Errors detected in pediatric oral liquid medication doses prepared in an automated workflow management system.
PURPOSE: The effectiveness of barcode-assisted medication preparation (BCMP) technology on detecting oral liquid dose preparation errors.
METHODS: From June 1, 2013, through May 31, 2014, a total of 178,344 oral doses were processed at Children's Mercy, a 301-bed pediatric hospital, through an automated workflow management system. Doses containing errors detected by the system's barcode scanning system or classified as rejected by the pharmacist were further reviewed. Errors intercepted by the barcode-scanning system were classified as (1) expired product, (2) incorrect drug, (3) incorrect concentration, and (4) technological error. Pharmacist-rejected doses were categorized into 6 categories based on the root cause of the preparation error: (1) expired product, (2) incorrect concentration, (3) incorrect drug, (4) incorrect volume, (5) preparation error, and (6) other.
RESULTS: Of the 178,344 doses examined, 3,812 (2.1%) errors were detected by either the barcode-assisted scanning system (1.8%,
CONCLUSION: BCMP technology detected errors in 1.8% of pediatric oral liquid medication doses prepared in an automated workflow management system, with errors being most commonly attributed to technological problems or incorrect drugs. Pharmacists rejected an additional 0.3% of studied doses.
American journal of health-system pharmacy : AJHP : official journal of the American Society of Health-System Pharmacists
Administration, Oral; Child; Drug Compounding; Hospitals, Pediatric; Humans; Medical Records Systems, Computerized; Medication Errors; Pharmaceutical Solutions; Pharmacists; Pharmacy Service, Hospital; Professional Role; Workflow
barcode; barcode-assisted medication preparation; medication; preparation; safety; workflow
Bledsoe, S., Van Buskirk, A., Falconer, R., Hollon, A., Hoebing, W., Jokic, S. Errors detected in pediatric oral liquid medication doses prepared in an automated workflow management system. American journal of health-system pharmacy : AJHP : official journal of the American Society of Health-System Pharmacists 75, 127-131 (2018).