Safeguarding Patient Safety Via Pakistan’s First Home Grown Bar-coded Medication Administration System Developed And Implemented At A Private Tertiary Care Hospital

• By: KHAN, Umer Ali (Aga Khan University Hospital, Pakistan)
• Co-author(s): Mr Umer Ali Khan (Aga Khan University Hospital, Karachi, Pakistan)
  Mr. Syed Shamim Raza (Aga Khan University Hospital, Karachi, Pakistan)
  Ms Faqeeha Shakeel (Aga Khan University Hospital, Karachi, Pakistan)
  
• Abstract:

  Background:
  
  Preventable medication related errors continue to occur in different health care setups compromising the patient safety. Medication errors pose significant patient Safety risks related to transcribing, dispensing and administration of Medication orders. These include wrong drug, wrong route of administration, wrong dose, and wrong patient etc.
  
  28% of all adverse drug events are due to Medication errors (Preventable errors) and 25% of the are due to LASA drugs1
  The burden of medication errors can be estimated by the fact that the extra medical costs of treating drug-related injuries occurring in hospitals alone are at least to $3.5 billion a year, and this estimate does not consider lost wages and productivity or additional health care costs, the report says2
  In terms of Government regulations governing Barcoding and traceability of medication there is no compliance from the manufacturers.
  Furthermore, automation in hospital pharmacy setup is nonexistent there are not pharmacies in Pakistan where automated unit dose dispensing systems, automated dispensing cabinets or medication carousels dispensers are operational. There are no government subsidies on important of such equipment's.
  
  Purpose: The aim of the implementation of BCMA is to aid physicians, pharmacist and nurses in the process of medication management and use to prevent medication errors / adverse events to enhance patient safety and quality of care.
  
  Methods:
  The aim of the implementation of BCMA is to aid Physicians, Pharmacist and nurses in the process of medication management and use to prevent medication errors / adverse events to enhance patient safety and quality of care.
  
  Medication management process is comprised of 8 steps starting with i) medication receiving, ii) medication labeling and storage, iii) transfer of medication from warehouse to pharmacy satellites, iv) ordering through CPOE, v) dispensing of medication, vi) medication review, vii) verification patient verification at bedside, and viii) mark administration in EMR.
  Because of lack of automation technologies unique solutions were developed where Data Matrix and QR code labels are used and pasted manually on all medication dispensing units inclusive of unit dose and commercial primary or secondary packaging.
  
  Barcode equipment were installed in satellites along with scanners and medication trolleys. In house Data Matrix and QR Barcode labels were initiated / generated for stored medication before transferring to any of the satellite in hospitals.
  BCMA was installed and implemented from prescribing of medication orders till administration of medications.
  
  Results: After implementation of BCMA analysis / examination showed a significant decreased in 50% decrease in annually reported medication related to medication administration and 74% decrease in annually reported medication errors. More than 1900 medications errors were prevented in 4 years since 2019.
  
  Conclusion:
  BCMA technology played a vital role in safeguarding patient’s safety in the hospital by preventing the medication errors from dispensing till administration.