We utilize Kitcheck and have had errors related to used medications being left in kits and sent back out. Looking to see what others are doing and to see if anyone has discovered a way to reliably stop this from happening.

Our current processes to try to catch this type of error.
1. pharmacists check both tagging of medications and the final check of the kit.
2. We discuss these errors on our pharmacy daily safety briefs.
3. We have discussed these error with our physician and nurse partners on our facility daily safety briefs to spread the message that used medications should not be placed back in the kits.
4. We have a sticker on the kits to not use as trash.
5. We continue to reinforce this with pharmacists, pharmacy techs and interns.

What we've tried - unsuccessfully.
1. Attempted to see if we could put the barcode labels over the med vial lids so it would be removed with the cap. Unable to consistently get this to stick well without risk of tags coming off in the kit, etc.

What we are working on.
1. Creating a competency for pharmacists and technicians who do kits.
2. Working to create an e-mail kitcheck report that gives a better heads up when large amounts of kits need to be replenished.

We do believe these new items will help, but none of our safety strategies completely eliminates the risk of a reoccurrence. Any feedback is appreciated.