A Tool to Fight In-Hospital Medication Diversion

by Kevin MacDonald

A Kit Check customer recently found seven vials of propofol in a room where they shouldn’t be. Some were full. A few were empty or partially used. Normally you would not have many options to even start your investigation. With hundreds of hospital pharmacy kits throughout the hospital containing propofol and other stock in cabinets, the diversion could have originated anywhere or even from multiple places.

In this instance, the vials all had Kit Check RFID tags so the origin of the medications and their flow through the hospital could be determined by running a report. The pharmacy operations manager put the vials in the RFID scanning station and the tags on each vial were identified in five seconds. The RFID tags are serialized making them unique. The serialization allows the pharmacist to know not just that the vial contains propofol, but what specific vial of propofol, its characteristics and where it has been. Data about each medication included:

  1. Unique identifier
  2. NDC
  3. Strength
  4. Lot Number
  5. Expiration Date
  6. When the medication was first tagged
  7. Who tagged and verified the medication’s RFID labeling
  8. Which pharmacy kit the medication was assigned to
  9. When the kit was last restocked and who handled the materials before sealing the kit

The first and last two data points in the list above provided the Director of Hospital Pharmacy with a place to start his inquiry. Using this information about expected location for those specific vials and the time that the kit was distributed, security camera footage was reviewed. The person responsible was quickly identified and the issue addressed.

Medication Lifecycle and Chain of Custody

Without medication serialization and a method for tracking processes, Directors of Pharmacy often feel like they are flying blind. This is a problem because Directors of Hospital Pharmacy are responsible for all medications within the hospital. Whether it’s in-hospital diversion, theft, recalls, shortage management, or an adverse drug event, all eyes are rightfully on the Director.
However, the tools for managing these situations are scarce. Most of the processes are manual. Kit Check fills a gap in medication visibility when it comes to pharmacy kits. All medications assigned to kits are visible and traceable for their full lifecycle in the hospital.

Granted, the primary reasons most hospitals adopt Kit Check are for the enhanced kit accuracy and a 90% reduction in kit replenishment time. However, medication visibility is a byproduct of the system and we are told it is the first time Directors of Pharmacy have had this capability at their disposal. This visibility is also being used to better manage drug shortages as my colleague, Doug Zurawski, pointed out in his blog last week.

What about Barcode vs RFID?

barcodeWhile barcode systems are used in some places today, they unfortunately do not provide the level of visibility required for medication traceability that diversion incidents require. Aside from the fact that barcodes actually slow down the kit replenishment process, these systems typically only carry NDC information. Dose, lot number and expiration dates are missing. This is because of the limited data storage space available in a barcode and is the primary reason that barcoded drugs are not serialized with a unique identifier. Without that unique identifier, traceability is not possible.

green_tagKit Check leverages RFID first and foremost because it is faster. An entire kit can be scanned in about five seconds and indicate which items are missing and if any are nearing expiration. That’s much faster than the typical 20-30 minute manual processing time today. The added benefit is that each tagged medication is also serialized and additional data is stored enabling traceability and greater pharmacy kit accuracy.

An article in Mayo Clinic Proceedings in July 2012 and hosted in the NIH US National Library of Medicine stated:

“Specifically, harm can come not only to drug diverters but also to their patients and co-workers and to the reputation of the health care institution that employs them.”

While we are never happy to hear about the misuse of drugs within a hospital, we are glad that Kit Check enabled a quick resolution to the propofol diversion situation. If you have more questions about Kit Check and how it can provide greater visibility for you pharmacy kit medications, please click this link and fill out the contact request form.

Image credit Padlock with Chain: APICS