Clearly, bar code scanning technology offers an effective strategy to avert medication errors and enhance patient safety. In addition, bar code scanning improves inventory management and accurately tracks medications throughout the facility. Increasing the number of scans and ensuring that as many medications as possible are scanned are goals of most pharmacy directors. 

Lehigh Valley Health Network is a large, integrated delivery network comprised of three hospitals with a total of approximately 950 beds, as well as eight health centers and 100 physician practices. Our facility’s hybrid medication distribution system includes two robots that prepare all of the 24-hour cart exchanges for all three facilities, as well as first doses for all of our patients. The robot technology is supplemented by automated dispensing cabinets (ADCs) in our nursing units, which are used mainly to house controlled substances and some stock medications. Our technology suite includes intelligent infusion pumps, a fully integrated computerized prescriber order entry system, and BCMA. 

The health system has made it a priority to increase the number of times medications are scanned, as well as the percentage of products that are scanned. Ideally, bar code scanning would be utilized at every point wherein the drug is manipulated, such as any medication preparation steps—including those that occur in the compounding area—and at every point in the distribution process through the point of administration. Currently at our health system, bar code verification is applied when medications are loaded into the robot, by the robot upon dispense, and finally, by nursing at the point of administration. Because we felt this final step in the process was the key to impacting patient safety, we concentrated our initial efforts on improving scanning at the bedside.

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Enforcing Bar Code Verification Procedures
We expect consistent scanning policy adherence and we measure performance down to the individual nurse. To ensure bar code verification is taking place at the points required in our policy and procedure, scanning percentages are now included as a criterion in nurses’ annual evaluations. We have found that nursing’s actual scan rate now greatly exceeds the required 90%: an average of 98% of our bar coded products are now scanned by nursing. Any nurse who fails to reach the 90% benchmark is re-educated and required to improve his or her scanning compliance. In actuality, this adherence is generally self-monitored as nurses are no longer comfortable administering a medication without a scan. When there is a scanning failure, pharmacy hears about it right away.

Our medication safety officer works with nursing leadership to uncover workarounds and ensure all nurses are scanning consistently. For example, we have uncovered instances where nurses keep a wristband with them to scan instead of scanning the patient’s actual wristband. We also have seen nurses who keep empty medication packaging with them and scan that rather than the patient’s actual medication. The obvious safety issues that can develop as a result of such workarounds must be addressed proactively and corrected immediately. In addition, any adverse medication errors that occur are evaluated to determine if the use of technology played a role in the event.

Scanning Failures
Although pharmacy makes every effort to ensure that all items leaving the pharmacy are bar coded and that the bar codes will scan properly, occasionally nurses find that items fail to scan. To encourage nurses to avoid workarounds when scanning failures occur, it is important to develop a simple reporting process that allows pharmacy to quickly resolve the error. We created a failure-to-scan form wherein nurses simply check off the error message displayed when the scan fails, attach the label and package, and forward it to pharmacy for swift resolution (see Figure 1). Utilization of this straightforward form has decreased the use of workarounds at our facility. 

Scanning in the Drug Distribution Process
All medications that are stored in robots and ADCs are protected by the safety of bar code technology, and scanning the drug and the patient’s wristband is required before administration. Most of our oral solids, as well as some of our injectables, are scanned. Scanning is not currently employed, however, when stocking ADCs, as our current cabinets do not have that capability. Because not all of our medications are housed in robots and ADCs, a robust checking procedure is employed when items must be picked manually. A technician obtains and prepares the medication and a pharmacist performs a double-check  prior to dispensing and before loading into the ADC. 

Repackaged Products
We repackage and/or overwrap over 500 different oral solids and injectables  at our facility, and bar code scanning is employed during this process to ensure safety and accuracy. The bottle is scanned, the repackaging completed, and then the technician performs an initial check of the product. The pharmacist then rescans and verifies the item is correct and has been placed in the correct canister to be loaded into the robot. Every repackaged product, whether it is stored in the robot or in another area of the pharmacy, is scanned to verify that the right product is in the right package. A small RFID chip in the canister ensures the correct medication is contained in the canister and eventually repackaged. 

Returned Products
When medications are returned to pharmacy, they are scanned and then placed in the returns rack in the robot; the robot then identifies the correct location and restocks the drug for future dispensing. Returned items that are not stored in the robot are not protected by bar code scanning, but are manually returned to stock by pharmacy technicians. We consider the manual returning of medications not housed in the robot an opportunity for medication safety improvement within the pharmacy. 

Future Directions
Beside the obvious patient safety benefit from bar code scanning, another benefit is that bar coded medications can be easily tracked throughout the hospital. Significant time can be spent attempting to locate nonscanned medications, impacting pharmacy and nursing workflow. Our future plans include scanning more of our medications to further improve safety and streamline workflow.

Within the next year, additional bar code scanning at various points in the drug distribution process is planned to improve the safety of medications that are not located in a robot or ADC. In addition, within the next two years we also plan to upgrade our ADCs to implement scanning upon stocking. We are eagerly anticipating increased patient safety and more efficient workflow as a result of these initiatives.

Robert Begliomini, RPh, PharmD, MBA, FASHP, is the administrator of pharmacy services at Lehigh Valley Health Network in Allentown and Bethlehem, Pennsylvania. He received his BS and PharmD at The Philadelphia College of Pharmacy and Science and an MBA from DeSales University.