ISMP Medication Safety Alert! May 21, 2009 Vol. 14, Issue 10: “Please let us know if you identify problems 
with a company’s unit dose package barcode. An example of an ARICEPT (donepezil) unit-dose package with a barcode problem appears in Figure 1 (shown in the PDF version of the newsletter). Note that the labeling material has been applied to the unit-dose package in such a way that tearing the doses apart destroys the barcode! Problems like this are due to inadequate quality control and are by no means isolated to one company. When issues like this occur, staff are forced to take extra steps to maintain the quality of the barcode, or they have to relabel products so they can be scanned at the bedside. This, of course, takes time and also increases the risk of a labeling error. If you send barcode problems to us along with a publishable photo, it will help us remind companies about the need for adequate quality control.” - Fortunately for us we haven’t seen anything like this, yet.
