This column was prepared by the Institute for Safe Medication Practices (ISMP), an ECRI affiliate.
A specialty pharmacy filled a prescription for Jakafi® (ruxolitinib) 5 mg tablets with 15 mg tablets by mistake and shipped it to the patient. Jakafi is a kinase inhibitor used to treat myelofibrosis and polycythemia vera in adults, and graft-versus-host disease in patients aged 12 and older. After the patient received the delivery, they noticed they had a different appearance than expected and alerted the pharmacy. The prescription was written correctly by the provider for Jakafi 5 mg tablets, and it was entered correctly into the dispensing software; however, the label was incorrectly placed on the manufacturer’s bottle of Jakafi 15 mg tablets. When the verification pharmacist scanned the product’s barcode, they received an error alert. The pharmacist overrode the alert as he assumed the barcode scan did not work without recognizing the wrong strength of the product was scanned.
The staff at this pharmacy had previously experienced barcodes on some products not scanning but firing alerts because the barcode information was not in the pharmacy computer system. To overcome this issue, they manually added these products and barcodes into the dispensing software to ensure barcode scanning would function correctly. However, at times, when the barcode was not in the pharmacy system, some staff would override the barcode scanning alert if they did not have time to enter the medication barcode information into the dispensing software to allow for accurate barcode scanning. In this case, the Jakafi barcode information had already been added to the software and was scannable; the pharmacist assumed that it had not yet been added to the pharmacy system when the system fired the alert.
Before new products are added to a pharmacy’s inventory and made available for dispensing, the pharmacy should establish a process to test the product’s barcode to make sure it will scan properly with their software and barcode scanning hardware. The pharmacy system should be updated as necessary with any missing product barcode information. When staff engage in barcode scanning workarounds, they should uncover the system-based reasons for the workarounds so they can be remedied. Coach the pharmacy staff involved to raise awareness of the risk associated with the behavior and encourage safer behavioral choices in the future. Work with staff to identify and fix any system barriers that may lead to overriding barcode scanning. Identify an individual or team to track and review data from the pharmacy and barcode scanning system, including the percentage of medications with an unreadable barcode, scanning compliance rates, and overridden or acknowledged alerts. Use this data to identify and address any barriers to using the technology safely and effectively.
To help identify dispensing errors, at the point-of-sale, review the pharmacy labels and content of each prescription container with the patient to check that the medication is correct and what is expected — even if this requires opening the bag. For specialty pharmacies, mail order pharmacies, and community pharmacies that ship or deliver medications to patients’ homes, advise the patient (verbally and in writing) to open their prescription container or sealed manufacturer package to verify the medication prior to taking it. If the medication does not look right, they should contact the pharmacy.