HORSHAM, PA—Despite ongoing advocacy by the Institute for Safe Medication Practices (ISMP), some pharmaceutical manufacturers continue to place barcodes on rounded medication container surfaces, which can lead to scanning failures that can compromise patient safety and create billing issues.

The July 15, 2021 issue of the ISMP Medication Safety Alert!^® Acute Care newsletter reports on a recent situation where a hospital discovered while auditing their 340B program that they were not receiving the correct contract price for a rabies immune globulin product because it was not being not being charted to the medication administration record. The barcode was printed horizontally on the curve of the round vial, and could not be completely read by the laser scanner.

ISMP recommends that linear barcodes on round ampules, vials, inhaler canisters, and oral liquid bottles only be printed perpendicular to the curve of the container, usually along the edge of the label on one side, rather than horizontally around the curve. Purchasers are advised to avoid products with curved barcodes when possible, if scanning technology is being used during product selection and administration.

“Placing barcodes on curved medication container surfaces is an ongoing patient safety concern,” says ISMP President Michael Cohen, RPh, MS, ScD (hon), DPS (hon), FASHP. “It can result in the medication not being scanned for verification, and the dose may be repeated if another practitioner believes it has not been administered. The healthcare team might also make incorrect decisions about patient care based on an inaccurate medication history.”

ISMP is calling for the U.S. Food and Drug Administration (FDA) to consider raising manufacturer awareness of this problem, and addressing it in the finalized draft guidance on Safety Considerations for Container Labels and Carton Labeling Design to Minimize Medication Errors.

For more information on this issue, see ISMP’s previous newsletter coverage at: https://www.ismp.org/resources/barcode-related-safety-briefs

About the Institute for Safe Medication Practices

The Institute for Safe Medication Practices (ISMP) is the nation’s first 501c (3) nonprofit organization devoted entirely to preventing medication errors. ISMP is known and respected for its medication safety information. For more than 25 years, it also has served as a vital force for progress. ISMP’s advocacy work alone has resulted in numerous necessary changes in clinical practice, public policy, and drug labeling and packaging. Among its many initiatives, ISMP runs the only national voluntary practitioner medication error reporting program, publishes newsletters with real-time error information read and trusted throughout the global healthcare community, and offers a wide range of unique educational programs, tools, and guidelines. In 2020, ISMP formally affiliated with ECRI to create one of the largest healthcare quality and safety entities in the world, and ECRI and the ISMP PSO is a federally certified patient safety organization by the U.S. Department of Health and Human Services. As an independent watchdog organization, ISMP receives no advertising revenue and depends entirely on charitable donations, educational grants, newsletter subscriptions, and volunteer efforts to pursue its life-saving work. Visit www.ismp.org and follow @ismp_org to learn more.

For more information, contact:
Laurie Menyo, Director of Strategic Communications
610.825.6000 ext. 5310
lmenyo@ecri.org

Renee Brehio, ISMP Public and Media Relations
614.376.0212
rbrehio@ismp.org