A community pharmacy using robotic dispensing technology has helped identify a barcode duplication issue affecting several medicines manufactured by Relonchem Ltd, prompting a formal notification from the Medicines and Healthcare products Regulatory Agency (MHRA).
The MHRA has issued a Class 4 Medicines Defect Notification (EL(25)A/44) warning pharmacy teams about duplicate Global Trade Item Numbers (GTINs) and European Article Numbers (EANs) that could confuse automated dispensing systems. The full notification is available on the MHRA website .
The defect involves the assignment of duplicate barcodes for certain batches of:
- Losartan potassium / Hydrochlorothiazide 50 mg/12.5 mg and 100 mg/25 mg coated tablets
- Risperidone 0.5 mg tablets (Almus livery)
While the product details, strength and quality are correct, the duplication means automated dispensing equipment could misidentify affected stock. The problem was first discovered by a UK pharmacy whose robotic dispensing unit flagged the duplication during verification.
Relonchem confirmed that the error is related to barcode assignment rather than medicine content, and there is no impact on patient safety or product quality. The affected batches remain safe for dispensing, but the MHRA advises caution when using automated systems.
Guidance for pharmacy teams
The MHRA’s alert highlights the increasing importance of barcode accuracy as automation becomes more common in community and hospital pharmacy settings. Pharmacy teams in Scotland and Northern Ireland are advised to:
- Identify any affected batches and flag them within stock control systems.
- Segregate or manually select affected packs to prevent robotic mis-selection.
- Train staff on how to manage barcode alerts and verify products visually where necessary.
- Continue to report any incidents or suspected mix-ups via the MHRA’s Yellow Card scheme.
Pharmacies using robotic dispensing technology should review system settings to ensure duplicate barcodes trigger an alert. Even where stock is safe to use, reliance on automated selection without manual oversight could increase the risk of a packaging error.
Regulatory advice
The MHRA has classified this as a “caution in use” notice rather than a product recall, reflecting that the medicines remain of acceptable quality. The agency has stated that future batches will carry updated and corrected barcodes to prevent recurrence.
The alert reinforces how effective digital systems can be in detecting potential supply chain issues before they affect patients. The incident also demonstrates the growing value of collaboration between technology providers, manufacturers and pharmacy professionals in maintaining medicines safety.
Implications for practice
For community pharmacies, especially those using automation, the case serves as a reminder to balance technological efficiency with human oversight. Barcode integrity is central to safe dispensing, and vigilance remains essential even when systems are designed to enhance accuracy.
Pharmacy teams should remain alert to future MHRA defect notifications and ensure processes are in place to review and act on new alerts promptly.