Emergency Drug Box Accuracy: Analysis of Manual Replenishment Errors and the Use of RFID as a Preventative Strategy

Background: Emergency drug boxes (EDBs) contain essential medications and supplies for use during life-threatening emergencies. Most health system pharmacies use a manual process for stocking these boxes, relying on individuals to perform the tasks. This approach is inherently prone to human error. Objective: To assess the accuracy of the current manual stocking process for EDBs, determine the clinical severity of any errors found, and evaluate the potential for using radio frequency identification (RFID) technology to mitigate these errors. Methods: This was a 2-phase retrospective study conducted at a large academic medical center. Phase 1 involved the assessment of adult and pediatric EDBs for stocking errors. Phase 2 evaluated the clinical severity of the errors discovered. The adult and pediatric Cardiopulmonary Resuscitation Committees independently ranked each identified error on a 3-point scale (1 = unlikely harm to 3 = severe discomfort or clinical deterioration). The study calculated the percentage of errors that could be detected by the implementation of RFID technology. Results: In total, 451 EDBs were analyzed for stocking errors. 106 (24%) contained at least one error, resulting in 132 identified errors. Implementing RFID technology would detect 96 of these 132 errors (73%). Of the detectable errors, 43 (40%) were ranked 2 or 3, indicating a higher likelihood of clinical harm or deterioration. Conclusion: Manual restocking and checking of EDBs are vulnerable to human error, which can have serious consequences and jeopardize patient safety. Adopting RFID technology can greatly improve the accuracy and reliability of this essential process.