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Law forcing pharmacies to scan drugs could reduce ‘look-alike’ errors

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Janice Perkins: "Some of the most common dispensing errors are look-alike issues"
Janice Perkins: "Some of the most common dispensing errors are look-alike issues"

An EU directive forcing every pharmacy to install barcode scanners by 2019 could reduce errors caused by similar-looking medicines, Well Pharmacy’s superintendent has said.

The Falsified Medicines Directive (FMD) will require new packs of prescription medicine to have a barcode and an anti-tampering device (ATD). From February 9, 2019, every pharmacy in the UK will be required to check the ATD and scan the barcode to 'decommission' the medicine.

Well superintendent Janice Perkins – who is also chair of the Community Pharmacy Patient Safety Group – told C+D: “Some of the most common dispensing errors are well known look-alike sound-alike issues and this is an ongoing challenge.”

“The use of barcode scanning has the potential to virtually eliminate this issue,” she said last month (April 27).

A National Pharmacy Association (NPA) Medication Safety Officer (MSO) report stated that, between October and December 2017, there had been an “increase in serious cases” of look-alike sound-alike errors involving drugs such as esomeprazole and escitalopram, and rabeprazole and rivaroxaban.

“Secondary care has done some great work” as part of its ‘scan for safety’ project – the introduction of barcoding standards – and Ms Perkins said “FMD also has the ability to facilitate this [in community pharmacy] as products will be scanned as part of the decommissioning process”.

WHO global patient safety challenge

The World Health Organisation’s (WHO) global patient safety challenge, launched in March 2017, identified “confusing ‘look-alike sound-alike’ medicines names and/or labelling and packaging” as “frequent sources of error and medication-related harm” around the globe.

The Community Pharmacy Patient Safety Group – which consists of representatives of all of the larger pharmacy chains, as well as the NPA – has been "challenged" by England's chief pharmaceutical officer Keith Ridge as part of the WHO initiative, said Ms Perkins.

The group will be “working with NHS Improvement on [look-alike sound-alike errors] in the coming months and also exploring the human factors relating to this”, Ms Perkins explained.

“We all know [look-alike sound-alike errors have] been happening for a long period of time. If it was easy to fix then it would have been fixed,” she added. “The use of technology might take us into a different perspective with that.”

15 Comments
Question: 
Do you think installing scanners will make your pharmacy safer?

R A, Community pharmacist

Or maybe hire more staff or reducing workload could also decrease the risk of making mistake!

Benjamin Leon D'Montigny, Non Pharmacist Branch Manager

I seem to remember there being a study that showed that standardised blank packaging with basic description resulted in fewer errors compared to current packaging.

Lucky Ex-Locum, Superintendent Pharmacist

This is true. When everything was in plain pots and the only way to find out what was in it was to read the label, errors were very rare.

Daniel McNulty, Superintendent Pharmacist

Compare that advantage to the potential errors with multiple patients' bags reopened and rescanned at the point of supplying at busy times of the week and the even more harrassed staff even more rushed off their feet due to the extra time all this takes.

Has anyone organising pharmacy noticed that hospitals and community pharmacies are different?

Jagdeep Johal, Community pharmacist

I have seen this implemented in other countries and it's actually a great tool. The system also prints off bag labels to be scanned out at the point of pick up. Which is a great help when patients are questioning if they got their medication because a quick check will tell you if it's been scanned out of the pharmacy or not!

Really? Wow, Superintendent Pharmacist

My PMR scans out all medicines on pick up and its recorded.... I refer to this every day.

Lucky Ex-Locum, Superintendent Pharmacist

Which system is that?

A Hussain, Senior Management

Possibly Analyst as it has this feature

George Ibrahim, Community pharmacist

Yes Analyst has it. It allows you to scan the product barcode and you can order by EAN number in my experience which allows an acuity with respect to ‘specific manufacturer’ requests. Teva atenolol and allopurinol 100mg is the worst culprit of these identical box situations 

A B, Community pharmacist

I believe most PMR system providers are going to have a mechanism to allow an aggregated barcode to go on the bag label which covers all of the medicine inside. So you would only have to scan the bag and not the individual items inside. 

This will help a bit, but I agree this will be a big headache when it comes into force.

I found this website to have some decent information: www.fmdsource.co.uk ,especially the FAQ section.

Richard MacLeavy, Non Pharmacist Branch Manager

But at some point you will have to scan each individual medicine otherwise how will it know which medicines to decomission. Its this that will take the time

 

A B, Community pharmacist

Yes, you would have to scan the product during the dispensing process to make up the aggregated barcode to go on the bag label. 

Delectable Skeptic, Community pharmacist

Shouldn't be such a thing as "lookalike errors" if the manufacturers were actually interested in patient safety.  It is a regulatory failure as well as a failure of common sense.  Not hard to make the packs different enough but still retain your company's branding.

Sandra Wiles, Community pharmacist

Completely agree with you - the MHRA should be making manufacturers produce packacking that is visually distinctive plus a picture of the tablet on the front. 

Lucky Ex-Locum, Superintendent Pharmacist

How about the drug companies make packs look different to each other? That would work as well but might be too radical I suppose.

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