Patient safety
Improving medication safety in hospitals
George Lawton at GS1 explains why two-dimensional barcodes on medicine packs matter for patients, staff and medicines security.
Across the NHS, safety often comes down to moments that last a few seconds. A nurse uses digital technologies to scan a patient wristband and a medicine pack. The electronic system provides an additional layer of verification, confirming the five rights of medicine administration: the right patient, right medicine, right dose, right route and right time. Batch and expiry are captured automatically in the background. Care continues. That only works when the pack carries a
reliable, machine-readable identifier that systems can trust. Right now, many do not. Since the Windsor Framework came into force on 1 January 2025, EU Falsified Medicines Directive safety features have been disapplied in Northern Ireland, aligning it with Great Britain where they have not applied since 2021. For UK-only packs, use of a two-dimensional (2D) barcode is optional and at the marketing authorisation holder’s discretion. The consequence is a system where some packs arrive with a scannable barcode, some do not, and some carry data that automated systems cannot process. What follows is a chain reaction across the
entire medicines journey, from the pharmacy goods-in door to the patient bedside. Each break in the process turns reliable digital checks into manual workarounds. On 4 February 2026, the House of Lords Public Services Committee called on government to accelerate digitisation and mandate 2D barcodes so the NHS can see stock in near real time, act earlier on shortages and make recalls faster and safer. This is why this matters on the front line.
Link one: receipt into pharmacy In a hospital setting, the chain begins at the pharmacy door. As stock arrives, the pharmacy team uses digital medicines management systems to complete the goods receipt process. Each medicine is scanned using a 2D barcode reader, capturing the DataMatrix that includes the GTIN, batch number and expiry date. This information is pulled directly into the pharmacy system, checked against the local formulary and stock catalogue, supporting accurate inventory management, first expiry first out logic and
64
www.clinicalservicesjournal.com I October 2026
Link two: closed loop medicines management Beyond the goods-in door, 2D barcodes are the foundation of closed loop medicines management (CLMM): the end-to-end digital process that connects prescribing, procurement, supply, dispensing and administration into a single, traceable chain of custody for every medicine, for every patient. In a functioning closed loop system, an
automated replenishment alerts. When the identifier is missing, unreadable or encoded incorrectly, that first link breaks immediately. The system rejects the item, requiring pharmacy staff to quarantine stock, search for workarounds and manually enter batch and expiry details, reintroducing the very transcription risks that automation is designed to eliminate while adding avoidable workload to already stretched teams. The rest of the delivery may sit in limbo, slowing replenishment to clinical areas that are waiting. The MHRA Inspectorate has documented the
pattern: wrong product identifiers, missing or unreadable symbols, incorrect formats rejected by automated systems and reuse of identifiers across different products. These are not edge cases. They are avoidable, recurring failures with predictable consequences. In August 2025, a Class 4 medicines defect
notice confirmed that multiple batches of fexofenadine 120mg tablets carried a barcode that, when scanned, identified a different prescription medicine: naratriptan 2.5mg tablets. A similar issue arose with simvastatin tablets in July 2025. The Pharmaceutical Journal reported in November 2025 that barcode errors on medicines could have “potentially fatal consequences,” in the words of Henrietta Hughes, the patient safety commissioner for England.
electronic prescription is generated in the ePMA, clinically verified by a pharmacist and transmitted to the dispensing robot. At the point of care, the nurse uses barcode medication administration (BCMA) technology to scan both the patient’s wristband and the medicine, confirming patient identity, medicine, dose, form and timing before administration. Each step updates the same electronic record automatically, including batch and expiry, creating a complete chain of custody. An estimated 237 million medication errors occur in the NHS in England every year, of which 54.4 percent are administration errors. Where closed loop medicine workflows have been implemented, the results are compelling. At Alder Hey Children’s NHS Foundation Trust, the technology delivered a 50 percent reduction in medication error. At Cambridge University Hospitals, approximately 2.2 percent of potential medication errors across around 11,500 daily administrations were averted through barcode scanning alerts. At St George’s University Hospitals NHS Foundation Trust, scanning prevented practitioners from administering to the wrong patient on 14,678 occasions and from giving the wrong medication or dose on 113,674 occasions in a single year. When a pack arrives without a reliable 2D
barcode, the loop breaks. Data must be entered manually, a step that is slower, prone to error and harder to audit. Similar packaging for the same drug in different strengths is a known risk: a scan confirms not just what the product is, but which strength, form and batch. In October 2025, 32 pharmacy professionals wrote to the MHRA urging it to mandate 2D barcodes and include GTINs in the medicine licensing process.
Page 1 |
Page 2 |
Page 3 |
Page 4 |
Page 5 |
Page 6 |
Page 7 |
Page 8 |
Page 9 |
Page 10 |
Page 11 |
Page 12 |
Page 13 |
Page 14 |
Page 15 |
Page 16 |
Page 17 |
Page 18 |
Page 19 |
Page 20 |
Page 21 |
Page 22 |
Page 23 |
Page 24 |
Page 25 |
Page 26 |
Page 27 |
Page 28 |
Page 29 |
Page 30 |
Page 31 |
Page 32 |
Page 33 |
Page 34 |
Page 35 |
Page 36 |
Page 37 |
Page 38 |
Page 39 |
Page 40 |
Page 41 |
Page 42 |
Page 43 |
Page 44 |
Page 45 |
Page 46 |
Page 47 |
Page 48 |
Page 49 |
Page 50 |
Page 51 |
Page 52 |
Page 53 |
Page 54 |
Page 55 |
Page 56 |
Page 57 |
Page 58 |
Page 59 |
Page 60 |
Page 61 |
Page 62 |
Page 63 |
Page 64 |
Page 65 |
Page 66 |
Page 67 |
Page 68
