IntelliGuard® Resources

Lessons Learned from the Tragedy at the UCLA Pharmacy

Posted on Sep 21, 2017 by Valerie Fritz

 Intelliguard RFID Solutions Prevent Medication Errors

"UCLA Pharmacy Closed After State Finds it Sent Out Drugs With Expired, Potentially Dangerous IngredientsThis disturbing headline appeared on the front page of the LA Times. You can read the full story here. In summary, more than 1,000 IV bags of sterile medications for heart patients and others with serious health issues had been made with expired and potentially dangerous ingredients, according to state Board of Pharmacy records.  The expiration dates on those drugs ranged from November 2015 to September 2016 and at least 350 bags of the adulterated medications were reportedly delivered to patients.

The LA Times headline appeared coincident to a meeting our team was having at one of our client hospitals.  As you can imagine, it was a sensitive discussion topic among the executives in attendance.  The situation described at UCLA is dire, and as some of the comments to the LA Times article confirm, this happens more often than most want to admit. During our meeting, the Director of Pharmacy, who has been using IntelliGuard since 2015, confidently turned to his Chief Medical Officer and stated: “Thank God we have Intelliguard in place to keep us off the front page of the newspaper.” Although bad press certainly can be a motivating business factor, the discussion took a more thoughtful turn:  All were in agreement that the bigger issue is how this major violation of pharmacy regulations put patient safety at risk and how their use of IntelliGuard puts the pharmacy at ease knowing they have every safeguard in place to ensure this doesn’t happen at their facility. 

While the investigation is ongoing and yet to conclude whether outdated compounds were administered to patients; as evidenced in this case, the challenge of achieving medication inventory goals is an objective that is nearly impossible to meet in an environment filled with manual processes, little visibility and few automation tools. While the root cause of this incident is yet to be concluded, we do know intelligent inventory solutions that use advanced technology to prevent human error and common mistakes are available.

Intelliguard RFID Solutions for Hospital Safety

Radio frequency identification (RFID) technology, which is prevalent in retail and other industries, is growing rapidly in healthcare improving patient safety, reducing errors and improving workflow. RFID provides fast, automated data capture of all elements of the medication distribution process including alerts, notifications and reporting of expired and soon to expire drugs. The situation at UCLA would not have occurred, or at the least, would not have continued for so long, had modern RFID technology been part of the process.

All pharmacies have the opportunity to take this common sense step towards utilizing proven technology to reduce regulatory exposure, improve patient safety, decrease workflow interruptions and reduce pharmacy staff labor requirements – to not only stay off the front page of the newspaper, but most importantly to ensure safe, quality care for every patient they serve. 

To learn more about IntelliGuard Solutions, click here and we’ll connect you with an expert who can help you explore whether RFID is right for you.

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