Pediatric labels for bar code medication administration (BCMA)

One of the questions marks surrounding BCMA, known as MAK in Siemens language, is how to label pediatric oral syringes. Unlike most adult unit-dosed medications, pediatric dosages come in a variety of sizes. Where an adult patient may receive 25mg of captopril, a pediatric patient may receive a range of doses based on weight (0.15-0.3 mg/kg/dose for infants). The captopril tablet used by adults is barcode ready from the manufacturer. The pediatric dose, on the other hand, is not. For pediatric patients we compound a 0.75mg/mL oral suspension and pull the doses into oral syringes based on the provider’s order. Captopril is only one example as we do the same for hydralazine, spironolactone, propranolol, sildenafil, etc.

Figuring out how to barcode the pediatric oral syringes is turning out to be quite a challenge. Because they are not unit-dosed and barcode ready from the manufacturer, it is difficult to create a standardized system to identify not only the medication contained in the oral syringe, but the dose as well.

Based on several meetings and some time spent with a Siemens consultant I have come up with three possible solutions that may suit our needs.

1. Use the “IV” pathway in the pharmacy system to enter the oral syringes.
2. Use our AutoLabel system from Talyst to generate medication, but not dose specific, barcode labels.
3. Have the pharmacy system generate a patient/drug specific barcodes directly on the dispensing label.

Use the “IV” pathway to enter pediatric oral syringes
Using the IV order entry screen to generate labels for pediatric oral syringes makes a lot of sense to me. Labels generated via this pathway currently contain a barcode linked to both the patient and the medication. Seems like a no-brainer.

To make use of this process a specific “Method” field on the IV order entry screen must be used. The methods available in the Siemens Pharmacy system include:

PUSH – IV Push
ALTLVP – Alternating Large Volume Parenteral
ALTTPN – Alternating Total Parenteral Nutrition
KVO – Keep Vein Open
PLAIN – Plain IV solution
LVP – Large Volume Parenteral
TPN – Total Parenteral Nutrition
PIGBCK – Piggyback
ENTRL – Enteral
PLIRR – Plain Irrigation Solutions
IRR – Irrigation Solutions (may contain additives)

Each method is assigned a certain set of criteria. For example the PUSH method does not allow for carrier solutions, only additives; the LVP method allows a single carrier solution plus up to 10 additives; so on and so forth.

The method most commonly used for pediatric oral syringes is ENTRL. This makes sense as the enteral route is utilized for tube feeds. In fact, most facilities I’ve spoken to that use Siemens Pharmacy end up using the ENTRL method for their pediatric oral syringes.

With the ENTRL method I can use a single carrier plus 0-11 additives. For pediatric oral syringes the carrier would be a place holder like “SYRINGE” or “PEDS SYRINGE”, and the additive would be the oral medication being used, i.e. erythromycin suspension, amoxicillin suspension, etc. It’s a perfect solution. Unfortunately, our facility hijacked the ENTRL method for a different purpose several years ago.

Enhancement requests for a separate “oral” method on the IV screen have been submitted to Siemens, but no word yet on whether this change will be made.

Strike one.

Use the AutoLabel system from Talyst
In order to make efficient use of our AutoLabel system we would have to create separate pediatric entries in the pharmacy drug master (PDM – a.k.a. medication dictionary, formulary, etc) for each pediatric mediation. For example: amoxicillin suspension 500mg/5mL for adults and PN Amoxicillin suspension 500mg/5mL for pediatrics.

Fortunately for me, we are already using this naming convention for all pediatric oral solutions/suspensions in our PDM. The entries begin “PN [generic name]“, i.e. PN Captopril 0.75mg/mL Suspension. This allows the pharmacist to quickly identify pediatric oral medications during order entry. When they need to search our system for pediatric syringes they simply type “PN[space]“ and hit enter. That brings all the available products up in an alphabetical list.

The disadvantage to this system is obvious; the barcode is not tied to the specific dose or patient information. It only identifies the drug. There would be nothing in the barcode to uniquely identify the dose held in the oral syringe and would therefore do nothing to alert the nurse administering the medication to an incorrect dose.

Strike two.

Generate a patient/drug specific barcode directly from the pharmacy system
Siemens Pharmacy has the option to print a barcode on every label generated from the pharmacy system. The barcode is tied to both the patient information as well as the medication.

Two distinct disadvantages to this process are:

1. Risk of attaching the dispensing label to the wrong product
2. Scanning the manufacturer’s barcode is always preferred to scanning a pharmacy generated barcode.

There really isn’t anything that can be done about issue #1 above. Incorrectly labeling a medication is an ever present risk in a hospital environment.

To minimize the impact of issue #2 we can use a perforated label that allows one to peel the barcode off the label prior to applying it to the product. This limits the application of the label to products that do not have a manufacturer’s barcode, such as pediatric oral syringes.

The image on the left below is one of our labels showing the location of the barcode. The image on the right is an example of a perforated label showing how the barcode could be removed prior to application.

The issue is still being discussed. However, based on the information I’ve been able to accumulate thus far, I believe we will end up using the patient/drug specific barcode generated from the pharmacy system. I don’t see a better alternative at the moment.