The manual management of pharmacy-based medication kits is a labor-intensive process rife with opportunity for error, especially during inventory and restocking. For hospital facilities that manage a large number of medication kits and trays, ensuring that every medication and pharmacy product is accurate, within expiration dates, and accounted for before and after use can be a challenging task. While bar coding all medications to the dose level can assist greatly in inventory management, human error remains when stocking and managing medication kits. In recent years, a new technology has been applied to medication tracking and management—radio frequency identification (RFID). The application of RFID to pharmaceutical tracking and management promises to assist in developing a comprehensive system for controlling medication kits and trays.
At Riverside Regional Medical Center (RRMC)—a 500-bed, community teaching hospital located in Newport News, Virginia—we utilize a wide range of automation technologies, including automated dispensing cabinets (ADCs) in each operating room and procedural room, and a carousel for drug storage and electronic inventory management in the central pharmacy. In order to better manage tracking and accountability for the several types of kits and trays the pharmacy prepares, we opted to review how an RFID system might benefit our operation.
Challenges to Manual Kit Preparation
The pharmacy at RRMC currently provides adult, pediatric, and neonatal crash trays; open heart re-entry, malignant hyperthermia, and rapid sequence intubation kits; as well as stroke kits and STEMI kits. For anesthesia, we supply labor and delivery trays and local anesthetics trays, contributing to the approximately 100 physical kits and trays in circulation overall.
Prior to adopting RFID, managing the kits and trays was a time-consuming task necessitating duplicate work for both a technician—to physically inventory and fill trays—and a pharmacist—to recheck the entire tray to verify every product was correct, complete, and no products were at or near expiration. The method for identifying expiring medications was particularly unsound, as we had to wait until any given tray was physically returned to the pharmacy and relied upon the technician or pharmacist taking notice of any medications that were approaching expiration. Medications within a 60-day expiration window were removed. While relatively simple, the rote process of manual management required several hours per day of dedicated technician workload, as well as approximately 2 hours per day for pharmacist verification.
Although the proper completion and verification of kits and trays was challenging, the management of complex medication kits intended for emergency medical providers in the field was particularly time consuming, and as we began adding more in-house kits and trays to our medication distribution model, the issue compounded. This motivated us to seek out ways to alleviate some of the time and effort spent on management of in-house kits and trays, so we could devote the proper resources to emergency kit handling, as well as better utilize technician and pharmacist time.
In June of 2015, RRMC implemented RFID tracking for all medication kits and trays. Integral to this implementation was the fact that capital funding, sometimes required for new pharmacy technology, was not required. In this case, we needed only purchase the individual RFID tags, which are placed on each medication product in each kit and tray provided by the pharmacy (and each kit has its own tag); the cost of the scanning device (see PHOTO 1) and on-site training was incorporated into the cost of the tags (see PHOTO 2). This factor, combined with a vendor-provided ROI analysis that demonstrated significantly reduced need for technician and pharmacist labor, made a compelling case for acquisition.
RFID in Use
The best time to tag medication items is immediately upon receipt from the manufacturer; as medications arrive in a case or pack, multiple tags can be done at a time. A technician takes each medication and scans the manufacturer bar code to upload the product’s information into the software. The tech then enters the lot number and expiration date for each medication. If the lot number is new, the technician must reenter the lot number and expiration date a second time to ensure there are no errors. Once this step is done, the tech can generate as many tags as needed for the specific lot number and expiration date that correlates with the medication’s NDC.
Once tagged, the items are set in a separate area for pharmacist verification. The pharmacist takes all the tagged items from a single lot and places them into the scanning station; the system will identify how many tagged items are in the scanning station. The pharmacist then removes one randomly selected item and re-enters the lot number and expiration date. If all information matches appropriately, the pharmacist approves the medications in the system and the tagged items are then linked to the RFID tag indefinitely.
Whether there is a new kit or tray being assembled in the pharmacy or one currently in use that is returned to the pharmacy, a technician reviews the contents of all unsealed trays to ensure there are no opened or used products. By way of example, let us consider an adult crash tray, which has its own RFID tag indicating it as such, and a range of appropriate medication products, each with their own tag. The tray is placed inside the scanning station and scanned. After scanning all RFID tags at once, the station notifies the technician if any specific medications are missing or expiring within 60 days.
If the tray is missing any products, the technician places the appropriate medications, which have been individually RFID tagged and checked by a pharmacist, into the tray and scans it again. If correct, the technician sees a large green check on the device’s screen indicating the tray is complete. The technician then prints a completion form, which indicates the type of tray and its contents, and places it with the tray for pharmacist verification. Once this is complete, the tray is ready to be used.
Benefits of RFID
Implementing RFID for verifying and tracking our numerous medication kits, trays, and boxes has greatly improved the efficiency of this process, as well as reduced the risk for error. Given the accuracy afforded by RFID scanning technology, we submitted a waiver request to the Virginia State Board of Pharmacy that would eliminate the need for final pharmacist verification. Eliminating this step is conditional upon requiring a pharmacist to check every tagged medication before the kits or trays are assembled as discussed above. This process is electronically stored in the system for tracking purposes in the event of any issues. Although we are still awaiting approval of the waiver, we expect it will be approved, which will further reduce the amount of time dedicated to this task.
Our staff is highly satisfied with this new approach, as the overall process is significantly less tedious. We are now able to produce and restock medication kits quickly and with assured accuracy, factors particularly beneficial to ED and OR settings. In addition, the system’s ability to detect inventory at or nearing expiration is a significant asset to our medication distribution workflow, as well as our ability to predict inventory replacement needs. Even without the removal of the post-scan pharmacist check, the use of the system has greatly reduced the amount of time pharmacists spend verifying the kits, mainly due to the knowledge that a pharmacist has already reviewed each tagged item in the kit. Since implementation, confidence in the tagging process, and the RFID system in general, has allowed the verifying pharmacists to work much faster.
Although the impact of introducing this new process primarily has affected the pharmacy, we did educate our physician safety committee and anesthesia group on the use of RFID technology and its impact on workflow. Of course, those groups also have been pleased with the improved efficiencies.
The application of RFID technology in the pharmacy has proven to be an asset to the management of medication kits at RRMC. The unique nature of the scanning technology—identifying numerous products at once and negating the need for individual bar code scans—simply saves time.
As with any pharmacy technology adoption, it is wise to discuss its use with other experienced facilities, and we were fortunate to have local facilities using the same technology with whom we were able to consult. Ideally, all hospital pharmacies in our practice region will adopt this technology, which would allow us to apply it to the emergency medicine boxes that are sent back and forth between facilities.
Ultimately, RFID was the most logical solution to the issues weighing down our medication kit distribution process. The ROI analysis clearly indicated the cost of the tags was negligible compared to the workforce and safety gains that would be enabled by the system. Given our satisfaction with RFID, we are considering adopting it for our anesthesia system drawer swap-outs to further improve the efficiency of OR technicians.
Lindsay Enzor, PharmD, BCPS, is a director of pharmacy for Cardinal Health, supporting Riverside Regional Medical Center (RRMC) in Newport News, Virginia. She received her PharmD from Virginia Commonwealth University, attended the Pharmacy Leadership Institute at Boston University, and completed a post-graduate year residency with RRMC. Lindsay is in the process of attaining her MBA at St. Leo University.
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