My organization (UW Medicine) is soon going live with Alaris-Epic smart pump interoperability and we have been working through the concern raised in a recent ISMP Acute Care Safety Alert newsletter from 3/13/25. In brief, the issue was that a nurse mistakenly associated a medication-containing bag (amiodarone mixed in D5W) to an order for D5W because they scanned the manufacturer's barcode on the D5W bag and not the patient-specific label applied by the pharmacy. This resulted in the amiodarone infusing at the prescribed rate of D5W (much faster than intended).

As recommended, we performed a mini-FMEA of our dispensing practices and concluded that our major risk is with pharmacy-admixed items (where we add medication to a diluent bag) because we currently affix our pharmacy label to the BACK of the diluent bag so that the checking pharmacist can confirm it was made in the correct diluent type and volume.

We've talked through two options to address this risk, but operationally have concerns with both.

1) We could cover the diluent bag's barcode with our pharmacy (Epic) labels. However, given the proximity of the barcode with the printed diluent name and volume we would have to either affix the label to the side of the bag (making it difficult to read and possibly increase risk of it falling off), or have the tech flag the label to the bag and then the pharmacist fully applies the label after confirming the mixture was made correctly. With the latter, we have concerns that the labels will fall off or stick to another bag when being put into baskets for checking, making it a risk that we have unlabeled/mislabeled bags containing medications.

2) We also considered putting a "medication added" sticker over the barcode on the diluent bag. However, this would require extra supplies and time. We would also have to do this step AFTER the mixture was complete because the techs scan the barcode during Dispense Prep and we don't want to prevent this safety step from occurring.

Have any institutions who are already live with interop already worked through this? Are you willing to share your process and any advantages/disadvantages you've seen with said process?

Thank you,
James