Pharmacy Purchasing & Products: How does Rady Children’s Health
utilize RFID technology?

Ann McKinstry, RPh: Our facility was an RFID pilot site for 2.5 years. Throughout that time, we worked to refine general standard operating procedures (SOPs) in order to best tailor these processes to our facility. Now, RFID is utilized to track medication usage and inventory data related to anesthesia trays, emergency (code) medication trays, emergency fluid trays, intubation trays, pharmacy code response trays, and patient transport trays. This technology and the resultant data help pharmacy track the location of these trays to ensure there is enough stock on hand for the required amount of product, and simplifies tray processing and restock, automatic billing for anesthesia, and expiration date and recall monitoring.

For additional background on Rady Children’s Health’s RFID processes, see the January 2025 Pharmacy Purchasing & Products article, Identify Inventory Management Improvements with RFID, Part 1.

Manage Controlled Substances

PP&P: How do you work with the anesthesia department to improve RFID-related workflows?

McKinstry: Anesthesia assigned one provider to lead RFID initiatives. Key responsibilities for this role include attending meetings with the vendor and with pharmacy, collaborating on workflows, sharing software and hardware changes with the provider team, and answering questions about how pharmacy can best provide services to anesthesia. Because the facility has instituted a variety of changes to locations of services, a key effort is ensuring the trays contain the appropriate medications for each location and that they are replenished on a suitable frequency. Input from the providers is imperative to the success of this effort.

Look-alike, sound-alike medications present a particular challenge, which is exacerbated by drug shortages. When a shortage occurs, it is not uncommon for the only available replacement product to look quite similar to an existing product in the tray. In this situation, we work with the anesthesia lead to strategize how to best stock the trays to allow the providers to pull what they need accurately and quickly in a stressful situation. It is also important to simultaneously review the replenishment process to safely accommodate any changes to tray layout.

For example, if a tray contains two high-use 2 mL vials which look similar but have drastically different indications of use, a mix up between vials would have negative consequences for the patient. Mix ups in tray content between these two vial types could occur during replenishment by pharmacy or when the provider returns an unused medication to the tray.

Pharmacy experimented by placing one of the vial types in a small, labeled, easy-to-open plastic box within the tray. This plastic box is scanned separately from the tray to confirm content, and then the tray is scanned without the box initially to confirm that drug type is not anywhere else in the tray, before adding the box back to the tray for the final check. In addition, to confirm all pharmacy inventory is accurate, a scan is completed of the primary RFID inventory bins on the pharmacy shelf prior to beginning any tray replenishment.

PP&P: How can RFID impact controlled substance management?

McKinstry: Both providers and pharmacy prioritize controlled substance oversight and reconciliation management. Historically, providers would remove controlled substances from the RFID tagged tray in the anesthesia workstation and document the dose in the anesthesia workstation. Then they would document the same dose in the EHR. Once the dose was administered, any waste would require a witness. The provider would then waste the syringe and return to the anesthesia workstation with the witness to document and sign off on the wastage. Thus, the amount administered and the amount wasted would typically balance against the amount removed from the anesthesia workstation.

However, when requiring staff to operate within two systems, the opportunity for human error increases. We saw two to three errors per day in documentation where what was charted in the EHR did not match what was charted in the anesthesia workstation. As the department responsible for controlled substances, pharmacy was charged with identifying, then tasking the provider with correcting, these errors. Notices were sent to the anesthesiologists requesting they reconcile every event where the two systems did not match the documentation. An additional concern was that this focused the provider’s attention on clerical work rather than patient care.

Working with the anesthesia workstation and EHR vendors, we removed documentation requirements within the former and enabled them only within the EHR. For pharmacy reconciliation, anesthesia balancing and reconciliation is now reviewed solely within the EHR. This resulted in a reduction from two or three reconciliation issues per day to an average of one per month.

Inventory Management

PP&P: What are some techniques Rady Children’s Health utilizes to manage RFID inventory?

McKinstry: To effectively manage inventory movement, the first step is to identify the fast-moving products. This holds true for all pharmacy inventory, including RFID-tagged products. Our highest use area is anesthesia, with a dozen particularly fast-moving products that require regular inventory replenishment. Unfortunately, these drugs are not all available from the manufacturers as RFID tagged products. In fact, less than 5% of the RFID inventory comes pre-tagged by the manufacturer. As such, the technicians must label these vials and syringes by hand with individual RFID tags. To ensure a consistent tagging process, we created a detailed workflow guide which is posted on the wall in the RFID management area (see the FIGURE). In addition, the bins for RFID labeled storage are color coded to match the days on the reference guide.

For example, on Monday and Thursday, the technicians replenish every high-use product bin color coded with a blue dot. All high-use products utilize a two-bin system, one of which contains sufficient inventory for the next 24 to 36 hours, and another that extends that supply to a full 72-hour period. This process ensures there is always sufficient inventory on the shelf for tray replenishment, even while the second bin is in the process of being filled.

It is important to work with 72-hour cycles because weekends and holidays are typically problematic due to having less staff on hand. This system has improved our ability to ensure a sufficient inventory of tagged products is always available without needing to add RFID tags during low staff times. Furthermore, this approach ensures a significant volume of a single drug is tagged at one time. By batching the tagging process, we can improve quality control. The standard quantities are tagged by the technician and scanned for confirmation of drug and 100% quantity tagged, and then a final check by the pharmacist occurs as the last step before inventory is placed on the RFID shelves. This streamlined process avoids the need to continuously start and stop, and eliminates the risk of mixing up different inventory, thus helping to ensure the wrong products are not tagged in error.

Click here to view a larger version of this FIGURE.

PP&P: What is the process for ensuring trays are accurately filled and tracked?

McKinstry: The replenishment technician reviews the tray prior to the automated scanning within the cabinet. While the automated scanning is quite robust, it does not entirely replace a physical inspection. For example, if a tagged medication is missing a cap, or a portion of the volume has been removed from a syringe, this will be identified by the technician. It is important to note that there is no system in place to prevent the provider from returning an unopened or a used vial or syringe. The manual scan of the tray is essential to confirm content prior to the first scan. The tray is then placed into the scanning cabinet and any medications not at par level will populate on the screen. In addition, any medication expiring in the next 72 hours will be identified for replenishment; also, any medication that was recalled or changed within inventory will populate a task message for the technician. After the technician replenishes the tray, they conduct a second scan to confirm the par levels are correct and the products are accurately placed. Finally, the pharmacist conducts the same visual inspection and confirmation scan.

PP&P: How does your facility use RFID data to improve inventory management?

McKinstry: Our vendor has a data warehouse that allows superusers to run high level reports detailing usage patterns. Quarterly, we review high-use items within the pharmacy inventory as well as anesthesia usage within the trays. Each tray is laid out for maximal efficiency, so when providers request the addition of a new product to the tray, we typically must remove or reduce another item to make room. Because of this, superusers regularly review inventory data seeking to identify ways to increase efficiency and decrease waste.

Pharmacy compounds some products for the trays in ready-to-use syringes which have a short expiration. We constantly review data to determine where and how often these syringes are used, and how often any amount of the product is wasted. Reviewing this data with anesthesia helps us identify which patient care locations use the specific product and whether the utilization and ease of use offsets the higher cost of providing the medication in a ready-to-use syringe.

PP&P: What are some tips organizations can use when incorporating RFID into their inventory operations?

McKinstry: As with the introduction of any new technology, staff training is key. At the outset, buyers may need to be reminded to include RFID inventory in their overall counts to avoid over purchasing inventory. Likewise, the technicians should be trained on product placement to offset any readability issues. For products wrapped in foil, ensure that they are placed in the tray such that the tag is not blocked but rather is accessible to the reader.

A strong relationship with IT can help navigate some challenges. For example, be sure there is sufficient network capability prior to system installation as this will provide a seamless scanning environment and avoid the need to troubleshoot.

PP&P: How can a facility maximize RFID use in its interaction with other technologies?

McKinstry: Vendors can provide valuable insight as to how best maximize the technology. Our automated dispensing cabinet vendor visited Rady Children’s Health to see our team’s utilization of RFID tags within trays, tray delivery, storage for controlled and non-controlled trays, and anesthesia workstations. They specifically sought to learn from our workflow and identify any gaps or issues. Two specific issues were identified for future software and hardware improvements: pharmacy’s inability to load an RFID tagged controlled substance into the main controlled substance vault with the same NDC (eg, a “fake” NDC must be used) and the inability for the main controlled substance vault to scan RFID tagged controlled substances and trays within the vault towers.

Pharmacy and anesthesia providers continue to work with both the EHR vendor and a labeling vendor to improve safety during patient care. These technologies rely on each other for the dispensing of the medication and documentation of all medication details, including the RFID tag information, dose, and any required waste, as well as the proper labeling of a syringe with scanning capabilities for the same EHR documentation mentioned. Opportunities for improvement to the current system, as well as new technology advancements, are discussed and trialed. These assessments can pertain to software, hardware, or a combination thereof.

Looking Ahead

PP&P: What are your goals for the future expansion of RFID within your facility?

McKinstry: We are constantly looking at new technology as it is released and refined to seek opportunities for improvements. We work closely with our vendor and with the anesthesia department to identify specific issues within the alerting, software, or hardware to see how they can improve our ability to provide care for our patients. What we do at the bedside and how we care for our patients is our main focus for expanding RFID use.

When the tagged trays leave the pharmacy in the delivery carts, the tags are not read again until the tray is placed in the anesthesia workstation. Likewise, when the tray leaves the OR to be returned to the pharmacy, there is a gap in time when the tags are not being read. Ideally, we would like to utilize RFID technology to read the tags no matter where they are in the process of delivery and replenishment.

The ability to read tags wherever they are in our system, rather than just at the pick up and drop off points, would allow us to gather information and send alerts should workflows or storage practices deviate from SOPs. This would also provide the ability to continually ascertain if we have sufficient tagged inventory for the patients that we expect to care for during a given period of time.

The RFID tags offer the capacity to capture a wealth of data including manufacturer information, lot numbers, and expiration dates. However, because our RFID tags are not scanned at the EHR administration point, we do not benefit from the automatic flow of that information into the patient chart. Should a patient experience an adverse reaction, retrieving the relevant data is still a manual process that involves accessing the workstation database. As this technology becomes more widespread, we expect it will also be incorporated into EHR systems.

Because RFID is a rapidly changing technology, we welcome the opportunity to work with various vendors to demonstrate our processes and to get feedback on how other facilities address issues such as labeling, monitoring inventory, and streamlining administration. I encourage pharmacy to explore opportunities in RFID use throughout the medication use process and to collaborate with their vendors to support the expansion of this important technology. Ultimately, pharmacy must be a voice for driving better patient care by advocating for widespread RFID adoptions and through sharing ways to maximize efficiency through its use.

Ann McKinstry is a quality Improvement pharmacist at Rady Children’s Health in San Diego, California.