At some point in the past few days it was decided that our technicians should re-label all injectable controlled substances with one of our “after market” flag labels. I’m not sure when or how the decision was made, but it was. When questioned about it, the rationale behind the decision was that the nurses were wasting unused medication at the ADCs and not taking the vial to the bedside. And apparently the solution was to use our flag labels because they offer a peel away section that can be taken to the bedside with the drug in a syringe for scanning and administration purposes.
A little bit of information on our labeling process may be in order. To generate a bar-code label with our software we have to enter the particulars of the drug into the application database. One piece of information, perhaps the most important piece, is a unique identifier. We’ve settled on the NDC number, which is often contained in the bar-code on the manufacturers product. With me so far? Good. So to make things easy we typically scan the bar-code on the medication package, which in turn automatically populates the unique identifier field. We do this to mimic the bar-code on the manufactured item as closely as possible; works great most of the time.
Now the problem. Take a look at the image below making sure to pay particular attention to the numbers beneath the bar-codes. Notice the similarities. The first 11 digits, highlighted in yellow, are the same for the drugs on the top and the bottom. The same is true for the first 11 digits on the second and third drugs, highlighted in green. Unfortunately these are completely different drugs. The second item is a 1mL vial of midazolam 5mg/mL injection and the third item is a 2mL ampule of fentanyl 50mcg/mL injection. No problem because the last five digits of the number in the bar-code are different, right? Sort of. Our labeling system truncates the information at 11 digits. So when the pharmacist attached these drugs to our cross-reference file the BCMA system couldn’t tell the difference. Doh! The solution was simple, but only after the mistake was caught. I won’t tell you how we caught the error, just know that it was caught.
The system broke down in several places and no blame is necessary. However there are some important lessons to take away from the experience: pay close attention to what you’re doing, be careful, check the product after you label it and before it goes out, and know the limitations of your technology.
Some people have asked me how we handled the bar-coding issue above. The issue is actually being handled from two different directions. The solution on my end was really quite simple. For items like those mentioned in the post I remove the first five digits from the unique identifier after scanning the bar-code information into our AutoLabel system. It just takes a second and eliminates the duplicates. See, I told you it was simple.
The second piece is coming directly from Talyst. Someone at Talyst read my blog post and shot me an email regarding the issue. I gave them a little more detail and they put me in contact with a couple of their engineers responsible for the labeling system. They’re currently working on a more technical solution.