Patient safety driving increased RFID use in hospitals
As promised, this blog is intended to provide information about the latest in RFID use in hospital pharmacies. A recent article published in HealthcareITNews confirms patient safety as a benefit of RFID in pharmacies, and we couldn’t agree more. The writer discusses kit checking technology using RFID at The University of Vermont Medical Center (UVMC).According to the director of pharmacy services there, “patient safety was the main reason for utilizing RFID technology” and further stressed that ‘that when humans are involved, there's always a concern…”
HOWEVER…
We believe the writer missed an important patient safety implication in the fundamental workflow process. The article goes on to describe what we believe is a vital difference in the workflow processes of the 2 foremost companies that supply RFID kit and tray management technology solutions to hospital pharmacies. It involves the very first step in enabling drug inventory automation with RFID, that is, how RFID tags are programmed and affixed to the medication vials and/or packages.
Avoiding error is a health care effort and pharmacists assume a leadership role in implementing safe medication use efforts in their organizations
In the UVMC example,
“as the pharmacy receives drugs that are going to be going into these kits – pharmacy technicians put into the software system what the drug is, the quantity, the lot number and the expiration date. Then they print out the RIFD tag from that information and label the drugs with it”.
This workflow process for adding RFID labels to medications is risky as it requires the technician to first: select a printed label from a remote printer, and then affix it to the correct medication - thus creating a handling error risk of drug mix-up by selecting the wrong label.
Also, because in this process RFID labels are printed before they are attached to the medication package, human readable printing of drug information on the label is required to help minimize drug mix-up.
Packaging and labeling operations must have controls sufficient to prevent product/package/label mix-ups. The FDA issues strict quality system regulations labeling requirements to ensure that labeling operations are controlled so that correct labeling is always issued.
THE FACT IS ...
Relabeling creates DUPLICATE, often incomplete and potentially different information on the medication vial. This can create a source of confusion for the clinician (which label do they rely on as the source of truth?) and poses a serious risk of medication error if the clinician relies on the relabel that is incorrect and the wrong drug is administered.
The Intelliguard® RFID Solutions Smart Tag Processing Approach
MEPS Real-Time, Inc. DOES NOT RECOMMEND OR REQUIRE printed relabeling of drugs for its Intelliguard® Kit and Tray Management System.
By design, our Intelliguard® RFID Smart Tags contain no human readable information, instead they consist of an antenna and a chip that are associated with a unique device identifier # (UDI). The association of the RFID Smart Tag and the specific drug information is done programmatically via a scan of the manufacturer’s barcode and the RFID Smart Tag encoded only after it is affixed to the medication, avoiding any potential for mix-up. Once associated, each UDI is placed into a relational database and utilized throughout the system.
>> See Introduction to Intelliguard® Kit and Tray Management System
With the Intelliguard® System, the manufacturer’s label is not impeded in any way, allowing the recommended safe medication handling practice of relying on the FDA approved label for all necessary drug information.
The fact is, drugs are already labeled with everything the clinician (pharmacy or nursing) needs to know. Having it twice (i.e., once on the vial label and again on an RFID label) is just unnecessary information and presents a key medication safety risk in product/package/label mix-ups.
RFID in hospital pharmacies is proven to impact patient safety, but buyer beware: you must assure that solutions intended to improve patient safety, don’t inadvertently introduce new medication error risks.
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