Dispensing products from the pharmacy in bar coded unit of use has become a foundational expectation of an effective medication-use process. Regulatory, safety, and best-practice literature clearly articulate the need to provide unit dose, ready-to-administer products with a bar code that can be easily scanned at the point of administration. Additionally, increasing automation and technology integration within pharmacy operations further underscores the need for a bar code on all medications.
A robust pharmacy operation should utilize a bar code scan to verify the accuracy of every step in the medication-use process. In addition to scanning upon dispense, products should be scanned during both loading and removing from any storage device (eg, carousel, robot, automated dispensing cabinet), and during compounding, bar code scanning should be employed to verify correct product selection. Moreover, bar codes facilitate tracking to verify that a product has been delivered to the patient care area. Finally, scanning serves as the final check that the correct product is about to be administered to the correct patient.
While organizations may be able to provide the majority of medications to patients in bar coded unit of use, less than half deliver 100% of medications to the units in this format.1 To achieve this goal, ensuring that all products leave the pharmacy with a scannable bar code is critical.
Functional Bar Codes
While the medication safety benefits of utilizing bar code scanning are obvious, ensuring that a functional bar code is available for these scans can prove challenging. Fortunately, the majority of products are available from the manufacturer in bar coded, unit-of-use format, which facilitates efficient scanning. Using the manufacturer’s bar code eliminates the risk of the wrong bar code or label being affixed to the product during the repackaging or dispensing processes. Therefore, if available and functional, the manufacturer’s bar code should be used for all scans, unless the product has been manipulated as part of a compounded product. This new compounded product should then be affixed with a new label containing an institution-specific bar code to avoid the risk of the new product inadvertently being used as the original product.
One issue that pharmacies must navigate is the process for ensuring a product and its bar code are added to the EHR or pharmacy IT system. Ideally, the pharmacy department should develop a process in which every bar code is validated when a product enters the pharmacy; however, the complex procurement supply chain that pharmacy departments must traverse can complicate standardizing this process. A possible solution is to implement an integrated, perpetual inventory system within the EHR. Such a system facilitates receiving the medication into inventory, and also serves as a check that the bar code is in the system. Bar codes that are not in the system should be quarantined to prohibit them from entering the medication distribution system until they have been added to the EHR.
Bar Code Challenges
Several other categories of medications may be challenging to provide in a bar coded format. For example, compounded products are a significant subset of dispenses from many pharmacies. Because the action of compounding creates a new product, the manufacturer’s bar code may be unavailable or no longer accurate, depending on the type of container closure system that is used.
The most straightforward way to close this gap is to include a bar code on the patient label of the compounded product. The bar code should be generated by the EHR, and it should be integrated with the medication administration record and the bar code medication administration (BCMA) system. Depending on the pharmacy’s operations and state regulations, a subset of compounded products may be prepared as anticipatory or batch compounding to ensure a compounded product is ready when a patient needs it. In addition, batch compounding often serves to minimize waste as multiple doses can be obtained from a single vial. During this process, pharmacy should apply a bar coded label to the newly compounded product that the EHR can utilize during BCMA to identify a mislabeled or incorrect dispense.
While pharmacies strive to make available every medication a patient might need, there are inevitably situations in which a patient’s home medication must be used. This typically occurs when a non-formulary medication is needed, and utilizing a supply brought into the hospital by a patient is the timeliest option. After verifying the identity of the product, a pharmacist should generate a bar code and affix a new label to the product so the bar code can be scanned during administration.
Multiple Strength Medications
Some doses may require two different strengths of the same medication to equal the total dose needed for a patient. Multiple strength medications typically have bar codes; however, due to operational processes or IT intricacies, the bar codes may not be applicable to the BCMA process (see CASE STUDY 1).
Multiple Syringe Products
Other products may require multiple syringes or bags to equal a complete dose. For example, a large dose of doxorubicin may need to be dispensed in two or more syringes. Each of these syringes should be labeled with a unique bar code, and the EHR should require the nurse to scan the bar codes on both products before the administration is considered complete.
Multidose products can be a challenge in the effort to dispense 100% of products in bar coded unit of use (see CASE STUDY 2).
Products from Outside of the Pharmacy
Products that do not originate in the pharmacy often do not contain functional bar codes; among these drugs may be contrast agents, radiopharmaceuticals, plain IV solutions, and dialysis products. While most of these products contain a manufacturer’s bar code, since they circumvent the pharmacy department’s procurement processes, ensuring the bar code is functional and programmed into the EHR may be challenging.
Radiopharmaceuticals are most often procured from a regional nuclear pharmacy and typically do not contain a functional bar code that can be utilized with the EHR. If an institution has an in-house nuclear pharmacy, the nuclear medicine IT system utilized to dispense the radioactive doses is likely different from the EHR. These in-house produced radiopharmaceuticals may contain a bar code that can be utilized during the compounding and dispensing of the radiopharmaceutical, but it will likely not be functional if the EHR is utilized to scan and document administration. To close this gap, label the radiopharmaceutical with both the original manufacturing label from either the outsourcing nuclear pharmacy or the in-house nuclear medicine IT system and the EHR. However, note that this added step can create a risk of mislabeling.
2D Bar Codes
Two-dimensional (2D) bar codes confer a data rich medication-use process. The incorporation of lot number and expiration date in a 2D bar code allows these data to be automatically captured during the compounding, dispensing, and administering processes. 2D bar codes also allow for more focused recall or notification alerting, as well as an additional check that a product is within date before it is utilized.
As these advanced bar codes become more prevalent, and eventually required, supplemental development of the EHR or IT system may be necessary to ensure proper management. All processes must be designed around the EHR’s capabilities; some EHRs are only able to support a single bar code for any given product, while others are able to support many bar codes and link all of them to a single product.
Radiofrequency identification (RFID) is a newer technology that holds promise to facilitate tracking of medications throughout the medication-use process. A product labeled with an RFID tag can be tracked throughout the hospital without requiring bar code scanning. For example, when a product labeled with an RFID tag is removed from a refrigerator, the system recognizes that the product has been removed and can automate inventory adjustments or a replenishment order.
Some organizations are currently utilizing RFID technology to track crash carts as they are moved around the facility. Looking to the future, opportunities to utilize RFID technology will likely increase.
Bar coding continues to be a foundational concept of an effective medication-use process. Products compounded in-house; home medications; products that do not originate from pharmacy; and multiple strength, syringe, and dose products must include functional bar codes. While bar coding the majority of products in the pharmacy may be straightforward, dispensing 100% of products with a working bar code requires significant due diligence.
Ryan W. Naseman, PharmD, MS, BCPS, is the senior director of acute care pharmacy services at University of Kentucky HealthCare, where he is responsible for all hospital-based pharmacy operations and clinical pharmacy programs. He received his PharmD from Ohio Northern University, as well as an MS in health-system pharmacy administration from the Ohio State University while completing a combined PGY1/PGY2 residency in health-system pharmacy administration at the OSU Wexner Medical Center.
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