reduced compensation claims, lower litigation costs and better bed/patient through- put (less bed days lost due to adverse events).
Pharmacy Work fl ow Tracking
As well as tracking of medicines through the supply chain, barcodes can also be used to track prescriptions through the pharmacy dispensing process ( pharmacy tracking ).
In smaller pharmacies, this may not be necessary, but work fl ow tracking is useful in large hospital pharmacy departments, where there may be a large workload with prescriptions and orders arriving in the department from various different locations.
As previously discussed in Chap. 3 , the ef fi ciency of the discharge process in hospi- tals is important to ensure good bed management, allocation of resources and continu- ity of care. However, the process of dispensing discharge prescriptions or TTOs ( to take out medicines) is one that often causes problems for hospital pharmacy. The discharge prescription is initiated on the ward after the medical team has decided that a patient can