Prepared for 

Immunization Services Division 

National Center for Immunization and Respiratory Diseases 

Centers for Disease Control and Prevention 

Prepared by 

Deloitte Consulting LLP

May 2018

Implementation 

Guide for 

Decision Makers –

2D Vaccine 

Barcode Scanning
- 2 -

2D Barcode Scanning: The Issue, Opportunity, and Current Pilot

Issue

 >100 million vaccines administered annually in the US

 Most vaccines manually typed into electronic medical 

record (EMR), with documented errors/inefficiencies 

 Lot number, expiration date, and product ID printed in 

small font to fit on vaccine vials/syringes

 Accuracy of vaccine records critical to patient safety 

and in the event of vaccine recall or disease pandemic

Opportunity

 2D barcodes on most vaccine vials/syringes and 

scanning technology available, but not widely used to 

record vaccine entries

 Even small improvements to vaccine record accuracy 

or efficiencies can have meaningful impact due to 

volume and consequences of inaccuracies

 Two previous CDC pilots found scanning improved 

accuracy, time savings, and user satisfaction, though 

challenges remained, including low scanning rates

Current Pilot and Reporting  Findings Report + Implementation Guide

 CDC partnered with a large health system to pilot 2D barcode scanning implementation across 27 diverse care 

centers (2015 – 2017); care centers varied by specialty, size, vaccine volume, geographic location

 Data collected through deidentified EMR vaccine records, online survey, observations, and group discussions

Pilot Findings Report [separate document]

Detailed findings and methodology from pilot

o

o

o

o

Significant improvements to vaccine record quality 

and efficiency with scanning entry process

Adherence strategies improved scanning rates

Staff satisfaction and improved staff safety

Challenges observed and improvements identified

Implementation Guide [current document]

Six-step guide to support health organizations in deciding 

if vaccine 2D barcode scanning is right for them and aid 

the implementation decision-making process

Guidance for each 

step from pilot 

findings 
3

Plan Train

Adjust

Decide Assess Sustain

Implementation Guide Outline

2. Implementation Guide Steps

• Decide

• Plan

• Train

• Assess

• Adjust

• Sustain

3. Learn More About Our Work

1. What is Vaccine 2D Barcode Scanning?
4

2. Implementation Guide Steps

•

•

•

•

•

•

Decide

Plan

Train

Assess

Adjust

Sustain

3. Learn More About Our Work

What is Vaccine 2D Barcode Scanning?

1. What is Vaccine 2D Barcode Scanning?
- 5 -

Vaccine 2D Barcode Scanning

What's in a 2D barcode on a vaccine?

Vaccine two-dimensional (2D) barcodes contain more data than traditional, linear barcodes 

How does it work?

Vaccinators scan the 2D barcode on a vaccine 

vial or syringe with a 2D barcode scanner, 

which then populates data into their electronic 

medical record (EMR)

2D barcodes are now on most vaccine vials and syringes, but scanning is still not widely used
6

Plan Train

Adjust

Decide Assess Sustain

1. What is Vaccine 2D Barcode Scanning?

3. Learn More About Our Work

2. Implementation Guide Steps

• Decide

• Plan

• Train

• Assess

• Adjust

• Sustain

Implementation Guide Steps
Implementation Guide Steps

Plan Train

Adjust

Decide Assess Sustain

- 7 -

Overview of Implementation Guide Steps

Six steps in the Implementation Guide described in 

brief below, then detailed content follows

Aim is to support planning and decision-making to 

implement vaccine 2D barcode scanning

Pilot findings provide foundation for contents within 

each step (refer to separate pilot Findings Report for 

detailed pilot findings and methods) 

Decide

Decide if adoption of 2D 

barcode scanning of vaccines is 

right for your facility or 

organization, weighing 

resources needed and potential 

benefits of scanning

Plan

Plan for scanning 

implementation, identify how 

scanning fits into your vaccine 

administration workflow, and 

create strategies to maximize 

scanning use

Train

Train staff on scanning, 

including development of 

training materials, practice 

using scanners, and adjust to 

the scanning process

Assess

Assess use of scanning, identify 

challenges being experienced 

and any sites or practitioners 

needing additional support to 

consistently scan vaccines

Adjust

(if needed) Adjust strategies to 

achieve consistent scanning (e.g., 

adjustments to workflow, scanner 

location, or other changes) and 

address challenges experienced 

Sustain

Sustain consistent scanning 

practices once fully 

implemented and consider 

expanded use of scanning
- 8 -

Implementation in Action: Key Lessons Learned

Early Planning and Decisions Made a Big Difference (Take the Time to Get It Right From the Start)

• Sites that found early and lasting success with high and consistent scanning rates typically: 

–

–

–

–

–

–

–

–

Revised their workflow process and protocol from the start

Strategically selected scanner location, with input from staff

Patterns of Consistent Scanning and Full Implementation Were Evident Early 

• Given the same information, tools, and strategies, sites performed differently, with differences seen early 

High-volume sites, such as Pediatrics/Shot Clinic, scanned at high rates from the start until pilot end

Low-volume sites, including Internal Medicine, struggled the most to scan consistently

Adherence Strategies “Nudged” Participants to Scan More Frequently

• All three groups with a strategy added to promote scanning had the highest scanning rates and the group 

receiving only the training had the lowest scanning rate

Increases to scanning rates aligned with the timing of each strategy implemented

• Scanning rates matter, as benefits of scanning are only realized if the technology is actually used

Adjustments to Resolve Challenges Mid-Course Improved Scanning Use

• Revisiting foundational planning decisions and making revisions improved scanning rates and buy-in

• Ideas for adjustments, even after implementation underway, include: 

Offering troubleshooting support to work through specific challenges, 

Providing data on scanning rates to staff and leaders, and 

Engaging leaders at sites and within organization

Several key lessons for successful vaccine scanning implementation became evident from pilot 

data. This guidance can benefit other organizations embarking on this process.
Plan Train

Adjust

Decide Assess Sustain

Decide
- 10 -

Decide

Step 1: Decide Whether or Not to Adopt 2D Barcode Scanning

Assess whether vaccine barcode scanning is right for your organization – are needed elements 

in place to use scanners? Also, weigh potential benefits and up-front costs to implement 

scanning.

Icons along the top right will help guide through each step. 

Technology & Support Needs

• EMR system that supports 

2D barcode scanning for 

vaccines

•Configuring scanners for 

EMR and installing scanners

Potential Benefits

•Improved vaccine record 

accuracy 

• Time savings

•Improved staff satisfaction 

and other benefits

Up Front Costs & Time Needs

• Purchasing scanners/stands

• Training staff/leaders

•Revising vaccine entry and 

workflow processes

•Configuring/installing 

scanners
- 11 -

Decide

In order to appropriately use 2D barcode scanners, the following foundational elements are needed

Electronic Medical Record (EMR) System

• An organization needs to have, or be able to set up, an EMR able to capture data entered at vaccine 

administration.

–

–

–

Some EMRs have 2D barcode scanning functionality built in; updates may be needed for functionality.

Ideally, the EMR will be able to capture all data available in the scanned barcode (product ID, lot 

number, expiration date).

Scanner Configuration and Installation

• Support from an IT resource will enable the configuration, testing, and installation of scanners.

Most scanners “out of the box” require some set-up to ensure that scanners function or interface with 

the specific EMR system correctly. This set-up, which we refer to as configuration, ensures that data 

encoded in the 2D barcode populates correctly in the EMR. Configuration process may vary by scanner.

• Scanners will need to be plugged into a computer, unless cordless scanners are used.

• An organization should determine the best type of scanner for their needs. AAP outlines considerations 

when choosing a scanner. 

• Maintenance of scanners and resolution of any scanner/EMR interface challenges should also be considered.

Takeaway Proper configuration of scanners will ensure data are populating correctly in the EMR when scanned

Technology & Support Needs: Foundational Elements for Implementation
- 12 -

Decide

Potential Benefits with Use of Vaccine 2D Barcode Scanning

Main benefits of vaccine 2D barcode scanning observed during the pilot included:

Improved Vaccine Record Accuracy

• Vaccine lot number, expiration date, and NDC data fields significantly more accurate when

scanned rather than entered manually (5-9% improvements, depending on data field)

• Improvements varied by specialty and data field

Time Savings

• Average 21 seconds saved per vaccine scanned (from timed observations) – a 75% improvement

• One pilot site added 12+ vaccine appointments weekly due to time savings

Staff Satisfaction & Other Benefits

• Participants described various aspects of satisfaction with scanning

• Reduced eye strain, reduced hand- and joint-related problems, and disposing of barcoded

syringes in room instead of carrying for later entry highlighted as staff safety benefits

Learn More Brief discussion of benefits provided next. 

Detailed reporting on each benefit found in the barcoding pilot Findings Report 
Decide

- 13 -

Benefits: Scanning Greatly Improved Accuracy of Data

Vaccine lot number, expiration date, and 

NDC data fields significantly more 

accurate when scanned rather than 

entered manually (p<.01) 

• Lot number field improved 4.6% (to 99.7%) when scanned

• Expiration date field improved 9.2% (to 99.97%) when scanned

• NDC field improved 5.7% (to 99.99%) when scanned

Accuracy = Complete + Accurate Record (a record must first be complete and data in the field also accurate)

Why Accuracy Matters

Even small improvements to accuracy are meaningful, with over 100 million vaccines likely administered annually in the US** 

– a 1% improvement in data accuracy could impact a million or more vaccine records. Pilot site accuracy improved by 5-9%. 

*A data element was considered “complete” if the field was not blank. “Accuracy” was determined by comparison with our reference file. Lot numbers and NDC matching the reference file 

were deemed “accurate,” whereas records with something in the field, but without a match to the reference file were “inaccurate.” As lot numbers were needed to identify correct expiration 

dates, records with inaccurate or blank lot numbers were not included in the expiration date analysis. For NDC, matches to either the unit of use or unit of sale were counted as “accurate.”

**Estimated 130+ million vaccines administered to ages <18 years, extrapolated from sample (Rogers et al, 2018: https://www.ncbi.nlm.nih.gov/pubmed/29249524); estimated 10 million <1 

year of age (VAERS, 2015); over 150 million doses of injectable flu vaccine available for 2017–2018 season (https://www.cdc.gov/flu/protect/keyfacts.htm)
Decide

- 14 -

Benefits: 75% Time Savings with Scanned Vaccine Entry

Time measurements comparing vaccine entry methods across nine of the pilot sites found an 

average of 21 seconds saved per vaccine entered when vaccines scanned (average of 7.04 

seconds when scanned and 28.19 seconds when not scanned*) – a 75% improvement 

Potential Time Savings

• While time savings varied by site, the average calculates out to 5.83 hours saved per 1,000 vaccines scanned.

• These nine sites administered more than 45,000 vaccines during the six-month pilot. If each entry were scanned, 

time savings would total 262 hours saved (for these nine sites), ranging from 3–116 hours for individual sites 

based on volume scanned.

*Time measurements taken outside actual patient encounters to ensure protocol consistency (using a test EMR portal that functions the same way as the actual EMR); same protocol used 

and same vaccines recorded across both scanned and not scanned observations; measurements with 13 practitioners across 9 sites
- 15 -

Decide

Benefits: Staff Satisfied and Experienced Other Scanning Benefits

Most users reported being satisfied with their experience scanning 2D barcodes, preferred 

scanning over other entry options, and found it worthwhile to make the change in their process. 

Other benefits also identified.

94%

Prefer scanning

over other 

options

94% (n=152) agreed/strongly agreed with the statement, 

“Overall, I prefer recording data about vaccines 

administered to patients using 2D barcode scanning over 

any approaches our care center has used in the past.”

These bad boys are 

a game-changer

Pilot Participant

76%

Key Benefit: 

Reduced eye 

strain

76% (n=105) identified reduced eye strain as a key benefit of 

scanning (magnifying glasses were seen during site visits)

64%

Key Benefit: 

Disposing of 

syringes in 

room

64% (n=88) identified disposing of syringes in room instead of 

carrying around for later entry as scanning benefit experienced

“...[Scanning] decreased risk for hand- and 

joint-related problems related to data entry.” 

- Survey Respondent

“It saves time, ensures 

accurate and consistent 

data entry, and provides 

an extra safety step 

prior to administration.” 

- Survey Respondent
- 16 -

Decide

Up Front Costs and Time Needs

Initial resources needed for implementation include obtaining equipment and preparing staff and scanners 

Purchase Scanners

• Corded scanners cost ~$150–$350 

each, with cordless options $500–

700 (as of September 2016)

– AAP outlines considerations 

when choosing a scanner

• Number of scanners needed varies 

based on set-up/placement

• Order stands/wall mounts, if using

• If the number does not match the 

need, scanners may not be used

Train Staff & Leaders

• Staff need to be trained on using 

the scanner, and within the EMR

–

–

Pilot training took less than 30 

minutes per session (often in 

small groups of immunizers 

and leaders)

CDC created training videos

that show how to scan

• Leaders addressing staff 

questions should have knowledge 

about scanners

Revise Vaccine Workflow

• Prior to scanner installation, 

leaders/staff should determine how 

scanning fits into workflow 

– Some EMRs have safety features 

(pop-up alerts), which require 

scanning prior to administration, to 

get most benefit of function

• Scanner set-up/location linked to 

workflow process and affects costs 

(number of scanners, adding/moving 

computers, as needed)

Configure Scanners

• EMR must enable 2D scanning

• Each scanner needs to be set up 

to communicate with the EMR 

(parse/place data in right fields)

• An organization needs to be able 

to set up/configure scanners 

purchased specific to their EMR

• The configuration process should 

be maintained by technical 

support staff for future use (e.g., 

if a scanner needs to be reset)

Install Scanners

• After a workstation with a 

computer and appropriate EMR 

set-up is identified for 

installation, a technical or clinical 

support staff member can plug 

the scanner into the computer 

port

• Configured scanner is now ready 

for scanning unit-of-use barcodes 

For successful implementation, an 

organization needs to engage key 

players at various points along the way
Plan Train

Adjust

Decide Assess Sustain

Plan
- 18 -

Plan

Step 2: Plan for Implementation of Vaccine 2D Barcode Scanning

Once determination is made to implement vaccine barcode scanning, planning begins

Set Expectations & Gather Support

• Set expectations for implementation

• Prepare sites for scanning

• Ensure leader engagement/buy-in

Select Scanner Location & Workflow

• Identify best scanner location/set-up

• Revise workflow protocol to include

scanning

Identify Ways to Maximize Use

• Understand variability in scanning

rates from pilot and how may guide

decision-making for others

• Select strategies to encourage

consistent scanning

Develop Planning Materials

• Develop implementation plan and

timeline

• Determine reach of implementation

• Plan to evaluate and assess scanning

implementation
- 19 -

Plan

Set Expectations and Gather Support

Determine Expectations for Scanning Implementation

• Decided how and when scanning would be implemented and expectations for participating sites

• Support made available to sites during implementation

Prepare Sites for Scanning 

• Communicated expectations for scanning implementation with staff 

• Provided anticipated timeline, preparation tasks, and other initial “asks” of participating sites

• Shared potential benefits and challenges with scanning

Ensure Leader Engagement and Buy-In

• We worked initially with organizational leaders, and through them, with site leads

• Leaders at all levels provided the foundation for accountability and consistency of use

• In the pilot, site leads could make scanning mandatory and ensure formal inclusion in the 

workflow and verification process

 Ensure site-lead buy-in, as the leads set expectations with staff and are critical component in the site’s culture

 Engage leaders and staff in scanner implementation discussions – their expertise is valuable and buy-in critical 

 Make scanning mandatory rather than an optional adjustment to the process

Prior to the start of scanning, we worked with the pilot organization (Sutter) to identify and communicate 

expectations with relevant parties. Engagement of both leadership and staff was necessary to promote 

successful implementation.

“Our boss should 

make it mandatory, 

then it won’t be an 

issue” - Discussion 

Participant

Additional Tips for Success Identified During the Pilot
- 20 -

Plan

Select Scanner Location

In group discussions, pilot participants described their decision-making process for scanner location. 

Survey data and challenges identified by participants during the pilot provided additional context. 

Highlighted next are four key considerations to identifying the best location for scanners.

1. Determine Most Convenient Location

2. Ensure Location Works For Staff Using the Scanners

3. Location Supports Scanning Prior to Administration of Vaccines

4. Weigh Different Potential Locations

Learn More Further detail on pilot scanner set-ups/locations and related analyses in the pilot Findings Report 
- 21 -

Plan

1. Select Scanner Location: Determine Most Convenient Location

When determining the best scanner location(s), think about areas that are conveniently located for staff 

administering and recording vaccines. Several considerations around convenience are below.

Considerations for Scanner Location

• Locating scanners along the workflow path (e.g., 

where vaccines pulled from refrigerator, near draw 

station, or verification locations) identified as way to 

minimize extra steps and seamlessly blend into the 

workflow process to become second nature

• Using obvious locations (e.g., in line of sight) noted 

as helpful when staff are rushed or distracted

• Locating scanners in preferred locations required 

adjustment to space for some pilot sites (e.g., adding 

a computer, moving items, or relocating vaccines)

• Including a back-up scanner or scanners in more 

than one location (helpful when busy or in large 

space) identified as beneficial by participants

• Scanner stands/wall mounts provide options for 

where/how scanner sits and provides handsfree/“always on” functionality

“I think it was easy 

to remember 

because it is right 

where we prep the 

meds. Use the 

second one out 

here as a backup, if 

needed or it’s 

busy.” - Discussion 

Participant

“I think that’s the biggest 

barrier, is just trying to 

find that workflow where 

they don’t have to 

backtrack.”

- Discussion Participant

“We did have to get extra 

PCs installed, but that was a 

minimal cost and definitely 

worth it.”

- Discussion Participant

“What we did was centralize the draw 

stations. It actually helped tremendously... 

All vaccines are now stored centrally in 

one location. And they draw at the same 

location.” - Discussion Participant

Takeaway Having scanners in locations where they are consistently used is critical
- 22 -

Plan

2. Select Scanner Location: Ensure Location Works for Staff

Further, ensure scanner location(s) being considered are agreeable to staff giving and recording 

vaccines. Lack of agreement with selected scanner location was problematic at some sites in the pilot.

Considerations for Scanner Location

• Some pilot participants noted they did not scan because the scanner location selected did not work for them. 

Reasons provided included:

–

–

–

–

Scanners located off workflow path

Computer log-in delays or issues with computers where scanners are set up 

Lack of interest in participating

Not being included in the decision-making process for scanner location

“It worked for [name] in the 

lab, worked for [name] at their 

desk, worked for me only in my 

room. If you’re going to just 

put in the lab, everybody isn’t 

going to use it. If only at desk, 

not all going to use it.” 

- Discussion Participant

“There’s no way we can expect someone to log 

off the computer, so someone else can log on, 

scan their vaccine, then log back off. It just 

wasn’t going to work.” - Discussion Participant

“...decision made by someone else. There 

was no consulting on where they ended 

up.” - Discussion Participant

“I would use it if in an 

individual patient 

room, because that’s 

where I’m inputting 

all information... and 

don’t have to log in 

twice. It’s an extra 

step, I’m not going to 

do that.” - Discussion 

Participant

Takeaway Engaging staff in decision-making process may promote buy-in and increased scanner use
- 23 -

Plan

3. Select Scanner Location: Supports Scanning Before Administration

Also ensure scanner location(s) being considered support scanning vaccines prior to administration to 

maximize benefits of scanning achieved.*

*Pilot participants used an EMR that had pop-up notices such as when a vaccine was expired or did not match the doctor’s order. Scanning prior to 

administration may offer perceived safety benefits when using such an EMR.

Considerations for Scanner Location

The layout at some sites can add extra steps or impede scanning of vaccines 

prior to administration, depending on scanner location 

• Scanning before

–

–

administration in the pilot provided benefits of:

Pop-up alerts, which identified if a vaccine was incorrect or expired, 

with benefits to both patients and staff* 

Staff safety benefits, where staff are able to dispose of syringes 

upon administration rather than holding for entry later

• Some pilot participants described a workaround put in place to utilize 

scanning only after administration to improve speed of entry (time 

savings with scanning and using only one entry step) and accuracy of 

data (since scanned at some point), but missed out on other critical 

safety benefits (including those highlighted above)

• Other pilot participants stated that their scanner location impeded their 

ability to scan prior to administering vaccines. Reasons included not 

being near scanners until after vaccines administered or not having 

enough time to get to the scanner location prior to administration

“We had an immunization 

error, Hep B given instead of 

Hep A. That was caught by 

the scanner "vaccine not 

ordered" when documenting 

after administration.” 

– Survey Respondent

“I used to work in different 

offices. For us, the fridge 

room is pretty central. For 

other offices, the fridge is 

located way across from 

their desk. If they had to go 

back to their desk, I feel like 

[scanning] wouldn’t happen 

before.” 

- Discussion Participant

Takeaway Scanning prior to administration can maximize benefits to patients and staff
- 24 -

Plan

4. Select Scanner Location: Weigh Different Potential Locations

Finally, weigh the various scanner location(s) being considered. Pilot feedback and scanning rates for 

various scanner locations are provided to share pilot learnings as others consider their best location. 

Considerations for Scanner Location • No single location was preferred by all pilot participants or all participating sites

• Two scanner locations elicited the most positive feedback from pilot participants: the refrigerator/draw room

and individual desks

• Pilot participants described the importance of having a back-up scanner or alternate location available

• Location selection links to the number of scanners needed (and if stands/wall mounts preferred)

• Primary benefits and challenges identified by pilot participants for refrigerator/draw and individual desks below

• Scanning rates across various scanner locations/set-ups within pilot follow

Location Benefits Identified Challenges Identified

Refrigerator/

Draw Area

• Already in these areas to pull or prep vaccines

• Single or fewer computers/scanners needed, even

for larger staff and vaccine volume

• Great enthusiasm for this scanner location from

staff and leaders; “it just makes sense”

• May require new computer, if not already

there

• Back-up scanner suggested, during busy

times or if scanner problems

Individual 

Desks

• Enough computers may already be in place

• Familiar location for previous entry/workflow

process

• May add steps (worse for some layouts), if

not part of vaccine administration path

• Requires as many scanners as people

“I think that’s a key thing, that the med location and scanner need to be together. I think 

that’s a huge barrier. And having it be a step after they pull the medication out is key. So 

there isn’t time to add in other steps along the way.” - Discussion Participant

“I liked it at my desk better.” 

- Discussion Participant
- 25 -

Plan

Scanners in More than One Location Had Highest Pilot Scanning Rates 

Aggregate scanning rates for various scanner locations in pilot ranged from 92% – 97%*

• Scanners at more than one location (used equally often or a primary + backup option) had higher 

scanning rates than single location set-ups

–

–

Refrigerator/draw/prep area paired with another location (used equally or as primary, with 

backup also) had highest scanning rates (both 97%)

Refrigerator/draw/prep area as only scanner location had lowest scanning rate (92%)

*Scanner location and scanning rates starting in pilot week 7 (when observed and location had stabilized); in order to report by scanner location and not scanning rates for individual sites, 

two scanner locations removed from comparison (only one site had each of two specific scanner location configurations)
- 26 -

Plan

1.

2.

Revise Workflow Protocol to Include Scanning

Once determination is made of the best location for scanners, formal revision of the workflow 

process to include scanning can further support scanning. Pilot participant feedback provided 

guidance below. 

Develop a revised workflow & identify exact workflow step where scanning takes place 

–

–

–

–

–

For sites with multiple scanning locations/multiple workflows, determine the steps and ordering for 

each

Pilot staff described difficulty remembering to scan initially because it was not integrated into their 

usual workflow process and was not mandatory

Without a revised workflow in place specific to scanning, staff described doing things differently and 

being unclear on expectations

Include staff administering vaccines in workflow revision discussions

Staff can voice their preferences, include their day-to-day expertise into the plan, and identify any 

concerns from the start

Satisfaction with the final product and buy-in were noted as increased (during pilot) with this inclusion

“Before we all had our own way of how, where, 

when we documented, and this streamlined it 

for us, so we are all doing the same way now.”

- Discussion Participant

“I think it’s important for staff to have a clear 

understanding of what the expectation is and that 

we have a standard process. Standard work is 

extremely important, especially if it is something 

that you will be holding people accountable to.” 

- Discussion Participant
- 27 -

Plan

Success Strategies for Selection of Scanner Location & Revised Workflow

Pilot participants described reasons for their success and identified ways others could select 

scanner location and revise workflow processes with greatest success.

• Determine location of scanner and how scanning fits into workflow early (prior to 

installation and start of scanning, if possible); adjust location and workflow process as 

needed, rather than struggling with a set-up or process that is not working or not being used

• Ensure staff are clear on expectations – whether scanning is mandatory and when in the 

vaccine administration process scanning is to take place

• Engage both leaders and staff in scanner location and workflow change discussions

• Make scanning second nature, so that it integrates into process effortlessly

• Scanners in the med room/refrigerator/draw areas identified as best location for many 

because they already go there to pull or draw vaccines; this location did not work for all pilot 

staff or sites

• Backup scanners provide another option for scanning during busy times, when there are 

problems with primary scanner, or for sites with an expansive layout

• Don’t roll out new workflow and entry process during busy time, such as flu season; it’s hard 

to adjust to a new process and work through challenges when too busy
- 28 -

Plan

Identify Ways to Maximize Scanning Use

Participating pilot sites scanned at fairly high rates, on average, though variation found. 

Knowledge of these variations, which may carry over to other organizations:

Identify Sites or Practitioners Likely to Need Additional Support

Specific site and practitioner characteristics were linked to scanning rates in pilot. Scanning rate data provided 

information on challenges being experienced and identified where additional support was needed.

• Sites with a lower volume of vaccines given (e.g., Internal Medicine) had lower scanning rates and required

more support to fully implement scanning, compared with sites with higher-volumes

• Sites or practitioners without consistent scanning habits also needed additional support to increase scanning

Identify Strategies (“Nudges”) to Maximize Scanning

Inclusion of various strategies improved scanning rates in the pilot, beyond providing only training to 

participants. Benefits of scanning are only realized if scanning is actually used; therefore, identification and 

inclusion of such strategies to maximize scanning is important. 

• Signing commitment cards, providing scanning rates to practitioners, and leader visits greatly improved rates

• Strategies added from the start and at mid-pilot effectively improved scanning in the pilot

Strategically Select Sites When Resources Limited

An organization might not have resources to implement scanning across all of their sites initially. 

• Selection of higher-volume or specific specialty sites may provide the greatest use and benefit, given higher

scanning rates and limited additional support needed by these site types in the pilot

• Alternately, selection of sites with most room for improvement (e.g., low accuracy) can provide great benefit
39% – 99%

74% – 97% 92% – 96%

Plan

71% – 98%

- 29 -

Variability Found in Pilot Scanning Rates

Analyses of pilot scanning rates found variability by site, specialty, vaccine volume, and strategy groups

Site

•Though the overall scanning 

rate was 94% (n=67,951) 

across all sites during the 

pilot, individual sites varied 

from 39% to 99% of vaccines 

scanned

Specialty

•Pediatric sites (97%) and a 

Shot Clinic (99%) had highest 

scanning rates; Internal 

Medicine sites had lowest 

scanning rates (71%), with 

Family Medicine sites in the 

middle (87%)

Volume

•Average scanning rates varied 

by weekly vaccine volume, 

from 74% for low-volume sites 

(<25 vaccines weekly), to 90% 

for medium-volume sites, to 

97% for high-volume sites 

(>100 vaccines weekly)

Adherence Strategy Group

•Four groups compared; all 

groups with a strategy 

beyond training had the 

highest scanning rates, 

compared with the Trainingonly group, on average and 

at the end of the pilot

Learn More Detailed reporting on variability in scanning rates found in the barcoding pilot Findings Report 
- 30 -

Plan

Adherence Strategies Significantly Improved Scanning Rates 

Adherence strategy groups aimed to maximize scanning use, with groups differing by 

levels of resources to implement and timing during the pilot. 

Significant differences found in average scanning rates across these groups,* with: 

• Training-only group having the lowest average scanning rate and 

• All other groups (with some additional strategy implemented) having significantly

higher average scanning rates

*Statistically significant at the p<.0001 level
- 31 -

Plan

Adherence Strategies Most Effective at Family & Internal Medicine Sites 

Adherence strategies performed similarly for Pediatric and Shot Clinic sites, with 

significant variation seen for Family Practice and Internal Medicine sites.*

Training-only groups had the lowest scanning rates across all specialties in pilot.

*Differences statistically significant at the p<.001 level
- 32 -

Plan

Scanning Rates and Feedback Highlight Success of Scanning Reports 

Significant increase in scanning rates observed after release of initial scanning adherence reports (for sites 

receiving reports, blue line).* Increases continued as additional reports released through end of pilot. Minimal 

changes in scanning rates for sites not receiving reports (green line). Grey bars show report releases. 

Staff reaction to reports described increased vigilance, improved awareness, and competition among colleagues. 

“It [the reports] definitely 

made me more vigilant.”

- Discussion Participant

“I need to step up my game.”

- Discussion Participant

“Humans are competitive. In this kind of thing it’s 

like, [name], you didn’t scan? You knocked down 

our score 6% because you missed one.” 

- Discussion Participant

*Statistically significant increase in scanning rates after reports released for sites receiving reports compared with those not receiving reports; significant at the p<.001 level

**For sites receiving scanning reports, weekly vaccine volume varied from 838 to 1,615. For sites not receiving scanning reports, volume varied from 1,239 to 2,190.
Plan

- 33 -

Leadership Involvement Mid-Pilot Improved Scanning Rates

An unplanned (but effective) strategy involved a visit by health system leadership to a site with low 

scanning rates mid-pilot. 

Comparison below of scanned (blue) and not scanned (grey) vaccines across the pilot (for this site) 

show a changed pattern after leader visit (on March 22nd, shown with red bar).

Significant increase in scanning rate found after leader visit to 

this site (p<.0001).

Average 

Scanning Rates

Pre-visit: 34% 

Post-visit: 97% 
- 34 -

Plan

Use of Scanner Stands Beneficial to Many Pilot Participants

Pilot participants had the option to use a scanner stand, which holds the scanner 

in place and eliminates the need to hold the button down, allowing users to 

waive the vaccine under a continuous beam and scan with one hand. 

Survey participants provided feedback on the use of stands during the pilot.

55 of 138 survey respondents (40%) used a stand during the pilot. The 55 respondents having used 

a stand were then asked if use of the stand improved their scanning experience. 

Respondents noted that 

stands made scanning 

“faster” and “easier”

Pilot Scanner Stand
- 35 -

Plan

Additional Strategies That May Further Improve Scanning

Pilot staff/leaders identified their own strategies and suggestions to help others scan more consistently.

Post Reminders to Scan/Protocol to Follow

• A few sites developed signs to remind them to scan

• One site posted training one-pager to wall near fridge

Resolve Challenges Being Experienced

• Develop a cheat sheet that includes:

o

o

o

o

How to hold the scanner/vial

Tips to get tricky labels to scan

Whom to call if there are problems

• Develop a protocol for physicians on how they could aid efficiency

For example, ordering vaccines while still in the patient room 

enables vaccines to be in the system, scanned, and verified promptly

Formalize Protocol of Scanning within Workflow 

• Make scanning mandatory and communicate this from the start

• Add a “verbal check” into the verification process (asking if vaccine

already scanned) to ensure scanning prior to vaccine administration

• Have specific people (one or two) do all tray verifications to add

consistency and accountability

Ensure Scanning Takes Place and as Intended

• Observe staff to ensure workflow is implemented as intended and not

using a workaround

• Identify other sources of data available to assess scanning

“One of the biggest frustrations 

for supervisors is looking at 

adherence to standards, 

workflows, and policies, a lot of it 

is based on observation... When 

you give an employee a review 

that they are not pleased with, it 

would be extremely beneficial to 

have data to support that.” 

- Discussion Participant

“You can’t train someone to a 

standard process and then not 

audit them and not follow up to 

make sure. Just because someone 

has been trained doesn’t mean 

that it’s not still going to fall to the 

wayside.” 

- Discussion Participant
- 36 -

Plan

Develop Scanning Implementation Plan and Timeline

Once determination is made to adopt 2D barcode scanning for vaccines, development of 

an implementation plan provides a solid foundation for implementation. 

Determine Sites for Scanning

• Determine the reach of scanning implementation to include all sites or a select number of sites

• Organizations with limited resources may strategically select a limited number of sites for 

implementation 

Determine Number of Scanners/Stands Needed 

• Identification of scanner set-up locations for all sites informs the number of scanners needed

• Ensure site leaders/staff are engaged in this discussion to improve scanner number estimate

• Determine if scanner stands/wall mounts needed, for which sites, and how many needed

Determine Project Materials Needed

• Materials for development include those to train staff on scanner use and protocol

• Additional materials may be developed to support consistent use (detailed in Step 3 “Train”)

Timeline for Implementation 

• Develop an estimated timeline for completion of tasks and launch of scanning

• An organization may time implementation to ensure that higher-volume times of year are 

included (such as flu season and back-to-school) or may want to implement during a slower time 

to allow staff to learn and adjust away from busier schedules
- 37 -

Plan

Develop Plan to Evaluate and Assess 2D Barcode Scanning Efforts

After key scanning implementation decisions made, develop plans for both a broader 

evaluation of the full implementation effort and an early pulse-check assessment. Data 

collected early enables course correction, while data collected throughout provides a more 

complete picture.

What

• Identify key metrics and questions to answer with evaluation activities, who will collect these data, how and

when data will be collected, how data will be analyzed, and how findings will be used

• Consider:

–

–

–

–

–

–

What information is most important to leadership and other stakeholders?

What information needs to be monitored to ensure scanning is working correctly?

How do you identify any on-the-ground challenges with using 2D barcode scanning?

How

• Our pilot data included collection and analysis of de-identified EMR vaccine records, online survey, on-site

observations, and group discussions

• Indicator of whether scanning took place or not (dependent on EMR) was critical to our evaluation

Scanning rates used to identify sites and individuals struggling to scan and needing additional support, as 

well as those scanning consistently from early in the pilot

Scanning rates identified variability in scanning implementation and adherence strategy success 

Scanning rates provided to some staff and sites in reports to maximize their use of scanning

Learn More Detailed reporting on variability in scanning rates found in the barcoding pilot Findings Report 
Plan Train

Adjust

Decide Assess Sustain

Train
- 39 -

Train

Step 3: Train and Introduce 2D Barcode Scanning

Prepare to train participants, install scanners, and for the early stage of initial scanner use 

Training Preparations

• Plan training and

implementation support

• Develop training materials

Introduce Scanning

• Conduct training

• Install scanners

• Allow adjustment period
- 40 -

Train

Plan Training and Implementation Support 

Prepare for upcoming trainings and scanner implementation by gathering the right people and 

setting up training environment

Identify Scanning Champion and Implementation Support Team

• Identify a scanning champion (site leader or person dedicated to scanning implementation across sites)

• Identify person(s) to support implementation process, from testing the scanners, working with staff to

determine the best workflow, planning logistics, and setting up trainings

Identify Trainers and Staff to Train

• Identify trainers—this may be a champion at each site or a resource dedicated to all trainings

• Confirm which staff to train at each site

Plan Set-up and Logistics for Training

• Create a training (or sandbox) environment in your EMR—preload dummy data for use during training

• Collect assorted vials/syringes and bring scanners to provide hands-on scanning practice during training

• Configure scanners (as described in Decide Phase)

• Identify space for training—depending on site and staff size, this may be a desktop at a station, a

breakroom with a computer, or a dedicated training room

• Set training schedule—depending on site size and patient schedule, training may take place one on one

in intervals throughout the day or in a large group session at a predefined time (lunch, before/after

patients)

• Have a mechanism to track who has received training (e.g., sign-in sheet)

• Have a plan to train anyone not available during trainings (such as through a train-the-trainer process)
- 41 -

Train

Develop Training Materials

Training that Includes:

• Benefits of scanning and rationale for

implementation of scanning--examples as

identified in the pilot are patient safety, staff

safety, and time savings

• Recommended scanner location and

workflow (if any)

• Changes from current workflow (if any)

• Screenshots of fields that will be populated

with scan

• Demonstration of scanning integration with

the EMR and any steps/EMR fields that still

need to be completed by staff

• Troubleshooting tips and tricks

• Provide opportunity to use scanners

• Describe any additional strategies that will

be rolled out to maximize scanning and use

(e.g., commitment cards/scanning rate

reports)

Handout that Includes:

• Identified site workflow(s) (if any)

• Tips and tricks

• Contact information for help and questions

Optional Materials:

Some pilot participants created their own 

materials to promote scanning or identified 

other materials that would have been helpful, 

such as:

• Develop tips and tricks for scanning—this

could be posted by scanners (e.g., how to hold

the scanner, move vial to aid scanner)

• Reminder to scan sign posted near

vaccines/prep area or scanners
- 42 -

Train

Introduce Scanning

Train participants, install scanners, then allow them to get familiar with scanning and their new 

workflow in actual practice. In the pilot, training and scanner installation occurred together. 

Conduct Training

• Log in to training (or sandbox) environment prior to 

training start

• Introduce trainer/champion and training purpose 

• Log names of all participants (e.g., in sign-in sheet)

• Walk through training materials

• Allow all staff hands-on experience to try out 

scanners using the training (or sandbox) environment 

in EMR

• Ask for questions—capture all questions to improve 

subsequent trainings

Install Scanners

• Scanners already configured and tested for 

correct use within a given EMR can be installed 

at locations selected for scanning use

• Each scanner is plugged into the computer port, 

then is ready for scanning unit-of-use barcodes 

Allow Adjustment Period

• Communicate the time frame for grace period in 

which staff can continue to use traditional 

approach for data capture or scanning as they get 

used to scanning

• Communicate point at which staff should 

commence scanning all 2D barcoded vaccines and 

set leadership expectations about frequency of 

scanning

• Follow up to request feedback on experience with 

scanners, adjustments made (location/workflow), 

and ensure sites have fully implemented scanning

• Follow up to review workflow and scanner usage 

• Be prepared to offer suggestions to support use of 

scanning 
Plan Train

Adjust

Decide Assess Sustain

Assess
- 44 -

Assess

Step 4: Assess Implementation of Scanning 

After an initial period of using scanners (a few days/weeks), monitoring the implementation 

process, including rates of scanning, can provide guidance on how scanning implementation is 

going, where additional support and adjustment are needed, and where successes are being 

found.

Gather Information

Assess Early Status

• Collect data for early 

assessment of scanning

• Gather feedback from 

staff/leaders to aid 

understanding

Evaluate Across Implementation

• Continue data collection to 

evaluate implementation 

broadly and identify any 

changes taking place

Analyze Data

• Analyze data at regular 

intervals, including within 

the first few weeks

• Use scanning indicator (if 

available) to monitor 

scanning rates

• Identify types and extent 

of challenges faced 

• Assess whether protocol 

is being followed

Implementation Status 

• Use collected data to 

determine how 

implementation is going for 

sites and staff

• Determine which sites or 

staff need additional 

support/adjustment and 

those finding early 

implementation success
- 45 -

Assess

Gather Information

Carry out evaluation plans (previously developed), including both an early pulse-check and broader 

understanding of implementation overall.

Gather data identified, which can be used early (in first few weeks) and on a regular basis to 

understand scanning implementation, successes, and help identify challenges needing resolution.

Early Status Check (First Few Weeks)

• Collect data that will inform an assessment of 

scanning implementation; consider including 

data on extent scanning is used

• Gather feedback from staff and leaders at sites 

to help understand:

–

–

–

Any initial barriers to full implementation

Challenges faced in early stages of 

implementation

Strategies for early success 

• Assessment early in the scanning process can 

identify sites or staff needing course correction 

and provide them support quickly

Evaluate Broader Implementation

• Continue data collection throughout 

implementation efforts to understand fuller 

picture of implementation, challenges, and 

successes

• Findings from the broader implementation can 

provide lessons learned to other sites within 

the organization waiting to implement 

scanning or perhaps to the field more broadly 

to guide future efforts by others
- 46 -

Assess

Analyze Data to Understand Support Needs and Early Successes

Use of collected data to assess scanning implementation identifies sites and staff doing well, 

those struggling, and any in between. 

Such identification enables targeted support for sites in need, better understanding of 

challenges being experienced, and lessons to be learned from sites easily integrating scanning.

Identify Sites or Practitioners Likely to Need Additional Support

• Sites or practitioners without consistent scanning habits can be readily identified and offered support

• Contextual information beyond just scanning rate can identify breakdowns in scanner use and support needs

Identify Challenges Being Experienced

• Types and extent of challenges being experienced by sites and practitioners

Identify Alterations to Intended Use

• Adjustments or workarounds to scanning guidance in place can limit benefits experienced

Identify Early Successes

• Assess any clear patterns of successful implementation

• Strategies by sites or practitioners aiding their use of scanners or ease of implementation

• Success strategies can be utilized to help struggling sites or practitioners adjust
- 47 -

Assess

Pilot participants described deviations from the trained scanning protocol that could 

limit safety benefits of scanning. Two examples highlighted below.

Assess during early implementation to ensure such workarounds are not taking place.

Beware:

Workarounds Can Limit Scanning Benefits

Entry of Vaccine Data in One Step 

• Two versions of this workaround identified – both create vaccine entry shortcuts 

• Both versions described by multiple pilot participants, across several pilot sites, 

from the pilot start and through the end

1. After Administration

Waiting until after vaccine administration to scan, when all data are now available 

for entry (such as site of injection). If EMR functionality has pop-up alert checks 

(such as expired vaccine or match to doctor’s order), these benefits are not realized

2. Prior to Administration

Entering data not yet confirmed (such as site of injection, time given) prior to 

vaccine administration

Survey 

Confirmation

17% of 138 survey respondents 

indicated scanning vaccines after

administration (survey at end of 

the pilot period)
- 48 -

Assess

Scanning Patterns Can Identify When Consistency is Found (or Not)

Figures below show four scanning patterns by pilot sites, which differ by how they started, variability in scanning rates, 

and when consistent scanning seen (from start, midway, never). 

Even within the first few weeks, patterns of consistency were seen (or not). 

This enables targeted support for sites in need and lessons to be learned from sites easily integrating scanning.

Consistency = habit formation
- 49 -

Assess

Pilot Scanning Patterns Identified Early Success Sites

One pattern, the “Start Strong, Stay Strong” group, found early and lasting scanning success.

Their consistently high scanning rates indicate habit formation was developed and maintained 

(further supported by additional data gathered at these sites).

Goal is this pattern

Which Sites Fit This Pattern?

 All Pediatric/Injection (Shot) Clinic and highvolume sites in pilot fit this pattern 

(across all adherence strategy groups)

 3 Family Practice and 1 Internal Medicine site 

(each signed commitment cards, received scan 

reports, or shared a leader with Pediatric sites) 

Learn from Successes of These Sites

 Early and thoughtful planning decisions identified scanner location/protocol 

that worked for them and adjustments made as needed to ensure use

 Solutions found versus challenges allowing scanning to stop

Dig Deeper Case example of several sites within the “Start Strong, Stay Strong” group presented next
- 50 -

Start Strong, Stay Strong Case Example: Successful Implementation Assess

Across Multiple Sites

Case Example: Start Strong, Stay Strong

Specialty Vaccine Volume Scanner Location(s) Intervention Groups Pilot Scan Rate (avg)

Peds (3 sites) 

FP (1 site)

894-2,659 total (Peds) 

234 total (FP)

Primary refrigerator 

area + back-up 

elsewhere (all sites)

Report + Card (Peds 2);

Scanning Report (Peds 6); 

Training-only (Peds 9 + FP 10)

97% - 99% (Peds)

96% (FP)

Context: Same leader implemented barcode scanning across four sites (3 Peds and 

1 FP); two received scanning rate reports and two were training-only sites

Outcome: High engagement from start to end of pilot across all four sites; staff 

found implementation easy, even a few reluctant to try a new process

Keys to Success: Determined workflow prior to scanner installation, leader 

oversaw implementation and checks to ensure compliance (set protocol and 

expectations, follow-through); scanner location (in med room) critical for this site

“As an LVN that doesn’t 

need to have someone 

double check, it gives me 

a safety check.” 

“I don’t want to go to a 

site that doesn’t have it 

because I don’t want to 

have to type it.”

Note: The drop for FP 10 in June was due to 4 vaccines not scanned in the time period and being a low-volume site 
- 51 -

Assess

Pilot Scanning Patterns Identified Sites Needing Support

The other three pilot scanning patterns started with extensive variability, indicating an 

inconsistency in scanning habits and ongoing challenges experienced. 

Of these, the “Start Slow, Get Strong” group found better consistency partway through pilot. The 

other two groups (in blues) struggled to find consistency, even by pilot’s end.

 All of these sites need additional support

 Ways pilot sites improved scanning described in 

upcoming “Adjust” step

 Hope is to find consistency at some point, even if 

not at start (similar to grey group) and not

duplicate patterns of blue groups

Dig Deeper Further details on these patterns, including case examples, in the Adjust section
- 52 -

Assess

Determine Implementation Status

An organization should determine the best data they have available for assessment, timing of assessment, and 

their own cut-offs for categories (e.g., high/low rates, threshold for consistency, etc.). 

As an example, using the combination of scanning rates and challenges identified can provide context into a site’s 

full implementation of scanning. An organization might use this data to categorize sites as outlined below.

Consistent Scanning and Few Challenges

• High and consistent scanning patterns observed and 

few to no ongoing challenges may mean that sites 

won’t require adjustments

– Monitoring should continue to ensure they don’t 

experience a new challenge or lose ground

Similar to early weeks of pilot pattern:

Start Strong, Stay Strong (14 sites)

Sustain May Be Ready to Sustain Practices:

Can Go to Sustain Phase Next

Inconsistent Scanning and/or Challenges

• Low, medium, or inconsistent early scanning rates 

• Any level of scanning rate, even high, if there are 

several remaining challenges or a potential major 

disruption is imminent

Similar to early weeks of pilot patterns:

Start Slow, Get Strong (8 sites)

Solid Start, Lose Ground (1 site)

Lows and Highs (4 sites)

Adjust Adjustments Needed: 

Move to Adjust Phase Next

• Scanning rates/patterns (used in example above)

• Challenges being experienced (used in example above)

• Confirmation that revised workflow protocol in use or revised/workarounds developed

• Assess staff satisfaction with scanner location

• Other data to determine whether there is full implementation or need for adjustments

Potential Assessment Criteria for Inclusion
Plan Train

Adjust

Decide Assess Sustain

Adjust
- 54 -

Adjust

Step 5: Overview: Adjust (if needed)

An initial assessment of implementation may have found that some sites or staff still struggle with 

consistent scanner use. Troubleshooting challenges and making adjustments may improve workflow 

integration and increase scanner use. Those with high and consistent scanner use can skip this step.

Identify Challenges

• Use data collected in “Assess” 

phase to understand types and 

extent of challenges

• Gather more detailed 

information from specific 

sites/staff needing support

• Determine if a few specific 

solutions can address most 

challenges or need multiple 

solutions 

Develop Solutions and Adjust

• Develop solutions specific to 

challenges faced by sites or staff

• Revisit previous steps/suggestions 

from the “Plan” phase for 

potential resolutions to challenges

• Implement solutions to address 

challenges

• Allow integration period for 

changes

• Assess whether changes have 

improved scanning use
- 55 -

Adjust

Sites Addressing Challenges and Making Adjustments Found Eventual Success

With adjustment, even low scanning sites can improve and find consistency. 

The “Start Slow, Get Strong” group found better consistency mid-pilot by adjusting their practices. 

Which Sites Fit This Pattern?

 5 Family Practice and 3 Internal Medicine sites

 All except one site received strategies to 

maximize scanning 

• 6/8 sites received scanning reports, 1 signed 

commitment cards (FP4) 

• 1 site received training-only (FP9)

How These Sites Moved from Variability to Consistency

 Six sites received scanning reports (alone or with commitment card), with increases after report releases

 The single training-only site in this group found consistency after experiencing a vaccine error and 

revising their process (see next case for details)

 Another site received an unexpected leader visit, then made multiple adjustments (upcoming case)

 One site realized they did not have enough scanners and requested more (in week 7)

Dig Deeper Two case examples from the “Start Slow, Get Strong” group presented next
- 56 -

Start Slow, Get Strong Case Example 1: Adjust

Revise Everything After “Aha” Moment

Case Example: Start Slow, Get Strong

Specialty Vaccine Volume Scanner Location(s) Intervention Group Pilot Scan Rate (avg)

Family Practice 

(FP9)

Medium 

(1,508 for pilot)

Patient rooms, changed to single 

shared in refrigerator area

Training-only 83%

Challenge: Limited engagement by staff and leadership; difficulty remembering to 

scan; low scanning rate initially

What Changed? Administering an expired vaccine (early in pilot) was “aha” moment; 

site leaders looked at process and revised workflow to ensure scanning took place 

prior to administration; reorganized vaccine storage and scanner locations, obtained 

new computer for refrigerator room, defined a standard process and retrained staff, 

added verbal check into verification process (“has this been scanned?”), added audit

Outcome: Increased scanning rates; streamlined vaccine location (time savings seen); 

staff clear on protocol/expectations and leaders audit for compliance; leader wants 

better way to track scanning (such as scanning reports) to keep staff accountable

“Once we figured out the 

workflow that worked well. 

Initially it was difficult.” 

“I think that’s a key thing, that 

the med location and scanner 

need to be together. I think 

that’s a huge barrier.”

“We’re human and we’re not 

perfect. But that’s what makes 

this so amazing. It does help 

add that extra layer of security 

for the patient and protection 

for the employee as well.” 
- 57 -

Start Slow, Get Strong Case Example 2: Adjust

Scanning Process Overhaul After Leader Visit

Case Example: Start Slow, Get Strong

Specialty Vaccine Volume Scanner Location(s) Intervention Group Pilot Scan Rate (avg)

Internal Medicine 

(IM5)

Low 

(386 total for pilot)

Shared in refrigerator room Scanning Report 60%

Challenge: Low engagement from start; saw low scanning rates in early reports, but did not 

know how to address issues, did not prioritize full participation or understand all benefits

What Changed? Visit by leadership to pilot site (March 22, green arrow in Figure below) 

encouraged full participation and shared tips and tricks to improve use; site lead developed 

detailed scanning protocol, required staff scan vaccines before administration, added 

scanning into verification, and created reminder sign to aid compliance; engaged staff in 

process and encouraged identification and resolution of issues as they arose 

Outcome: Scanning rates increased quickly and remained high; Staff described enthusiasm 

for scanning, time savings, and safety benefits; leader/staff like report accountability

“Once we started using 

it, we started loving it.” 

“Once we developed the 

new workflow it really 

improved.”

“...potential for cost 

savings because we can 

scan and then get rid of 

vial in pharmaceutical 

waste in room...”
- 58 -

Adjust

Key Challenges Found in the Pilot Across Multiple Data Sources

Pilot participants identified challenges experienced through various data collected across the pilot. 

Several themes appeared across multiple data sources. 

Awareness of these challenges may aid identification and resolution by others implementing scanning. 

Learn More Further details on participant challenges found in the barcoding pilot Findings Report 
- 59 -

Adjust

Select Challenges and Solutions Identified by Survey Participants

Survey respondents (n=138) 

agreed/strongly agreed they experienced 

specific challenges (figure right) with 

scanning. 

Inconsistency of scanners (e.g., needing to 

scan more than once) most frequently 

identified as a challenge (n=28).

*Survey question: Please indicate the extent to which you agree or disagree with the following statements regarding potential challenges you may have experienced when using 

2D barcode scanning to record data about vaccines administered to patients. Agree/Strongly Agree responses considered as challenge.

Survey respondents experiencing inconsistent scanning challenges (n=28) then asked to describe any 

patterns noticed and solutions to resolve these issues. Examples of categories and responses below.

Specific Vaccines/Vaccine Labels

• Specific vaccines identified as 

particularly problematic (DTaP, 

hepatitis) 

• Barcodes on certain vaccines 

partially cut off at the edge of 

the label

• Differences seen when labels 

are light or dark 

No Pattern Identified

Several indicated “No patterns” 

or “None”

“It isn't always the same 

vaccine. Not sure what the 

issue is.” 

– Survey Respondent

Strategies Used to Resolve

• Holding vial specific way

• Holding for extended period

• Restarting EMR, closing chart

“How the vial is held under 

the scanner makes a 

difference if it is picked up by 

the scanning process.” 

– Survey Respondent
- 60 -

Adjust

A Focus on the Lowest-Performing Staff Members Can Pinpoint Struggles

Low scanning rates at the worst-performing centers were frequently driven by just one or two people. 

Use of scanning rate data can identify sites and practitioners with low scanning rates.

Identification of individuals struggling to scan consistently and resolution of challenges being 

experienced can greatly improve scanning participation and benefits. 

13 Sites (of 27 in pilot) had <90% Scanning Rate

• Staff members with the most unscanned vaccine administrations at 

these sites usually had very low (<50%) personal scanning rates.

• Unscanned vaccinations in this group often concentrated in one or two 

staff members.

CASE EXAMPLE (from a site with 59% scanning rate):

One staff member had a 40% personal scanning rate, with 

missed scans for this staff member accounting for 53% of the 

site’s missed scans. 

Two staff members at this site accounted for >80% of the site’s 

total missed scans. 

Takeaway The difference between high- and low-scanning centers is often just a few struggling staff 

members
- 61 -

Adjust

Develop Solutions and Make Necessary Adjustments 

• Develop solutions specific to challenges faced 

by sites or staff members

• Revisit steps and suggestions from “Plan” 

phase for resolutions to challenges experienced

Develop Solutions

Solutions to Challenges 

May Include

Pilot Adjustments Made to 

Improve Scanning

• Implement solutions to address challenges

• Allow period to integrate into practice

• Assess whether changes improved scanning

Make Adjustments

–

–

–

–

–

–

Changing scanner location

Revising workflow to (better) incorporate 

scanning

Engaging staff and leaders further

Reminding participants why scanning is 

important and benefits of scanning

Sharing strategies to scan more easily

Adding adherence strategies, even midcourse (providing scanning rates, (re)signing 

commitment card)

–

–

–

–

–

Use of scanner stands 

Leadership visit to troubleshoot challenges and 

reenergize staff

Revising entire process of scanner location, 

workflow process, and staff engagement, to 

increase scanner use

Development of reminder signs posted by 

refrigerator or other commonly seen location

Adding verbal check into verification process 

(asking if vaccine already scanned) to ensure 

scanning prior to administration

Learn More Further details on solutions developed and adjustments made in the barcoding pilot Findings Report 
- 62 -

Sustain Adjust

Adjust

Redetermine Implementation Status – Consistency Now Found?

After making adjustments to address identified challenges, and giving staff time to adapt to any 

changes, sites’ implementation status should be reassessed to determine next steps.

Successful Adjustments

Consistent Scanning and Few Challenges

• For example, if scanning rates:

1. Increase to the predetermined threshold 

and

2. Appear consistent/stable, and 

• Identified challenges appear resolved or 

minimal

Similar to late pilot scanning patterns of:

Start Strong, Stay Strong (14 sites)

Start Slow, Get Strong (8 sites)

May Be Ready to Sustain Practices:

Can Go to Sustain Phase Next

Adjustments Not Made/Not Successful

Inconsistent Scanning and/or Challenges

• For example, if scanning rates:

1. Have not increased to point of 

predetermined threshold, or

2. Are not consistent/stable, or

• Multiple remaining challenges, regardless of 

scanning rate, or

• Remaining significant challenge(s) identified 

(e.g., potential major disruption)

Similar to late pilot scanning patterns of:

Solid Start, Lose Ground (1 site)

Lows and Highs (4 sites)

Further Adjustments Needed: 

Stay in Adjust Phase

“Start Solid, Lose Ground” case next 

shows struggling site/no adjustment

Dig 

Deeper
- 63 -

Solid Start, Lose Ground Case Example: Adjust

Strong Start, then Disruption and Decline 

Case Example: Solid Start, Lose Ground

Specialty Vaccine Volume Scanner Location(s) Intervention Group Pilot Scan Rate 

Internal Medicine 

(IM7)

Low 

(553 total for pilot)

Individual room/desk moved to single 

shared scanner near refrigerator room

Training-only 39%

Challenges: Engagement at the start did not maintain; strong staff personalities 

and limited leadership engagement; dissatisfaction with scanner location

What Changed? Office moved in early February, and staff separated into two 

suites; staff in one suite dissatisfied with new scanner set-up/location, which 

changed from patient rooms/individual desks to shared area near refrigerator

Outcome: Staff in one suite stopped scanning altogether as leadership had not 

resolved tension between staff on scanner location; other suite described 

satisfaction with location and scan benefits; scanning rate very low by pilot end 

“Our boss should just make it 

mandatory...” 

(scanner location) “decision 

made by someone else...”

“I would use it if...don’t have 

to log in twice. It’s an extra 

step, not going to do that.” 

What 

Now?

Sites struggling after an extended period need an overhaul – revisit the “Plan” and “Adjust” 

steps and think critically about challenges being experienced and creative solutions to solve
Plan Train

Adjust

Decide Assess Sustain

Sustain
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Sustain

Step 6: Sustain and Expand Use of Barcode Scanning 

Once scanning is fully and consistently incorporated into the vaccine data entry process, 

sustain this practice. Strategies to further improve and expand barcode scanning also 

explored.

Sustain Use of Scanning

• Establish threshold for 

regular or consistent 

scanning to move into 

sustain phase

• Continue to monitor 

scanning

• Ensure ongoing use and 

buy-in of staff and leaders

Expand Use of Scanning

• Expand scanning to other 

sites within the health 

system (if appropriate)

• Engage immunization 

community to support 

scanning efforts
- 66 -

Sustain

Sustain Use of Scanning

Once staff are scanning regularly, additional monitoring may be needed to ensure sites do not 

lose ground and any new issues are addressed. 

Pilot sites overwhelmingly wanted to continue scanning after the pilot ended and suggested 

expanding scanning efforts within their organization.

Sustaining Scanning: Recommendations From Pilot 

Experience Supporting Implementations

• An organization should define its own threshold for regular or consistent scanning, at which a site stays

in the “sustain” phase

– Ensure only 2D barcoded vaccines (those able to be scanned) are included in scan rate estimates

• Continue to monitor scanning and address challenges within pilot sites to improve scanning further

• Ensure best location for scanners, right number of scanners, and effective workflow protocols in place

at all sites using scanners

97% of survey respondents reported “Yes!” or “Leaning 

toward yes” when asked if they would like their site to 

continue scanning after the pilot ends (n=159 of 164) 

“Please don’t take our scanners away!” 

– Workflow discussion participant who 

knew pilot was ending

Consider expanding scanning to any sites not previously included within the organization, using lessons 

learned, once at least some original sites have reached the sustain phase
- 67 -

Sustain

Improve Scanning and Implementation Further – Pilot and Beyond

Survey respondents (n=164) identified necessary changes for 2D barcode scanning to be used more 

regularly at their site. Multiple options could be selected. Most frequently “no changes” selected 

(n=102), perhaps suggesting that high buy-in was achieved or the implementation was appropriate. 

Beyond the pilot, such feedback provides guidance on ways to further improve 2D barcode 

scanning. Parties best able to address identified changes are identified.

Role for Immunization Community

Various immunization community members are 

best positioned to address changes identified 

by pilot participants to increase use of scanning

• Vaccine Manufacturers: The most

selected actual change needed was

having 2D barcodes on all vaccines (n=65)

• EMR Vendors: Expanded EMR

functionality (n=6) that would enable

more information to be populated in the

EMR with a scan would require

engagement of EMR vendors

• Health Care System: Changes to scanner

locations(n=11), increasing staff buy-in

(n=5), and better alignment with the

workflow (n=2) could be addressed by

organizations implementing scanning
- 68 -

Sustain

Engage Immunization Community to Support Scanning Efforts

Various ways the immunization community can support improvement and expansion of scanning efforts

Vaccine Manufacturers/Pharmaceutical

• Include 2D barcodes on all vaccines

• Ensure print quality/contrast of labels to be easily

picked up by scanners

• Ensure 2D barcodes on labels print correctly (do not get

cut off)

• Consider adding 2D barcodes to other medications

EMR Vendors

• Ensure/increase functionality of EMR to support scanning

• Ensure indicator (scan flag) available for health care system

to track whether scanning took place or not

• Streamline scanner configuration to work easily with EMR

(currently coordination of EMR/scanner/health system)

• Add pop-up alerts if vaccine scanned does not match order or

is expired (or others identified by users)

Scanner Vendors

• Ensure scanner functionality with barcodes and EMR

• Streamline scanner configuration to work easily with

EMR (currently coordination of EMR/scanner/health

system)

• Ensure scanner has right sensitivity/ability to support

scanning barcodes on curved vials and prefilled syringes

or labels with limited contrast

Health Systems/Practitioners

• Communicate with vendors any needs identified by health

system/practitioners to support scanning and maximize

benefits (such as expanded EMR functionality, barcodes on

additional products, improvements to labels, etc.)

• Expansion of scanning through adoption by new health

systems and scaling for those scanning on limited basis

• Ensure right scanner locations, workflow process, and staff

buy-in to support successful implementation
69

1. What is Vaccine 2D Barcode Scanning?

2. Implementation Guide Steps

•

•

•

•

•

•

Decide

Plan

Train

Assess

Adjust

Sustain

Learn More About Our Work

3. Learn More About Our Work
- 70 -

Find Additional Information About Our Work

Where can I find additional information?

• Visit the CDC 2D barcode site for 2D vaccine resources : 

https://www.cdc.gov/vaccines/programs/iis/2d-vaccine-barcodes/about.html

• Search key words: “CDC 2D Barcode”

What’s on the CDC 2D barcode site?

• 2D barcoding pilot reports and other pilot materials

–

–

–

Pilot Findings Report 

Implementation Guide for decision-making (this document)

Summary reports from previous pilots

• Current list of 2D barcoded vaccines

• 2D Scanning Functional Requirements

• AAP Guidance

• GS1 Guidance

• Training videos