in community pharmacies · educating the healthcare community about safe medication practices in...

Educating the healthcare community about safe medication practices

in

This project was supported by grant number R18HSO17910 from the Agency for HealthcareResearch and Quality. The content is solely the responsibility of the authors and does not necessarily

represent the official views of the Agency for Healthcare Research and Quality.

From the InstItute For saFe medIcatIon PractIces

Assessing BArcode VerificAtion system reAdiness

community PHArmAcies

wwwwww..iissmmpp..oorrgg//AAHHRRQQ//bbaarrccooddee

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Advisory Panel.......................................................................................................................................................

executive summary ..........................................................................................................................................

instructions for conducting the readiness Assessment ..............................................Important Details about the Readiness Assessment Tool ......................................................................4Directions for Using the Readiness Assessment Tool ..............................................................................4Directions for Entering Data and Generating Reports.............................................................................6Legal Protection of Readiness Assessment Data Submitted to ISMP................................................7

readiness Assessment for Pharmacy Leadership/owner ...........................................Demographics .......................................................................................................................................................8Readiness Assessment Tool.............................................................................................................................9

readiness Assessment for Pharmacy staff ................................................................................Demographics.....................................................................................................................................................15Readiness Assessment Tool..........................................................................................................................16

Appendix A—Putting Bar-coding technology into context ....................................Uses and Benefits of Bar-coding Technology in Community Pharmacies ...................................20Impact of Barcode Product Verification Systems on Dispensing Errors ....................................21Incidence of Bar-Coding Technology in Community Pharmacies....................................................21Factors that Impact the Decision to

Implement a Barcode Product Verification System .........................................................................22Challenges Implementing Barcode Product Verification Systems...................................................23Selecting the Right Barcode Product Verification System ..................................................................24Costs Associated with Barcode Product Verification Systems .........................................................24Conclusions ................................................................................................................................................24

Appendix B—Vendor selection............................................................................................................Elements to Consider During Vendor Selection ......................................................................................25

Appendix c—costs...........................................................................................................................................Direct Costs Associated with Barcode Verification Systems .............................................................29

references .................................................................................................................................................................

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table of contents

*Photo on front cover courtesy of Kirby Lester, LLC.



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Advisory Panel

The Institute for Safe Medication Practices (ISMP) thanks the following members of our voluntary AdvisoryPanel, who provided input into the development and reveiw of Assessing Barcode Verification SystemReadiness in Community Pharmacies.

JJoohhnn BBeecckknneerr,, RRPPhhDDiirreeccttoorr ooff PPhhaarrmmaaccyy aanndd HHeeaalltthh SSeerrvviicceessUkrop's Super Markets, Inc.Richmond, VA

LL.. PPrreessttoonn HHaallee,, RR..PPhh.. NNaattiioonnaall MMaannaaggeerr,, SSttrraatteeggiicc AAccccoouunnttss Qs/1 201 West St. John Street Spartanburg, SC 29306

HHoowwaarrdd KKrraammeerr,, RRPPhhDDiirreeccttoorr PPhhaarrmmaaccyy,, HHuummaann RReessoouurrcceess,, aanndd GGoovveerrnnmmeenntt AAffffaaiirrssSears Holdings CorporationKmart PharmacyRoyal Oak, MI

BBrriiaann MMoorrrriiss,, RRPPhh,, MMBBAAPPrroodduucctt MMaannaaggeemmeenntt,, RReegguullaattoorryy aanndd PPrrooffeessssiioonnaall AAffffaaiirrss DDiirreeccttoorrMcKesson CorporationMcKesson Pharmacy SystemsAtlanta, GA

GGrreeggoorryy SShhaaeeffffeerr,, RRPPhh,, MMBBAA,, FFAASSHHPP,, FFAASSCCPPVViiccee PPrreessiiddeennttPharmacy Healthcare Solutions, Ltd. (PHS)Harrisburg, PA

CChhrriissttoopphheerr TThhoommsseennPPrreessiiddeennttThe ThomsenGroup, Inc.Kansas City, MO



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Community pharmacies face new challenges everyday. Pharmacists are increasingly asked to optimizecomplex medication regimens and provide innova-tive patient care services while responding todemands for increased efficiency. Operationalpressures such as increasing prescription volumes,workforce shortages, and shrinking third-partyreimbursements are taking a toll on the pharmacist’sability to work efficiently and safely. Today, prevent-able adverse drug events are a leading cause of harmto patients.2-3 Given these challenges, communitypharmacies are seeking technological solutions tokeep up with new market demands and reduce therisk of errors. Studies have shown that improve-ments in medication error rates, staff efficiency andutilization, inventory control, customer service, andcost may all be afforded through the use ofpharmacy technology.4-16

Bar-coding technology is well-established in industriesoutside of the healthcare sector and is now being usedwithin healthcare to enhance efficiency and safety, andin pharmaceutical wholesale operations to improvesupply chain inventory and efficiency. Numerousstudies prove the effectiveness and cost benefits ofusing bar-coding technology during the drugdispensing process.2,4,7,9,11,12,17-21 About 75% of wrongdrug or wrong dose errors are captured and correctedusing barcode technology,12,17 and there is sufficientevidence that barcode scanning is becoming thestandard of practice in pharmacies.22

Although bar-coding technology is mature withabundant evidence regarding its effectiveness, a 2006study showed that only half (53.5%) of US communitypharmacies utilize a barcode scanner for verifica-tion/identification of medications.16 The study alsorevealed significantly lower adoption in independentpharmacies (11.5%) compared to chain pharmacies(62.6%). Yet, on average, independent pharmaciesprocess more prescriptions per hour than chainpharmacies, increasing vulnerability to errors.16

According to a survey conducted by the Institute forSafe Medication Practices (ISMP) in 2009,23 the mostfrequently reported reasons for implementing barcodescanning for product verification included a desire toimprove the accuracy and safety of the dispensingprocess, the ease with which the technology fit withpharmacy workflow, improvement of staff efficiencyand inventory control, and a belief that the technologywas necessary to stay in business.24 The most commonreasons for NNOOTT implementing barcode scanning forproduct verification—other than cost—included uncer-tainty regarding the ‘right’ vendor product, satisfactionwith the current system (without barcode productverification), and perceptions that the technologywould reduce staff efficiency.24

This tool, AAsssseessssiinngg BBaarrccooddee VVeerriifificcaattiioonn SSyysstteemmRReeaaddiinneessss iinn CCoommmmuunniittyy PPhhaarrmmaacciieess, was developedto help address the reasons why barcode scanning hasnot been implemented and to facilitate the adoption ofthis technology in an estimated 19,000 communitypharmacies that do not currently utilize it for productverification. Given the resource commitment topurchase bar-coding systems and the potential fortechnology to have a profound effect upon the workenvironment, this tool will help community pharmacyleaders better understand the issues related to barcodeproduct verification systems. It will also help leadersassess the pharmacy’s readiness for the technology,prepare for the selection of a system, and implementthe technology effectively. The assessment tool willserve as a conduit to building a solid foundation uponwhich to install the technology.

Please see AAppppeennddiixx AA,, PPuuttttiinngg BBaarr--ccooddiinngg TTeecchhnnooll--ooggyy iinnttoo CCoonntteexxtt for additional information. Also,please keep in mind that this tool does not includespecific tasks associated with the actual implementa-tion of a barcode product verification system.

GGooaallss ooff tthhee RReeaaddiinneessss AAsssseessssmmeenntt

Increase awareness of the current issues associatedwith implementation of a bar-coding system forproduct verification

Explore readiness of community pharmacies for imple-mentation of a barcode product verification system

Guide the selection of a vendor system to maximizevalue and meet pharmacy needs

Facilitate successful introduction of a barcodeproduct verification system into the dispensingworkflow in pharmacies that have made implemen-tation of this technology a short- or long-term goal

BBaarrccooddee ssccaannnniinngg iiss ttoo ppaattiieenntt ssaaffeettyy wwhhaattwweeaarriinngg sseeaattbbeellttss iiss ttoo ppaasssseennggeerr ssaaffeettyy——nnootttthhee oonnllyy tthhiinngg bbuutt cceerrttaaiinnllyy aa ssaalliieenntt tthhiinngg..11—Mark Neuenschwander, Editor of I’ve beenthinking...™™



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instructions for conducting the readiness Assessment

IImmppoorrttaanntt DDeettaaiillss aabboouutt tthhee AAsssseessssmmeenntt TTooooll

This readiness assessment has been designed to be used in any community pharmacy practice,regardless of the number of stores in the organization or staff employed. When reading theinstructions for utilizing the assessment and entering data, choose the format and team member-ship that makes the most sense for the store(s) that will be participating in the assessment process.

There are ttwwoo sseeccttiioonnss to the readiness assessment: one for the PPhhaarrmmaaccyy LLeeaaddeerrsshhiipp//OOwwnneerr and onefor PPhhaarrmmaaccyy SSttaaffff. Typically, only one PPhhaarrmmaaccyy LLeeaaddeerrsshhiipp//OOwwnneerr assessment will be completed foreach pharmacy organization, although larger organizations may choose to complete more than onePPhhaarrmmaaccyy LLeeaaddeerrsshhiipp//OOwwnneerr assessment. One or more PPhhaarrmmaaccyy SSttaaffff assessments will be completed,depending on the number of stores owned by the pharmacy organization and selected for participation.The PPhhaarrmmaaccyy LLeeaaddeerrsshhiipp//OOwwnneerr assessment(s) will be linked to the PPhhaarrmmaaccyy SSttaaffff assessment(s).

Each assessment is divided into five distinct elements related to successful implementation of a barcodeproduct verification system. These elements are based on the ISMP Ten Key Elements of the MedicationUse System (for details about these key elements, visit: www.ismp.org/communityRx/aroc/tools.asp).Each element includes multiple items to help a community pharmacy evaluate its readiness for imple-menting this technology. The items in the PPhhaarrmmaaccyy SSttaaffff assessment are the same or related to theitems in the PPhhaarrmmaaccyy LLeeaaddeerrsshhiipp//OOwwnneerr assessment, although the latter tool for pharmacy leadersincludes additional items that are not on the PPhhaarrmmaaccyy SSttaaffff assessment.

Each assessment has items that fall into one of two categories:

PPrreerreeqquuiissiitteess:: These are items that sshhoouulldd bbee iinn ppllaaccee before attempting to implement a barcodeproduct verification system. FFaacciilliittaattoorrss:: These items aarree nnoott rreeqquuiirreedd,, bbuutt wwoouulldd mmaakkee iitt eeaassiieerr to implement a barcode productverification system.

DDiirreeccttiioonnss ffoorr UUssiinngg RReeaaddiinneessss AAsssseessssmmeenntt TTooooll

SSeelleecctt tthhee ssttoorree((ss)) tthhaatt wwiillll bbee ppaarrttiicciippaattiinngg iinn tthhee aasssseessssmmeenntt..

FFoorr iinnddiivviidduuaall pphhaarrmmaacciieess, only one store will complete the assessment. FFoorr iinnddeeppeennddeenntt oorr cchhaaiinn pphhaarrmmaaccyy oorrggaanniizzaattiioonnss wwiitthh mmuullttiippllee ssttoorreess, all or a subset of all storeswill complete the assessment. This tool allows users to link the results of the PPhhaarrmmaaccyyLLeeaaddeerrsshhiipp//OOwwnneerr assessment(s) to PPhhaarrmmaaccyy SSttaaffff assessment(s) for up to 50 stores. Large chainorganizations may want just a sampling of stores to complete the PPhhaarrmmaaccyy SSttaaffff assessment.However, pharmacy organizations desiring participation of more than 50 stores can repeat theprocess for each set of 50 stores and generate separate reports for each set of 50 stores.

EEssttaabblliisshh tthhee aasssseessssmmeenntt tteeaammss..

In most cases, just one team will be appointed to complete the PPhhaarrmmaaccyy LLeeaaddeerrsshhiipp//OOwwnneerr assess-ment. However, very large pharmacy organizations may want multiple teams to complete the PPhhaarrmmaaccyyLLeeaaddeerrsshhiipp//OOwwnneerr assessment. The team(s) should include leaders and other key staff, as applicable,who help design work processes and make business decisions for the pharmacy, such as:

Corporate leadership or the pharmacy ownerDirector of pharmacy services

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Regional field managers/supervisorsClinical informatics representativeNon-clinical information technology representativeRisk management/quality/safety representative

In an independent pharmacy, the owner may serve alone as the only member of the PPhhaarrmmaaccyyLLeeaaddeerrsshhiipp//OOwwnneerr assessment team.

Each individual participating store should appoint an assessment team to complete the PPhhaarrmmaaccyy SSttaaffffassessment. The team(s) should include frontline staff (and middle managers, if applicable), including:

At least one staff pharmacistAt least one pharmacy associate (technician)Pharmacy manager

Although the composition of the teams will vary between pharmacy corporations and independent owners,the teams should include adequate representation from senior leadership, management, and frontline staffas specified above.

Each team should be provided with sufficient time to complete the readiness assessment. Typically,users can expect to spend about 2 hours to complete the PPhhaarrmmaaccyy LLeeaaddeerrsshhiipp//OOwwnneerr assessment andabout 1½ hours to complete each PPhhaarrmmaaccyy SSttaaffff assessment. Additional time is needed to prepare forthe team meetings, as outlined next.

PPrreeppaarree ffoorr tthhee aasssseessssmmeenntt tteeaamm mmeeeettiinnggss..

Establish a meeting time for each assessment team. Have each member of the team read and review theapplicable readiness assessment tool in its entirety before the meeting.

CCoommpplleettee tthhee PPhhaarrmmaaccyy LLeeaaddeerrsshhiipp//OOwwnneerr aasssseessssmmeenntt((ss)) aanndd tthhee PPhhaarrmmaaccyy SSttaaffff aasssseessssmmeenntt((ss))..

Discuss each item in the readiness assessment and evaluate the pharmacy’s success with implementingit. As necessary, investigate and verify the level of implementation with other staff outside of the team. When a consensus on the level of implementation for each item has been reached, place a checkmark in the appropriate column using the following scoring key:

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There has been nnoo aaccttiivviittyy to implement this characteristic in the pharmacy/pharmacyorganization or for any patients, prescriptions, drugs, or staff.

This characteristic has been ddiissccuusssseedd ffoorr ppoossssiibbllee iimmpplleemmeennttaattiioonn in thepharmacy/pharmacy organization, but is not implemented at this time.

This characteristic has been ppaarrttiiaallllyy iimmpplleemmeenntteedd in the pharmacy/pharmacy organizationfor ssoommee oorr aallll patients, prescriptions, drugs, or staff.

This characteristic has been ffuullllyy iimmpplleemmeenntteedd in the pharmacy/pharmacy organization forssoommee patients, prescriptions, drugs, or staff.

This characteristic has been ffuullllyy iimmpplleemmeenntteedd in the pharmacy for aallll patients, prescriptions,drugs, or staff.

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EEnntteerr yyoouurr fifinnddiinnggss aannoonnyymmoouussllyy vviiaa tthhee IInntteerrnneett..

Have one member of each team go to www.ismp.org/AHRQ/barcode to enter the team’s findings intoa secure, anonymous database. See below for further instructions on data submission.

GGeenneerraattee aa rreeppoorrtt..

Once the data have been entered, a report can be generated which will identify strengths (itemsscored 4-5) and weaknesses (items scored 1-3) related to the organization’s readiness for imple-menting a barcode product verification system. Discrepancies between the PPhhaarrmmaaccyy LLeeaaddeerrsshhiipp//OOwwnneerr assessment(s) and PPhhaarrmmaaccyy SSttaaffff assessment(s) for the same or similar items will be visible inyour organization’s assessment report, which is accessible to the PPhhaarrmmaaccyy LLeeaaddeerrsshhiipp//OOwwnneerrteam(s) only. See below for further instructions on generating reports.

DDeevveelloopp aanndd eexxeeccuuttee aann aaccttiioonn ppllaann..

Form an improvement team with representatives from both the PPhhaarrmmaaccyy LLeeaaddeerrsshhiipp//OOwwnneerr assess-ment team(s) and PPhhaarrmmaaccyy SSttaaffff assessment team(s). Have this team analyze the results, identify theorganization’s strengths and weaknesses, and develop an action plan to improve the organization’sreadiness for implementing a barcode product verification system. Discrepancies between leadershipand staff assessments should be addressed in the action plan. Place higher priority on addressingitems that are considered a PPrreerreeqquuiissiittee (see page 4 for the definition of a PPrreerreeqquuiissiittee).

Execute the action plan and evaluate the organization’s progress in paving the way for successfulimplementation of a barcode product verification system.

DDiirreeccttiioonnss ffoorr EEnntteerriinngg DDaattaa aanndd GGeenneerraattiinngg PPaassssccooddeess aanndd RReeppoorrttss

Pharmacy organizations can enter the results of their completed readiness assessments using our secureweb-based survey form, available on the ISMP website (www.ismp.org/AHRQ/barcode). ISMP will NNOOTTbe able to identify pharmacies that have submitted data, as the PASSCODES used for data entry (seebelow) will be generated by the web-based program and provided only to the pharmacy organization. Toaccess the survey form, go to: www.ismp.org/AHRQ/barcode. The site can be accessed from any computerwith Internet capability. The web-based survey form is a large file and may take a few minutes to access.The detailed instructions for entering the data that follow below are also available on the website and canbe printed for reference before or during the data entry process.

SSeett uupp aa UUSSEERR IIDD aanndd oobbttaaiinn PPAASSSSCCOODDEESS..

Once the assessment website has been accessed, one member of the PPhhaarrmmaaccyy LLeeaaddeerrsshhiipp//OOwwnneerr assess-ment team (or designee) initially will be asked to set up a USER ID and password. Please record the USERID and password, and keep it in a safe place. The USER ID and password will allow the PPhhaarrmmaaccyyLLeeaaddeerrsshhiipp//OOwwnneerr team(s) to view progress with the assessment and the survey report. Forgotten USERIDs and passwords can be sent to the PPhhaarrmmaaccyy LLeeaaddeerr//OOwwnneerr via email.

Once the USER ID has been established, the PPhhaarrmmaaccyy LLeeaaddeerrsshhiipp//OOwwnneerr will be asked how many leader-ship/owner teams and pharmacy staff teams (individual stores) will be participating in the assessment.Once the numbers have been entered, a unique PASSCODE will be issued for each leadership/owner teamand each of the participating stores. These PASSCODES will be used to enter the survey results into the

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secure database and link the findings together. IISSMMPP wwiillll nnoott bbee aabbllee ttoo ttrraaccee tthheessee PPAASSSSCCOODDEESS bbaacckk ttooiiddeennttiiffyy aa ppaarrttiiccuullaarr pphhaarrmmaaccyy oorr pphhaarrmmaaccyy oorrggaanniizzaattiioonn. The PPhhaarrmmaaccyy LLeeaaddeerrsshhiipp//OOwwnneerr will be able toview a list of all the PASSCODES issued when logging in to the database.

DDiissttrriibbuuttee tthhee UUSSEERR IIDD aanndd PPAASSSSCCOODDEESS..

Provide the PPhhaarrmmaaccyy LLeeaaddeerrsshhiipp//OOwwnneerr assessment team(s) with the assigned PASSCODE(s). Provideeach participating PPhhaarrmmaaccyy SSttaaffff assessment team with one of the assigned PASSCODES.

EEnntteerr tthhee aasssseessssmmeenntt fifinnddiinnggss..

Have one representative from the PPhhaarrmmaaccyy LLeeaaddeerrsshhiipp//OOwwnneerr assessment team(s) and one representa-tive from each PPhhaarrmmaaccyy SSttaaffff assessment team enter their findings into the database after logging in(www.ismp.org/AHRQ/barcode, then clicking on the designated hyperlink) and entering the asssignedPASSCODE. The special, web-based survey tool will immediately download the information into a securedatabase maintained solely by ISMP. Each assessment team should enter its findings during a singlesession, as the PASSCODE can only be used once, and a response to each item is required beforeproceeding to the next screen.

Only a PASSCODE, not the USER ID and password, is required to enter the findings from the PPhhaarrmmaaccyyLLeeaaddeerrsshhiipp//OOwwnneerr assessment(s) and the PPhhaarrmmaaccyy SSttaaffff assessment(s). The USER ID and password areused by leadership/owners only to view progress and generate reports.

MMoonniittoorr pprrooggrreessss aanndd ggeenneerraattee rreeppoorrttss..

The USER ID and password created by the PPhhaarrmmaaccyy LLeeaaddeerrsshhiipp//OOwwnneerr will allow authorized users toaccess all data from the pharmacy organization, monitor progress during the assessment process, andview/print a survey report. The aggregate data submitted by PPhhaarrmmaaccyy SSttaaffff will be available for viewing byPPhhaarrmmaaccyy LLeeaaddeerrsshhiipp//OOwwnneerrss, but only the PASSCODES used to enter the pharmacy staff data will bevisible. Thus, pharmacy organizations that have included multiple stores in the assessment process will notbe able to link data to a specific store unless they have manually recorded the store associated with eachPASSCODE before distribution.

Reports that are generated using the PPhhaarrmmaaccyy LLeeaaddeerrsshhiipp//OOwwnneerr USER ID and password will includeresults from the PPhhaarrmmaaccyy LLeeaaddeerrsshhiipp//OOwwnneerr assessment(s) and all PPhhaarrmmaaccyy SSttaaffff assessment(s) thathave been entered into the database. The report will align leadership and staff items that are the same orsimilar so differences between the groups can be easily detected. If you misplace these reports, author-ized users can reenter the PPhhaarrmmaaccyy LLeeaaddeerrsshhiipp//OOwwnneerr USER ID and password to access and reprint areport. However, changes to the data that were originally submitted cannot be made.

LLeeggaall PPrrootteeccttiioonn ooff RReeaaddiinneessss AAsssseessssmmeenntt DDaattaa SSuubbmmiitttteedd ttoo IISSMMPP

The Institute for Safe Medication Practices (ISMP) is a Federally Certified Patient Safety Organization(PSO). As described in the 1995 Patient Safety Act, any patient safety data—such as the results of thisreadiness assessment—that has been collected within an organization’s patient safety evaluation systemand prepared for the purpose of submitting the data to a certified PSO is granted Federal protection ofthat patient safety data. This means that the readiness assessment data submitted to ISMP by a healthcarepractitioner cannot be used against the pharmacy organization or any of its employees during a civillawsuit. The information is protected from legal discovery, and neither ISMP nor the pharmacy organiza-tion will be required to disclose the information if the above-mentioned conditions have been met.

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DDeemmooggrraapphhiiccss AAbboouutt yyoouurr aasssseessssmmeenntt tteeaamm

Please indicate the number and type of individuals who participated in completing this PPhhaarrmmaaccyyLLeeaaddeerrsshhiipp//OOwwnneerr section of the assessment tool.

Corporate Leadership/Pharmacy Owner ________

Director of pharmacy services ________

Regional field managers/supervisors ________

Clinical informatics representative ________

Non-clinical information technology representative ________

Risk management/quality/safety representative __________

Other:__________ ____________(number) (type of individuals)

AAbboouutt yyoouurr pphhaarrmmaaccyy oorrggaanniizzaattiioonn

Please check the one category that best describes this type of pharmacy organization.

Independent pharmacy Traditional chain pharmacyMass merchant chain pharmacy Supermarket chain pharmacyHospital outpatient pharmacy Long-term care pharmacyHMO Pharmacy Mail order pharmacy Other: ____________________

Please check the appropriate box indicating the total number of stores in your pharmacy organization.

1 2 to 5 6 to 9 10 to 4950 to 99 100 to 499 500 to 999 1,000 or more

Please check the one category that best describes the type of ownership of this pharmacy organiza-tion.

Privately owned, for-profit Investor-owned, for-profitInstitution owned, nonprofit State or local government ownedMilitary Veterans AffairsUS Public Health Service Other: ____________________

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PPrreerreeqquuiissiittee::Item should bein place beforeimplementingbar-coding

FFaacciilliittaattoorr:: Item notrequired butwould make iteasier to implement bar-coding

No activity

PossibleImplementation

PartiallyImplemented

FullyImplementedSome

FullyImplemented All

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RReeaaddiinneessss AAsssseessssmmeenntt TToooollttII.. EEnnvviirroonnmmeennttaall FFaaccttoorrss Environmental factors, such as poor lighting, cluttered work spaces, noise, interruptions, and non-stop activitycontribute to medication errors when healthcare providers are unable to remain focused on the medication useprocess. Staffing pattern deficiencies, excessive workload, and complex work processes also contribute to abroad range of errors. In addition, building an infrastructure into the environment that supports advances intechnology presents unique challenges to healthcare organizations today.

IItteemm ## PPrreerreeqquuiissiittee//FFaacciilliittaattoorr EElleemmeenntt � 2 3 4 5 NNAA

TTeecchhnnoollooggyy EEnnvviirroonnmmeenntt1 FF The pharmacy has successful experience with integrating/

interfacing information system technologies.2 FF Barcode technology is available and already used for various

functions in the pharmacy (e.g., point of sale, reordering stock)3 FF A network to support information transfer via radio frequency is

available in the pharmacy.4 PP Information systems are protected with security and access

control systems.5 PP An information system back-up process has been prepared in case

of a technology failure. 6 PP Recovery and back-up plans associated with technology failures

are regularly tested in the pharmacy or pharmacies.7 PP Resource allocation plans for a barcode product verification

system have factored in the costs associated with hardware andsoftware requirements (including interface costs), and staffingresources needed to maintain the system.

PPhhyyssiiccaall EEnnvviirroonnmmeenntt8 PP Consideration has been given to where to place computer termi-

nals, docking stations, battery chargers, and other equipmentassociated with a barcode verification system in a manner thatbest supports the natural workflow of the dispensing process.

9 PP There is adequate space in the production section of thepharmacy for computer terminals and other hardware associatedwith a barcode verification system.

10 PP There is adequate space in the prescription verification section ofthe pharmacy for computer terminals and other hardware associ-ated with a barcode verification system.

11 PP There are sufficient electrical outlets in the pharmacy for chargingand operating the equipment associated with a barcode verifica-tion system.

12 PP Resource allocation plans for a barcode product verificationsystem have factored in costs associated with changes needed inthe physical environment.

WWoorrkkflflooww13 PP The processes associated with medication dispensing have been

thoroughly examined through flowcharting or process mappingto promote detailed understanding of staff needs and the currentworkflow.



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14 FF Pharmacists and pharmacy associates consistently follow existingprocesses for medication dispensing. (Variations in the wayprescriptions are filled, checked, and dispensed make the applica-tion of technology difficult.)

15 FF The impact of a barcode product verification system on timerequirements, work rhythm, and job responsibilities has beenevaluated by comparing a flowchart of the hypotheticaldispensing process with the technology against a flowchart of thecurrent dispensing process without the technology.

16 PP A process has been established to make staff aware of the targetedtimeline for installation of the barcode product verification systemso that interruptions can be anticipated and managed.

II.. EEnnvviirroonnmmeennttaall FFaaccttoorrss (continued)


IIII.. DDrruugg LLaabbeelliinngg,, PPaacckkaaggiinngg,, aanndd NNoommeennccllaattuurreeTo facilitate proper selection of medications during the dispensing process, pharmacies should ensure that allproducts are available in clearly labeled packages and take steps to prevent errors with look-alike and sound-alike drug names, ambiguous drug packaging, and confusing or absent drug labels.


17 FF Wholesaler price labels on commercial products do not hide thecontainer’s barcode or portions thereof, or any other vital labelinformation.

18 PP Standard operating procedures ensure that auxiliary or warninglabels on packages do not hide the container’s barcode orportions thereof, or any other vital label information.

19 PP Standard operating procedures ensure that the “X” used to markopen stock bottles does not cross over the manufacturer’sbarcode.

20 PP The capacity to place a bar-coded label on return-to-stock itemshas been anticipated, and standard operating procedures forcarrying out this process have been developed in accordance withapplicable state pharmacy regulations.

21 PP Procedures have been developed to test the barcode on packagesfrom new manufacturers or for new products to ensure it isscannable and accurate.

22 PP Procedures have been identified to address situations whencommercial products arrive in the pharmacy with no barcode orhave a barcode that cannot be scanned.

23 PP Procedures have been identified to ensure accurate scanning ofNational Drug Code (NDC) numbers when the manufacturer doesnot utilize leading zeros in the NDC number on the stock label. (Abarcode system cannot directly match the pharmacy labelbarcode and the manufacturer’s barcode if one includes leadingzeros and the other does not.)





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IIVV.. SSttaaffff CCoommppeetteennccyy aanndd EEdduuccaattiioonnEducation can play an important role when combined with system-based error-reduction strategies. However,activities with the highest leverage include ongoing assessment of healthcare providers’ baseline competenciesand education about new medications, non-formulary medications, new technologies related to medication use,high-alert drugs, and medication-error prevention strategies.

IIII.. DDrruugg LLaabbeelliinngg,, PPaacckkaaggiinngg,, aanndd NNoommeennccllaattuurree (continued)


26 PP Drug information updates, including NDC numbers and productimages, for pharmacy computer systems are received from adatabase vendor and loaded at least once each quarter (every 3months).

27 PP Medications listed in the pharmacy computer system databaseinclude the NDC for prescription drug products (or anotherunique code useful in the scanning process) and the UniversalProduct Code (UPC) for over-the-counter products.

IIIIII.. DDrruugg IInnffoorrmmaattiioonnTo minimize the risk of errors, up-to-date drug information must be readily accessible to pharmacy staffthrough references and computerized drug information systems.


24 FF A method has been developed to add pharmacy-compoundeddrug products to the drug file so that a scannable barcode on thelabel can be generated.

25 PP Label printers have the capacity to produce a high-resolutionbarcode (C or better ANSI [American National Standards Institute]standard) on prescription labels, drug monographs, and thepatients’ receipts.



28 FF The periodic use of pharmacy agency staff or per diem staff whohave little or no orientation to the pharmacy systems, technology,processes, and workflow is minimized.

29 PP In the past year, educational programs and interactive discussionshave been held with pharmacy staff about the value of barcodeproduct verification systems.

30 PP In the past year, educational programs and interactive discussionshave been held with pharmacy supervisors/leaders about thevalue of barcode product verification systems.



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31 PP Capabilities have been assessed regarding the organization’sability to provide educational programs and hold interactivediscussions with all potential users of the barcode system to beinstalled later, including float per diem staff.

32 PP In the past year, interactive discussions have been held with frontlinepharmacy staff about potential anxieties and job dissatisfactionrelated to the use of barcode technology, in order to reduce the riskof circumventing or ignoring the technology.

(Examples include anxieties and job dissatisfaction related to loss ofcontrol over aspects of the job that were previously important toprofessional staff, degradation of clinical skills that are replaced bytechnology, the impact of technology on the professional staff’s worklife, suspicions about technological capabilities, concern aboutpotential tracking of individual medication error rates, untoward useof tracking data, and unchecked optimism and complacency due tooverreliance on technology.)

33 PP Qualified pharmacy or corporate personnel are available forongoing staff training and support once the barcode system is upand running.

34 PP Resource allocation plans for a barcode verification system havefactored in the costs associated with training professional staff touse the system (including indirect costs associated with staffreplacement during training).

IIVV.. SSttaaffff CCoommppeetteennccyy aanndd EEdduuccaattiioonn (continued)

VV.. CCuullttuurree,, QQuuaalliittyy IImmpprroovveemmeenntt,, aanndd RRiisskk MMaannaaggeemmeenntt PPrroocceesssseessPharmacies need strong leadership, planning, and collaboration to improve medication safety. They needsystems for identifying, reporting, analyzing, and reducing the risk of medication errors. A culture of safetymust be cultivated to encourage frank disclosure of errors and near misses, stimulate productive discussions,and identify effective system-based solutions. Strategically placed quality control checks also are necessary.Simple redundancies that support a system of independent double checks for high-risk, error-prone processespromote the detection and correction of errors before they reach and harm patients.



LLeeaaddeerrsshhiipp aanndd PPllaannnniinngg35 PP Pharmacy leadership/owners are committed to expanding use of

proven technologies to improve medication safety.

36 PP A barcode product verification system fits well into the corpo-rate/independent pharmacy’s overall clinical information systemplanning strategy.

37 PP The desired goals associated with a barcode product verificationsystem (e.g., targeted safety improvements, financial gains,productivity impacts, how the technology will be used to enhancethe organization’s mission and maintain its values) have beendefined (and agreed upon in corporate entities) and clearly articu-lated by pharmacy leadership/owners to pharmacy staff.





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FFaacciilliittaattoorr:: IItem notrequired butwould make iteasier to implement bar-coding


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38 PP Pharmacy leadership/owners are committed to allocating theresources necessary to implement a barcode product verificationsystem.

39 FF Pharmacy leadership/owners have taken steps to ensure that theimplementation of barcode verification technology will not createproblems with labor regulations or concerns if job responsibilitieschange.

40 PP Pharmacy leadership/owners have involved a representativesample of frontline pharmacists and pharmacy associates (e.g.,technicians) in initial discussions and planning meetings to solicitinput regarding how the technology will affect pharmacyworkflow.

41 PP Criteria for evaluating potential vendors’ stability, experience,service, and specific technological characteristics for a barcodeproduct verification system have been compiled (see Appendix B,EElleemmeennttss ttoo CCoonnssiiddeerr DDuurriinngg VVeennddoorr SSeelleeccttiioonn).

42 PP A core team comprising frontline staff, managers, clinical informa-tion technology expert, risk manager (if applicable), and corporateleaders/owner has been identified to make recommendationsregarding vendor selection, clinical support requirements, andtechnology requirements.

43 PP The core team plans to visit other pharmacies currently using thebarcode product verification systems under consideration.

44 PP The core team has authority to set timelines, define specificationsand processes, and work closely with the users of the barcodeproduct verification system to elicit feedback and remedytechnology and workflow issues.

45 FF Pharmacy leadership/owner(s) has assigned at least one staffmember responsibility to seek out and communicate informationabout barcode verification systems’ problems from externalsources (e.g., medical literature) that might affect proper use of thebarcode product verification technology.

46 PP Resource allocation plans for a barcode product verificationsystem have factored in the costs associated with staff time spenton the core team charged with facilitating implementation of thetechnology.

CCuullttuurree47 PP Pharmacy leadership/owners demonstrate a commitment to

patient safety by creating a safe environment for pharmacy staff toreport risks and errors and by encouraging staff to report errorsand safety concerns, including those related to technology.


VV.. CCuullttuurree,, QQuuaalliittyy IImmpprroovveemmeenntt,, aanndd RRiisskk MMaannaaggeemmeenntt PPrroocceesssseess (continued)



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48 FF Reportable events include hazardous situations that could lead toan error as well as actual errors, including those that have beendetected and corrected before they reach a patient.

49 FF Pharmacy staff report and openly discuss errors without undueembarrassment or fear of reprisal from peers and managers/leadership/owners.

50 PP Pharmacy staff feel comfortable reporting and frankly discussingany barriers they encounter to following existing processes(standard operating procedures) related to medication dispensing.

51 PP Data related to medication errors are not used by managers/leadership/owners as a measure of employee competence orvigilance during performance evaluations. (Score 1 if errors areused to measure competence or vigilance during performanceevaluations; score 5 if errors are never used for this purpose.)

52 FF Discussions have been held with frontline pharmacists and associ-ated staff to prepare them for increased error detection capabili-ties with barcode product verification systems, in order to preventdefensive attitudes when the data are available and reviewed.

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53 FF A process has been established to utilize focus groups of frontlinestaff for “off the record” discussions to learn about perceivedproblems with the dispensing process.

54 FF A system is in place to review error reports and feedback forquality improvement purposes.

55 FF Effective mechanisms are in place to provide regular, meaningfulreports to pharmacy staff about progress with medication safetyobjectives.

56 FF Effective mechanisms are in place to provide regular, meaningfulreports to pharmacy leadership/owner/managers about progresswith medication safety objectives.

57 FF Medication safety objectives are celebrated and widely communi-cated when met.

UUssiinngg DDaattaa ttoo IImmpprroovvee MMeeddiiccaattiioonn SSaaffeettyy

58 PP Pharmacy leadership/owners demonstrate strong interest in beingable to intercept potential errors before they reach patients.

59 PP Time and resources have been allocated to analyze and useaverted errors data generated by the barcode technology forsystem enhancements and other improvements.

VV.. CCuullttuurree,, QQuuaalliittyy IImmpprroovveemmeenntt,, aanndd RRiisskk MMaannaaggeemmeenntt PPrroocceesssseess (continued)



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