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Most adverse drug events are caused by one or more system breakdowns within the medication-use process.1 At our institution, we have implemented bar-code scanning during the pharmacy distribution process to reduce dispensing errors. Every medication dose is verified by bar-code scanning during technician selection of medications. To ensure that each medication dose has a bar code, we have implemented a pharmacy-based bar-code-repackaging center. A bar-code medication-repackaging center within a hospital pharmacy introduces a new system within the dispensing process that has the potential to contribute to medication dispensing errors. The endpoint of designing safe systems is to create an efficient environment in which it is difficult to generate an error and where the system provides mechanisms to detect and fix errors before reaching the patient.1 A multistep quality-control process, standard procedures for workflow and process, and limited staff access are a few of the system-design components implemented in our repackaging center to prevent errors.
Cina et al. (Tue,) studied this question.