Case Study: Barcode-Enabled Medication Dispense Tracking System Reduces Re-Dispenses at Health System


A barcode-enabled medication dispense tracking system may help reduce medication re-dispenses, missing medication requests, and delivery turnaround time, according to a case study presented at the American Society of Health-System Pharmacists’ 2021 Midyear conference. The investigators found that the ability to track the status of a medication in real-time may assist with communication gaps between departments and facilitate patient safety improvements.

Administrating and making medications available to patients in a timely manner is a challenge in the hospital setting, according to the investigators. Although there are several factors contributing to these issues, one potential limitation is an inability to identify the location of a medication in the dispensing process. This can result in an increase in pharmacy workload with re-dispensing of medications, nursing dissatisfaction, and potential compromises in patient safety due to delayed administration, according to the study.

The recent introduction of medication dispense tracking technology allows for health systems to increase transparency and accountability within pharmacy and nursing departments by providing real-time updates as a medication is delivered to the patient care unit, according to the researchers. In the case studied, the medication dispense tracking system was implemented using a team-based approach, which involved couriers, nursing, and informatics specialists.

The implementation consists of 2 phases, starting with pharmacy couriers who perform on-demand medication delivery throughout the day, followed by pharmacy technicians who deliver scheduled medications during daily cart exchange. Staff were provided with training references for use of the mobile devices and education was provided to nurses to understand the utility of the dispense tracking documentation in the medication administration record.

To evaluate the volume of medication re-dispenses, the number of missing medication requests, and turnaround time from order verification to delivery on the unit, the investigators conducted a quasi-experimental study. According to the results of that study, the ratio of medication re-dispenses per 1000 missing medication requests decreased from 218 before the tracking system was implemented to 163 after the implementation of the system.

Further, pharmacy staff can now see the status of a medication from the point of preparation to the point of delivery on the patient care unit for a significant portion of non-automated dispensing cabinet dispenses. According to the investigators, this assists with the triaging of phone calls and missing medication requests from nursing staff even after a medication has left the pharmacy.


Zafar N, Deyhim N, Bhakta S. Implementation of an integrated mobile barcode-enabled medication dispense tracking system. Presented at: ASHP Midyear 2021. Accessed December 7, 2021.

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