Standardization Improves Syringe Bar Coding

November 2012 - Vol.9 No. 11 - Page #74
Category: BCMA

Assigning bar codes to products as a means to catalogue inventory and track dispensing and sales is not a new concept. Grocery stores in the 1930s were the first to use a punch card, bar code system for checking out customers.1 As the concept evolved, technology was created to automatically read product information at the point of sale; however, early attempts—such as the use of ultraviolet light sensitive ink—were found to be too expensive and unstable. By the late 1960s, an electronic laser reader was developed that could read black and white symbols and the grocery industry, which saw the early potential benefits of such a system both for tracking sales and managing inventory, realized an industry standard would need to be established. This standard eventually became the Uniform Product Code (UPC) still in use today2 and helped enable bar coding technology to be rolled out to most grocery stores by the mid-1970s. 

As the other applications of bar coding began to emerge, the Health Industry Business Communication Council (HIBCC) was founded in 1983 to develop a standard for data transfer using uniform bar code labeling; an initiative that resulted in the Health Industry Bar Code (HIBC) Standards.3 Despite these advancements, clinical applications did not begin to incorporate bar coding until the 1990s, largely due to pharmaceutical manufacturers’ slow incorporation of bar codes into product packaging. Now that bar codes have become integral to the management of medications in the health care environment, studies have shown that medication administration using bar code technology can decrease medication errors by 65-86%.4 Today, more and more facilities are implementing bar code medication administration (BCMA) systems to improve medication safety by verifying that the right drug is being administered to the right patient in the right dose and at the right time.

Develop Policies and Procedures For Proper Labeling
Tenet Healthcare Corporation—comprising 49 acute care hospitals in 11 states—has been in the process of rolling out BCMA functionality throughout the system in conjunction with computerized prescriber order entry (CPOE), an initiative referred to as the IMPACT program: improving patient care through technology. The mission of the IMPACT program is to have a fully integrated electronic health record and personal health record throughout the Tenet network by 2014. Having such functionality will impel our staff to use common technology and to share health information throughout our hospitals and across our communities. There are currently 26 facilities live on BCMA and CPOE with 14 more in process, and the remaining nine are scheduled to kick off later this year. In order to facilitate and standardize processes within and among hospitals, bar coding standards have been developed which include the following policies and procedures:

  • 75% or more of purchased medications should contain manufacturer bar codes unless the facility has a high volume unit dose packaging machine
  • Nursing should scan the manufacturer’s bar code, if possible, on all medications
  • For medications without a manufacturer’s bar code, pharmacy should create one through the pharmacy information system (PIS) using a two-dimensional bar code (DataMatrix), as opposed to a linear bar code, to enhance legibility and scanning efficiency when packaging medications
  • The 11-digit NDC of the drug should be placed within the bar code of the drug. If repackaging a portion of the manufacturer’s package, the system Med ID is used as the unique identifier to refer to the parent product being packaged

Placing emphasis on the acquisition of pre-made syringes in unit dose with a fixed and robust manufacturer’s bar code is advantageous because a scan of that bar code automatically verifies the correct drug and dose. However, scanning a PIS-generated label affixed to a syringe after the fact may verify that there is an order for a specific drug, but the label could have been affixed to the wrong medication. This type of error—especially if the PIS-generated label obscures critical information on the manufacturer’s label—could easily make its way to the patient, as the BCMA system would read the bar code as the correct medication for the patient. Consequently, the most frequent cause of BCMA-related errors is mislabeling. According to a USP MEDMARX report from 2006, 51% of the errors associated with bar code technology were the result of attaching the wrong bar code to a product. Affixing a bar code label indicating the wrong strength accounted for another 23% of the errors reported.5

Creating further challenges, BCMA demands that the pharmacy provide all medications in unit-of-use form, ready for administration. This can be particularly difficult in a pediatric environment where manufactured drugs must be repackaged and sometimes compounded to obtain the correct dose. Determining the best and safest methodology to bar code both oral and intravenous syringes is a difficult decision, especially in view of the errors that can occur.

Using Technology to Mitigate Syringe Labeling Errors
There are various labeling systems available for bar coding syringe medications, and Tenet Healthcare facilities utilize multiple types of systems to provide this function depending largely on their respective workloads and the sophistication of their pharmacy operations. Some systems have more advanced features, such as color-coding syringes within the OR suite. Outsourced compounding companies can provide compounded syringes, including prefilled oral syringes, in many strengths and sizes with color accented labels to help prevent errors, and some unit-based ADCs now have the ability to create and print a bar code label onsite after scanning a vial. 

Beyond providing enhanced patient safety within the facility, hospitals bar coding syringes must print labels that comply with Joint Commission NPSG.03.04.01 regarding medication labeling, as well as their state board of pharmacy. Therefore, the label elements used by Tenet hospitals include generic and brand name, strength/concentration, volume, preparer, checker, preparation date/time, expiration date/time, manufacturer, lot number, and bar code. Given that most syringes have a relatively limited surface area for labeling, 2D DataMatrix or Aztec bar codes are preferred due to their small size and speed of scanning success. The use of colored labels to differentiate between IV products and oral syringe products, to highlight drug names and concentrations, and to denote high alert drugs has been shown to help increase safety. Furthermore, colored, enhanced (Tallman) text on the label can eliminate the need to apply additional auxiliary labels to denote refrigeration, expiration date, and/or special handling (ie, chemotherapy). Despite these benefits, color use is facility specific and is often arbitrarily determined, so hospitals must be careful not to solely rely on color to denote a particular drug product, as doing so can lead to error.

Collaborative Standardization and Special Populations
In the effort to dispense all medications in a unit-of-use format, standardization of doses is of utmost importance. Key to this process, though, is working with physicians so that requests for insignificant changes in doses do not then require new syringes to be made. 

Many facilities have standardized doses for the most common oral medications provided to pediatric populations because they are weight based and have a dosing range. Standardizing the most common intravenous medication concentrations and volumes likewise promotes patient safety and reduces errors. The Institute for Safe Medication Practices has published a list of Standard Concentrations of Neonatal Drug Infusions to be used in all hospitals where neonates are treated (see Table 1).6

Click here to view a larger version of this Table

Implement Syringe Preparation Guidelines for Labeling
For most hospitals, a PIS-specific label produced by order entry is used to label syringes. Pharmacists enter orders for either oral or intravenous syringes and select the syringe label format to produce the small label required for these products. These syringes are then compounded, labeled, and checked by a pharmacist during specific points in the process. Ensuring that the correct dose is labeled after compounding is often the greatest challenge to patient safety for medication administration, especially in small pharmacies with limited or no space designated specifically to compounding oral medications and intravenous syringes. Again, the PIS label only links the order to whatever product is labeled, so special attention must be paid to the step of placing the correct label on the correct product and part of this involves limiting the number of products being produced by the same staff member at a time. Moreover, purchasing pre-labeled, compounded syringes and linking those bar codes to the PIS allows the bar code to specifically identify the correct product and indicate that the product is accurate to the order. However, purchasing compounded syringes can add additional cost to pharmacy budgets. Generally, volume of syringes used is the main factor in determining whether to buy pre-compounded syringes or to compound those products in-house. With this in mind, a facility must weigh the cost/benefit of implementing a strict compounding and labeling protocol with the cost/benefit of outsourcing. 

Automation Provides Maximum Control
One technology package that has emerged as a viable solution to overall compounding safety is DoseEdge from Baxter (formerly Baxa). This combination of hardware and software allows for integration of product verification technology with the actions of physical compounding for both oral and intravenous syringe preparation. The software can integrate with most existing PIS networks and provides a closed loop system for preparation and dispensing with little chance for error. Every step of the process is documented via bar code verification and image capture providing a comprehensive safety solution for not only intravenous and oral syringes, but any sterile product. Dose preparation is prioritized in an electronic queue and is standardized for every product giving the technician specific instructions for each dose. This system provides automatic dose and dilution calculations with a clear audit trail of doses prepared and checked and does not allow for preparation to be interrupted or stopped once begun, therefore mitigating errors due to interruptions.

Until recently, syringe preparation has been a totally human-dependent, non-automated procedure. The introduction of automated systems offers a safety net for those manual tasks and significantly reduces errors for this process by incorporating bar coding in the preparation steps versus just at the administration step. Ensuring that the correct dose is labeled after compounding is no longer a challenge and this new technology may truly become the automation standard for pharmacy compounding.

Now that Tenet Healthcare is approaching full integration of BCMA and CPOE functionality across all of its facilities, we are much more confident in our ability to augment patient safety through standardized labeling and accurate accounting of the medication preparation process. As we pursue the elimination of medication errors through multiple improvement processes, Tenet’s IMPACT program will continue to grow and combine best practices and technological advancements across facilities. Our efforts to standardize processes—from formulary decisions to automation uniformity to closed-loop medication preparation—are driven by a mission to better serve our patients through the mitigation of waste and the creation of monitored and efficient protocols. Ensuring the proper identification and management of IV and oral syringe doses is of central importance to this initiative. 


  1. Rodnay, N. The evolution of Barcode Systems. EzineArticles Web Accessed October 4, 2012.
  2. Bellis, M. Bar Codes. Inventors Web October 4, 2012
  3. Health Industry Bar Code Standards. Health Industry Business Communications Council Web Site. October 4, 2012
  4. Wright AA, Katz IT. Bar coding for patient safety. N Engl J Med. 2005;353:329-31.
  5. Cochran GL, Jones KJ, Brockman J, et al. Errors prevented by and associated with bar-code medication administration systems. Jt Comm J Qual Patient Saf. 2007 May;33(5):293-301.
  6. Standard Concentrations of Neonatal Drug Infusions. Institute for Safe Medication Practices Web Site. October 4, 2012.


Carla J. Maslakowski, MS, MEd, RPh, is the director of clinical pharmacy informatics in the applied clinical informatics department at Tenet Healthcare Corporation. She received her bachelor of science in pharmacy degree from Creighton University in Omaha and her master’s degree in education and computer science from Plymouth State University, Plymouth, New Hampshire. Carla also completed an ASHP hospital pharmacy residency and an MS in hospital pharmacy at the University of Kansas.


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