Pharmacy Guidance Document - himss

Guidance Document: 

Costs, Benefits and Potential Unintended 

Consequences of Automating the Pharmacy 

Medication Cycle in Acute-Care Settings 

Enterprise Information Systems Steering Committee 

Nursing Informatics Committee and 

Pharmacy Task Force 

January 2010 

©2010 by the Healthcare Information and Management Systems Society (HIMSS) 

1

Authors 

David Butler 

Yadim David 

Suzanne Enquist, RPh 

Chris Jellison, RPh 

Tara K Jellison, PharmD 

Martin Kappeyne 

Dennis A. Tribble, PharmD 

James Stewart 

Judy Van Norman 

President, Heartland Innovations LLC 

Biomedical Engineering Consultants LLC 

Asst. Professor, Baylor College of Medicine and University of Texas School 

of Public Health 

Sparrow Health System, MI EMR Project Team 

Parkview Hospital, IN Pharmacy Inventory Manager 

Parkview Hospital, IN Pharmacy Clinical Manager 

Green Leaves LLC, Principal 

Chief Pharmacy Officer, Chief Technology Officer 

AmerisourceBergen Technology Group, IL Director, Integration Engineer 

Banner Health, Sr. Director Care Transformation 

Contributors / Editors 

Christel Anderson 

Denny C. Briley, PharmD 

Janet Bochinski, MSN, PNP 

Edna Boone, MA, CPHIMS 

John Falkenholm, PharmD 

Pat Feehery RN, BS, CRNI, CLNC 

James J. Finley, MBA, RN-BC 

Kevin Glaza, RPh 

HIMSS, Senior Manager Clinical Informatics, Staff Liaison 

GE Healthcare IT, Enterprise Solutions Product Strategy, Pharmacy 

Unisys Corporation, Manager 

HIMSS, Senior Director HIS, Staff Liaison 

Lutheran General Hospital, IL Pharmacy Manager 

Sparrow Health System, MI EMR Inpatient Clinical Project Manager 

Dearborn Advisors, Delivery Services Executive 

Sparrow Health System, MI EMR Project Team 

Melissa Glaza, RPh, MHA Sparrow Health System, MI Lead Application Coordinator EPIC Rx / 

Beacon 

Mike Hibbard, RN, MHSA, PMP 

Timothy R. Lanese, RPh, MBA, 

FASHP, CPHIMS 

Susan Lessani, RN 

Jane McNeive, RN-BC 

Nicole A. Mohiuddin, MS, RN-BC 

Cheryl D. Parker, RN, MSN, PhD 

Mercy Health Partners, Chief Information Officer, Clinical Informatics 

Officer, Central Division 

Eclipsys Corporation, Solutions Consultant - Pharmacy 

CareFusion, Clinical Analytics Consultant 

Stormont-Vail HealthCare, IS Applications Manager 

Title? Independent, IL 

Motion Computing, Senior Informatics Specialist 


2

Susan Robertson, RN, MSN, CPHQ 

Darla S. Shehy, BSN, RN 

Portia Towns, LPN, BHA/HIS 

Mike Wisz, MBA 

Michael H. Zaroukian, MD, PhD, 

FACP 

North Shore Long Island Jewish Health Systems, Director, Clinical 

Information Systems 

Penn State Hershey Medical Center, Manager of Nursing; Quality and 

Informatics 

North Shore/LIJ Health Systems, Project Manager EMR - Operational 

Specialist 

Principal, Mike Wisz & Associates 

Michigan State University , Chief Medical Information Officer and Professor 

of Medicine, Director Clinical Informatics and Care Transformation Sparrow 

Health System, MI 


3

Table of Contents 

1. INTRODUCTION....................................................................................................... 5 

1.1. Purpose.......................................................................................................... 5 

1.2. Scope and Organization of Guidance Document ....................................... 5 

2. OVERVIEW: THE INPATIENT MEDICATION MANAGEMENT PROCESS .................. 6 

3. PRINCIPAL TECHNOLOGIES................................................................................ 9 

3.1. Auto-ID: .......................................................................................................... 9 

3.2. Pharmacy Inventory Management ............................................................. 14 

3.3. Drug Unit-Dose Packaging ......................................................................... 17 

3.4. Pharmacy Bar coding/Labeling.................................................................. 20 

3.5. IV Compounding Systems / Automated Bag & Syringe Fillers/Automated 

Infusion Compounding Robots.................................................................. 24 

3.6. Central Pharmacy Robotic Dispensing Systems ..................................... 32 

3.7. Decentralized Automated Dispensing Cabinets....................................... 38 

3.8. Electronic Medication Administration Record (eMAR) ............................ 41 

4. CONCLUSION ........................................................................................................ 44 

APPENDIX A - REFERENCES ....................................................................................... 46 


4

1. INTRODUCTION 

1.1. Purpose 

This guidance document provides pharmacy and nursing professionals with concise, 

practical information on selecting and deploying available technologies for automating 

the movement of medications and the location tracking of pharmacy-related devices 

(e.g., automated infusion pumps) in acute-care settings. In so doing, we will emphasize 

the flow of medications and medication-related work processes from the receiving dock 

to the pharmacy, to the unit of care, and finally, to the patient’s bedside for 

administration. We will look at how these technologies help pharmacy and nursing 

professionals receive, process, distribute and administer medications in a safe, timely 

and efficient manner. Although data on cost-benefit and return-on-investment remain 

sparse and reports largely anecdotal, we will attempt to give the reader a sense of the 

strength of the current business case for investing in pharmacy-related automation in 

acute-care settings, while acknowledging the potential unintended consequences that 

may be encountered. 

1.2. Scope and Organization of Guidance Document 

In accordance with the purpose of this guidance document and considering the very 

busy health professionals for whom it is intended, we have limited the scope of the 

document to provide a concise overview of the technologies and principles for effective 

pharmacy-related automation in acute-care settings. A corresponding executive slide 

deck is also available to facilitate communication about the potential business case for 

expanding pharmacy-related automation in the acute-care setting. Each technology 

section is structured to provide answers to the following practical questions: 

• What is this technology, how does it work and how has it been put to work in 

pharmacy-related automation activities? 

• In which stages of medication management in the acute-care setting can this 

technology be most helpful? 

• What benefits can I expect from the use of this technology? How strong is the 

evidence for such benefits? 

• What unintended, adverse consequences are associated with the use of this 

technology? How can the risks be mitigated? 

• How does this technology work with other pharmacy-related automation 

technologies, and do they need to be in place for this technology to work? 

• What is the cost to implement this technology in a typical 250-500 bed acute-care 

facility? Are there credible examples of published cost-benefit analyses that 

provide a strong business case for the use of this technology? 

• Where can I obtain more information about this technology? 


5

This guidance document is organized according to pharmacy-related automation 

technology types, with each technology introduced and discussed in order of its 

appearance and relevance to the stages of medication management in acute-care 

settings—from arrival at the facility to patient medication administration at the patient’s 

bedside. In order of appearance, the technologies discussed include: 

1. Auto-ID technologies. 

2. Pharmacy inventory management. 

3. Drug unit dose packaging. 

4. Pharmacy bar coding/labeling. 

5. IV compounding systems/automated bag & syringe fillers/automated infusion 

compounding robots. 

6. Central pharmacy robotic dispensing systems. 

7. Decentralized Automated Dispensing Cabinets (ADC). 

8. Bar code Medication Administration-Electronic Medication Administration Record 

(BCMA-eMAR). 

2. OVERVIEW: THE INPATIENT MEDICATION MANAGEMENT 

PROCESS 

A typical example of the medication management process in an inpatient facility is 

shown in Figure 2-1. This guidance document focuses on the movement of medications 

from their arrival at the facility from the external supply chain, through medication 

processing, dispensing from pharmacy inventory, distribution to patient-care units and 

administration at the bedside. (Processes 3, 4 and 5 in Figure 2-1). 


6

Figure 2-1: Inpatient Medication Management Process 

Medication Cycle Phases 

Monitoring 

phase 

6 

multidisciplinary 

Ordering 

phase 

1 

Verifying 

phase 

2 

P 

Administration 

phase 

5 

HIMSS © 2008 Pharmacy Informatics Task Force: A. Flynn 

Distribution 

phase 

P 

core pharmacy 

4 

Dispensing 

phase 

P 

3 

P 

supply chain 

HIMSS Pharmacy Informatics Task Force 2007© 

For an acute-care facility with automated pharmacy and medication administration 

technologies, the on-site medication management process follows a progression 

through the three major phases, shown in Figure 2-2. 


7

Figure 2-2: Inpatient Medication Management Processes—Guidance Document 

Focus Areas 

The process typically starts with the arrival of medications in the receiving area of the 

acute-care pharmacy. Individual medications may arrive in bulk containers or unit 

doses, with or without bar code or other auto-identification labels that can be read by 

the facility’s pharmacy information system. 

Medications must be unboxed and processed for placement into inventory. Those 

medications that did not arrive with readable bar codes will require additional 

processing, either on arrival or sometime prior to interaction with other pharmacy 

automation technologies. Solid medications arriving in bulk containers can be loaded 

into unit-dose packagers to separate the medications into single-dose packages and 

add an internally recognized bar code to facilitate additional automated processing. 

Unit-dose packaged medications (solid and selected liquid medications) can then be 

presented to a central pharmacy robot (if available) that loads the medications into 

appropriate storage spaces within the robot. The robot subsequently dispenses the 

appropriate medications for individual patients at a specified time as part of a cart fill 

process. 

Meanwhile, other liquid medications and compounded solutions for intravenous (IV) 

administration can be processed using other pharmacy automation technologies and 

prepared for distribution to satellite pharmacies within the acute-care facility, or placed 

in decentralized automated dispensing cabinets (ADC) on care units. Finally, 

medications can be taken from the ADCs and administered to patients at the bedside, 

using pharmacy-related automation technology to verify compliance with the “five rights” 

of medication administration (right patient, right drug, right dose, right time and right 

route). Any medications not administered due to discharge or order changes after 


8

distribution can then be returned to the pharmacy and placed back into inventory, a 

process that can also involve automated methods. 

3. PRINCIPAL TECHNOLOGIES 

3.1. Auto-ID: 

What is auto-ID, how does it work and how has it been put to work in pharmacyrelated 

automation activities? 

Auto-ID represents a broad family of technologies that enable automatic identification of 

people or things. Auto-ID technologies include bar codes, radio frequency identification, 

infrared and ultrasound-based identification systems, magnetic strip cards, optical 

character recognition, voice recognition and biometric authentication systems. 

Bar codes: Bar codes represent the most mature, cost-effective and commonly used 

Auto-ID technology. With the recent adoption of data rich, easily scanned 2-D formats, 

barcoding should be considered a critical element of system solutions targeted at 

reducing errors and improving operational efficiencies throughout the various 

medication handling and administration processes. Bar codes will be covered in more 

detail in section 3.4, “Pharmacy Barcoding/Labeling Technologies.” 

Voice Recognition and Biometric Authentication: Voice recognition and other biometric 

systems are typically used for health professional authentication to computers or room 

access control systems. Fingerprint biometric systems have become a common 

authentication technology in two-factor system sign-on protocols. They have even been 

used in lieu of written signatures for “signing off” on medication orders in some EHR 

systems. Fingerprint authentication provides some definite advantages to badge 

readers, both in terms of workflow enhancements and in eliminating the potential for 

sharing or inappropriately using another individual’s badge to authenticate computer 

access or electronic record approval. 

RFID: Radio frequency identification (RFID) has received significant press and 

discussion in healthcare, as well as other industries, including consumer packaged 

goods and the U.S. Department of Defense (DoD). Although the roots of RFID date 

back to World War II and the development of radar and “Friend or Foe” identification of 

aircraft crossing the English Channel, it is still considered an emerging technology. 1 

RFID uses radio frequency (RF) electromagnetic waves to identify people or things. Like 

an aircraft transponder, an RFID “tag” receives radio signals and responds with a 

unique identifier. An RFID “reader” sends out a radio signal and looks to receive 

identification information from RFID tags within range. Because radio waves do not 

require line of sight and can pass through walls and various substances, RFID enables 

the identification of every tagged item or person in range of the reader, regardless of its 

visibility (such as a patient’s identification wristband beneath bedcovers). Unlike bar 

codes that are read one at a time and require line-of-sight with the bar code reader, 

RFID can potentially identify the entire contents of a closed box or automatically identify 


9

all of the infusion pumps in a given room. Additionally, because the tag is really an 

electronic device, it is possible to read and write information onto the tag throughout its 

life. 2 

RFID devices are designed to be active or passive. Active RFID uses battery-powered 

tags and enables longer read ranges and the potential for additional functionality. Active 

RFID tags can also be used for locating assets or people within hospitals and other 

healthcare facilities. This application is also referred to as Real Time Locating Systems 

(RTLS). Passive RFID tags do not have batteries but rather are powered by the energy 

of the radio waves sent by the RFID reader. Although limited in read range, passive 

RFID tags are significantly lower cost and are thin enough to be embedded in a label or 

easily attached to a small object. 3 

Proximity Cards: One form of passive RFID that is growing in use is the “proximity” card. 

Proximity cards have commonly been used in hospitals as employee badges for room 

access control or user authentication to computer systems and have become the new 

standard for subway access and credit card transactions outside of the United States. 

Proximity cards provide for more rapid read rates than magnetic strip cards; yet with 

their short read ranges, they ensure that only a single, closely aligned card is read. 

Wi-Fi/Ultrasound/Infrared: In addition to pure RFID-based systems, similar technologies 

have emerged to provide a means to automatically locate and identify mobile medical 

equipment and/or people. These include leveraging a WiFi network infrastructure to 

triangulate and locate devices communicating on the network, or installing infrared or 

ultrasound-based systems to enable “room level” location and association of people and 

equipment. These systems are included in the RFID-related discussion that follows. 

RFID and other emerging Auto-ID/location technologies will likely become common— 

even dominant—technologies for automatic identification over the next 10 to 20 years 

as the cost of the technologies declines and clear business cases for their integration 

into clinical systems are refined. Until then, bar codes, magnetic strip employee badges, 

proximity cards and fingerprint readers will remain the dominant strategies for automatic 

identification and authentication. 

In which stages of medication management in the acute-care setting can Auto-ID 

be most helpful? 

Auto-ID has the potential to enhance processes in a number of stages of medication 

management in the acute-care setting, from product delivery at the hospital loading 

dock to administration at the bedside. Bar codes provide a cost-effective and proven 

means to quickly and accurately enter information regarding medications (manufacturer, 

lot number, expiration, formulation, etc.), as well as the identification of staff members 

and patients. Bar coding systems also can provide a time stamp associated with each 

scanning event. As mentioned earlier, employee badges utilizing magnet strips, bar 

codes or proximity cards, fingerprint readers and other biometric sensors can also 

enable efficiencies in quickly identifying and documenting caregivers and other staff 

members involved with managing the storage, dispensing and administration of 


10

medications. These also add a layer of security beyond using passwords to authenticate 

users. 

In the future, RFID tags may be used to detect and prevent counterfeiting and diversion 

of high-value drugs. 4 Although aimed at the supply chain prior to hospital receipt, 

hospital pharmacies could also use these RFID tags to speed up delivery of 

medications to clinical units and help reduce the risk of data entry errors. Some 

manufacturers are designing RFID technology into their systems to confirm that the 

appropriate cartridge or item has been connected to the medication delivery system, 

thereby helping ensure that the patient receives the right drug and dose during a 

procedure. 5 

Active RFID systems can be used as part of an RTLS to locate infusion and IV pumps 

and other mobile equipment critical to delivering and administering medications to the 

right patient, through the right route, at the right time. These RTLSs have been 

implemented in a number of hospitals to enhance the utilization and regulatory 

compliance of mobile medical equipment. A growing number of hospitals have found the 

value of RTLS to be greatest in ensuring that the right equipment is in the right place at 

the right time. Patient flow and operational efficiency in the emergency department 

(ED), operating room (OR) and patient bed areas can be greatly enhanced, with a 

beneficial effect on timely and efficient delivery of required medications. 6 

The visibility of pharmaceuticals at the item level becomes more challenging and laborintensive 

as drugs move from the central pharmacy and are staged in locations closer to 

the point of medication administration. RFID provides a potential way to track and 

manage drugs stored in cabinets or refrigerators in close proximity to patient care areas. 

Passive RFID tags on items or unit-dose packages could be read by “smart” cabinets or 

refrigerators with embedded RFID readers. RFID cabinets are beginning to be installed 

in cardiac catheterization laboratories and other areas where high costs and shelf life 

are critical factors. 

Similarly, medical devices are being tracked and managed by caregivers with the help 

of RFID to reduce costs associated with product outdating, management of lot recalls 

and inventory control, while ensuring appropriate charge capture and product 

documentation. 7 At least one pharmaceutical distributor is using RFID-enabled 

refrigerators to ensure appropriate control of costly specialty drugs consigned to acute 

care facilities. The refrigerator both monitors the contents and the temperature of the 

refrigerator to ensure compliance with temperature requirements and appropriate 

inventory management. 8 A refrigerator manufacturer recently announced an RFIDenabled 

refrigerator that utilizes industry-standard RFID reader technology “to store 

reagents, vaccines and other temperature-sensitive substances.” 9 

Finally, RFID may replace bar codes in the future for bedside medication administration. 

St. Claire Hospital in Pittsburgh, PA, developed a system using passive RFID-enabled 

patient wristbands, passive RFID-enabled staff ID badges and bar coded medication 


11

unit-dose packaging and IV bags. The system employed a handheld device with a dual 

passive RFID/bar code reader attachment. The hospital felt that the RFID provided a 

faster and more accurate read of the patient and staff member than bar code 

technology available at the time. They also liked the fact that they could obtain an Auto- 

ID verification of patient identity in most instances without needing to physically touch 

the patient to rearrange the wristband or move blankets. 10 

What benefits can I expect from the use of Auto-ID? How strong is the evidence 

for such benefits? 

Common to all potential pharmacy-related Auto-ID applications in the acute-care setting 

is the benefit of leveraging the technology to speed up identification, authentication 

and/or location of the item or person of interest. Auto-ID use can improve 

documentation accuracy while also improving workflow speed and efficiency. It also 

helps reduce the amount of time that would otherwise be required to manually sign on 

and off the system, giving health professionals more time for direct patient care. The 

bulk of published studies documenting these benefits involve bar codes and bar code 

medication administration systems. 11,12 

In the future, RTLS that automatically locate mobile assets and people throughout the 

facility will increasingly be used to drive workflow improvements. RFID-enabled smart 

cabinets and refrigerators that automatically take inventory of their own contents will 

enhance inventory management of expensive, limited shelf life medications and 

supplies. RFID use at the bedside of the future also holds the promise of enabling a 

quicker read rate with less inconvenience to the patient, along with the ability to read 

and write information into the patient’s wrist band, providing patient safety enhancement 

opportunities beyond those available from the read-only technology upon which bar 

codes are based. 

What potential, unintended adverse consequences are associated with the use of 

Auto-ID? How can the risks be mitigated? 

All Auto-ID technologies are vulnerable to the possibility that inaccurate data will be 

associated with the bar code, proximity card, RFID tag or other auto-readable item. 

Original data entry accuracy is important to ensure that only correct information is 

automatically transmitted throughout each of the various processes associated with 

medication management and administration in the acute-care setting. Because a bar 

code or RFID scanner may give an audible response that a “read” was successfully 

completed, the caregiver may erroneously assume that all of the information associated 

with the bar code or RFID tag also was correct. 

For example, a bar coded wristband attached to the wrong patient could lead to 

medication administration errors if a second form of patient identification was not 

implemented (picture, verbal questioning, etc.). 

As mentioned above, RFID use in acute-care settings is still an emerging area for which 

potential adverse consequences are still under discussion. For example, concerns have 

been raised regarding potential RFID signal interference with implantable medical 


12

devices. By elevating these concerns, vendors and end users can ensure that the 

systems designed and implemented do not adversely impact the health and well being 

of patients and caregivers. 13 Some hospitals have explored RFID-enabled employee 

badges that can be read from several feet to provide initial sign-on identification for 

shared computers. The concept can work well when only one caregiver is near the 

computer but when multiple staff members are in close proximity to a computer, the 

system may inadvertently sign in or sign out the wrong person. Programming to 

gracefully force out the second user improves the efficiency of using RFID. Another 

consideration in fine-tuning the “readable range” is to consider physical barriers as well 

as body shapes of the caregiver. 

Like other computer systems, Auto-ID enabled systems need to be designed and 

implemented with care to ensure that appropriate electronic security measures are in 

place to prevent theft of confidential patient or hospital information. Bar codes can be 

easily replicated and employee Auto-ID badges can be stolen or used by unauthorized 

personnel. RFID transmissions similar to WiFi broadcasts require consideration by 

vendors to ensure security measures are taken to prevent unauthorized RFID readers 

from capturing confidential information. 14 

Since RFID represents a broad family of technologies, it is important to understand the 

trade-offs of capabilities vs. limitations to ensure an appropriate “fit” for a given 

application. Nowhere is this more apparent than with RTLS. There is a broad range of 

RTLS technologies in use, from highly accurate but expensive Ultra Wide Band (UWB), 

to low-cost Wi-Fi-based systems, to infrared and ultrasound. 

All of these systems can mark a location of an asset or person on a floor plan map; but 

understanding the inherent precision and accuracy of each technology enables better 

selection of the appropriate technology. Some technologies can provide accuracies to 

within a few feet, while others are only good to within 20 feet or 30 feet in all directions. 

Some pioneering hospitals have implemented workflow systems that required 

automatic, real-time location of patients and staff members at a room level, only to find 

that the technology they implemented did not have sufficient accuracy, consistency and 

response time to accurately document care events or patient locations. New 

technologies and innovations are emerging each year, and the ability to capture patient 

location and care delivery events automatically will eventually be solved in an 

economical fashion. 

It is also important to note that while Auto-ID technologies can decrease the risk for 

errors, their use does not eliminate the need for or value of final verification/confirmation 

by the nurse at the bedside. Errors in bar codes and labeling can occur, and the nurse 

who carefully inspects the medication to be given and confirms the five rights prior to 

administering it remains the last, best defense against serious medication administration 

errors. 

How does Auto-ID interface with other pharmacy-related automation technologies 

and do they need to be in place for Auto-ID to operate? 


13

Auto-ID technology itself is an enabler of other solutions; they are not stand-alone 

systems. The ability to automatically identify, authenticate or locate medications, 

equipment, patients and staff members promotes quality, safety and efficiency. A 

cohesive strategy should be developed to maximize the use of technologies like bar 

codes and, in the future RFID, to drive quality and efficiency improvements throughout 

the entire medication management and administration process in the acute-care setting. 

What is the cost to implement Auto-ID in a typical acute-care facility? Are there 

credible examples of published cost-benefit analyses that provide a strong 

business case for the use of this technology? 

As mentioned above and in greater detail in section 3.4, there have been several 

published studies as to the costs and benefits of implementing bar code technology in 

the medication administration process. Due to the emerging nature of RFID technology 

in the healthcare setting, interested organizations should seek out the most current 

information available. 15-17 RFID and other Auto-ID technologies are not stand-alone 

systems, but rather tools that enable hospitals or vendors to automate less efficient 

manual or automated work processes. Sustainable cost-benefit models will only be 

attained when work processes and equipment are re-engineered to leverage the full 

capabilities and limitations of the appropriate technology that enhances the pharmacy 

mission of delivering the right drug at the right time to the right patient in the right dose 

and route. 

Where can I obtain more information about Auto-ID? 

Auto-ID technologies, like RFID, can be further researched by referencing the HIMSS 

Web site in the following areas: 

• Patient Safety and Quality Outcomes Committee 

• Management Engineering and Process Improvement Community 

• Clinical Informatics including: 

o Pharmacy Informatics 

o Nursing Informatics 

• HIMSS Store 18 

3.2. Pharmacy Inventory Management 

What is pharmacy inventory management technology, how does it work, and how 

has it been put to work in pharmacy-related automation activities? 

Pharmacy inventory management solutions take many forms in today’s pharmacy 

practice. One of the primary uses of an inventory management solution is the 

continuous monitoring of drug product quantities in the pharmacy. By establishing 

“MAXimum” and “MINimum” levels for the products stored in the pharmacy, 

appropriately configured inventory systems can generate and transmit electronic orders 

to vendors for additional medication deliveries when product inventories reach the 

MINimum, ordering only the amount needed to reach the MAXimum. Automated 

ordering of just the right amount of medication at just the right time allows for tighter 

control of inventory dollars and, assuming the minimum level is sufficient and delivery is 

timely, ensures adequate on-hand quantities at all times while optimizing inventory turns 


14

and decreasing the likelihood of having medications reach their expiration dates before 

use. Inventory management systems also often serve as a point of electronic integration 

between pharmacy information systems, pharmacy drug vendors, and other pharmacy 

automation systems by receiving requests for drugs from the different systems and 

driving replenishment activities. 

In which stages of medication management in the acute-care setting can 

pharmacy inventory management technology be most valuable? 

A pharmacy inventory management solution is a key component of the hospitalpharmacy 

supply chain. By communicating directly with a drug wholesaler, inventory 

management systems ensure that the correct product is ordered and that the cost 

information stored in the system is accurate and up-to-date. As mentioned earlier, these 

systems are also valuable in driving the different medication replenishment cycles, 

including automated drug cabinet (ADC), cart fill and others. 

What benefits can I expect from the use of pharmacy inventory management 

technology? How strong is the evidence for such benefits? 

One benefit of using a pharmacy inventory management solution is that it can bring 

improved consistency and efficiency to many processes. As various systems interface 

with the inventory management system, the picking processes are the same for cart fill, 

first fill (cart fill update), and ADC replenishment. This process consistently allows for 

easy training and fewer errors. 

Another benefit pharmacy inventory management technology brings is the opportunity 

to accurately report drug expense. Because the system tracks inventory and cost 

information, the pharmacy department can take purchasing information and reconcile 

the data with fluctuations in inventory value to get a more complete and accurate view 

of expenses. 

Additionally, the pharmacy department’s ability to generate activity reports is enhanced 

because replenishment data from multiple systems are aggregated in a single 

database. This also allows for identification of products that are rarely used and should 

be considered for removal from the hospital formulary. 

Pharmacy inventory management systems can also help reduce the manual labor 

needed to maintain the pharmacy inventory. The automatic monitoring feature of such 

systems can replace much of the traditional human workflow process of “walking the 

shelves” to update inventories and make re-order timing decisions. 

What potential, unintended, adverse consequences can be associated with the 

use of pharmacy inventory management technology? How can the risks be 

mitigated? 

Like any technology, a pharmacy inventory management system is only as good as the 

information it contains. Monthly cycle counts must be performed to ensure the inventory 

report is accurate. Accurate and timely backups of the system must be performed and 


15

several days’ backups should be archived to ensure that corrupt data do not overwrite 

the only good backup. 

The ability to generate meaningful information from a pharmacy inventory management 

system also depends on the ability to easily integrate data from multiple systems into a 

single database (i.e., doses dispensed vs. doses administered). This can often be a 

challenge as data exports can be difficult and vendors are not always forthcoming with 

their data dictionaries. 

Inventory management systems are usually interfaced to another “picking” solution (i.e., 

re-packager, carousel, robot, etc.). When a problem arises with the interface between 

the pharmacy inventory management system and one or more “picking” solutions, the 

normally interfaced data will need to be added manually, which can have a significant 

negative impact on workflow efficiency and introduce the risk of data entry errors. 

While the pharmacy inventory management system may serve as an excellent solution 

for most medications, there will likely remain at least a few critically important but 

inconsistently used drugs that will require manual monitoring. Such medications cannot 

be allowed to be “out of stock” for patient safety. 

How does pharmacy inventory management technology work with other 

pharmacy-related automation technologies? Do they need to be in place for 

pharmacy inventory management technology to work? 

Pharmacy inventory management systems are often interfaced to a pharmacy 

information system, a drug wholesaler, and ADCs. Additionally, within the pharmacy, 

these systems often facilitate the replenishment cycle by providing data to re-packaging 

and picking systems. These systems can also be linked to automated inventory control 

equipment, such as a carousel. 

However, to provide benefit to the pharmacy department, only one system needs be 

present to track decrements in the inventory and one system to track increments in the 

inventory. This is most often provided by a pharmacy information system and a drug 

wholesaler system, respectively. The remainder of the systems mentioned (repackager, 

ADCs, etc.) are not prerequisite technologies for the pharmacy inventory 

management system to be effective, although they can bring additional efficiencies to 

medication management processes. 

What is the cost to implement pharmacy inventory management technology in a 

typical acute-care facility? Are there credible examples of published cost-benefit 

analyses that provide a strong business case for the use of this technology? 

Purchasing a pharmacy inventory management system can cost $100,000 or more 

depending on the scope of products included and the degree of integration or 

interfacing with other pharmacy-related technologies. Annual software maintenance 

fees typically run between 15 and 20 percent of the initial licensing costs. 


16

While there are few data in the peer-reviewed literature on the costs and benefits of 

pharmacy inventory system implementations in acute-care settings, there are a number 

of case studies and white papers available from the companies who market these 

systems. For example, following the implementation of a pharmacy inventory 

management system, a health system in Lexington, KY, identified an increase in 

inventory turns of 21 percent and a reduction in inventory value of 18 percent, resulting 

in a first-year savings of more than $300,000. 19 Additionally, a health system in Fort 

Wayne, IN, realized a $600,000 reduction in inventory after implementation of a 

pharmacy inventory management system. 20 

Where can I obtain more information about pharmacy inventory management 

technology? 

Several vendors currently market inventory management systems. Most are marketed 

in conjunction with other technology solutions. These vendors include Cardinal Health, 

McKesson Corp., AmerisourceBergen ® , Omnicell ® , Talyst ® Inc., Swisslog ® , and others. 

More information can be found by visiting the respective vendor Web sites, searching 

the Internet or researching pharmacy or nursing trade magazines. 

3.3. Drug Unit-dose Packaging 

What is drug unit-dose packaging technology? How does it work, and how has it 

been put to work in pharmacy-related automation activities? 

Unit-dose packaging technology allows a pharmacy to re-package bulk medications into 

single-use doses. These medications include tablets, capsules and liquids. The 

medications are loaded either onto or into the machine (depending on the packager) 

and result in a fully USP-compliant unit-dose package. 

Packagers with the capability to interface with pharmacy information systems have been 

used in pharmacies since the 1990s. Unit-dose re-packagers can facilitate patientspecific 

cart fills. A re-packager can create multiple unit-dose medications sequentially 

from the device. Between each medication is a perforation creating a final strip of 

medications specific to the needs of each individual patient; the medications can then 

be separated by the dispensing pharmacy or the administering nurse. Re-packagers 

may also package multi-dose packages that can be useful in long-term care facilities. 

Unit-dose packaging technology is important because many medications are currently 

not manufactured in unit-dose form. For hospitals, unit-dose medication dispensing is 

required by The Joint Commission as part of medication management standard 

03.01.01 EP 10 and is considered a best practice by the American Society of Health 

System Pharmacists (ASHP). 21,22 Even without an interface to the pharmacy information 

system, the devices can facilitate unit-dose medication creation. 

Following initial use for cart fills, these re-packagers began to be interfaced with 

automated dispensing cabinets (ADCs) to create cabinet-specific refill strips. Repackagers 

can now provide packages with bar codes that are specific to the institution’s 


17

information system. As will be mentioned in section 3.4 on bar coding and labeling, not 

all bar codes work with all systems, so the re-packagers provide value by ensuring that 

the bar codes created and dispensed are compatible with the facility’s information 

system. Some re-packagers are also able to create “robot ready” unit-dose packages. 

Re-packagers can also interface to pharmacy inventory management systems. 

In which stage of medication management in the acute-care setting can drug unitdose 

packaging technology be most helpful? 

Re-packagers are generally used as part of the dispensing phase, although they can 

also be used as part of the receiving phase when bulk items can be re-packaged before 

being placed in inventory Having medications re-packaged as unit doses is also helpful 

in the medication administration phase to facilitate safe practices. The creation of unitdose 

packages that contain medication-specific bar codes also supports safety by 

facilitating bar code scanning-enabled medication administration at the bedside. 

What benefits can I expect from the use of drug unit-dose packaging technology? 

How strong is the evidence for such benefits? 

Vendors state that these devices can process up to 60 doses per minute for oral solid 

medications and 15 to 32 doses per minute of liquid medications. 23-26 Compared to the 

time required for manual re-packaging, it has been claimed that oral solid packaging 

labor is reduced by 65 percent. 27 By providing ADC-specific medications, it has been 

estimated that the re-packagers can reduce ADC fill time by 70 percent. 28 The dollar 

value of such reductions depends on the volume of re-packaging and the extent of ADC 

use at the institution. 

When used in combination with inventory carousels, re-packagers can facilitate 

inventory control measures. By preferentially using items stocked in the carousels that 

were previously packaged over those created in real-time by the re-packager, 

medication waste is reduced. 

There may also be financial benefits to the purchase of bulk medications re-packaged 

in-house over manufacturer supplied unit-dose medications. Manufacturer supplied 

products may be more expensive and/or require additional work to be recognized by an 

internal bar code scanning application. In 2006, Lanwood Regional Medical Center in 

Fort Pierce, FL, was able to save $15,000 by purchasing bulk products. 29 This benefit 

must be weighed against the organization’s existing inventory, cost of packaging 

supplies, impact on expiration dating and technician time involved in using and 

maintaining the re-packager. According to a 2008 survey by the American Society of 

Health-System Pharmacists® (ASHP) on dispensing practices in hospitals, only 31 

percent of hospitals re-packaged medications, primarily motivated by a desire to 

achieve cost savings. 30 

What potential, unintended, adverse consequences are associated with the use of 

drug unit-dose packaging technology? How can the risks be mitigated? 

Unit-dose packaging devices must be well maintained. Without proper maintenance, 

package integrity and printing quality may be compromised and render products unsafe 


18

for dispensing. Frequent cleaning and calibration of the system, and adequate training 

of personnel in loading the packaging and ink can dramatically decrease the likelihood 

of such problems. Proper inspection of the product prior to dispensing is important to 

ensure that no compromised product leaves the pharmacy. 

Although the automated re-packager is far more advanced than its manual predecessor, 

medication mix-ups can still occur. For canister-based packagers, safeguards are 

provided with the system to prevent mix-ups when refilling. For oral solid medications 

packaged using a special tablet system tray, human error is a risk, much as it is with 

manual re-packaging. “The ASHP Technical Assistance Bulletin on Repackaging Oral 

Solids and Liquids in Single Unit and Unit-dose Packages” advises that an individual 

other than the packaging operator verify the packages, with ultimate responsibility for 

the integrity of the process being with the pharmacist. 31 

How does drug unit-dose packaging technology work with other pharmacyrelated 

automation technologies and do they need to be in place for the unit-dose 

packaging technology to operate? 

As mentioned above, it is not essential that a re-packager be interfaced with other 

technology, but the benefits of the product are greatly increased when used as part of a 

comprehensive medication management and administrative solution. Interfaces with the 

institution’s pharmacy information system and ADCs can occur at implementation or in 

subsequent stages. 

What is the cost to implement drug unit-dose packaging technology in a typical 

acute-care facility? Are there credible examples of published cost-benefit 


Cost of an oral solid re-packager is approximately $200,000, plus $30,000 for annual 

device maintenance. Packaging supplies generally range from $0.02 to $0.04 per dose. 

Review of existing inventory and determination of canister medications are additional 

implementation costs. Cost of a liquid re-packager is approximately $17,000 to $22,000. 

Packaging supplies generally cost $0.05 to $0.08 per dose. 

In using a 500-line item re-packager, JFK Medical Center in Atlantis, FL, was able to 

stock 95 percent of its oral solid inventory in the device. By having 80 percent to 90 

percent of its ADC inventory in the re-packager, JFK Medical Center was able to reduce 

the time spent selecting refill medications by 75 percent, from eight hours to two hours. 

This reduction in staff technician time was converted to a packaging technician who 

streamlines the packaging process. This technician supports the quality assurance of 

their bar coding process. 32 Overall, these changes would suggest a net decrease in 

technician time needed for the pharmacy operation when implementing oral solid repackaging 

in coordination with bedside bar code scanning of medications. 

Where can I obtain more information about drug unit-dose packaging 

technology? 

Several vendors currently market oral solid re-packagers. Vendors include 

AmerisourceBergen ® , CareFusion ® , Cardinal Health ® , McKesson ® , Omnicell ® , 


19

Swisslog ® and Talyst ® . KLAS ® , an independent research company that conducts 

interviews with healthcare providers regarding various technologies, has also published 

information in this area. In September 2008, Talyst ® Inc. released their report on “High 

Volume Unit-dose Packaging”. 33 This report focuses primarily on AmerisourceBergen ® , 

McKesson Corp ® and Talyst ® Inc. It provides user feedback on various aspects of the 

technology. 

Vendors for liquid re-packagers include EUCLID ® , Spiral Paper Tube Corp ®, and 

Medical Packaging ® Inc. More information can be found by visiting the vendors’ 

respective Web sites, searching the Internet, or researching pharmacy or nursing trade 

magazines. 

Figure 3.3 Pharmacy Unit-Dose Packaging Footnote 34 

3.4. Pharmacy Barcoding/Labeling 

What is barcoding/labeling technology, how does it work and how has it 

been put to work in pharmacy-related automation activities? 

Barcoding has been commercially available since 1974, and is now available in different 

formats (one-dimensional and two-dimensional) that can be read with a scanning 

device. 


20

A typical 1-D bar code 

A typical 2-D bar code 

The scanning software reads the code. The code format determines the amount of data 

encoded in the bar code. This information can then be used to check against a 

database to obtain additional information about the bar code-labeled item. The simplest, 

1-D bar codes contain the least amount of data, usually a number, while 2-D codes can 

embed more and different types of data. Over the decades, bar codes have become 

more sophisticated and have incorporated more error-checking features, tolerance to 

damage to part of the label and in some cases design features that allow the label to be 

read independent of the bar code orientation relative to the scanner/reader. However, 

unlike RFID tags, bar code technology can be less efficient than RFID because it 

requires establishing a clear “line of sight” between the bar code and the reader, 35 which 

may require repositioning the patient, the reader and the health professional. 

It has been estimated that up to 38 percent of inpatient medication errors occur at the 

medication administration stage 36,37 Bar codes can be used to identify patients (i.e., 

wristbands), equipment, locations and most items that are in some form of container, or 

those that can accept a label. As acute care environments become more computerized 

and automated, these codes are being used to track every aspect of medication 

handling such as receipt of bulk lots, unit-dose packaging, filling orders (central 

pharmacy, decentralized cabinets), and bedside medication administration. However, 

according to a 2008 survey, bar code technology has been implemented in only 25 

percent of hospitals. 38 At this time, there is no accepted standard format for 

manufacturer bar codes. Different companies may include different information as part 

of their barcoding processes. 

Unless the bar codes from the supplier conform to and are integrated with the code 

used in the acute-care setting, a second, hospital-specific bar code may need to be 

generated and applied to the item (packaging, wristband, etc.). This requires specialized 

printers at various locations, or an extra printing tray that only prints label/wristband 

sheets. 


barcoding/labeling technology be most helpful? 

Bar code technology is an enabling technology that can be used at every major step of 

medication handling, including: 

• Pharmacy inventory management, including supply chain. 39 

• Stocking of floor supplies (carts and dispensers). 

• Filling of orders. 


21

• Identification of healthcare professionals and patients involved in the handling 

and administration of medications. 

• Bar code medication administration (BCMA), 40 which is also referred to as bar 

code point of care (BPOC), 41 and is generally implemented in conjunction with 

electronic medication administration (eMAR) applications. 

• Electronic medication administration (eMAR; provider, patient, drug, dose, 

delivery method being identified), which can be implemented along with or prior 

to BCMA. 

Properly implemented bar code identification can reduce adverse drug events (ADE) 

and support quality assurance measures required or recommended by the Joint 

Commission 42,43 , the Food and Drug Administration (FDA) 44 and others such as the 

Leapfrog Group, the Ambulatory Quality Alliance (AQA), the National Quality Forum 

(NQF), and others. For best results, a comprehensive plan for implementation and 

rollout of bar coding should be implemented within the organization. 45 

What benefits can I expect from the use of barcoding/labeling technology? How 

strong is the evidence for such benefits? 

Barcoding is an established technology that has proven itself in the pharmacy and 

hospital environment. 46 Bar code technology helps healthcare professionals fulfill the 

“five rights of medication administration,” 47 including the right patient (bar code), right 

medication (bar code), right dose (bar code), right time (eMAR) 48 and right route (CPOE 

and eMAR). Though using a barcoding system does not necessarily cut down on the 

number of steps to perform, it can reduce typing and populate an electronic record with 

detailed information as well as rapidly perform crosschecks, thereby increasing the 

overall safety of the medication administration process. 

Reduction of dispensing errors can be achieved when a bar code system is integrated 

into hospital systems to identify the person administering the medications, the patient, 

the drug, the dose, the route and the timing of administration. These data can then be 

fed into an eMAR system, which can check all the parameters against a prescribers 

order. 

Comparative metrics from before and after an implementation are difficult to obtain, 

because often the necessary data were not collected prior to adoption of the digital 

systems. Additionally, the adoption of barcoding systems in healthcare is a rapidly 

evolving field with usability of the systems improving rapidly. 49 Overall, users who have 

implemented digital systems do not want to go back. 50 

Barcoding/labeling technology improves tracking and accuracy at every stage of the 

medication management process, as well as allowing for faster medication inventory 

updates, particularly in the inpatient setting. When bar coding/labeling technology is 

used in combination with other technologies (e.g., eMAR), additional benefits may be 

seen. One large study showed that the incidence of potential and real adverse drug 

events decreased by more than 63 percent after the implementation of a bar code 

system. 51 When staff was required to scan all drug doses, the incidence decreased 93 


22

percent or more. Some health systems are tying scanning compliance rates to 

performance goals of nurse managers. 

What potential unintended adverse consequences can be associated with the use 

of bar coding/labeling technology? How can the risks be mitigated? 

In a computerized environment, users may incorrectly assume that all data within the 

system are always correct. Users of bar code-enabled systems may assume that the 

database linking the bar code to information is always correct, or that the correct label 

was applied to a given object or that the patient is wearing the correct wristband. When 

scanning, the operator must still verify the patient’s name and ensure that the five rights 

of medication administration have been satisfied. In the example of the patient ID, many 

hospitals require two data points to identify a patient, such as the patient’s name, plus 

birth date; or bar code, plus the patient’s photograph. Similarly, the process flow that 

leads to building a bar code database and labeling all the items linked to that database 

should use “inherently safe” methods. An inherently safe process is one that has 

incorporated safety from the beginning and creates an environment where it is easier to 

do the right thing. 52 

When an implemented BCMA/BPOC system does not adequately address workflow and 

ease of use, providers may substitute workarounds that introduce new sources of 

errors. An example would be affixing patient-identification bar codes to computer carts 

for easy access, rather than reading the bar code attached to the patient’s wrist. Koppel, 

et al, have examined this issue in some detail, identifying over 30 workarounds to bar 

code system problems and making some practical recommendations. 53 One risk can be 

mitigated by ensuring the patient ID bar code is of a different symbology (type) than 

other labels printed on the nursing unit. Another way of mitigating certain risks and 

workarounds is to only allow certain areas to print patient bar coded patient wrist bands. 

Other less anticipated consequences include underestimating the costs to maintain the 

systems (hardware, software, consumables, user training), time and resources needed 

to apply patches and system upgrades, response to system downtime or maintaining 

policies and quality improvement measures to monitor and ensure best practices. As 

with all complex software, software and security patches can also cause unexpected 

failures in integrated systems unless the institution has a clear-cut and enforced policy 

to deal with the testing and release of changes. 

It should be noted that due to the plethora of bar code formats, there should be no 

assumption that because a product carries a bar code, it is usable without modification 

in the local environment. Computers only recognize bar codes that they have been 

programmed for, and the system could otherwise potentially misinterpret a code, 

generating incorrect results if the bar code is placed for a different purpose and linked to 

a different system. 

How does bar coding/labeling technology work with other pharmacy-related 

automation technologies, and do they need to be in place for bar coding/labeling 

technology to work? 


23

Bar coding is an interconnecting technology for other applications within and outside the 

pharmacy environment. Bar codes are core components of automated inventory 

management, tracking, robotic dispensing systems, preparing single-unit medication 

doses, IV compounding systems, automated bag and syringe fillers and automated 

infusion-compounding robots. Additionally, use of bar coding or other auto-ID 

technology is an essential component of effective closed-loop medication systems. 54,55 

What is the cost to implement bar coding/labeling technology in a typical acutecare 


provide a strong business case for the use of this technology? 

The financial cost of implementing bar coding/labeling systems within the pharmacy and 

the health organization can vary widely, depending on how the system is integrated into 

the overall healthcare IT architecture of the institution. Calculation of the financial 

benefits of bar coding/labeling technology should include the averted cost of ADEs and 

time efficiencies gained during ordering, stocking, distribution, administration and billing 

processes. 56 Even so, results may be ambiguous because it can be difficult to capture 

all parameters affecting costs. 

Cost depends on the size of the organization, the applications in which the technology is 

used, where in the acute-care setting the technology is deployed, and how many 

interfaces are required for support of legacy systems. The licensing costs can range 

from tens of thousands to hundreds of thousands of dollars. The total cost to implement 

bar coding/labeling technology (software, hardware, infrastructure, personnel) averages 

between one and three times the cost of licensing the technology and may exceed $1 

million if linked to robotic systems. The annual maintenance cost (software, hardware, 

infrastructure, personnel) averages between 15 percent and 30 percent of the total cost 

of implementation. 

Where can I obtain more information about bar coding/labeling technology? 

There are multiple vendors manufacturing and selling bar code systems, bar code 

printers or other technologies that rely on bar codes. HIMSS has also developed a white 

paper that looks at the selection process of BCMA/BPOC 57 and published a book on 

implementing bar coding and auto identification in healthcare. 58 Searching trade 

magazines as well as the Internet can yield much information (on the Internet, search 

under both “barcode” and “bar code.”). Most large vendors active in electronic health 

records (EHR), pharmacy systems and medication administration have information 

pertaining to bar coding and labeling. Reviewing the HIMSS list of exhibitors attending 

such events as the HIMSS Annual Conference & Exhibition, will yield a lengthy list of 

prospects. If you have a pre-existing EMR/EHR, consult with your vendor to see which 

bar code systems are already integrated into the application. 

3.5 IV Compounding Systems/Automated Bag & Syringe Fillers/Automated 

Infusion Compounding Robots 


24

What is IV compounding, filling and automated infusion robotics technology? 

How does it work? How has it been put to work in pharmacy-related automation 

activities? 

Recent technological innovations and the ability to compound new, customized 

chemical components and drug research preparation have rejuvenated the 

administration of drug mixing and dispensing operations. Attaining better outcomes in 

patient and work environment safety; lowering costs through automation and resource 

pooling; and better shelf-life management of costly drugs significantly impact healthcare 

delivery. Adding accurate drug delivery tools and more efficient workflow processes to 

those that are already deployed to reduce medical errors, challenges pharmacists to be 

better informed about the deployment and integration of these innovations. 

Intravenous medication therapy is an integral part of in-patient acute care, as well as 

outpatient treatment and home care programs. Pharmacies that provide medications for 

IV administration are responsible for preparing medications that are safe, accurate, 

sterile, stable, labeled appropriately and placed in a container consistent with the 

anticipated mode and route of administration to the patient. In addition, it is necessary to 

comply with industry standards for sterile-product compounding and disposition, such as 

those of the United States Pharmacopeia (USP), 59 and the Food and Drug 

Administration’s Good Manufacturing Practices (FDA, cGMP) and Institute for Safe 

Medication Practices (ISMP). 

The medication safety movement has prompted healthcare facilities to employ 

technology as a means for preventing medication errors and to eliminate preventable 

ADEs. Bar-coded medication administration, improved patient identification and 

administration and the use of software-embedded medication safety feature in infusion 

pump devices assure achieving the five rights of intravenous medication administration. 

However, even the most advanced and integrated IV infusion software application 

cannot detect an IV medication that has not been manually compounded appropriately 

or sterilized, or is not chemically stable. While technologies that automate the 

preparation of medications for IV administration are available—such as centralized IV 

compounding systems; bag and syringe fillers; and decentralized IV compounding 

satellites—it is the pharmacist's oversight that is as critical as ever to ensure quality and 

safety. 

IV Compounding Systems. Within the last 30 years a resurgence in pharmacy 

compounding of customized drug preparations has occurred. 60 Pharmacy compounding 

is the preparation and mixing of drugs according to a prescription of a licensed clinician 

(pharmacist, physician or veterinarian) to fit the unique needs of the individual patient. 

Examples include changing the form of the medication from a solid to a liquid; removing 

non-essential ingredients from the medication; or to obtain the exact dose needed. It 

may also be done for voluntary reasons, such as adding favorite flavors to a 

medication. 61 There are standards published by the United States Pharmacopeia and 

National Formulary (USP-NF) for compounding. Compounding pharmacies are licensed 


25

and regulated in the 50 states and the District of Columbia by their respective state 

boards of pharmacy. 62 

Total parenteral nutrition (TPN) compounders are the oldest of these technologies. With 

companion order entry software, a TPN compounder can perform complex TPN 

calculations and provide clinical alerts for safety issues associated with parenteral 

nutrition, such as osmolarity limits, electrolyte concentrations, lipid content and 

precipitation. After the formula is entered and verified in the software program, it’s sent 

via interface to the compounder. There, the compounder operator accesses the formula 

and initiates the automated compounding. Automated calculations and compounding of 

TPN are done in a fraction of the time required by a manual process. Additionally, 

automated systems allow for consistent and accurate documentation that can be stored 

electronically. With or without integrated software, a compounder can be manually 

programmed to pump desired quantities of stock solutions into a final container. Nonnutritional, 

automated IV compounding uses include batched preparation of cardioplegic 

solutions, electrolyte replacement solutions and base solution for use in epidural or 

intravenous patient-controlled analgesia (PCA) preparation. 

Automated Bag & Syringe Fillers. 2003 saw the introduction of table-top syringe filling 

devices that automatically fill, cap, weigh, verify and barcode label sterile syringes with 

accuracy of +/- 0.2 mL and speed of up to 100 syringes in eight minutes. 

Automated IV Compounding Robots. Intelligence-embedded automated systems that 

use precise electromechanical robotics and special environments are now deployed as 

part of the core pharmacy cycle. The progenitor of the IV automation process is a 

relatively simple clean hood space and pharmacy pump. Most people would probably 

identify TPN compounders as the first real robotic process. Remote IV Automation 

(RIVA) was first demonstrated at an ASHP meeting in 1989 and has a single articulated 

robotic arm that moves each dose through a preparation process. IV stations with a 

small, low-cost IV compounding device intended to provide just-in-time admixture at the 

nursing station have subsequently been introduced. 

These technologies can be categorized into three basic classes: 

1. Programmable, manually operated, table-top compounders. Their common element 

is simplicity and they are designed to be operated within a standard laminar air-flow 

hood. 

2. Automated robotic syringe-filling systems . 

3. Automated, programmable enclosed system for filling virtually any package—their 

common element is sophisticated electromechanically articulated arm and clean 

environment. 


26

The compounding preparation and production cycle is described in the following flow 

chart that was adapted from Intelligent Hospital Systems, robotic IV automation—RIVA 

product. 

Table 1: Robotic IV Automation Flow Chart (adapted from www.intelligenthospitals.com.) 

The RIVA robotic IV automation system is an integrated system designed to automate 

the process of preparing IV admixtures in the hospital pharmacy in the process flow 

chart described in Table 1. The process highlights the issues of safety, efficiency, 

effectiveness and regulatory compliance. The pharmacist can interact with the process 

through a workstation screen or remote order entry and control. 


27

The production process begins with inventory item validation. Items can be identified by 

a variety of systems, including image and bar coding recognition, as well as height and 

weight verification. To assure sterility of final preparations, a port disinfection system 

sterilizes both vial stoppers and IV bag ports. After inventory items are verified, several 

fluid transfers occur within the compounding area. Vials can undergo reconstitution and 

syringes or bags receive final product based on order requirements. Final weight and 

verification checks ensure that every dose is accurate. When a dose is complete, it 

receives a label with bar code and print information. RIVA then checks the ID to ensure 

the information is correct, and the robot moves the dose to an output chute so that it can 

be verified by pharmacy staff and sent to the appropriate patient unit. RIVA increases 

the safety of admixtures for the patient by improving dose accuracy, reducing the 

chance of cross contamination and reducing medical errors. 

Safety features improve dose accuracy, reduce the chances of cross contamination and 

use verification to reduce medical errors. Efficiency and effectiveness are achieved 

through reduction in overall waste, reduced need for pre-filled items—filling both IV 

bags and syringes in the same system—and integrating into the pharmacy processes 

and information systems. Regulatory compliance is achieved by meeting USP 707, 

NIOSH and OSHA requirements, and the ability to provide an electronic audit trail of all 

orders prepared by the system. When used for compounding of chemotherapy drugs, 

additional closed system transfer and outside venting hood are included. IV 

compounders are classified as Class II Exempt devices under the FDA Risk and Quality 

System Regulations (21CFR820). 

IV Station has some interesting features: 

• Face-recognition login. 

• Vial identification based on a vision system. 

• Low price point (~250-300K). 

• The ability to daisy-chain several systems to make a large, relatively high 

throughput product. 

In the acute-care setting, during which stages of medication movement can IV 

compounding, filling and automated infusion robotics technology be most 

beneficial? 

Pharmacies providing admixed IV medications for inpatient acute care, as well as 

outpatient and home care would use automated compounding or robotic preparation in 

the pharmacy medication preparation stage. One robot is available for use by nurses at 

the point of care. However, all of these devices provide mechanical dose production 

assistance. 

What benefits can I expect from the use of IV compounding, filling and automated 

infusion robotics technology? How strong is the evidence for such benefits? 

Automated compounding devices provide quick, consistent, accurate, aseptic delivery of 

product into a final container. When used in combination with partner software for 

calculations and clinical screening, medication safety can be enhanced. Evidence is 

strong in regards to the expected benefits of a compounding machine, such as a TPN 


28

compounder. However, inappropriate use of the software or compounder, 

misinterpretation of the device warnings or clinical flags, or inconsistent usage 

procedures, can contribute to adverse outcomes as a result of using this technology. 

Automated, robotic IV compounding provides independent preparation inside an ISO 

Class-5 enclosed environment. The self-contained ISO Class-5 environment of the IV 

robot ensures product sterility without requiring staff to wear sterile garb or stay in a 

special preparation area. Staff is protected from exposure to hazardous substances and 

physical ailments associated with performing repetitive admixture manipulations for long 

periods of time. Cost savings are achieved through the reduction or elimination of sterile 

garb for staff, cleaning materials and special supplies required to maintain a USP-797- 

compliant compounding operation. Possible re-allocation of IV compounding staff may 

allow for reassignment of staff to clinical activities to further enhance medication safety. 

Bar code verification, specific gravity measurement, picture verification and weight 

measurement are methods robots employ to ensure accuracy, thereby decreasing the 

potential for a medication error or adverse drug events. There is strong evidence that 

the benefits of sterility, stability, accuracy and minimized employee exposure are 

associated with use of even the basic functionality of this technology. Feedback from 

hospital pharmacy directors suggests that ROI for this technology is still a complex 

issue that must be individually calculated and analyzed. 


IV compounding, filling and automated infusion robotics technology? How can 

the risks be mitigated? 

An automated compounder must reside in a laminar airflow hood within an ISO Class-5 

clean room. An automated compounder requires a significant amount of operator 

programming and participation during admixture, such as manual input of a formula into 

the software program, manual load of stock solutions onto the compounder, manual 

labeling of the final containers and manual addition of ingredients with a volume too 

small for the pump to accommodate. Each manual step in the compounder process 

introduces the potential for contamination, calculation error or medication error. 63 To 

mitigate the risk of an unintended adverse consequence due to manual steps 

incorporated into the automated compounder workflow, rigorous aseptic standards and 

operating procedures must be introduced, monitored and enforced. 

Implementation of automated technology, especially the more complex robotic systems, 

is associated with a significant staff learning curve. Staff must learn how to properly 

operate, clean and stock the technology, as well as incorporate use of the new 

technology into to revised workflows, policies and procedures. Emphasis placed on user 

training of the technology and additional staffing during the initial phase of automated 

technology implementation may help with throughput during this challenging time. 

How does IV compounding, filling and automated infusion robotics technology 

interface with other pharmacy-related automation technologies, and do they need 

to be in place for IV compounding, filling and automated infusion robotics 

technology to operate? 


29

Automated IV compounding devices and robots may be programmed to interface with 

pharmacy computer systems or may work as stand-alone products. In a stand-alone 

configuration, the compounder or robot would be instructed to run batches of commonly 

used IV admixtures. Batched product must be labeled appropriately, including 

information such as final concentration and/or volume, ingredients, date and time of 

compounding and expiration, bar code and an internal lot number. Batched products 

would then be used by the pharmacy staff to fill physician orders. In an interfaced 

configuration, the automated compounding device would receive data directly from the 

pharmacy computer system and fill patient-specific orders. Multiple times throughout the 

day, the operator would send information from the pharmacy system to the robot, and 

the robot would then compound what is needed during the specified timeframe. IV 

robots are capable of placing patient-specific, bar-coded labels. 

Where can I obtain more information about IV compounding, filling and 

automated infusion robotics technology? 

There is clear need for up-to-date information, ranging from space preparation and 

conditioning (space size, height, venting, cooling and security) to maintenance of 

software and hardware to operation and training issues. Sources included user groups, 

publications and conferences, , review agencies and vendors. 64,65 

Figure 3.5 Drug preparation station (2009). 


30


31

3.6 Central Pharmacy Robotic Dispensing Systems 

What is a central pharmacy robotic dispensing system, how does it work and how 

has it been put to work in pharmacy-related automation activities? 

A robot automates the pharmacy dispensing process using bar code labeling 

technology. This process includes dispensing medications to a patient, a cart to be 

exchanged or an automated dispensing cabinet (ADC). The robot is usually located in 

the central pharmacy and automates storage, dispensing, returning, restocking and 

crediting of unit-dose medications. McKesson’s Robot-Rx ® and Swisslog’s PillPick ® are 

two examples of systems that streamline the processing of cart fill and first doses. 

The pharmacy robot can dispense both initial doses and all doses required over a 24- 

hour period. When new medication orders are processed into a pharmacy information 

system, the information is transferred across an interface to the robot. The robot 

dispenses first doses by selecting the appropriate number of the correct unit-dose 

medications. The automated cart fill process dispenses a 24-hour supply of patient 

medications after the initial doses have been dispensed. Fill lists for patient-specific 

medications are generated in the pharmacy information system for each nursing unit. 

The fill lists are sent through the interface to the robot. 

Depending on the type of robot and whether it is a first dose or a cart-fill situation, it will 

dispense medications into a labeled envelope or bin, or arrange them on a fastened, 

labeled ring. In each scenario, the label includes the patient's name and bar code. The 

medications are then transported to the nursing units. Charges for medications are 

generated either at the point-of-administration or as fill lists are generated, depending 

on system set-up. 

Medications are transported from the pharmacy to the nursing units and placed into 

patient-specific medication bins. During medication administration, nurses scan the barcoded 

medications to verify the five rights at bedside. 

Medications dispensed, but not taken by the patient are returned to pharmacy. The 

robot restocks returned medications to the appropriate pegs or station within the robot 

picking area. Depending on system set-up, return credits and billing information may or 

may not have to be provided to the pharmacy information system. 

A robotic system can also perform multi-site filling operations as well as restocking of 

unit-based ADCs. 

In which stages of medication management in the acute-care setting can a central 

pharmacy robotic dispensing system be most helpful? 

Pharmacy robotic dispensing systems automate the repetitive and otherwise laborintensive 

task of dispensing medications from central pharmacy inventory, thereby 


32

decreasing medication handling mistakes that can contribute to noncompliance with the 

five rights of medication administration, with harmful or potentially fatal consequences. 

Combining the use of bar codes with central pharmacy robotic dispensing technology 

ensures accuracy and allows detailed information tracking, such as lot numbers, 

expiration dates and unique-dose identifiers. Together, these technologies aid in 

preventing medication selection errors, help manage unit-dose inventories and prevent 

dispensing of expired medications. 

What benefits can I expect from using a central pharmacy robotic dispensing 

system? How strong is the evidence for such benefits? 

Using a robot to dispense both initial doses and cart fills frees pharmacists and 

technicians from error-prone and repetitive manual tasks. Labor can be redirected to 

higher value-added activities instead. Information about the benefits of deploying bar 

code-based automation can be found through the Internet and in journals, such as the 

American Journal of Health System Pharmacy and the Journal of the American Medical 

Association. 

With a reduction in pharmacy technician labor requirements for manual medication 

dispensing and checking, technicians can be used to support other important pharmacy 

activities. Maintenance of the robot also provides new employment opportunities for 

technicians, including positions as unit-dose packaging and automation (robotic) 

specialists. 

Pharmacist labor required to check the accuracy of medication dispensing is also 

reduced with robust central pharmacy robotic dispensing systems. Pharmacists no 

longer have to manually check first doses or all cart fill doses. In many states, the board 

of pharmacy allows reduced pharmacist quality checks for robot-dispensed medications; 

5 percent to 10 percent random checks are allowed in some cases. With the high 

reliability of pharmacy robotic dispensing systems, pharmacists can shift more of their 

time to overseeing clinical activities that may have a broad impact on patient safety. 

Medication selection errors are reduced significantly with a robot, improving patient 

safety. The accuracy of a dispensing robot is 99.9 percent. While the majority of the 

medication errors result from incorrect orders and transcriptions, almost half of the 

medication errors in manual dispensing environments occur because of dispensing or 

administration errors. 66 A 2006 study by Cina, et al., found that although pharmacy 

technicians accurately filled more than 96 percent of the medication doses, pharmacists 

intercepted only 80 percent of the pharmacy technician errors. 67 Medication dispensing 

errors increase in work environments with heavy workloads and high levels of 

interruption, distraction and noise. 68-70 

Pharmacy robotics technology improves charge capture and billing accuracy for 

hospitals that have not fully implemented a BCMA system with billing-upon-medication 

administration. In a centralized distribution system, typically 20 percent to 30 percent of 


33

all medications dispensed are returned to the pharmacy. This is a result of discontinued 

medications or order revisions, as well as patient discharges and transfers. 

In the absence of pharmacy robotics technology and billing only upon administration, 

the return process is generally time consuming and labor intensive. A technician must 

sort through all returned medications and manually credit each patient’s profile in the 

pharmacy information system before physically returning each medication to stock. After 

implementing robotics, the technician instead scans the bar code on the returned 

medications and places them on a return rack. A transaction is automatically created to 

tell the pharmacy information system that the appropriate patient account should be 

credited for specific medications. When all scanning is completed, the return rack is 

placed into the robot, and the robot returns the medications to the appropriate place in 

stock. 

The return process is streamlined when medications are billed upon administration. 

Scanning medications to issue credit is not necessary. Unused medications are simply 

placed on the return rack for the robot to put back into stock. In addition, an automated 

system utilizing bar code technology decreases the number of missing patient 

medications, trims inventory and decreases expired medication costs. 

What potential unintended, adverse consequences can be associated with the 

use of a central pharmacy robotic dispensing system? How can the risks be 

mitigated? 

Mislabeled medications can cause harmful medication errors. Unit-dose re-packaging is 

largely a manual process, and for hospitals that utilize bar coding, bar codes must be 

added to the package, adding another manual step and source for error. The nextgeneration, 

high-volume re-packaging machines, such as Swisslog’s ATP ® System and 

McKesson’s ® PACMED ® , include bar code verification during the re-packaging process. 

Bar code verification prevents improper loading of high-speed packagers and allows 

batch-specific information, such as expiration dates, to be tracked. 71 

Selecting a pharmacy robot with limited capacity is less expensive, but can lead to a 

higher-than-desired amount of manually picked medications, or “manual picks.” Most 

hospitals have 2,500 to 3,500 medications on the formulary. The average robot capacity 

is 400-600 of the pharmacy’s top-moving medications. Robots with larger capacities are 

more expensive. 

In addition, the expectation that pharmacy robotic dispensing technology will reduce the 

need for other resources is not always valid. Instead, technology may shift rather than 

decrease staffing allocations. Failure to allocate resources needed for ongoing 

maintenance and system optimization can lead to inefficient or inaccurate robot 

performance, a higher-than-desired number of manual picks and point-of-care 

administration issues. Optimization of robotic dispensing systems after implementation 

too often falls short because required resources are underestimated or not provided. 


34

Manual picks occur frequently when high-use items are not part of the robot online 

inventory. The number of manual picks increases as new medications are added to the 

pharmacy information system formulary, prescribing habits shift and robot formulary 

updates lag. The robot formulary must be maintained to reflect changes made to the 

formulary in the pharmacy information system. If the systems are not kept in step, bar 

code scanning issues arise, workarounds emerge and safety is compromised. 

The key to using technology most efficiently is to devote full-time employees to routine 

maintenance tasks and system optimization. Train enough subject matter experts to 

assume responsibility for operational tasks and troubleshooting across all shifts and all 

systems. Proper training could also alleviate employee concerns, such as a fear of 

technology or potential for job loss. 

Failure to recognize and redesign flawed processes uncovered in the existing manual 

system can cause unintended adverse consequences in the automated system. 

Scrutinize workflow processes and procedures for risks and inefficiencies and resolve 

these issues prior to any technology implementation. Include all stakeholders, whether 

they are clinical, technical or administrative to help identify and resolve these issues. 72 

What if the interface between the robot and the pharmacy information system goes 

down? Should downtime procedures include using the robot independently to fill carts? 

If so, then plan for order entry to be completed in the robot system. However, remember 

that the order information entered into the robot may not interface back to the pharmacy 

information system. In such cases, once the pharmacy information system is 

operational again, backlog order entry must be completed. 

The pharmacy information system and robot can operate independently; if one is down, 

the other remains operational. When the robot goes down, paper medication 

administration records (MAR) can be generated and used to complete cart fills. 

Similarly, when the pharmacy information system is down, the robot and automated 

dispensing cabinets may still operate. While new orders will not cross the interface to 

the robot, the robot and automated dispensing cabinets can dispense medications for all 

existing orders. Downtime procedures should provide guidelines to continue with 

pharmacy operations in the event that either or both systems experience downtime. 

Mechanical problems with the robot conveyer or other parts can make the system 

inoperable. Avoid downtime disasters by performing recommended routine maintenance 

and replacing worn parts. 

Software issues can also cause the robot system to go down. Look for a system that 

has a backup drive to keep the system operational in the event of hardware failure. 

Under-utilization of this type of technology is something that must be noted. It is crucial 

to have a firm understanding of how a pharmacy robot performs. Inadequate knowledge 

can lead to inefficient workflows, incorrect reporting and potential problems with 


35

Figure 3.6.1 Pharmacy Robotic Dispensing System Footnote 34 

Figure 3.6.2 Pharmacy Robotic Dispensing System Footnote 34 


37

3.7. Decentralized Automated Dispensing Cabinets 

What are decentralized automated dispensing cabinets, how do they work and 

how have they been put to work in pharmacy-related automation activities? 

ADC technology is popular in the healthcare industry, particularly in hospitals. ADC 

technology has increasingly been accepted as integral to medication inventory 

management, administration and distribution processes. Since 2007, more than 80 

percent of hospitals use some type of ADC technology. 73 ADC technology provides a 

mechanism for moving medications out of the central pharmacy and closer to the point 

of care. Secure distribution and storage of medications throughout the hospital reduces 

the time and labor involved in the medication administration process, as well as 

providing a means for controlling medication costs through electronic inventory 

management functions. 

Using ADC technology is quite simple. The cabinets typically reside near nursing 

stations. After electronically accessing the cabinet through biometric, badge reader or 

login and password authentication methods, the nurse is presented with a list of patient 

names on a touch screen. Next, the nurse selects a patient name and is presented with 

a list of pharmacist-approved patient medication orders. The nurse’s last step is to 

select the available medication based on the scheduled time. The cabinet drawers open 

one at a time, prompting the nurse to remove the medication. The medications are 

secured by limiting the nurse to only the medications needed for the selected patient. All 

user transactions are logged to a central database for reporting, charge capture and 

auditing. 


38


decentralized automated dispensing cabinets be most helpful? 

ADCs are prevalent in the processing/distributing and medication administration phases 

of the medication management process (Figure 2-2). However, with wholesalers 

offering services that provide pre-packed totes for cabinet replenishment, ADC 

technology has also started to expand into the receiving medication phase. 

After totes are delivered to the hospital by the wholesaler, a pharmacist checks the 

order and the totes are delivered right to the nurse floor and placed into the cabinet 

inventory; bypassing central pharmacy inventory. However, not every wholesaler offers 

this service, so the process is not yet in wide use, and most acute-care pharmacies opt 

to store medications in a centralized location or in a storage and retrieval system. 

What benefits can I expect from the use of decentralized automated dispensing 

cabinets? How strong is the evidence for such benefits? 

Some of the reported benefits include a reduction in ADEs and medication costs, 

increases in charge capture, pharmacy and nurse productivity and assistance in 

meeting The Joint Commission standards and National Patient Safety Goals. 

Increased awareness of the impact of ADE in the media is a compelling reason to 

consider adopting ADC technology. Saudi Aramco Medical Services Organization 

reported a decrease in ADE of 27 percent after implementing ADC technology. 74 They 

also realized a 43 percent reduction in medication restocking costs and an overall 

medication cost reduction of 42 percent. 75 

A Shore Memorial Hospital study 76 found similar benefits associated with nursing 

productivity. After ADC implementation, nursing productivity increased by reducing the 

time required to reconcile narcotics by 93 percent, and data reflected an 80-percent 

reduction in medication stock stored on nursing units. 77 In a separate study, Parkview 

Health (Fort Wayne, Indiana) reduced their medication inventory by $600,000 and 

saved 20 percent in labor costs using ADCs. They also improved order delivery time 

from 90 minutes to 60 minutes; reduced medication confirmation and authorization time 

by 30 percent; reduced medication administration errors by 75 percent; and essentially 

eliminated the time it took to order and manage medication inventory after integrating 

their ADCs with the pharmacy information system, packaging, storage and inventory 

management software. 78 

Lastly, ADCs help hospitals and health systems meet regulatory requirements. For 

example, ADC technology facilitates compliance with The Joint Commission Medication 

Management Standards by preventing unauthorized individuals from accessing 

medications and providing secure access to medications when the pharmacy is 

closed. 79 ADCs are used in many different ways. The two basic modes are first 

dose/PRN medications only (the rest are supplied by traditional cart fills) and “cart-less,” 

where as many of the medications as possible are included in the cabinet. Which 

process is used will impact the number of cabinets needed, as well as the labor needed 

to keep them filled. 


39


decentralized automated dispensing cabinets? How can the risks be mitigated? 

As with the implementation of any technology, workflow changes associated with ADC 

implementations can introduce new risks. ADC technology disrupts traditional 

pharmacy, nursing and medical work systems, forcing a redesign of services and 

requirements. Careful consideration should be given to the planning, execution and 

overall management of the ADC system. The risk of users rejecting the technology 

increases if effective implementation design principles are ignored. 80 

While planning for ADC technology, consideration must be given to cabinet footprint, 

drug capacity and location. The ADC should fit in its intended space with minimal 

structural changes to limit construction related charges. Further, the size of the ADC 

should be large enough to accommodate sufficient quantities of the medications 

typically given at the nursing unit. Lastly, the location of the ADC should be somewhere 

that optimizes and supports efficient nurse workflow. 

Another unintended consequence is the incorrect assumption that ADC technology will 

eliminate medication errors, leading to behaviors that increase the risk of adverse drug 

events. Inefficiencies in the system, inadequate training and lack of guidance have 

contributed to the misuse of the ADC “override” function which permits the dispensing of 

a medication prior to pharmacist review of the medication order. 81 Moreover, 

maintaining the organization of your inventory is the first key to safe stocking 

practices. 82 Medications and their packaging often look alike. For this reason, similar 

looking medications and medications with “sound alike” names should not be stocked 

alongside each other in an effort to decrease the likelihood that a technician will place a 

medication in the wrong location. To mitigate the risk of medication placement errors, 

some systems use a “look-alike, sound-alike” approach to printing drug names called 

“TALLman” lettering. The goal of TALLman lettering is to make it more obvious that two 

similar looking or sounding drugs (e.g., hydrALAZINE, hydrOXYzine), are different. 

A strong policy and procedure practice should be followed to maximize the patient 

safety features of ADC technology. More information on the safe use of ADCs can be 

found in the cover story of the July 2008 issue of Pharmacy Purchasing and Products 

magazine 83 and the Institute for Safe Medication Practices (ISMP) Guidance on the 

Interdisciplinary Safe Use of Automated Dispensing Cabinets. 84 

How do decentralized automated dispensing cabinets work with other pharmacyrelated 

automated technologies, and do they need to be in place for decentralized 

automated dispensing cabinets to work? 

To maximize efficiency and patient safety, an interface between a pharmacy information 

system and ADC technology is required so that patient movement, medication orders 

and patient billing can be tracked. To further expand patient safety features, ADC 

technology should be integrated with other pharmacy automation, such as a dispensing 

robot, carousel or packaging device. Working together utilizing interfaces and bar 


40

codes, the technologies increase patient safety by ensuring the correct medication is 

packaged, picked, delivered and put away in the ADC accurately. Moreover, operational 

efficiencies are gained when there is automation present throughout the medication 

administration process. Shore Memorial reported an ROI of 28 percent and a net 

present value of $700,000 after its implementation of ADC technology, along with 

carousels and pharmacy software technology. 85 

What is the cost to implement decentralized automated dispensing cabinets in a 

typical acute-care facility? Are there credible examples of published cost-benefit 


The cost associated with ADC technology is fairly high. New Elm Medical Center, part of 

Allina Health System, utilized one Pyxis ® cabinet before implementing 10 others at a 

total cost of $600,000. 86 There is very limited research with regard to return on 

investment of ADC technology alone. However, most of the documented savings 

associated with pharmacy automation did include ADC technology as part of the overall 

technology solution. 

Where can I obtain more information about decentralized automated dispensing 

cabinets? 

There are not many ADC technology vendors in the market. A few of the dominant 

vendors for ADC technology include AmerisourceBergen ® , Cardinal Health (now 

CareFusion ® ), McKesson Corp. ® , Omnicell ® Corp. ® and Talyst® Inc. More information 

can be found by visiting their respective Web sites, by searching the Internet or 

researching pharmacy or nursing trade magazines. 

3.8.Bar code Medication Administration-powered Electronic Medication 

Administration Record (BCMA-eMAR) 

What is BCMA-eMAR, how does it work and how has it been put to work in 

pharmacy-related automation activities? 

The combination of BCMA and eMAR uses bar code reading technology to facilitate and 

electronically record the bedside administration of medications. BCMA-eMAR 

technology helps ensure that the five rights of medication administration—drug, patient, 

dose, time and route—are all accurately assessed prior to bedside medication 

administration,and then accurately recorded in the patient’s chart. A wired or wireless 

bar code reader is used to scan the caregiver’s name badge, the patient’s wrist band 

and the medication being administered, electronically verifying the information related to 

an individual dose of medication. Advanced clinical decision support (CDS) can be 

coupled with electronic health record (EHR) and computerized provider order entry 

(CPOE) to simultaneously check for other potential errors such as duplicate therapies, 

potential drug interactions and drug-lab, drug-food or drug-diagnosis contra-indications. 

In which stages of medication management in the acute-care setting would 

BCMA-eMAR be most helpful? 


41

BCMA-powered eMAR technology facilitates the administration and documentation of 

medications at the point-of-care. Utilizing BCMA-eMAR enables nursing medication 

documentation to be available to all healthcare practitioners in real-time. If the BCMAeMAR 

system detects a problem during the medication administration process, a 

warning message can be issued and displayed for the person administering the 

medication and recorded in the eMAR. The caregiver can then determine any further 

actions that are needed before proceeding. Electronic data collected related to the five 

rights can also be monitored for quality and performance improvement initiatives. 

Incorporating clinical decision support into BCMA-eMAR during medication 

administration can enhance patient safety and minimize adverse drug events (e.g., 

displaying the latest INR when preparing to administer sodium warfarin and then 

alerting the physician as to the potential adverse drug/result interaction). 

What benefits can I expect from the use of BCMA-eMAR? How strong is the 

evidence for such benefits? 

The overriding benefit of implementing a BCMA-eMAR system is to ensure patient 

safety and reduce medication errors at point-of-care. The greatest potential benefit of 

bar code functionality during the bedside medication administration process is the 

reduction of preventable adverse drug events (PADE). According to one study, a bar 

coded medication administration process reduced errors from 0.19 percent prior to 

implementation to a rate of 0.07 percent post-implementation. 87 The added costs of 

treating medication errors can be very high. 88,89 One study found 2 percent of 

admissions were associated with a PADE, with an added cost per patient of $4,700. 90 

Sometimes, the potential adverse drug events will appear to have increased shortly 

after implementation of a BCMA-eMAR system. This is due to prior under-reporting of 

“near misses” and medication errors. 

What unintended adverse consequences can be associated with the use of 

BCMA-eMAR? How can the risks be mitigated? 

The major driver for utilization of bar code medication administration is to enhance 

patient safety, not as an efficiency strategy. Numerous workarounds have been 

described to address workflow efficiency problems and issues, or deal with problems 

encountered in the use of BCMA-eMAR systems. 91 Documented examples include 

unreadable medication bar codes, malfunctioning scanners, unreadable or missing 

patient identification wristbands, non-bar coded medications, unreliable wireless 

connectivity or patient care emergencies. 

An example of a workflow efficiency workaround would be to scan a patient’s ID label 

placed on paperwork outside the room instead of directly scanning the patient’s 

wristband. This increases the risk that a nurse will walk into the wrong room and 

administer the wrong medications to the wrong patient. A strategy for monitoring and 

reporting frontline caregiver compliance with desired workflows related to the bar code 

medication administration process can help mitigate the risk of undesirable workflow 

adoption. 


42

Change management strategies and communications to ensure caregivers’ awareness 

of issues the technology is intended to address, as well as the current rate of 

medication errors in the acute-care setting, the successful adoption of the intended 

workflows. Adequate training and support for frontline caregivers are additional 

prerequisites to successful implementation. Medication errors can appear to increase 

when first using BCMA-eMAR systems because the technology captures more accurate 

data, such as medications missed or medications that are given late. 

How does BCMA-eMAR work with other pharmacy-related automation 

technologies, and do they need to be in place for the BCMA-eMAR system to 

work? 

Current best practice for bar code-enabled medication administration at the bedside 

requires that bar coded caregiver badges, bar coded patient identification (wristbands), 

individually bar coded medications and scanning technology be in place and 

consistently used. This provides the functionality necessary to verify that the five 

medication rights are met at the time of medication administration. 

Bar coded patient identification, individually bar coded medications and scanning device 

technology (wired or wireless) must be in place for the BCMA process to automatically 

and properly populate the eMAR. Caregiver bar code identifier scanning is preferred but 

not required. Alternatives include caregiver sign-in with user ID and password, or use of 

other auto-ID technology like biometric thumbprints or RFID proximity badges. 

What is the cost to implement BCMA-eMAR technology in a typical acute-care 


provide a strong business case for the use of BCMA-eMAR? 

One study evaluated the costs and benefits of a bar code medication administration 

system and found a positive ROI after one year of being fully operational. Total five-year 

costs of $2.24 million ($1.31 of capital and $342,000 per year of recurring costs) were 

offset by a net benefit at the end of five years, of $3.49 million. 92 In another study, the 

authors concluded that the combination of CPOE and BCMA-eMAR yielded a good 

return on investment because of reduced transcription errors, improved medication turnaround-times 

and timely result reporting. 93 

Where can I obtain more information about BCMA-eMAR systems? 

Additional information about the use of bar coded medication administration and eMAR 

processes may be obtained by accessing the HIMSS Pharmacy Informatics Task Force 

white paper entitled “The Ideal Bar code Point-of-Care System for the Pharmacy 

Informaticist.” 94 Another useful source of information on the topic is the HIMSS book 

Implementation Guide to Bar Coding and Auto-ID in Healthcare: Improving Quality and 

Patient Safety, edited by Ned J. Simpson and Kenneth A. Kleinberg. 95 


43

4. CONCLUSION 

The movement of medications from the receiving dock, to the pharmacy, to the unit of 

care and finally to the patient’s bedside for medication administration, requires a 

complex set of processes carried out by a multidisciplinary healthcare team to ensure 

the right medication is delivered to the right patient at the right dose, via the correct 

route and at the designated time. 

If implemented properly, pharmacy-related automation technologies have been shown 

to increase efficiencies in medication management workflow processes, maximize 

resource allocation and productivity, and help reduce adverse drug events. These 

advantages are increased when technologies interface with other systems, such as 

pharmacy information systems; or used in conjunction with other pharmacy automation 

enabling technologies, such as the use of bar code readers with eMARs, inventory 

management systems and unit-dose packaging systems. 

However, the risk of unintended consequences and adverse events needs to be 

considered and a mitigation plan generated as part of any pharmacy-related technology 

purchase. As indicated throughout this guidance document, potential technology-related 

adverse events can arise if systems are not carefully deployed and maintained, if 

human interactions with the system produce workarounds, or if those selecting and 

approving new systems fail to consider and mitigate the potentially adverse impact that 

disruptive new technologies can have on healthcare processes, workflow and safety. 96 

The chance of technology-related adverse events can be reduced by providing 

adequate resources prior to system selection and implementation, as well as 

appropriate monitoring and optimization after go-live. It is important to assess current 

medication management workflow processes and scrutinize workflow risk points and 

inefficiencies in each process when designing or changing the medication 

administration process. Additionally, once systems have been properly implemented, 

on-going evaluation of the workflow processes should be evaluated to ensure policy 

compliance and identification of potential human-computer interface risks. 

While independent, peer reviewed studies confirming a positive cost-benefit ratio for 

investing in pharmacy-related automation technologies remain sparse, case studies are 

emerging that provide anecdotal evidence of substantial cost-savings for the 

implementation of bar code medication administration, pharmacy inventory 

management and unit-dose packaging systems. 

As with any cost-benefit analysis, consideration needs to be given to key areas that may 

affect the net benefits an organization can expect from implementing medication 

management technologies. These include organizational culture issues; how the 

pharmacy-related automation systems are to be integrated with other systems; savings 

associated with averted errors and ADEs; expected time and efficiency gains; the 

possibility that technology may shift rather than reduce the need for resources; and the 

need for initial and ongoing training, system upgrades and maintenance. 


44

In closing, we believe there is an increasingly strong case to be made for greater use of 

pharmacy-related automation technologies to improve the quality and safety of 

medication management processes in acute-care settings. We also believe there are 

sufficient product choices to support organizations wanting to move forward in this area. 

Finally, we hope this guidance document helps pharmacy professionals, nurses and the 

healthcare executives they work with make more informed decisions about which 

technologies to implement in acute-care settings—and when. 


45

Appendix A—References 

1. Shepard S. RFID Radio Frequency Identification. New York: McGraw-Hill; 

2005:42-47. 

2. Garfinkel S and Rosenberg B. RFID Applications, Security, and Privacy. Upper 

Saddle River, New Jersey: Addison-Wesley; 2006:17-22, 329. 

3. Association for Automatic Identification and Mobility (AIM) ®.). Technologies: 

Real-Time Locating Systems. Available at: 

http://www.aimglobal.org/technologies/rtls. Accessed May 28, 2009. 

4. Swedberg. All Eyes on FDA for Drug E-Pedigree. RFID Journal. April 10, 2008. 

5. Health Imaging. 2007/FDA approves Covidien contrast delivery system with 

RFID. http://www.healthimaging.com Posted May 2007. Accessed June 1, 2009. 

6. Krohn. The Optimal RTLS Solution for Hospitals. Journal of Healthcare 

Information Management. Fall 2008. 

7. O’Connor MC. Florida Hospital to Use RFID to Track Implantable Cardiac 

Devices. RFID Journal. December 2008. 

8. Batchelder, B. ASD Healthcare Deploys RFID Refrigerated Drug Cabinets. RFID 

Journal. Sept 24, 2007. 

9. O’Connor MC. Terso Offers EPC-Enabled Medical Cabinets. RFID Journal. 

August 2008. 

10. Young D. Pittsburgh hospital combines RFID, bar codes to improve safety. 

American Journal of Health-System Pharmacy. December 15, 2006. 

11. Maviglia S, Yoo J, Franz C, Featherstone E, Churchill W, Bates D, Gandhi T, 

Poon E. Cost-benefit analysis of a hospital pharmacy bar code solution. Archives 

of Internal Medicine. 2007;167:788-94. 

12. Nolen A, Rodes D. Bar-code Medication Administration System for Anesthetics: 

Effects on Documentation and Billing. American Journal of Health-System 

Pharmacy. 2008; 655-659. 

13. Van der Togt R, van Lieshout EJ, Hensbroek R, Beinat E, Binnekade JM, Bakker 

PJ. Electromagnetic Interference from Radio Frequency Identification Inducing 

Potentially Hazardous Incidents in Critical Care Medical Equipment. Journal of 

the American Medical Association. June 25, 2008. 

14. Garfinkel S and Rosenberg B. RFID Applications, Security, and Privacy. Upper 

Saddle River, New Jersey: Addison-Wesley; 2006:17-22, 329+. 

15. Wicks AM, Visich JK, Li S. Radio Frequency Identification Applications in 

Hospital Environments. Hospital Topics. Summer 2006. 84(3), 3-8. 

16. Nagy P, George I, Bernstein W, Caban J, Klein R, Mezrich R, Park A. Radio 

Frequency Identification Systems Technology in the Surgical Setting. Surgical 

Innovation. March 2006, 61-67. 

17. Egan MT, Sandberg, WS. Auto Identification Technology and Its Impact on 

Patient Safety in the Operating Room of the Future. Surgical Innovation, March 

2007;Volume 14, Number 1;41-50. 

18. HIMSS®. Implementation Guide to Bar Coding and Auto-ID in Healthcare: 

Improving Quality and Patient Safety, Edited by Ned J. Simpson and Kenneth A. 

Kleinberg, 2009. 


46

19. Shack & Tulloch, Inc. Integrated Pharmacy Automation Systems Lead to 

Increases in Patient Safety and Significant Reductions in Medication Inventory 

Costs; Shack & Tulloch, ROI Series, 2008. Available at: 

http://www.mckesson.com/static_files/McKesson.com/MPT/Documents/MAIFiles/ 

CaseStudy_Shore_Memorial_Hospital.pdf 

20. Talyst®, Inc. (2009). Case Study - Parkview Health-Multi-Hospital Pharmacy 

Integration. Available at: www.talyst.com/resources/casestudies/parkview. 

Accessed June 5, 2009. 

21. History Tracking Report: 2008 to 2009 Requirements Accreditation Program: 

Hospital 2008 Chapter: Medication Management. The Joint Commission® 2008. 

Available at: http://www.jointcommission.org/NR/rdonlyres/2361EE77-1A31- 

4111-BB15-8FA044607E93/0/OME_MM_08_to_09.pdf. Accessed June 8, 2009. 

22. American Society of Hospital Pharmacists. ASHP statement on unit dose drug 

distribution. Am J Hosp Pharm. 1989;46:2346. 

23. Talyst®, Inc. (2009). AutoPack Oral Solid Packaging System. Available at: 

http://talyst.com/Products/Hardware/AutoPack. Accessed June 5, 2009. 

24. McKesson Corp®. Pharmaceutical Packing Solutions - PACMED Available at: 

http://www.mckesson.com/en_us/McKesson.com/For%2BPharmacies/Inpatient/ 

Medication%2BPackaging/PACMED.html. Accessed June 5, 2009. 

25. EUCLID® Spiral Paper Tube Corp. (2005). Speedy Wet Cadet®. Available at: 

http://www.euclidspiral.com/medical/euclidspiralmedical-wetcadet.html or 

http://www.euclidspiral.com/medical/pdf/Speedy%20Wet%20Cadet.pdf. 


26. Medical Packaging, Inc®. The Fluidose Series 5. (Copyright 2005) Available at: 

http://www.medpak.com/v1/Main/Default.aspx?expand=Fluidose. Accessed June 

15, 2009. 







29. Deschaine MR. High-speed packaging drives safety to the bedside. Nursing 

Management. November 2007;14-15 

30. Pedersen C, Schneider P, Scheckelhoff D. ASHP national survey of pharmacy 

practice in hospital settings: dispensing and administration. American Journal of 

Health-System Pharmacy. 2009;66:926-46. 

31. American Society of Hospital Pharmacists. ASHP technical assistance bulletin on 

re-packaging oral solids and liquids in single unit and unit dose packages. . Am J 

Hosp Pharm. 1983;40:451–2. 

32. Weizer M. The Bigger Packaging Picture. Pharmacy Purchasing & Products. Vol 

3 #5 ;2006. 


PACMED_Article_Pharmacy_Purchasing_and_Products_by_Michele_Weizer_(S 

ep2006).pdf Accessed at June 8, 2009. 


47

33. Klaus. High-Volume Unit Dose Packaging. Klaus Online Newsletter. September, 

2008. Available at: 

http://www.klasresearch.com/Klas/Site/News/NewsLetters/2008-09/UD2008.aspx 


34. Zaroukian, M. (2009) Sparrow Hospital Pharmacy Department, Lansing, 

Michigan. 




36. Sensmeier J. Clinical synergy yields safer care, better outcomes. The partnership 

between nurses and pharmacists is bound by a mutual commitment to patient 

safety. Nursing Management. November 2007;4-12. 

37. FitzHenry F, Peterson J, Arrieta M, Waitman L, Schildcrout J, Miller R. 

Medication administration discrepancies persist despite electronic ordering. 

Journal of the American Medical Informatics Association. August 21, 2007. 

38. Pedersen C, Schneider P, Scheckelhoff D. ASHP national survey of pharmacy 

practice in hospital settings: dispensing and administration. American Journal of 


39. No authors listed. Guidance for Industry: Bar Code Label Requirements - 

Questions and Answers. Office of Regulatory Policy, Center for Drug Evaluation 

and Research, Food and Drug Administration. 2006. Available at: 

http://www.fda.gov/downloads/BiologicsBloodVaccines/GuidanceComplianceReg 

ulatoryInformation/Guidances/Blood/ucm078949.pdf; Last accessed June 14, 

2009. 

40. Wideman M, Whittler M, Anderson T. Bar code Medication Administration: 

Lessons Learned from an Intensive Care Unit Implementation. In Henriksen K, 

Battles JB, Marks ES, Lewin DI, editors. Advances in patient safety: from 

research to implementation. Vol. 3, Concepts and methodology. AHRQ 

Publication No. 05-0021-3. Rockville, MD: Agency for Healthcare Research and 

Quality; Feb 2005. Available at:: 

http://www.ahrq.gov/downloads/pub/advances/vol3/Wideman.pdfhttp://www.ahrq. 

gov/downloads/pub/advances/vol3/Wideman.pdf; Last accessed June 14, 2009. 

41. HIMSS® Pharmacy Informatics Task Force. The Ideal Bar code Point of Care 

System for the Pharmacy Informaticist. 2007. 

www.himss.org/content/files/PITF_WP_IdealBar code.pdf 

42. Cochran GL, Jones KJ, Brockman J, Skinner A, Hicks RW. Errors prevented by 

and associated with bar-code medication administration systems. The Joint 

Commission Journal on Quality and Patient Safety. 2007 May;33(5):293-301, 

245. 

43. No authors listed. Guidance for Industry: Bar Code Label Requirements - 

Questions and Answers. Office of Regulatory Policy, Center for Drug Evaluation 

and Research, Food and Drug Administration. 2006. Available at: 

http://www.fda.gov/downloads/BiologicsBloodVaccines/GuidanceComplianceReg 

ulatoryInformation/Guidances/Blood/ucm078949.pdf; Last accessed June 14, 

2009. 


48

44. Franklyn BD, O’Grady K, Donyai P, Jacklin A,Barber, N. Error Management: The 

impact of a closed-loop electronic prescribing and administration system on 

prescribing errors, administration errors and staff time: a before-and-after study. 

Quality and Safety in Health Care. 2007;16:279-284. 




46. Institute for Healthcare Improvement. The Five Rights of Medication 

Administration. 

http://www.ihi.org/IHI/Topics/PatientSafety/MedicationSystems/ImprovementStori 

es/FiveRightsofMedicationAdministration.htm. July 11, 2007. 

47. Franklyn BD, O’Grady K, Donyai P, Jacklin A,Barber, N. Error Management: The 

impact of a closed-loop electronic prescribing and administration system on 

prescribing errors, administration errors and staff time: a before-and-after study. 

Quality and Safety in Health Care. 2007;16:279-284. 

48. Hook J, Pearlstein J, Samarth A, Cusack C. Using Bar code Medication 

Administration to Improve Quality and Safety: Findings from the AHRQ Health IT 

Portfolio (Prepared by the AHRQ National Resource Center for Health IT under 

Contract No. 290-04-0016). AHRQ Publication No. 09-0023-EF. Rockville, MD: 

Agency for Healthcare Research and Quality. December 2008. Available at: 

http://healthit.ahrq.gov/portal/server.pt/gateway/PTARGS_0_1248_846906_0_0_ 

18/09-0023-EF_bcma.pdf 

49. Hurley A, Bane A, Fotakis S, Duffy M, Sevigny A, Poon E, Gandi, T. Nurses’ 

Satisfaction with Medication Administration Point-of-Care Technology. Journal of 

Nursing Administration. July/August 2007. 

50. Poon E, Cina J, Churchill W, et al. Medication dispensing errors and potential 

adverse drug events before and after implementing bar code technology in the 

pharmacy. Annals of Internal Medicine. 2006;145:426-434. 

51. HIMSS® Pharmacy Informatics Task Force: Designing Inherent Safety Into 

Electronic Medication Order Entry Systems, How to make Computerized 

Physician Order Entry and e-Prescribing from the pharmacy informaticist 

perspective, August 2007 

http://www.himss.org/content/files/PITFePrescribingSafer.pdf 

52. Koppel R, Wetterneck T, Telles J, Karsh B. Workarounds to bar code medication 

administration systems: their occurrences, causes, and threats to patient safety. 

Journal of the American Medical Informatics Association. 2008 Jul- 

Aug;15(4):408-23. 




54. Schaeffer R. Closing the Medication Safety Loop. Health Management 

Technology. March 2009 Available at: 

http://www.healthmgttech.com/features/2009_march/0309_closing.aspx 





49







58. Leape LL, Bates DW, Cullen DJ, Cooper J, Demonaco HJ, Gallivan T, Hallisey 

R, Ives J, Laird N, Laffel G, et al. Systems analysis of adverse drug events. ADE 

Prevention Study Group. Journal of the American Medical Association 1995; 

274:35–43. 

59. United State Pharmacopiea (USP), http://www.usp.org/, (last visited November 

17, 2009). 

60. Mullarkey T. Pharmacy Compounding of High-risk Level Products and Patient 

Safety. Am. J Health-Syst Pharm. 2009; 66; Supplement 5. 

61. USP Compounding Backgrounder. 

www.usp.org/pdf/EN/aboutUSP/pressRoom/compoundingBackgrounder.pdf (last 

visited November 17, 2009). 

62. International Academy of Compounding Pharmacists. 

http://www.iacprx.org/site/pageserver?pagename=home_page (last visited 

November 17, 2009). 

63. Flynn EA, Pearson R, Barker KN. Observational study of accuracy in 

compounding i.v. admixtures at five hospitals. Am J Health-Syst Pharm. April 15, 

1997;54(8):904-912. 

64. RIVA overall flow chart, Intelligent Hospital Systems, 

www.intelligenthospitals.com. 

65. Flynn EA, et al. Dispensing accuracy and safety. J Am Pharm Assoc. 

2003;43(2):191-200. 

66. Leape LL, Bates DW, Cullen DJ, Cooper J, Demonaco HJ, Gallivan T, Hallisey 

R, Ives J, Laird N, Laffel G, et al.. Systems analysis of adverse drug events. 

ADE Prevention Group Study. Journal of the American Medical Association 

1995; 274:35-43. 

67. Cina JL, Gandhi TK, Churchill W, Fanikos J. How Many Hospital Pharmacy 

Medication Dispensing Errors Go Undetected. Journal on Quality and Patient 

Safety. 2006; 32(2): 73-80. 

68. Flynn A, Barker K, Gibson J, Pearson R, Berger B, Smith L. Impact of 

interruptions and distractions on dispensing errors in an ambulatory care 

pharmacy. American Journal of Health-System Pharmacy. 1999;56:1319-25. 

69. Barker, KN, Allan, EL. Research on drug-use-system errors. American Journal of 


70. Rolland, P. Occurrence of dispensing errors and efforts to reduce medication 

errors at the Central Arkansas Veteran’s Healthcare System. Drug Safety. 

2004;271–282. 

71. Omnicell® Corporation. Central pharmacy solutions Available. Available at: 

www.omnicell.com/PDF/solutions/Central_Pharmacy_Solutions.pdf. Accessed 

June, 10 2009. 


50

72. Safely implementing health information and converging technologies. The Joint 

Commission Sentinel Event Alert. 42, 2008. 

73. Institute for Safe Medication Practices Guidance on the Interdisciplinary Safe 

Use of Automated Dispensing Cabinets; 

http://www.ismp.org/Tools/guidelines/ADC_Guidelines_Final.pdf. 2008. 

74. Dib J, Abdulmohsin S, Farooki M, Iqbal M, Khan M, Ahmed J. Effects of an 

Automated Drug Dispensing System on Medication Adverse Event Occurrences 

and Cost Containment at SAMSO, ©Wolters Kluwer Health. Inc. Hospital 

Pharmacy. December 2006; 41(12):1180-1184. 

75. Dib J, Abdulmohsin S, Farooki M, Iqbal M, Khan M, Ahmed J. Effects of an 

Automated Drug Dispensing System on Medication Adverse Event Occurrences 

and Cost Containment at SAMSO, ©Wolters Kluwer Health. Inc. Hospital 

Pharmacy. December 2006; 41(12):1180-1184. 

76. Shack, J., Tulloch, S. The Pharmacy-to-Bedside Hybrid Medication Distribution 

System. Fairport, NY: Shack & Tulloch, Inc. (2006). Available at: 


Hybrid_Distribution_System_Business_Case_Analysis.pdf 






78. Talyst®, Inc. (2009). Case Study - Parkview Health-Multi-Hospital Pharmacy 

Integration. Available at: www.talyst.com/resources/casestudies/parkview. 

Accessed June 5, 2009 

79. Ryan GM, Jennings-Garant B, DiRusso B. (2006, July 14). Webcast: Meeting the 

Standard for Pharmacist. Order Review: The Override Challenge. Impact on 

Pharmacy and Nursing. Available at: 

http://www.cardinalhealth.com/clinicalcenter/materials/webcasts/Overrides.pdf. 


80. Colen HB, Neuenschwander M, Neef C, Krabbendam KJ. Using Automated 

Dispensing Machines to improve Medication Safety. Trends in Drug Distribution, 

Special Edition. European Association of Hospital Pharmacists Practice, Volume 

12; 2006. 

81. Gaunt M, Johnston J, Davis M. Automated Dispensing Cabinets: Don’t assume 

they’re safe; correct design and use are crucial. American Journal of Nursing. 

2007; 107:27-8. 

82. Cash, JJ. Stocking Policies and Procedures for Automated Dispensing Cabinets. 

Pharmacy Purchasing & Products. July 2008. 

83. Gaunt M, Johnston J, Davis M. Automated Dispensing Cabinets: Don’t assume 

they’re safe; correct design and use are crucial. American Journal of Nursing. 

2007; 107:27-8. 

84. Institute for Healthcare Improvement. The Five Rights of Medication 

Administration. Available at 

http://www.ihi.org/IHI/Topics/PatientSafety/MedicationSystems/ImprovementStori 

es/FiveRightsofMedicationAdministration.htm. July 11, 2007. 


51






86. New Ulm Medical Center. Health Edition: 2005. A safer, more efficient drug 

distribution process. Posted September, 2005. Available at 

www.allina.com/ahs/newulm.nsf/page/Pyxis Accessed May 28, 2009. 




88. Classen DC, Pestotnik SL, Evans RS, Lloyd JF, Burke JP. Adverse drug events 

in hospitalized patients. Excess length of stay, extra costs, and attributable 

mortality. JAMA. 1997;277:301-6. 

89. Bates DW, Spell N, Cullen DJ, Burdick E, Laird N, Petersen LA, Small SD, 

Sweitzer BJ, Leape LL. The costs of adverse drug events in hospitalized 

patients. Adverse Drug Events Prevention Study Group. JAMA. 1997;277:307- 

11. 

90. Cummings J, Ratko T, Matuszewski K. Barcoding to Enhance Patient Safety. 

Patient Safety & Quality Healthcare. September / October 2005. Accessed July 

10, 2009. Available at: http://www.psqh.com/sepoct05/barcodingrfid1.html 

91. Koppel R, Wetterneck T, Telles J, Karsh B. Workarounds to bar code medication 

administration systems: their occurrences, causes, and threats to patient safety. 

Journal of the American Medical Informatics Association. 2008 Jul- 

Aug;15(4):408-23. 


Poon E. Cost-benefit analysis of a hospital pharmacy bar code solution. Arch Int 

Med. 2007;167:788-94. 

93. Mekhjian H, Kumar R, Kuehn L, Bentley T, Teater P, Thomas A, Payne B, 

Ahmad A. Immediate benefits realized following implementation of physician 

order entry at an academic medical center. Journal of the American Medical 

Informatics Association. 2002 Sep-Oct;9(5):529-39. 


System for the Pharmacy Informaticist. 2007. Available at: 


95. Simpson NJ, Kleinberg KA, eds. Implementation Guide to Bar Coding and Auto- 

ID in Healthcare: Improving Quality and Patient Safety. Chicago, IL: HIMSS; 

2009. 

96. Safely implementing health information and converging technologies. The Joint 

Commission Sentinel Event Alert. 42;2008. 


52

Pharmacy Guidance Document - himss

Create successful ePaper yourself

Delete template?

Save as template?