ISMP Calls for Manufacturers to Stop Printing Medication Barcodes Across Round Surfaces

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Administration (FDA) to consider raising manufacturer awareness of this problem, and addressing it in the finalized draft guidance on Safety Considerations for Container Labels and Carton Labeling Design to Minimize Medication Errors.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