Pharmacy professionals play a pivotal role in patient care, ensuring that medications are dispensed accurately and safely. In this age of advanced technology, bar code scanning has emerged as a crucial tool in preventing medication incidents and making the pharmacy more efficient. When used correctly, bar code scanning can help identify selection errors before the medication reaches the patient, potentially saving lives and preventing harm. However, there are instances where workarounds and cognitive bias can compromise the effectiveness of this technology, putting patients at risk. In this blog post, we will explore the significance of bar code scanning in pharmacy practice and provide key recommendations for enhancing medication safety.
The Importance of Bar Code Scanning
Bar code scanning technology has
revolutionized the way medications are dispensed in pharmacies. It offers an
extra layer of protection by verifying the accuracy of medication selection. By
scanning bar codes on medication packaging, pharmacy professionals can ensure
that the right medication, in the correct strength and dosage, is dispensed to
the patient. This technology significantly reduces the chances of medication incidents,
which can have serious consequences for patients.
Incident Example from the National Incident Data Repository for Community Pharmacy
To emphasize the critical role of bar code scanning, let’s examine a real-life Manitoba incident. A patient contacted a pharmacy, expressing concern about the color of their medication tablets. Upon investigation, it was revealed that the correct strength of the medication had been scanned, but an incorrect strength was dispensed to the patient.
This report underscores how medication incidents can occur even when bar code scanning is used.
Workarounds and Cognitive Bias: Twin Concerns for Automation Safety
While bar code scanning is a powerful tool for medication safety, it is not foolproof. Community pharmacy care has become more complex and demanding than ever before. This quality of practice environment can encourage the use of workarounds that create an imbalance between efficiency and safety.
Pharmacy professionals must be aware of potential workarounds that can bypass the safeguards of barcoding technology. Some common workarounds include:
- Scanning one bottle multiple times when multiple bottles are needed.
- Breaks in the workflow between product scanning and filling.
- Manual entry of the intended bar code.
These workarounds can compromise the integrity of the bar code scanning system, leading to medication incidents and patient harm.
Automation bias and automation complacency can contribute to overconfidence in technology that obscures potential hazards. Automation bias is the tendency for people to place greater trust in an automated system and ignore contradictory information that comes from manual (non-automated) sources. Like automation bias, automation complacency results from over-trust in a system or technology leading to a decrease in vigilance to the ways it can fail. This pair of cognitive biases can weaken medication safety processes in the dispensary if left unchecked.
4 Key Recommendations for Safety
To ensure the effectiveness of bar code scanning technology and maximize patient safety, pharmacy professionals should consider the following recommendations:
One: Proactively Identify and Prevent Known Workarounds
It is crucial to identify and address known workarounds in the bar code scanning process. For example, scanning one bottle multiple times should be discouraged and monitored closely. Education and training programs should be used to raise awareness of a technology’s weaknesses and the dangers of bypassing safeguards. For example, ongoing and introductory training should include the following:
- An overview of the weaknesses or points of vulnerability of the technology or system.
- Review of past incidents or incident examples of technology failure.
- Direct experience with the technology’s failure. Have staff role-play an error in the technology so they know first-hand what that looks like.
Emphasize, acknowledge, and reward staff for maintaining safe practices especially when the pharmacy is busy and the temptation for workarounds is greatest.
Two: Implement Forcing Functions
The most effective strategies are those that make it impossible to perform specific erroneous acts. Implementing forcing functions within the workflow can prevent common workarounds. For instance, the system could be configured to reject scanning the same bar code multiple times within a short timeframe.
Three: Create a Standardized Verification Process
Use a manual verification to address automation complacency. This could include verifying the original prescribers order before dispensing the medication to the patient.
Four: Conduct Regular Audits and Quality Control
Complete regular audits of the bar code scanning process to ensure compliance and effectiveness. Quality control measures can help identify issues and improve the system’s reliability.
Bar code scanning technology is a vital tool in pharmacy practice, significantly reducing the risk of medication incidents and patient harm. However, it is essential for pharmacy professionals to be aware of potential workarounds and cognitive biases that can compromise safety. By proactively identifying and preventing these workarounds, raising awareness of cognitive bias, and implementing forcing functions and monitoring practices, pharmacy professionals can enhance medication safety and continue to provide high-quality care to patients.