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Medication Dispensing Errors and Potential Adverse Drug Events before and after Implementing Bar Code Technology in the Pharmacy

Eric G. Poon, MD, MPH; Jennifer L. Cina, PharmD; William Churchill, MS; Nirali Patel, PharmD; Erica Featherstone, BS; Jeffrey M. Rothschild, MD, MPH; Carol A. Keohane, BSN, RN; Anthony D. Whittemore, MD; David W. Bates, MD, MSc; and Tejal K. Gandhi, MD, MPH
[+] Article, Author, and Disclosure Information

From Brigham and Women's Hospital, Harvard Medical School, and Partners Information Systems, Boston, Massachusetts.

Acknowledgments: The authors thank Judy Hayes, RN, and Anne Bane, RN, for their support throughout the project; E. John Orav, PhD, for his editorial comments and assistance with statistical analyses; and Brandon Hays and Robin Johnson for their assistance with data analysis.

Grant Support: By the Agency for Healthcare Research and Quality (HS14053-02).

Potential Financial Conflicts of Interest: Consultancies: D.W. Bates (Cardinal Health); Honoraria: D.W. Bates (Cardinal Health); Grants received: D.W. Bates (Cardinal Health).

Requests for Single Reprints: Eric G. Poon, MD, MPH, Division of General Medicine and Primary Care, Brigham and Women's Hospital, 1620 Tremont Street, 3rd Floor, Boston, MA 02120; e-mail, epoon@partners.org.

Current Author Addresses: Drs. Poon, Rothschild, Bates, and Gandhi; Ms. Featherstone; and Ms. Keohane: Division of General Medicine and Primary Care, Brigham and Women's Hospital, 1620 Tremont Street, 3rd Floor, Boston, MA 02120.

Drs. Cina and Patel and Mr. Churchill: Pharmacy Services, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02120.

Dr. Whittemore: Administration Building, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02120.

Ann Intern Med. 2006;145(6):426-434. doi:10.7326/0003-4819-145-6-200609190-00006
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The rates of target dispensing errors and potential ADEs substantially decreased after the implementation of bar code technology: The target dispensing error rate decreased by 85%, and the rate of all dispensing-related potential ADEs decreased by more than 60%. Given these magnitudes in error reduction, bar code technology in the pharmacy compares favorably with other patient safety interventions, such as computerized physician order entry (1718) and pharmacist participation in intensive care unit rounds (1920). Moreover, these reductions in error rates are important clinically, given the high volume of medications dispensed from hospital pharmacies. Although nurses typically intercept one third of these dispensing errors before administration of the erroneous medications to patients, these error reductions translate into a substantial reduction in potential harm to patients.

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Overview of the pharmacy dispensing process.

*Sure-Med, Omnicell, Mountain View, California. CPOE = computerized physician order entry; MD = physician.

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