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Information is transferred to pharmacist who reviews order, makes changes if necessary and authorizes transaction.  Pharmacist authorization is mandatory according to HIPAA, IRB, State Pharmacy Boards, and other national regulatory bodies.



Stationary Apparatus,


On the patient floor, the nurse reviews information for the administration of medications at the central system.  The nurse accesses patient delivery schedule and alerts delivery staff.



Stationary Apparatus,



On the computerized touch screen, the order list for each patient is displayed.  The nurse confirms the order and medicine cabinet doors open one at a time (minimizes possibility of human error).  Nurse retrieves medicine then places medicine in patient specific cart (mobile apparatus used to deliver meds at point of care) drawer.  Each patient specific drawer is programmed with patient specific information including dosage, time, and route.  The nurse double checks the order.


Nurse, Patient


Bar-Code technology, EMR

Once all medicines are placed in the cart, nurse is ready for rounds.  Nurse delivers medicine to each patient.  Nurse scans patient barcode ID bracelet which then opens patient compartment on cart.  Nurse verifies information is logged into cart.





Nurse returns cart to machine.  Information regarding distribution of medicines is transferred to main system and logged.  Patient drawers used during rounds open and are cleared.  Cart is now ready for next round of distribution, thus closing the loop. 


In this application, physicians utilize the CPOE which runs on a portable handheld computer.  The CPOE assists each physician analyzes patient records while prescribing appropriate medications.  Linked to a central database, physicians are alerted to adverse drug-to-drug interactions as well as inappropriate dosages which prompt the physician to reselect correct medication and dosage amounts.  CPOE systems improve safety in several ways.  First, all orders standardized to include a dose, route, and frequency.  Second, and perhaps most critical, orders are legible (transcribed) and can be identified by the pharmacist in all instances.  Third, information can be accessed by the pharmacist at any time during the process.  Lastly, all orders can be checked for a number of problems including allergies, drug interactions, overly high doses, drug-laboratory problems (giving a patient a drug when they have a known biochemical factor that predisposes them to risk), and whether the dose is appropriate for the patient's condition.[18] Decision support in the prescribing stage critically reduces the potential for medication errors attributed to physician orders and in many cases reduces the need for order transcription.  Additionally, an electronic record maintains the integrity of the order improving patient safety and expected outcomes. 

At the dispensing stage, prescriptions are authorized directly at the workstation in a readable format while patient records are accessible by the nurse.  Additionally, pharmacists are able to review orders at their leisure at their own workstation to provide an additional layer of verification.  This information also allows pharmacists to adequately manage inventory of medications stored within the unit itself.   

The administration of medications is automated alerting nurses of pending tasks.  Nurses are equipped with access cards which allow entry into a single drawer on the cabinet and a single drawer on the cart.  The cabinet electronically monitors prescriptions and dosage time and route providing an additional layer of verification.  At the bedside, the patient barcode is scanned and the proper cart drawer is opened.  Bar coding ensures the correct preparation and dispensing of medications.  While bar code scanning is a critical element of the machine, the technology as a stand alone, can significantly improve medication errors by ensuring the correct preparation and dispensing of medications.  The use of barcode scanning allows simultaneous access to the patient’s medical records, information regarding the medication, information regarding correct dosage and frequency, and creates a seemingly flawless path towards the correct administration of medications.  Bar coding not only improves workflow, but reduces medication errors and dramatically improves patient safety.[19]  Moreover, patient barcode allows nurses to internally verify the 5 rights: medication, dose, time, route, patient.  An automated bar coding system integrated into the process reduces the need of paper records which effectively eliminates opportunity for human error in delivery of medication.[20]    It provides information needed to continually improve the safety and quality of the hospital’s medication management process.  Moreover, bar coding receives substantial support from nurses by relieving their apprehension about making errors, reducing their administrative burden, and promoting accurate documentation and charge capture improving efficiency.[21] 

Lastly, prescriptions and medication administration are recorded only once, mostly at the point of care as part of the routine workflow.  This ensures completeness of documentation for patient safety and enhances clinical decision making with credible support.  A comprehensive documentation process with one point of entry allows information to be collected, analyzed and monitored appropriately by physicians, nurses, and pharmacists.  While the closed-loop system provides a tool to reduce medication errors, it is not a solution in and of itself.  Proper data documentation and collection allows subsequent medication errors to be analyzed and addressed more efficiently. 


In addition to controlling risk factors that may harm a patient, inpatient facilities will realize tremendous cost savings through this application.  Moreover, errors due to patient mix-ups will be eliminated by the application of barcode technology, which reduces medication errors by 65-86% by serving as the gatekeeper for final delivery of medicine to patient[22].  Errors associated with incorrect dosages and dispensing of incorrect medicines with similar names will virtually be eliminated.  The application of this process also increases physician and nurse productivity which help to address issues related to nursing shortages.  In fact, overall nursing time for medication workflow with this application has decreased by 6.1 hours per 24-hour shift.[23] Nonetheless, the expected benefits of this system will help to increase staff productivity, create cost savings for the facility, and most importantly, increases patient care and satisfaction.




Significant emphasis has been placed on the value of standard reporting systems by accrediting organizations such as the Joint Commission for Accreditation of Health Care Organizations (JCAHO).  The need for quality improvement is more prevalent now than it has ever been.  Along with a heightened need to reduce preventable errors, costs must be controlled to adapt to declining reimbursements.  Operational and clinical synergies are opportunities to enhance patient experience and is proven to effectively reduce both cost and medication errors.  Current initiatives include implementing operational processes that have been successful in other industries, such as Six Sigma, as a way to create operational efficiencies.  Six Sigma, which provides a formal analysis of the source of error, establishes a high standard for acceptable quality is now widely accepted in healthcare as a powerful quality improvement tool.  The Six Sigma standard is a management tool that concentrates on measuring outcomes and error rates identifying opportunities for improvement.  If implemented successfully, errors will be limited to 3.4 per 1 million opportunities.  Alternative process improvement methods which have been successful in healthcare include ISO 9000 and the Baldrige Criteria.

There are several barriers which may prevent the successful integration of information systems in health care environments around the world.  Certainly, a significant investment, both financially and time, must be made to learn how systems discussed in this chapter can be successfully integrated.  Users must be willing to learn and change the way they practice to meet success.  Moreover, providers of care must have the infrastructure to apply new technologies or information systems.  Otherwise, they simply will not work. 



Successful integration of information systems depends on the widespread support and acceptance among physicians, nurses, and pharmacists.  One of the primary challenges to successfully reduce medication errors is to gain acceptance.  Allowing each entity to guide the design and support of such systems is critical to the overall success.  Information systems are simply a tool that allows providers to address the glaring need to reduce medication errors.  Cultural workflow attributes equally impacts the successful integration of information systems.  Access to capital, which poses a significant problem to low volume community facilities, is certainly an obstacle towards the integration of information systems.  However, there are low cost options including process re-engineering which can address larger issue contributing to medication errors, such as standard communication procedures. While the closed-loop design addresses all medication process steps, resource allocation and consumption can be a limiting factor.  The shortage of nurses and pharmacists combined with clinician’s limited time must be considered and evaluated in the design and implementation of the system.  Time savings, reduction in workload, inventory management, and lower medical costs are byproducts of an improved system that improves patient safety by dramatically reducing medication errors. 

Patient safety in all aspects is the cornerstone and expected future state of such initiatives and requires the continued collaboration of all participants.  The critical success factors which include improvements to each step in the medication delivery process, also includes acceptance by users, as well as strong linkages to organizational strategic plans.[24]  Creating the perception that the anticipated future state involves the intended implementation of each critical success factor in succession will ultimately penetrate and resolve problems at hand sustaining an environment commensurate with strategic objectives.







For Further Research

  1. Institute of Medicine: http://www.iom.edu
  2. Medical Errors: http://www.mederrors.com
  3. MDG Medical, Inc.: http://www.mdgmedical.com
  4. Institute for Safe Medication Practices: http://www.ismp.org
  5. To Err is Human: Building a Safer Health System.  Committee on Quality of Health Care in America.  2000. Institute of Medicine.
  6. Crossing the Quality Chasm: A New Health System for the 21st Century.  Committee on Quality of Health Care in America.  2001.  Institute of Medicine.
  7. Joint Commission on Accreditation of Healthcare Organizations (JCAHO)- http://www.jcaho.org
  8. The Institute for Healthcare Improvement – http://www.ihi.org
  9. National Foundation for Patient Safety – http://www.npsf.org
  10. American Medical Association – http://www.ama-assn.org



*1 A set of approaches utilized to efficiently integrate suppliers and clients (comprised of stores, retailers, wholesalers, warehouses, and manufacturers) so merchandise is produced and distributed at the right quantities, to the right locations, and at the right time, in order to minimize system wide costs while satisfying service level requests.  http://www.stanford.edu/~jlmayer

[1] Institute of Medicine.  “To Err is Human: Building a Safer Health System”. November 1999.

[2] “Medication Errors Add Time, Money to Hospital Stays”. Oct 7, 2003.  http://www.azcentral.com

[3] “Resources for Reducing Medication Errors and Improving Quality in Hospitals”.  http://www.mederrors.com

[4] “Graham, Snowe Legislation Would Reduce Medication Errors”.  May 3, 2001.  http://www.senate.gov/~graham

[5] Goldberg, Laurence A. “Closed-loop Medicines Management System”. Hospital Pharmacy Europe. Nov/Dec 2003.

[6] ibid

[7] http://www.healthmgttech.com/archives/h1102errors.htm

[8] http://www.siemens.com

[9] ibid

[10] “Graham, Snowe Legislation Would Reduce Medication Errors”.  May 3, 2001.  http://www.senate.gov/~graham

[11] http://www.mdgmedical.com/ServerRx.html

[12] Stachnik, Joan.  Strategies for Preventing Medication Errors Through automated Technology.  January 2003.


[13] Leape L.  “Systems Analysis of Adverse Drug Events”.  JAMA 1995.

[14] ibid

[15] ibid

[16] Bates D. “Using Information Technology to Reduce Rates of Medication Errors in Hospitals”.


[17] Stacklin, Jeff. “Hospitals to Test Rx System”. NE Ohio CrainTech, 6/02/03.  http://neohio.craintech.com

[18] Bates D. “Using information technology to reduce rates of medication errors in hospitals”.


[19]  http://www.healthmgttech.com.  Technology’s impact on reducing medication errors. 11/02.

[20]  http://www.healthmgttech.com.  Technology’s impact on reducing medication errors. 11/02.

[21] http://www.bridgemedical.com/news_2000_02.shtml

[22] Goldberg, Laurence A. “Closed-loop Medicines Management System”, Hospital Pharmacy Europe. 

     November/December 2003.

[23] ibid

[24] Dowling, Alan.  “Successful Strategies for HCIS Planning”. Financial Focus, 1987.