ee cone rcs Cost-Benefit Analysis of a H Bar Code Solution ospital Pharmacy Saverio M. Maviglia, MD, MSc; Jane Y. Yoo, MPP; Calvin Franz, PhD; Erica Featherstone, BS; William Churchill, PharmD; David W. Bates, MD, MSc; Tejal K. Gandhi, MD, MPH; Erie G. Poon, MD, MPH Background: far coding can reduce hospital phar- macy dispensing errors, but itis unclear if the benefits of this technology justify its costs. The purpose of this study was to assess the costs and benelits and determine the return on investment at the institutional level for implementing a pharmacy bar code system. Methods: We performed a cost-benefit analysis of a bar code-assisted medication-dispensing system within a large, academic, nonprofit tertiary care hospital phar- macy. We took the implementing hospital's perspective for a 5-year horizon. The primary outcome was the net financial cost and benefit after 5 years. The secondary out ‘come was the time until total benefits equaled total costs, Single-variable, 2-variable, and multiple-variable Monte Carlo sensitivity analyses were performed to test the sta- bility of the outcomes. Results: In inflation-and time value~adjusted 2005 dol- lars, total costs during 5 years were $2.24 million ($1.31 million in I-time costs during the initial 3.5 years and $342.00 per year in recurring costs starting in year 3) The primary benefit was a decrease in adverse drug events from dispensing errors (517 events annually), resulting inan annual savings of $2.20 million. The net benefit al- ter 5 years was $3.49 million. The break-even point for the hospital's investment occurred within 1 year after ‘coming fully operational. A net benefit was achieved, within 10 years under almost all sensitivity scenarios, In the Monte Carlo simulation, the net benefit during 5 years was $3.2 million (05% confidence interval, $1.2 mi lion to $12.1 million), and the break-even point for tuum on investment occurred afler 51 months (95% con- fidence interval, 30 to 180 months) Conelusion: Implementation ofa bar code-assisted me: cation-dispensing system in hospital pharmacies can r sult in a positive financial return on investment for the health care organization, ‘Arch Intern Med. 2007;167:788-794 EDICATIONS ARE THE most Freque adverse eve than a million injuries and nearly lion errots are intercepted before patient exposure." Given the high volume of medications dispensed by a hospital phar- macy, even a modest reduction in the over- all error rate might avert many preven rn cause of| nis." More 100000 Author Affiliations: snd Women's Hospital (Drs Mavigha, Churchill, Bates, Gandhi, and Poon and ‘Ms Featherstone), Ha ‘Medical School (Drs Mavigia, Bates, Gandhi, and Pastors Healthesre (Drs Mavigha, Bates, and Poon), Boston, Mas allege of Veginis, (0s Yoo); and Eastern Research Group, Lexington, (Or Franz), Downloaded From: on 4/12/2018 daths are attributable to medical errors a- nally Although few medication erors re sult in adverse drug events (ADES).” hos- pitals incur $2200 in additional costs per ADE" and $4685 per preventable ADE." Nationally, the cost of ADEs is $2 billion per year” Computerized physician order entry (CPOE) can prevent serious ordering er rors by up to 55%” However, many med cation erors occur in the dispensing, tran- scribing, and administering stages of the medication process.* Although medica- lions picked from inventory are rou tinely checked and doube-checked, 3% 6% contain an error?" and only 34% of dispensing errors and 2% of administra: igham sed Poon), and ; Medical Richmond Mass (aepRayED) ARGTINTERN MEDVOL IST APRN SOF able ADEs." Recently, we studied medication- dispensing error rates at our institution be fore and alter the implementation of a bar ccode-assisted dispensing system.” Before bar coding, 0.10% of dispensed doses had errors with the potential to harm patients (potential ADEs, usually incorrect medica- tion, strength, or dosage form). After imple- menting bar coding, the rate of potential ADEs from dispensing errors decreased to (0.07%. With approximately 6 million doses dispensed annually, this represents appro: mately 7260 averted potential ADEsannu- ally. Although not all potential ADEs lead toactual ADEs, the savings from this tech- nology may be substantial (©2007 American Medical Association, All rights reserved.Unfortunately, the cost ofthis technology is also sub- stantial. Individual health care institutions have limited, resouirces and must choose from several error-reducing interventions and investments. Overall, it has been dil- ficult to compare interventions because relatively litle is known about their cost-effectiveness, The purpose of this study was to assess the costs and benefits and de- termine the return on investment at the institutional level for implementing a pharmacy bar code system, Es) SETTING AND OVERVIEW Irigham and Women's Hospital (BWH) isa 735-bed, tertiary, academe, nonprofit medical center. ls inpatent pharmacy sef- ‘ce dispenses approximately 6 milion mediation doses for 35000 admissions annually. The hospital employs 61 fll- te pharmacist, 45 fulltime pharmacy technilans, and 2500 registered nurses, who are responsible for most medication ad- 'ALBWH, all physician orders ate entered inta a oclly de- ‘eloped inpatient CPOE system.” Medication orders ae set tlectronialy tothe pharmacy information system, approved by pharmacists, and then executed throughout the hospital Commonly used medications are stocked in semiautomated tmedication-lispensing devices in the nursing uns, whereas Iess commonly sed medications are lilld from ihe phar- macy, dispensed in unit doses and stored In ptient-speciic Arawers before administration in 2001, BWH allocated $3 milion to build astate-ofthe- arvbar code and electronic medication administration record stem 1o reduce the rate of pharmacy dispensing and nursing ‘ministration medication errors. The project was imple mented in phases During the pharmacy phase of the project, barcodes wereaffited tall medications at the unit-dose level. These bar codes were seanned to ensure that the correct medi- Cations atthe comect dose, srengih, and form were Being die- Pensed, This arcle focuses onthe costs and benelis associ ed with this bar code-seisted dispensing system, INTERVENTION Sorearasiy cee shacae Wty aa (COSTS AND BENEFITS All rlevan incremental costs from the hospital’ perspective ‘rereincuded: Direct capital costs included software develop then! (nly integration with the BWH CPOE and pharmacy Systems), hardware prchases (lisporabe app comps Crm scanner, atl eget forthe pharmacy eepackaging sn tes), and changes toilette (eles local sees net ‘work Also included wee premplementation planning cont Incurred by key indviduals who met with vendors crated products, and mde decisions uhoot new pharmacy proce (nepRaN TED) XRCHINTERN MEDVOL 167, APES DOT dures and worklow. In ation, both nal and period tas ing costs due io staf urmover were included Recuring cons included thencremental ime required for staff tosupport te sysicm and repacage mediations that did no have standard bar codes also tncluded direct costs, sich asthe lease agreements forthe repackaging center and carousel system, ad ‘peraing and maintenance cost for equipment. “The primary benefit was the cost savings ssocated with eventing ADEs. Dispensing error rates were measured Ketone’ an afer impleientation,” and then the errr reduc thon tate wae applied tothe toa dispensed doses to calculate the expected numberof avoided errors, Only erors withthe potential to har paents (potential ADEs) were considered, find only those that actually would have resulted in an ADE svere assigned a financial value. Estimates from the published literature about the proportion of dispensing errors that are intercepted (4%)," fhe rte at which potential ADEs resul in acial ADEs (1346)? andthe average incremental costo the iowptal of preventable ADEs ($4000 in 1905 dollars)” were used to translate error reduction rates to dollars saved. Because the savings from an averted ADE accrue to the hosp tal only under «prospective payment system, the savings were tnulipied by the proportion of such pallens st our insti ton (73%) "The primary outcome was the net financial cost and ben- fitduing the inal 5-year period rom preimplementation pla- ting though develope and oll, The secondary aut come was the ie when total benefits equaled total cost. Also Calculated were the cos of at coding per ADE averted and the Telurn on investment at 3 years (computed a the internal rte of return fora periodic sees of ess lows). DATA COLLECTION Primary data were collected from vaio sources, Direc capital conte were determined from BWH accounting records Individ- ale responsile for preimplementaton planing ed tak grids to document the te spent on the bar code projet, Whenever possible, thse time loge were crosechecked with objective ree fords, sch as calendar archives and attendee lis rm mectng tines (Microsoft Outlook; Microsoft ne, Redmond, Wack). Tie pent mang programing esting ding, ain tegrating software and hardware was exacted (roman elec tron project management sysiem (Planview, version 7.2; Plan- ‘ew ine, Austin, ex). Training hours for pharmacists and pharmacy technicians were alle from ining session alten {ince econs.allhour were cnveried into della based on wage tates provided by the BWH human resources department or rom ‘ther slay data compilation sources Ce, hitp/fwwy salary com) when this infrmation was unavallbl; an aditonal 30% dra aed to acco for fringe beni “The impact on pharmacy workilow was determined by sect observation, belore and fer intervention, ofthe te phar macy techniclane spent dlpensing medications Ther ef clency, expressed a doses lspensed per hour, was converted to dolae through wage information. On the bats ofcllec tive pharmacist report training of new personnel was thought tobe time neutral compared with traning before the bt coding jst was implemented. Furthermore, no significa, change was noted in stall turnover flr the implementation of bar coding Benefit wee calculated from directly observed rates of po- tena dispensing errors both before” and after the interven- tion" Adispensing eor was defined ae any discrepancy be- tween dispensed medications and physician orders or replenishment requests or any deviation from standard phar macy policies, Potenil ADEs were defined as dispensing er (©2007 American Medical Association, All rights reserved. Downloaded From: on 4/12/2018Table 1 Input Variables tothe Monte Carlo Simulation ‘Monte caro put Varaie taean(s0) source Doses acid by barcoding BLO(T5) Poon stal> Pre-br coding potent ADE rt," 0.19 (0.012) Catal” Poet-bstodng potent ADE a, %~ 0.07 (0008) Poon a> ate of iarcepton of potent ADEs, 240(76) Leap tal” Poles ADEs antiga 1a4(69) Sausetat ADEs, (Cost pr provera ADE S 4600 (2067) Baas eta Prospect payment, 725 (02) 203 BW ing ata apataged doce per mondo, 4026552700) Massie Cost por epaclagod dos, $ Onr Percontact, Carousel easing cot par dose, $ O03 Perconact, Pre-barcodngfl rat doses perhour 161} Measuad Postar coding ara, dosspechour 100} Maasurad ‘Aubrovatons: ADE, aber drug evn BI, Bigham and Womens Hosp “Ral dstbtns ware usd for alinpts, exept othe cost pat powentte ADE for ich xibuton vas used. Het shown are pus or Lebo an eapal(see Pours and). “incl hata 10% vaanes vas assume, Tages goon 3 aa nae in Fo we Sete an figure +. Components o me corte ofthe para ba-caing role. “etal fe ms costs was $1.3 mllonin 208 dolas Parana ovat ota 100% cave of rounding rors ith the potential to harm patients; potential ADEs were further classified as ie threatening, serious, or significant based, fon a previously validated 2-physican panel algorithm." STATISTICAL ANALYSES Costs and benefits were aggregated by fiscal quater and ana- Iyzed with Microsoft Excel 2003 (Microsoft ne). Costs and ben- clits were converted to constant 2005 dollar values using the Producer Price Index for General Medical and Surgical Hospi- tals. Future coste and benefits were discounted from the project start date (October 1, 2001) to adjust forthe time value of money. ‘We asstimed thatthe discount rate for costs equaled the dis- count rate for benefits. Because the nominal prime interest rate averaged 5% between 2001 and 2005," whereas annual inf tion averaged 2.4% during the same period, we assumed a real annual discount rate of 3% for the primary analysis. SENSITIVITY ANALYSES (One-way sensitivity analyses were performed on all nonmes- sured data inputs, such as discount and inflation rates, the pro- (aepRayTED) ARGHINTERN MEDVOL IGT APRN SOF hice ants an a ‘imran ae Cor ae Late aa ae Figure 2, Components of ecuring costs ofthe pharmacy barcoding projet The ll of th recuring cst was $342 000 anual 2005 ola sen. sen. eno. cura co Ete ss ve ‘gure 3. Cos expended ad nes accrued (tive discount 2008 ols) each quatro he pharma bar-caing reject tine i portion of dispensing errors that resulted in ADES, and the cost savings from an averted ADE. Furthermore, the elfect of adjust- ingall collected data upward or downward by 25% was also evalu ated. Because the primary outcome depended heavily on the ben- clits side of the equation, further sensitivity analyses were performed, including #2-way analysis of cost per ADE with pro- Spective payment rate, a 2-way analysis ofthe parameters used to estimate actual ADEs from observed rates of dispensed errors, and an analysis restricted only to serious adverse events, Finally, all cost and benelitinputs were simultaneously var- ied in a Monte Carlo simulation (@RISK, version 45 for Ex- cel Palisade Corp, thaca, NY). Normal distnbutions with base ‘case mean values were used asthe inputs with 2 conservative ‘exceptions. First, ecatise the output of the model depended _reaily on the cost per ADE, which was estimated from the lit- ‘erature rather than measured, a distribution was used to skew the distribution of this input to lower values. Second, because the recent historically low interest and inflaion rates on which the 3% real anna discount rate was based might not reflect the future, the Monte Carlo simulation assumed a normal dis- tribution centered on 5% for this input. Actual measured sta- dlard deviations were used when available, such as forthe er- ror rate distributions before and alter bar code system implementation (Table 1); otherwise, standard deviation of 10% of the mean was assumed, (©2007 American Medical Association, All rights reserved. Downloaded From: on 4/12/2018Fo ADE at (a a Gi Prospect aa at Atle Ee eager Prete OE ow ADE Rate Bu Cai tring a Vie Ros oa Fate te Bar Cr) ot Fate Big Fig Hoa AA Oa ee Soma Dedopa est era ag et Uta cat clap Rat Fila Oponton antares) ume Ct Tring Cos pea Manga ug) a range oer. aa aa igure 4, Result of Tay sensi anaes foreach fhe npt varies Chang coolant is th rato of tha percent change nth at amuse at Ett 25 years compared ith he eran change nth put arable, ADE inet adverse du Table 2. Years Until Cumulative elt Equals Cumulative Costas a Function of Estimated Cost per ADE and the Hospital's Prospective Payment Rate a Fa a sn sc nn 0 300 nes Tot 495-50 as EY a a ) oo ie tm ts SSeS ‘tao ioe SS ahs ‘Abrevton: ADE, averse dru ven, “oleae eats th acenar that rot lsaly approximate the baecae. ss} The total cost during 5 years was $. tion- and time value-adjusted 2005 dollars, This amount consisted of $1.31 million in L-ime capital investments for planning, development, and rollout (Figure ¥) followed Jy $342,000 annually in recurring costs (Figure 2). No- lably, planning expenses made up 61% ofthe I-time costs. The rate of potential ADEs decreased 63%, from 0.19% of dispensed doses before the implementation of bar cod ing to 0.07% afterward.” Assuming that 34% of the po- tential ADEs would have been intercepted" and 13.4% of the remainder would have resulted in actual ADEs, this corresponded to 517 averted ADEs annually, a sav- ings of $2.2 million annually. Throughout 5 years, the cumulative benefit was $5.73 million (the system be- ceame fully active in year 3) The net benefit throughout 5 years was $3.49 mil- lion, and the break-even point for return on investment occurred during the first quarter of year 4 or within the 24 snillion in infla- (aepnnyteD) ARCHINTERN MEDVOL 167 APRN first year of oper igure 3 shows how costs wer expended and benefits acerued through the 5-year ps riod, corresponding to an annualized return on inves ment of 104%, The average cost of bar coding peraverted ADE was $1573 through year 5, then only $661 per averted ADE thereafter (ie, after achieving steady state) ‘One-way sensitivity analyses showed that the outcomes were relatively insensitiveto thecost inputs Figure 4). The ‘cost factor with the biggest impact on primary outcome was the wage rate;a LO%bincerease in this input caused 4.4% dé ‘erease inthe net cumulative benefit at 5 years, n all cases inwhichacostinputwas varied, returnon investment (break- ‘even point) occurred within the first year of peration, The primary and secondary outcomes were more se sitive to the assumptions that went into calculating ben- clits (Figure 4). For example, a 10% increase in the pre— bar coding potential ADE rate decreased the 5-year net ‘cumulative benefit by 27%, Therefore, more detailed 2-way sensitivity analyses were performed for these variables (ables 2, 3, and 4). However, even in the worst-case (©2007 American Medical Association, All rights reserved. Downloaded From: on 4/12/2018Table 3, Years Until Cumul i Equals Cumulative Cost asa Function ofthe Estimates ofthe Rate al Which Potential ADEs Resul in Actual ADEs andthe Percentage of Potential ADES That Ae intercepted Betore Reaching the Patient Aves itercepeg Batre re ee Reaching Patent, 30 7 78 md 200 50 350 325 300 200 275 28 ano 500 375 350 aay 300 400 215 a9 600 425 350 325 300 300 00 500 750 475 400 350 325 325 30 eno 1175; 600 450 4400 350 350 325 ‘Abrevton: ADE, averse dru ven, “oleae eats th acenar that rot lsaly approximate the baecae. 4, Years Unt Cumulative Benetit Equals Cumulative Costas a Function of Pre-Bar Coding ost-Bar Coding Potential ADE Ral ‘re-tor Coding Foto Postar casg * etna ADE Rata, % ba 018 a0 ow ee 08 220 oat 05 750 ry 3 300 300300 300 300 006 350 350 325 325 a0 300 300 00 oor 315 350 350 325 5250 aa 300 00 oe 1 B15 350 350 82425 300 00 7) 48 125 308 350 350425 325 30 a0 5m 48 res 315 350350 425 325 ‘Abrevton: ADE, adverse drug vent “alelaes meats th acenar ht rot lsaly approximate the base cae. et et AE Ra = (ase Prvtate IE SS ‘era Ds Deseo = ttl AE nt at owt oA at etre eg fan Pol ADE Rast Bu Cai a apace Caspr Doe a Rear re errayarany ‘Sd pCotcens Figure laps with te largest eects on te Mota af simulation ougut (teva adjusted cums nt baa aS ents) Stand coeticits {the change standard devon nis) n the uta varabl eased by "SD ange nthe input arable AE ts sare dug ent scenario examined, in which the average savings from an averted potential ADE was set at only $1500 and the pro- spective payment rate was only 40%, bar coding still even- tually paid for itself. Most scenarios in the 2-way analyses, as well asa L-way analysis of reducing annual doses dis” pensed to 1.75 million, achieved net positive cumulative benefitsby year 10. Finaly, since the cost per ADE was based, conastudy of mostly preventable ordering and administrs- tion errors.* whose severity distribution may differ from that of preventable dispensing errors, we also performed fan analysis restricted to serious of life-threatening poten- tial ADEs. In that scenario, return on investment oc- 1¢ 10th erage cost per averted 11 through year 5 and $2401 thereafter. curred in ear, with the a ADE of $ The Monte Carlo simulation corroborated these find- ings. The net benefit throughout 5 years was $3.25 mi lion (95% confidence interval [Cl], -$1.22 million to $12.07 million), and the break-even point for return on investment occurred after 51 months (05% Cl, 30 to 180 months). In only 1.6% of the simulations did the inte vention never achieve a positive net benefit. The ave age cost per averted ADE was $1976 (95% Cl, $609 10 $5013) during the first 5 years and $873 (05% C1, $207 to $2542) after steady state. The Monte Carlo simmula- tion was most sensitive tothe percentage of potential ADEs resulting in actual ADEs; every standard deviation in- ‘erease in this variable caused a 0.68-SD increase in net benefits throughout 5 years (Figure 8), 2 0.20-SD de ‘erease in time to break even, and a 0.72-SD decrease in the cost per averted ADE. ee }- Across abroad range of assumptions, investment in a hos- pital-based pharmacy bar-coding system for dispensing medications was not only favorable but was cost saving from the hospitals perspective within a 5- to 10-year ho- rizon, This is similar tothe results ofa recent cost-benefit is of CPOE at this inst $9.5 million net benefit during 10 years and a break-even point of7 years, Since the medication-dispensing process is distinet from the medication-ordering process, the cost ‘savings from pharmacy bar coding is likely to be indepen- dent of what might be obtained from CPOE, anal tution," which measured a (©2007 American Medical Association, All rights reserved. Downloaded From: on 4/12/2018A strength ofthis study és that detailed prospectively measured costs and benefits were used, and when pri- mary data were unavailable, published estimates rather than expert opinion were used. Although one may dis- pute the 2 most important determinants of benehi, namely the proportion of dispensing errors that result in ADE and their cost, the analysis appeared to be robust when these variables were varied widely ‘OF course, Whether the implementation of a bar code-assisted medication-dispensing system is sue- cessful oF not ultimately depends as much on the implementation as on the system itself, both of which can introduce errors. Although the method used lo measure preintervention and postintervention error rates" cotined all erors that slipped passed the qual- ity control processes in place for the system as whol, diferent results may have been observed ifthe same system had been implemented with less planning oF stall training Although this suudy assessed the valtie of pharmacy bar coding, it did not evaluate other potential invest- ments the hospital could have made with its funds. As previously mentioned, the costs and benefits of inpa- tient pharmacy’ bar coding are comparable to those of CPOE. Until similar cost-benctit analyses of other error- reducing strategies are performed, both computer and nnon-computer based, such as increased pharmacist stall- ing oF decreased patient-nurse ratios, no conclusion can the made about the relative value of pharmacy bar cod- ing compared with these other interventions This stady took the implementing hospital's perspec live. Froma societal perspective, the costs would largely bye the same, but the benefits would be greater beeause they would also include benefits to the patient, sch as reduced pain and suffering, decreased length of stay and averted lost income. Therefore, a societal cost-benefit analysis would be more postive than tha reported herein, Suggesting that payers and purchasers shotld support hos. pilals without enough capital to fund the up-front costs ofthis technology This study had several limitations. It was conducted atasingle large academic institation with rich computer based decision support infrastructure, and the results may not be gencralizable to smaller community-based hos- pitals without such an infrastructure. However, the fact that hospital pharmacies across the nation use similar tan- dardized medication-dispensing processes" with simi- lar pre-bar code dispensing crrorates” suggests that the benefits of bar coding this process can be reproduced widely. Furthermore, neither CPOE nor bar code~ assisted medication administration is a prerequisite for implementing this technology. Itrequires only the pres- cence of a computerized pharmacy system, which most hospitals have." Certainly, the size of the hospital, or more precisely the number of dispensed annual doses, matters. Keep- ing costs constant, return on investment within 10 years was achieved with annual doses ofa least 1.75 million. However, itis likely that smaller hospitals would have lower expenses as well. Also, the fact that bar coding of uinitdose medications by manufacturers is now man- dated implies that portion of the costs measured in (aepRayTED) ARGTINTERN MEDVOL IGT APRN SOF this study (that associated with repackaging) might be avoided or reduced, The institution in this study decided to build its own software and lease ils repackaging equipment, Other hospitals may choose a different combination of lease, ‘buy, oF build options. As the technology matures and vendors produce more products, itis likely that these ‘options will become cost competitive with each other and therefore will not influence the net benefit signili- cantly Finally, the study design was based on. pre-post com- parison of error rates. A randomized controlled trial de- sign was not possible with such a large systemwide in- lervention. However, the pre-and postintervention periods ‘were temporally close, and no other significant changes ‘were made in the medication-dispensing process dur ing the transition to bar coding. Furthermore, no sig- nificant changes were noted in other pre-post measur ments, such as dispensing volume, case mix and severity, ‘or prospective payment rates. In conclusion, this study demonstrated that a hospi- taL-based pharmacy bar-coding system for dispensing medications was cost saving within a 5- to 10-year time frame across a wide range of assumptions. These data may be helpful to hospitals in prioritizing implementa- lion of bar coding among other investments being con- sidered. Accepted for Publication: December 6, 2006, Correspondence: Saverio M. Maviglia, MD, MSe, Clini- cal Informatics and Research Division, Partners Health- care System, 93 Worcester St, PO Box 81905, Suite 201, Wellesley, MA 02481 (smaviglia@partners.org) Author Contributions: The primary author had fall ac ‘cess to all ofthe data in the study and takes responsibi ity for the integrity of the data and the accuracy of the data analysis, Study concept and design: Mavighia, Bate ‘and Poon, Acquistion of data: Maviglia, Yoo, Featherston Churchill, Bates, and Poon, Analysis and interpretation of data: Maviglia, Yoo, Franz, Bates, Gandhi, and Poon, Drafting of the manuscript: Maviglia and Yoo. Critical re- vision of the manuscript Jor important intellectual content Maviglia, Franz, Featherstone, Churchill, Bates, Gandhi, and Poon. Statistical analysis: Maviglia, Yoo, and Franz Obtained funding: Maviglia, Bates, Gandhi and Poon. Ad- ministrative, technical, and material support: Yoo, Featherstone, Churchill, and Bates. Study supervision: Maviglia and Poon. Analysis and modeling: Pranz, Financial Diselostire: None reported, Punding/Support: This work was supported by grant HS14053-02 from the Agency for Healthcare Research and Quality EES 1. Brean TA eae LL, La ea nine of abere ers ad eh ‘tes in osptlng ptt: els rom he Haar Mal race Sty neg J Mea o9rs2¢370 76 2. Kon LT, Corgan. Donaléson MS, Ta vi Human: Bunga eer Ste Wash, OC Nason Aaa Pres: 100 4. Bes, ye OL, Vander Vie, Sec Late L Relsoneip be ‘en maiestin sors and adore dug evens J Gen nar Med 1085; 109-205, (©2007 American Medical Association, All rights reserved. Downloaded From: on 4/12/20180 0. w * Downloaded From: ssen 0, Pest, Eas RS, Lyd Burke. Avrsedugerntsin asia patos: xess length sta, oaacos and atrbble meray, ua, 39072730-206 ‘Sint L Actin LE Gees, tl Practical appreschta determining ote sd quency of adverse gees naa cae ator ABest Pram 200158126192 Bas DW Sp, len 0 ta averse rg Exes Prevention Stuy Grup, The costs of Gee cuy overs in hasan pons NA, 108727 amratt. xe DW Lege Cun, tl et compu pian ode ‘yan a team areton on preven of seus mean eros ANG, 28091-1016 ne Cle, Li, tances adece ug tea po ‘ual adverse rg evr JAW 108527420-34 Camp GU achive RL Using process can chase mane dpns- ing a cocking ers. Ao Heth Sst Pham 108 595-952 Ness JE Sultan SD, tga A. Aocracy of nin and pharmacists in ‘detyng peri rr. A Hop Pham, 0041 64357. asp Bates DW Cale ea ADE Pree Grou. Syste aces rg evr, JAMA TOBE. 27435-48, ‘McGhan WF, Soh WE sme DW Arado comparing pharmacies snd echnican as ipsa of pressions rambo patents ed Care ss 3. Peon Cina, Chacha etl Maton dispensing errs nd pot sis (nepRaN TED) XRCHINTERN MEDVOL 167, APES DOT a 2 vere rug evn eo and ater npmerting ar Code Technlogy inthe Pharmacy. Ao tr Med, 2006 15 26-43, nia aloiaat aan Str UnvstyEiencebsePra toe Cone: Paton Sty Prats ling Hast Cae Str San Fri Unvorsy of afer; 200 Cina, Gana TK hci et How my hsptl phamarymeaion deponing ere go unt? J Comm JO Patt St 2008327220 Us Daatmen ef Labor Suen of Liber Stati be go Ae ‘caseed Octobe 20,205. nado Governors Fate Resare Sym. fderaesene gv. Ae ‘caeedOtber 0,205. Kaushal ha AX Fata Return ite fora computing phy San ore ery jt Jn Med Ite Assoc 208 18261 256 Pip MT, rer ES. Beating the sjte pals fbr code medeaton ‘donation ith I Manag 2005181618 Ci Fanos Aon, Mee Chu W Madson arsine phamsy Sased barcode-rpacagig canter. Ar J Hea Syst Pharm, 200685 15-68 Peete CA Sebi Pa, eect ASHP nana uray o hit acy racic in hspil seins: pesing and adminis. A Health ‘jst Pharm 2003805268, Faod and Org Aminitation Bar Code Lae Regus fr Human Org Pructs and tga Pods Washingan, DE Food an Drug Ades ‘on 200 HHS #262008 (©2007 American Medical Association, All rights reserved. on O¥122018