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Preventing Medication Administration Errors in Hospitals with RFID Technology

Intelligent medication management technology can play a role in preventing many types of medication errors, especially in the operating room.

Medication errors remain a persistent and preventable challenge in healthcare, contributing to over 200,000 patient deaths annually and costing hospitals millions of dollars. These errors are often the result of a combination of factors, including staffing shortages, disjointed systems, high-pressure clinical environments, and limited supply chain visibility. Medication administration is the final and most critical link in a complex chain involving up to 30 separate processes—from physician orders to the bedside. At each stage, opportunities for error multiply.

To address this systemic problem, hospitals are increasingly investing in RFID-enabled medication management systems. These intelligent technologies offer an end-to-end solution, increasing accuracy, workflow efficiency, and patient safety.

Common causes of medication errors in hospitals

Clinicians are taught to follow the Five Rights of Medication Administration—right patient, medication, dose, time, and route. These steps help to ensure patient safety by minimizing medication errors at every level of care. However, even when providers practice these principles, several common factors continue to undermine safety:

1. High-Pressure Clinical Environments

When someone is in a rush, they’re more likely to make a mistake or forget something; this is especially true in a patient care setting. Fast-paced environments often exist across departments, from the pharmacy to the operating room and every unit in between. And these high-pressure settings increase the risk of mistakes. For example:

  • Pharmacy technicians may confuse “look-alike, sound-alike” medications like Lanoxin and Naloxone due to nearly identical packaging from the same manufacturer.
  • A nurse may input 500mL instead of 50mL into a patient’s electronic health record (EHR), potentially compromising future dosages and billing accuracy.

2. Manual, Fragmented Processes

Even a pharmacist with decades of experience will make mistakes, and that isn’t due to a lack of caring. Solely relying on human accuracy—especially across disconnected electronic systems—is not realistic. Tedious tasks like medication cart replenishment, cross-platform documentation, and properly recording medication waste due to expiration or over-ordering are time-consuming, increasing the risk for documentation errors and conflicting information amongst systems. 

3. Staffing Shortages

According to the 2024 National Pharmacist Workforce Study, 73% of pharmacists working full-time in 2024 rated their workload level at their place of practice as “high” or “excessively high”, compared to 66% in 2014.

Understaffing, especially within a hospital pharmacy, directly contributes to burnout by creating increased and unrealistic workloads, heightening the risk of oversight. Staffing shortages in the pharmacy can result in longer times to fill prescriptions, delays in kit and tray restocking, and gaps in inventory management, all of which can jeopardize hospital operations and patient safety.

The solution: RFID-powered technology systems

According to American Society of Health-System Pharmacists (ASHP) guidelines, hospitals must adopt robust systems to reduce the risk of medication errors and enhance patient safety. These guidelines, along with evolving regulations set forth by DSCSA, demand data integrity at every step of the medication journey; and obtaining that accurate, real-time data is made possible with RFID technology.

Benefits of RFID-enabled medication management systems:

  • Manufacturer-level tagging enables real-time tracking, eliminating the need for hospital staff to manually label medications.
  • Enhanced monitoring (e.g., temperature control and real-time, item-level visibility) improves drug integrity and helps prevent diversion.
  • Smart dispensing systems in high-risk areas like operating rooms ensure availability of correct, non-expired medications, improving response times during surgical emergencies. These systems help anesthesiologists feel more confident in providing care while simultaneously reducing or eliminating stockouts of critical medications.
  • Interoperability across systems (EHR, billing, medication administration) reduces duplication, missed information, and streamlines workflows.

Choosing to invest in intelligent, interoperable medication management systems is critical for health systems sooner rather than later. That’s because RFID plays a pivotal role in the digital transformation of healthcare that is currently underway. With RFID-enabled medication management solutions, hospitals and patients are protected by creating an environment of safety around every medication from manufacturer to the point of care.

Preventing medication errors in the operating room

From manufacturer to the hospital pharmacy, the last step on the medication management journey is the point of care. The operating room is an excellent case study of how dynamic and complex medication administration can be in practice. In the OR, anesthesiologists may need access to eight or more controlled substances within a matter of minutes. In these high-stakes scenarios, even a small error—such as administering the wrong syringe due to improper labeling—can be fatal. 

Similar to the pharmacy, medication errors that may occur in the operating room can be prevented with the latest technology. For example, RFID-powered anesthesia stations—which are part of an intelligent medication ecosystem—can help mitigate risks in the OR via:

  • Automated tracking drawers that record which medications were dispensed, by whom (only accessible by authorized users), and when. Data is tracked in real-time as soon as the drawer closes. As an added layer of protection, drawers automatically lock when they are closed.
  • Integrated labeling systems (e.g., Codonics Safe Label System that instantly prints accurate, legible labels for syringes being used in the operating room) that comply with ISMP guidelines, reducing labeling errors and potential risk for syringe swaps.
  • Simplified post-procedure documentation, including secure narcotic waste disposal to prevent drug diversion and ensure regulatory compliance.

Investing in innovation to prevent medication administration errors

Investing in RFID and intelligent, interoperable solutions enables:

  • Centralized, transparent inventory oversight that offers greater than 99% tracking accuracy
  • Real-time decision support at the point of care
  • Improved compliance (waste witness and improved accuracy of waste logs, enables compliance for program requirements by capturing inventory data for maximum 340B reimbursement)

Patients deserve to feel safe across all care settings, whether they come to a hospital through the ER, for a routine procedure, or a life-saving surgery. Ultimately, adopting intelligent medication management systems positions healthcare organizations to deliver optimal patient care by preventing harmful medication errors.