Implementing BCMA is important for improving patient safety and workflow as it helps track and verify all medications at the patient bedside. However, issues may arise in the pharmacy when a medication is not available from the wholesaler in unit dose or a product does not have an appropriate bar code associated with it. As part of the planning process to adopt BCMA at Mercy Medical Center, it became clear that our facility needed a more robust approach to managing these issues. 

Mercy Medical Center is a 238-bed, not-for-profit, tertiary care community hospital and serves as the regional level II trauma center for patients in northwest Iowa, northeast Nebraska, and southeast South Dakota. The medical center specializes in cardiac care, orthopedics, vascular surgery, stroke, and cancer care. The facility utilizes an EHR with CPOE that was initiated in 2005, and the central pharmacy provides 24/7 service via a hybrid distribution system including 24-hour cart fill and automated dispensing cabinets.

Prior to August 2011, the pharmacy manually repackaged some products into unit dose containers. The packaging records from this process were maintained in an archaic system of 3x5-inch notecards stored alphabetically in plastic bins. A generic system of labels for unit dose products were generated via a multitude of word processing documents on a single computer. Despite the room for error and inefficiency of this system, it complied with state law and remained status quo for many years. 

Choosing a Bar Coding Solution
In 2011 we inquired about a sustainable solution for bulk medication bar coding and repackaging. The solutions available in the market are vast and varied, and we considered numerous options including high-speed packagers, third-party outsourced repackaging, computer-assisted manual packaging solutions, as well as increasing the share of unit dose products we purchase from our wholesaler. While we wanted an automated solution, we found the high-speed packagers to be cost prohibitive given our volume needs, and outsourcing to a third-party repackager would not serve as a complete solution due to slower turnaround time, especially for any last minute on-demand orders.

After some research and consideration we decided to focus on purchasing adequately bar coded unit dose medications from our wholesaler, and to obtain Medi-Dose’s MILT 3.0 software for in-house bar coding of products we are unable to purchase in unit dose format. The software is easy to use and capable of producing labels for unit dose oral solids, syringes, cups, and other products. It provides consistent labeling, requires minimal IT maintenance, incorporates a searchable/viewable electronic audit trail, supports up to three tiers of user permissions, and requires a very modest initial investment for equipment, software, and space.



Using the Software
Once MILT 3.0 is installed and a basic formulary is constructed, using the system is very straightforward. The user logs in and selects the desired product, then updates the lot number and expiration date, selects the number of labels needed, and prints them. Both 1D and 2D bar codes can be created, and users can customize labels to include different data fields, bar code sizes and location, different font sizes and colors, as well as add symbols and images. Adding images to the labels is particularly useful to indicate chemotherapy or a controlled substance. After an optimal design is developed it can be saved as a label template. 

The software may be customized for use by technicians, pharmacists, or administrators with specific task privileges assigned to each user level. A reporting mechanism records which technician and pharmacist produced and checked each batch. The user’s initials plus the time and date of batch production can also be added to the labels. We use the production time and date as the lot identifier, making this data easily searchable via the reporting tool in the event of a recall.

The bar coding software complements our workflow and technology needs. It is installed on several networked computers that share a common network database as well as a dedicated laser printer. We have found that certain types of labels work best for different products. For example, a butterfly label works best with oral syringes, while a rectangular label is used for unit dose cups or larger products. We use smaller rectangular labels for oral solid packages, as well as for creating bar codes to apply to products that do not have a manufacturer’s bar code but require one for BCMA.

Improved Workflow and Safety
The software ultimately helps improve patient safety and workflow within the pharmacy by increasing the accuracy and consistency of unit dose labels for in-house packaged medications. Through the construction of medication-specific templates, spelling and syntax errors have decreased, reducing the amount of time spent repackaging inappropriately labeled products. The use of tall-man lettering and a uniform label format delivers additional safety.

Medi-Dose has consistently provided excellent customer service, including complimentary tech support in addition to several tutorials, which provide a concise end-user overview of how to successfully complete tasks using the software. The consistent label formatting, ease of use, and an effective audit trail make the program an indispensable addition to our pharmacy’s workflow and BCMA initiative.

Brett Bieber, PharmD, BCPS, is a member of the clinical pharmacy service and pharmacy systems team at Mercy Medical Center in Sioux City, Iowa and serves as adjunct faculty in the pharmacy technician training program at Western Iowa Tech Community College. He is a board certified pharmacotherapist and received his PharmD from Creighton University.