pharmacy robot behind multiple prescription errors at us afb

Officials at Wright-Patterson Air Force Base, one of the largest installations in the entire Air Force, were on high alert earlier this month following the news that one of the pharmacies located on base may have subjected thousands of people to potentially dangerous medication mistakes.

According to reports, the pharmacy became aware of a problem after receiving a call from a patient to report the presence of more than one type of pill in a prescription bottle filled by the pharmacy.

Shortly thereafter, base officials initiated a large scale alert — telephone calls, alerts posted on websites, social media messages and emails — to reach the 1,273 patients who had prescriptions for oral medications refilled sometime between April 23 and April 29 at the pharmacy. The alert asked those affected to bring their medications to select base locations to have them properly inspected and replaced if necessary.

Fortunately, no one suffered any harm from the medication mistakes, which personnel later narrowed down to seven separate instances. Here, all seven drug errors involved muscle relaxers being mixed with acetaminophen.

While an investigation into the matter by base officials, the Air Force Medical Operations Agency and the Air Force Surgeon General’s Office is still ongoing, preliminary reports indicate that the prescription errors can be traced to a so-called pharmacy robot.

For those unfamiliar with these machines, they operate by having a tech or pharmacist enter a prescription into the computer, which in turn prompts a robotic arm to pull a corresponding container of pills from the shelf. The robotic arm then dispenses the pills into a pill bottle, which is then labeled with the patient’s information.

The Air Force did not instruct pharmacies located at other installations to stop using their pharmacy robots in light of the incident at Wright-Patterson, but it did instruct those outfitted with similar machinery to run a systems check and safety review.

Until the exact cause of the medication mishap at the pharmacy on Wright-Patterson is determined — sources say either a human error or shipping error is likely to blame — prescriptions there will be filled by hand.

Stories like these once again raise a valid argument about just how effective pharmacy robots truly are. While they may save time and money, they are nevertheless entirely dependent on human operators loading them correctly and manually inputting the correct sequence of numbers and letters.

Does this story reaffirm your distrust of pharmacy robots or do you feel that they are still the way that most pharmacies should be heading?

Source: The Dayton Daily News, “Prescription errors jump to seven at base pharmacy, officials say,” Barrie Barber, May 2, 2014; The Dayton Daily News, “Base notifies thousands after pharmacy error,” Barrie Barber and Steven Matthews, May 1, 2014

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