Our stories - LabelSafe: Pharmacy and technology go hand in hand to promote medication safety
University of Michigan Health System develops software to improve the safety of medication repackaging and labeling.
Most patients don’t realize that many of the medications they receive in the hospital are shipped from the manufacturers in huge, bulk quantities. Hospital pharmacy staff then must repackage the medications into the single-dose containers distributed at the patient’s bedside. It’s a necessary process that, unfortunately, also creates the possibility for medication error.
For a health care provider such as the University of Michigan Health System, this means repackaging – and labeling – more than 1.4 million doses of medication every year.
Last year, the UMHS Department of Pharmacy Services staff took matters into their own hands to find a safe solution to drug repackaging and labeling. The answer – a new software program called LabelSafe – is a barcode label-making program that vastly improves medication repackaging and labeling accuracy.
“When it comes to repackaging medications, the label is the No. 1 area in which you can make mistakes,” says Department of Pharmacy Services Strategic Projects coordinator Michael McGregory, Pharm.D. “By incorporating barcode verification into the process, instead of traditional human visual checks alone, the safety and accuracy of the packaging and labeling process is greatly enhanced.”
Barcodes help at the “breakdown point” because they are used to generate the identification label for the medication. And it’s not just making sure that you have the right label for the right medication. You must have the right dose as well. “The difference between 1 mg. of Dilaudid and 2 mg. of Dilaudid can be huge, especially if the patient is a child,” says University Hospital Pharmacy director Jim Stevenson, Pharm.D. “Having a system that provides a fail-safe process is paramount.” Stevenson also is associate dean for Clinical Sciences and professor of Pharmacy for the U-M College of Pharmacy.
After a team of pharmacists, technicians and a physician met to discuss how to improve the unit dose labeling process, Stevenson asked McGregory and his staff to write the program that would be the cure. LabelSafe is a Web-based application that is a print-on-demand, “one stop shop” for all custom repackaging and labels.
“LabelSafe completely integrates with our packaging process and incorporates an automated barcode check,” McGregory says. That proved to be the right solution.
LabelSafe works like this: After pharmacy staff select a pre-built medication label that is appropriate for the drug being packaged, the computer screen reads, “Show me the barcode.” Staff hold up the bulk package to the scanner, and the software matches that barcode to the selected label. If the barcodes match, labels will print. If not, the system locks down until a pharmacist arrives, rectifies the error and prints the label. The process assures that the result is perfect.
Pharmacy Services has copyrighted LabelSafe and is pursuing commercial development through the University of Michigan’s Office of Technology Transfer.
“Barcode accuracy is important, and it will be even more important as we pursue bedside barcode verification of medications at the point of administration,” says McGregory. He, along with other Pharmacy Services staff, anticipate a time in the not-too-distant future when nurses can scan the individual dose package right before they give the medication to the patient.
In October 2006 alone, Stevenson says, LabelSafe prevented three labeling errors. Granted, a unit nurse may have discovered the discrepancy. But, Stevenson says, “Now, we don’t have to rely solely on human visual checks. And that’s great.”
