Purpose: A hospital pharmacy's efforts to identify and address challenges with bedside scanning of bar codes on large-volume parenteral (LVP) infusion bags are described.
Summary: Bar-code-assisted medication administration (BCMA) has been shown to reduce medication errors and improve patient safety. After the pilot implementation of a BCMA system and point-of-care scanning procedures at a medical center's intensive care unit, it was noted that nurses' attempted bedside scans of certain LVP bags for product identification purposes often were not successful. An investigation and root-cause analysis, including observation of nurses' scanning technique by a multidisciplinary team, determined that the scanning failures stemmed from the placement of two bar-code imprints-one with the product identification code and another, larger imprint with the expiration date and lot number-adjacently on the LVP bags. The nursing staff was educated on a modified scanning technique, which resulted in significantly improved success rates in the scanning of the most commonly used LVP bags. Representatives of the LVP bag manufacturer met with hospital staff to discuss the problem and corrective measures. As part of a subsequent infusion bag redesign, the manufacturer discontinued the use of the bar-code imprint implicated in the scanning failures.
Conclusion: Failures in scanning LVP bags were traced to problematic placement of bar-code imprints on the bags. Interdisciplinary collaboration, consultation with the bag manufacturer, and education of the nursing and pharmacy staff resulted in a reduction in scanning failures and the manufacturer's removal of one of the bar codes from its LVP bags.