June 18th 2017 1

An SBAR of the proposed technology change

Situation:

There is a possibility of making errors when dispensing prescriptions and in

particular dispensing an inaccurate medication, inaccurate strength or inaccurate

manufacturer (where some patients can only take certain manufacturers due to side

effects) which can in turn cause due harm to the patient. Current technologies being

used in preventing dispensing errors include bar code scanning and pharmacist visual

verification. There is however still additional scope for improvement.

Background:

Preventing prescription errors is potentially a $7 billion market. It is estimated

that a typical pharmacist fills about 13,000 prescriptions annually (Flynn, Barker &

Carnahan, 2013). According to a study posted in the Journal of American

Pharmaceutical Association (Flynn et al, 2003) noted that there are an estimated 3.3

million potentially important prescription errors among the 3 billion prescriptions filled

annually in the US (Flynn et al, 2003). Another study also noted that there are

approximately 100 undetected dispensing errors each day (Preventing Medication

Errors: A $21 Billion Opportunity, n.d). A report published by HPSO/CNA stated that

dispensing the incorrect drug has the highest percentage of claims at 43.8% and the

wrong dose made up 31.5% of the total professional liability closed claims (Gross,

2013).
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Assessment:

A review of the current pharmacy retail environment shows us that there can be

multiple times when a pharmacist can be distracted such as when the phone rings, a

patient or pharmacy technician is asking a question, they are multi-tasking for example

they be on hold with a doctor’s office or insurance company and are verifying filled

prescriptions at the same time. Although there are current safety checks in place there

are still occurrences of prescription misfiles. There is a need to provide additional

capabilities in order to minimize prescription errors to a goal of 0%.

Recommendation:

The use of visual computer aided machine learning algorithms can be used to

help provide a ‘second pair of eyes’ to ensure that the right medication is filled in the

right vial. The use of a visual camera/scanner can verity that the medication in the vial

is not only the right medication but the right strength and from the right manufacturer.

References:

Flynn, E. A., Barker, K., & Carnahan, B. (2003, March & April). National Observational

Study of Prescription Dispensing Accuracy and Safety in 50 Pharmacies.

Retrieved June 14, 2017, from http://www.scriptpro.com/Studies/National-

Dispensing-Accuracy-Study

Preventing Medication Errors: A $21 Billion Opportunity - NEHI. (n.d.). Retrieved June

14, 2017, from http://www.nehi.net/bendthecurve/sup/documents/Medication

_Errors_%20Brief.pdf
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Gross, A. (2013, November 11). HPSO report examines pharmacist liability. Retrieved

June 14, 2017, from http://www.pharmacist.com/hpso-report-examines-

pharmacist-liability