BAR-CODE STANDARDS POLICY

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Rosamund Richardson
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1 BAR-CODE STANDARDS POLICY PURPOSE The purpose of this policy is to define the institutional bar-code standard and approval process. POLICY STATEMENT It is the policy of The University of Texas MD Anderson Cancer Center (MD Anderson) that the Asset Management Department will provide guidance and oversight to existing and newly developed programs requiring use of Bar-Code Technology and radio frequency identification (RFID) implementations used within the institution. An approved bar-code standard, as described in this policy, is required prior to human, capital, space, or other resource allocation for all bar-code programs and expansion of existing programs. As RFID decisions for the institution are formalized and finalized, this policy will be revised. SCOPE This policy applies to all faculty, trainees/students, and other members of MD Anderson s workforce and to all areas of the institution. TARGET AUDIENCE The target audience for this policy includes, but is not limited to, all faculty, trainees/students, and other members of MD Anderson s workforce. DEFINITIONS Bar-Coded Medication Administration (BCMA): Typically involves scanning the patient s wristband and the medication to be administered, and comparing the data with the Medication Administration Record (MAR) to assure compliance with the six rights of medication administration: the right patient, right drug, right dose, right route, right time, and real time documentation (ref Am J Health-Syst Pharm. 2005; 62:2626-9). Bar-Code Registry: Database containing types, symbols, standard content, and owner identification currently in use at MD Anderson. Bar-Code Technology: A number of hardware and software components that may include a bar-code printing system, scanner, communications network, software applications running on a server, and interfaces for communication between software and server. Page 1 of 6

developed programs requiring use of Bar-Code Technology and radio frequency identification (RFID) implementations used within the institution.

2 Health Industry Business Communications Council (HIBCC): Nonprofit council that develops a standard for data transfer using uniform bar-code labeling and other electronic data interchange standards. Modulo 43 Check Digit Calculation: Check digit algorithms (a.k.a. Modulus Numbering or Mod numbering) used in conventional and bar-code numbering to increase read or scan reliability. Positive Patient Identification (PPID): Use of a minimum of three (3) unique patient identifiers to establish and confirm patient identity prior to any treatment or intervention. PROCEDURE 1.0 Bar-Code Standards 1.1 Bar-Code Technology A. The use of any Bar-Code Technology should comply with this policy. B. Bar-Code Technology should comply with all current bar-code standards, regulatory guidelines, and industry standards. 1.2 Bar-Code Registry An official Bar-Code Registry will exist and be maintained to accommodate institution-wide Bar-Code Technologies and to assure bar-code formats are not duplicated. The Bar-Code Registry will include graphics of bar codes in use at the institution. 1.3 Bar-Code Labels Bar-code labels, at a minimum, should contain: A. A unique qualifier to identify any institutional bar code using both the human and electronic eye and should read the same information, when possible. B. A visual cue indicating MD Anderson, when possible. 1.4 Data Format A. Data Format, at a minimum, should: Contain a unique prefix identifying the data owner. Relay a unique, item-specific reference, so that the receiving system can delineate relevant items (e.g., patient identifier from a medication identifier or one medication from another). Have approved symbology that does not interfere with or disrupt Positive Patient Identification (PPID) or Bar-Coded Medication Administration (BCMA) systems. B. For all non-patient care related uses, bar codes should contain at least two (2) data elements. C. Patient identification bar codes will include, at a minimum, medical record number (MRN), full name (last name, first name, middle initial when provided), and date of birth. Page 2 of 6

Positive Patient Identification (PPID): Use of a minimum of three (3) unique patient identifiers to establish and confirm patient identity prior to any treatment or intervention. PROCEDURE 1.

3 1.5 Wristband Bar-Code Format A. A unique qualifier ( AC ) is listed as the prefix and used to identify patient wristbands from other bar codes containing the patient s medical record number at the institution. B. A Modulo 43 Check Digit Calculation is used as additional data security and is the suffix listed as the last digit in the bar code. C. The AC qualifier and Modulo 43 Check Digit Calculation bar-code format is to be used exclusively on patient wristbands. This format cannot be applied to any other forms, documents, or labels within the institution. D. All patient wristbands comply with HIBCC standard for Positive Patient Identification. 2.0 Asset Tagging For the purpose of this policy, all asset bar codes should conform as closely as possible to the following: 2.1 Tag should be placed in a highly visible location on the asset, where it can be easily accessible. 2.2 Multiple bar codes should be avoided, if possible. 2.3 Bar codes should not be placed on top of each other or such that placement inhibits scanning visual fields. 2.4 Capital or Controlled equipment (as defined by the Asset Management Policy Manual) should bear only the Asset Management Property Identification Tag, once identified. Application of any other bar-coded tag, other than manufacturer serial numbers and/or part numbers, on Capital and Controlled equipment will not be allowed. Leased computer equipment shall bear only the CL computer lease asset tag. 2.5 Bar codes must read the same information to the human eye and the electronic eye (scanner). 3.0 Supply inventory Management For the purpose of this policy, all shelf labels should conform as closely as possible to the following: 3.1 Tag will be placed on the shelf, bin or other container in direct relationship to the item. 3.2 Tags must not overlap or in any other manner obscure another label. 3.3 Damaged or missing bar-code labels should be reported to Materials Management Services (MMS) for disposition. 4.0 Approval 4.1 Any new bar-code initiation venture will be routed to Asset Management for inclusion in the Bar-Code Registry and to assure compliance with this policy. 4.2 This policy will affect any new bar code and/or RFID programs implemented after January 1, Page 3 of 6

A Modulo 43 Check Digit Calculation is used as additional data security and is the suffix listed as the last digit in the bar code. C. The AC qualifier and Modulo 43 Check Digit Calculation bar-code format is to be used exclusively on patient wristbands.

4 4.3 Bar-code programs implemented prior to January 1, 2008 will be grandfathered; however, it is recommended that current bar-code solutions migrate to the two (2) data element requirement, when possible. 5.0 Tracking/Archiving/Reporting An official Bar-Code Registry shall exist and be maintained to assure bar-code formats are not duplicated and to accommodate institution-wide Bar-Code Technologies. 6.0 Security Unauthorized removal of any bar code from institutional assets is strictly prohibited. Page 4 of 6

0 Tracking/Archiving/Reporting An official Bar-Code Registry shall exist and be maintained to assure bar-code formats are not

5 ATTACHMENTS / LINKS None. RELATED POLICIES Patient Identification Policy (UTMDACC Institutional Policy # CLN0579). JOINT COMMISSION STANDARDS / NATIONAL PATIENT SAFETY GOALS Use at least two patient identifiers when providing care, treatment, and services. Standard: NPSG Comprehensive Accreditation Manual for Hospitals (CAMH), January OTHER RELATED ACCREDITATION / REGULATORY STANDARDS None. REFERENCES Advisory Board. Asset Management Manual (rev.2006). Positive Identification for Patient Safety: Part 1: Medication Delivery. The Health Industry Bar Code Standards, HIBCC. Page 5 of 6

01.01. Comprehensive Accreditation Manual for Hospitals (CAMH), January 2012. OTHER RELATED ACCREDITATION / REGULATORY STANDARDS None. REFERENCES Advisory Board.

6 POLICY APPROVAL Approved With Revisions Date: 05/29/2012 Approved Without Revisions Date: Implementation Date: 05/29/2012 Version: 29.0 RESPONSIBLE DEPARTMENT(S) Information Services Page 6 of 6

RECORDS MANAGEMENT POLICY

RECORDS MANAGEMENT POLICY PURPOSE The purpose of this policy is to: Assist departments in effective utilization of space and efficient information retrieval; Establish guidelines for disposal of records;