Ensuring a bar code is on every medication—including tubes, syringes, and oddly shaped items—impacts not only patient safety, but also the facility’s bottom line. With thorough bar coding, inventory tracking and billing accuracy are greatly improved. However, because medications come in various package sizes and types, there is not a single one-size-fits-all packaging solution and creativity is often required to ensure reliable bar codes are available consistently at the point of administration. 

CoxHealth, a 754-bed health system in Springfield, Missouri, implemented bar code medication administration in 2008. Shortly thereafter, difficulties in bar coding several types of items were uncovered. Finding effective methods of solving these bar coding conundrums helped improve patient safety, saved pharmacy time and frustration, and ensured purchases were tracked and therefore reimbursed appropriately. 

Bar Code Labeling Challenges
Problems were encountered with various products, including multiuse items with crinkled labels, syringe labels, missing labels, and over-the-counter products without NDCs, all of which required innovative solutions.

Multiuse Topicals. Tubes of ointments and creams create a recurring problem—bar code labels scan when first applied, but over time, the bar code becomes wrinkled and does not scan properly. Affixing an additional bar coded flag label to the end of the tube ensures that the product will scan, even when the tube is curled up and the bar code is obscured (see Figure 1). 

IV and Oral Syringes. IV and oral syringes are dispensed from the pharmacy with a patient-specific bar code on the label, which is the only bar code the nurse has access to when scanning. Oftentimes when the syringe reached the nurse, the label was wrapped around the syringe, rendering the bar code unscannable. To solve this problem, a second bar code was added to each label. Our information technology team customized the labels to include a string of Aztec 2D bar codes, allowing the nurses to scan successfully even when the label wraps around the syringe (see Figures 2 and 3). This solution has improved scanning rates on syringes considerably, so much so that we implemented this change to all of our patient-specific labels.

Missing Labels. An unexpected challenge was recently identified when several patient-specific oral syringes were discovered with missing dispense labels. These syringes had a somewhat greasy feeling, which prevented the label from adhering to the syringe. Fortunately, adhesive tape did securely fasten the labels to the syringes. Because taping every syringe individually is not an efficient long-term solution, we are working with the manufacturer to develop a better solution.

UPC vs NDC Codes. When we receive products that have no bar code, we typically add an Aztec 2D NDC bar code in our repackaging area. However, we occasionally encounter products with UPC codes but no NDC bar code. This presents an additional challenge as our packaging database is maintained by NDC code only. To solve this problem, we developed a verification procedure in the repackaging room that the packaging technician and verifying pharmacist can use to translate the UPC on the product to a specific NDC. This paper directory has been gathered from our supplier’s product catalog. The pharmacy buyer is then informed that the product in question came to the pharmacy without an NDC code so this problem can be avoided in the future. 

Scanning upon Receipt. With 400 products arriving in the pharmacy each day, scanning each one is time-prohibitive. To test incoming bar codes effectively, the pharmacy buyer notifies the pharmacy informaticist if an ordered item has not been purchased within the last two years, and provides pharmacy with the relevant information so that when the “new” item arrives at the pharmacy it does not cause any process slowdowns. Experience has indicated that the most recently purchased items are likely to scan without incident. When items are repackaged in the pharmacy, the technician scans the first dose of each product to ensure it scans correctly. Bypassing the scanning step for every product that enters the pharmacy allows us to focus on those items most likely to have scanning problems, thus creating a more efficient process. 

Tracking Scanning Failures
Bar codes that fail to scan are a concern for safety reasons, as this opens the door to dispensing the wrong dose or medication to patients. Staff frustration with unscannable items often leads to workarounds, which also increase the possibility of error. But in addition to the important safety benefits of ensuring accurate product bar coding, facilities also must recognize the financial rewards. Unscannable items result in lost charges. 

Daily reporting is necessary to track items that refuse to scan. At CoxHealth, the procedure for reconciling scanning failures is to run a report that details the medications dispensed and the total dollar amount; these numbers are then compared with the total dollar amount in the billing system. If any discrepancies are identified, the totals for each patient are compared until the missing charges are uncovered. Though this process can be time-consuming, it has consistently identified scanning failures. Last month a total of almost $39,000 was saved through review and reconciliation of these reports.

Integration Challenges
One significant roadblock to an optimal, hospital-wide bar coding system is that our facility currently uses two separate, nonintegrated systems for bedside bar coding and automated dispensing cabinets. This means two databases and two hardware devices, scanning two different symbologies, must be maintained, which is an inefficient use of employee time. Integrated systems are a key step in creating streamlined processes. 

Conclusion
Because bar code medication administration challenges are increasing along with the movement toward using more complex, data-rich bar codes, it is especially advantageous for facilities to involve all stakeholders—pharmacy staff, manufacturers, and wholesale distributors, as well as other hospitals that may be facing or have solved similar challenges—in developing innovative solutions. Ensuring that all products leaving the pharmacy are properly bar coded, trackable, and can be billed appropriately decreases unnecessary aggravation and missing charges while improving patient care.

Sarah Carter, CPhT, is a certified pharmacy technician at CoxHealth and is currently on the automation team, where she oversees the operations of the medication robot and the repackaging room. 

Kyle Waite is the pharmacy application systems analyst for CoxHealth. With ten years of pharmacy experience, Kyle maintains the automation databases and software for the pharmacy.