PTCE · Patient Safety and Quality Assurance · 6 min read
Error Prevention: Identifiers, Barcodes and Double Checks
- Identify approved patient identifiers and correct verification techniques across pharmacy workflow points.
- Explain how barcode scanning technology, safe storage practices, and visual checks prevent product selection errors.
- Describe the purpose, process, and limitations of independent double checks while maintaining clear boundaries regarding the pharmacist's role.
Patient Identification Standards and Verification Protocols
Patient misidentification represents a critical vulnerability in the pharmacy that can lead directly to dispensing medication to the wrong individual. To establish a standardized defense against this hazard, using at least two patient identifiers is designated as a Joint Commission National Patient Safety Goal. Technicians should verify at least two patient identifiers at applicable patient-identification steps, following the pharmacy’s procedures; the requirement does not mean repeating the check at every step of order fulfillment.
Acceptable patient identifiers include the patient's full legal name, date of birth, home address, telephone number, and medical record number. Conversely, a patient's room number or bed number is never considered an acceptable patient identifier, as individuals frequently change physical locations within institutional facilities. Pharmacy technicians must confirm these identifiers at every applicable workflow point, including initial prescription intake, order entry, and final pickup at the counter. When possible, technicians should ask patients or caregivers to state identifiers rather than confirm identifiers read aloud; when a patient cannot respond, technicians should follow the facility’s alternative identification procedure.
Technicians should check that the prescription and pharmacy record belong to the intended patient during processing, and verify the labeled prescription against the patient’s identifiers at pickup according to pharmacy policy. Some pharmacy computer systems display automated alert flags when profiles share similar or identical names. Technicians must actively verify patient identifiers rather than rely on an alert flag. When two patients share both a name and a date of birth, technicians must use another identifier that distinguishes their records, such as a medical record number, a different home address, or a telephone number. In inpatient settings, authorized clinicians verify the patient's identification wristband against the medication administration record before administering medication; this bedside check is not ordinarily a pharmacy technician task.
| Identifier Status | Approved Data Elements | Clinical Rationale and Requirements |
|---|---|---|
| Acceptable Identifiers | Full legal name, date of birth, home address, telephone number, medical record number | At least two person-specific identifiers should be checked at applicable identification points according to facility policy; verification need not occur simultaneously at every listed workflow step. |
| Unacceptable Identifiers | Patient room number, bed number | Tied strictly to physical layout rather than the individual; physical locations change and can lead to dispensing medication to the wrong individual. |
Common mistakes
- Accepting a patient's room or bed number as an identifier, which violates Joint Commission standards because room assignments change frequently.
- Bypassing a failed barcode scan by scanning a convenient substitute package or a master barcode sheet rather than verifying the actual container and its NDC with a pharmacist.
- Allowing a second colleague to review an already-completed calculation worksheet during a verification step, which introduces confirmation bias instead of performing a true independent check.
- Attempting to answer a patient's clinical question regarding medication side effects or administration at the counter instead of immediately transferring the patient to the pharmacist.
Key points
- Using at least two patient identifiers, such as name, date of birth, address, phone number, or medical record number, is a National Patient Safety Goal; bed and room numbers are never acceptable.
- Technicians should use open-ended identification questions when interacting with a patient who can respond, verify identifiers at applicable workflow points, and compare prescription, system, and label information as required at the relevant steps.
- A scan of a correctly mapped barcode can help confirm the product information associated with the scanned package, but it does not verify its contents or condition; technicians must still check expiration dates and perform applicable visual checks.
- These products warrant safeguards suited to the specific confusion risk, which may include physical separation or shelf alerts; Tall Man lettering is used for selected confusable drug names.
- High-alert medications, including insulins, anticoagulants, opioids, chemotherapeutic agents, and neuromuscular blocking agents, require robust safeguards, as colored bins alone are not sufficient.
- Independent double checks reduce confirmation bias by requiring a second practitioner to calculate or verify from the original source without viewing the first person's recorded results.
- All technician duties occur under the supervision of a licensed pharmacist, who holds sole responsibility for clinical reviews, drug-interaction evaluations, and patient counseling.
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