The benefits of automated medication storage and delivery include safer drug handling and more efficient medication delivery. Optimizing the use of medication carousels and robots has the capacity to improve the medication use process by refining both pharmacy and nursing workflow. However, when adopting automation tools for medication storage and delivery, the central goal of the initiative must be to determine—and put into action—a distribution solution that will ensure patient safety and improve the quality of patient care.
The University of Pittsburgh Medical Center (UPMC) Presbyterian Shadyside hospital is the flagship facility of UPMC, and serves as the centralized hub for an array of tertiary and community care services. UPMC Presbyterian Shadyside operates two campuses, known respectively as the Oakland and Shadyside campuses. Each site maintains a distinct identity and purpose within the UPMC organization. The Oakland campus is home to Presbyterian and Montefiore Hospitals. The combined academic medical center offers a Level I regional resource trauma center, in addition to other services that specialize in organ transplantation, cardiology and cardiothoracic surgery, critical care medicine, and neurosurgery. Shadyside Hospital is a community hospital offering specialized services in the areas of cardiology, medical and surgical oncology, orthopedics, geriatrics, urology, vascular medicine, endocrinology, and neurosurgery. UPMC Presbyterian Shadyside’s pharmacy services the medication preparation and delivery needs of approximately 2,000 patients daily, and the combined campuses dispense an average of over 30,000 medication doses each day. Hence, optimizing automation use to accurately and safely dispense such a volume is an important charge within pharmacy’s purview.
Robot and Carousel Usage
At the UPMC Presbyterian campus, medication carousels play an important role in storing and maintaining medication inventory. Seven carousels within the Presbyterian campus pharmacy store over 90% of the department’s medication. The small percentage of medications that cannot be stored in the carousels include items that require refrigeration or are designated for a specific specialty (eg, investigational drug services).
Presbyterian carousels are configured to store certain medications depending on function and use. Two carousels are dedicated to IV drugs and supplies for IV preparation in the sterile products room, two carousels are dedicated to replenishment of two robots on the Presbyterian campus (one each at Presbyterian and Montefiore Hospitals), and two are used for first dose dispensing in Presbyterian Hospital. The seventh carousel is used for medications to be stocked in ADCs. Implementation of medication carousels on the Shadyside campus is in-scope for future construction planning.
In addition to the two robots located on the Presbyterian campus, Shadyside Hospital also uses a robot for dispensing first doses and cart fill medications. While each robot services the needs of the individual hospitals where they are located, each robot also provides remote-site, 24-hour cart fill for other hospitals in the UPMC health system.
Determine the Ideal Location of Medications
Careful evaluation of where each medication should be stored within the carousel will improve efficiency of the automation and ensure accurate picking. When determining the optimal medication location based on use, several important factors must be considered: balancing weight distribution of items within the carousel, differentiating fast versus slow movers, and identifying high-risk medications and look-alike/sound-alike drugs.
Various strengths of high-alert and look-alike/sound-alike medications are separated in carousels to reduce the risk of dispensing errors. High-alert medication classes stored in carousels include cardiac medications (eg, dobutamine, labetalol, phenylephrine, epinephrine), blood coagulation modifiers (eg, heparin, warfarin, low molecular weight heparin, factor Xa inhibitors, etc), chemotherapy, and IV electrolytes. Examples of look-alike/sound-alike medications include amlodipine/amiloride, dobutamine/dopamine, ephedrine/epinephrine, cephalosporin antibiotics, and prednisone/prednisolone. In addition, low volume but high-risk medications are stored in the robot to decrease the potential for errors occurring during the manual pick process.
Because the carousel shelves move in a circular path, arranging mediations to evenly distribute weight along the loop will improve how quickly drugs can be accessed. In addition, identifying medications that are used most frequently and strategically placing them on the same shelf reduces the number of revolutions the carousel must make, saving wait time while the carousel locates the selected medication.
Ensuring that medications are loaded in the proper locations is vital to avoid dispensing errors, as well as to maintain automation efficiency. When dispensing errors occur, resolution can be time consuming. For example, when medication is returned to the pharmacy and restocked in the carousel, not all doses are scanned. However, it is mandatory that returned medications are scanned visually upon restocking into the carousels and ADCs. While the scanned dose may be correct, another dose (or doses) may not be. For this reason, education is provided to remind pharmacy staff to review all medications returned to and dispensed from carousels. Attentive, accurate loading will reduce the incidence of errors that must be corrected.
Patient safety must be the focal point of determining where to store medications. At UPMC, high-risk medications are limited to dispensing directly from the central pharmacy by the robot or carousels.
An integrated automation system is only as effective as the quality of its programming and whether or not safety mechanisms are fully and consistently employed. Implementing a robust bar code scanning process and analyzing metrics regularly are vital to the development of an effective and safe medication use process.
Bar Code Scanning
Although carousel and robot automation eliminates much of the risk from medication distribution, items still must be selected and removed by hand. To offset this risk, bar code scanning at the point of dispensing is utilized to assist in identifying picking errors. In addition, bar code scanning is especially useful to track medication location and quantities, thus ensuring adequate inventory levels are maintained.
In the ever-changing patient care environment, it is challenging to determine how often metrics should be reviewed. Recommendations for weekly to monthly optimization are typically ideal. Ongoing optimization is necessary to maintain dispensing efficiency and inventory control. The reports used to guide growth must be configured to clearly delineate areas of improvement. For example, reporting tools for robot optimization have been customized to include manually picked medications that are not stocked in the robot. Another report identifies medications in the robot requiring par level adjustment based on 30-day usage patterns and average daily use. Evaluating these reports in tandem provides a solid foundation for optimization and effectively informs decision-making. While both Shadyside and Presbyterian Hospitals rely on optimization reports for the robot and ADCs, Presbyterian Hospital takes advantage of additional reporting for medication carousels. This allows the opportunity for improved inventory control of all medications stocked across the automation platform.
Building the Database in the EHR
Developing the database in the electronic health record (EHR) can be a challenging process. When building our EHR, the goal was to create a database that the entire UPMC health system could share, despite the fact that not all of our health care facilities share the same specialties and treat similar patients; for example, UPMC Shadyside specializes in oncology patient services while Presbyterian hospital is primarily focused on critical care. Therefore, the most frequently utilized drugs differ in each facility. To remedy this issue, medications in the formulary can be assigned to individual facilities, allowing each hospital better control over its inventory.
Adding a Medication to the Formulary
All additions to the formulary at UPMC are initiated through the pharmacy and therapeutics (P&T) committee. Safety considerations, route of administration, and specific indications are decided at the P&T level and then disseminated to various departments, including medicine, nursing, and pharmacy. Following this decision, multiple processes occur simultaneously to ensure timely implementation of the formulary medication. The various health system IT teams build the medication into the pharmacy and CPOE systems, and each individual facility in the health system must create the formulary entry in the automation workflow software system. Once these processes are completed, individual product assignment to ADCs, carousels, and robots can occur.
Inventory control is an ongoing concern for most pharmacies, and utilization of carousel and robot technology allow for improved inventory control and medication storage. Reports must be utilized to identify inventory location, quantity on-hand, and ordering needs, which in turn reduces the amount of time required to locate a particular medication. When medications are centralized in carousels, inventory counts are more accurate and easier to quantify. In addition, careful inventory evaluation can be useful to identify purchasing trends and expose opportunities for inventory reduction and cost savings.
We are currently in the process of collaborating with our drug distributor to develop a medication ordering interface to facilitate purchase orders for medications stored in the carousels and robots. When this project comes to fruition, we anticipate enhanced ease of ordering and inventory control.
The primary advantage of carousel and robotic technology is enhanced medication safety, but an additional benefit of utilizing these technologies is improved drug delivery turn-around time. While accessing medications typically takes less time when automation is employed, a significant time commitment is still required to verify that the bar code has scanned accurately, the medication is packaged correctly, and that the medications picked by the robot and from the medication carousel are accurate. To ensure a safe medication dispensing and delivery model, appropriate medication verification processes must not be ignored. Be certain to guard against the false sense of security that can develop after automation has been employed—although carousels and robots add another layer of safety, appropriate safety checks must still be performed. While dispensing and delivery time savings may be realized when technology is employed, keep in mind that configuring the automation and performing the necessary safety checks are still required and will necessitate a time commitment.
Configuring the most opportune locations for medications stored in carousels and robots requires planning and an up-front time commitment. After this step has been completed, the process for locating a drug becomes easier and faster. For example, once all IV medications requiring compounding were located in the IV room carousel—separate from the medications that are used to fill the ADCs or robots—locating any required IV medications became a seamless process.
An additional time saving strategy has been realized at the health system level through implementation of a centralized packaging and distribution network. Unit dose packaging of oral solids and liquids for automation dispensing occurs at one location, allowing for improved opportunities for system-wide inventory control. An additional automation platform exists for identifying the specific location of a particular medication within the health system.
Effective staff training is a required element of any carousel and robot implementation or optimization program. UPMC partners closely with our automation vendor to provide appropriate staff training to ensure correct use of the technology. Prior to implementation, super-users are identified and trained at the vendor’s training facility; the super-users then train their coworkers (the train-the-trainer model) using an implementation guide supplied by the vendor. Short quizzes are given at the end of the training and the material is incorporated in the department’s annual competency assessment.
The demand for improved medication safety and increased efficiency in pharmacy processes is an ongoing challenge that can be assisted by the implementation of appropriate technology solutions. Using carousel and robotic automation has the capacity to improve drug distribution and optimize the medication use process, provided these technologies are used to their full potential.
Joedell Gonzaga, PharmD, MPH, is the pharmacy manager in automation and technology at the University of Pittsburgh Medical Center (UPMC) Presbyterian campus. He received his Doctor of Pharmacy from Northeastern University and completed a pharmacy practice management residency at the UPMC.
Madalyn Bates, RPh, is the pharmacy manager for information systems and automation at UPMC Shadyside. She received a BS in pharmacy from the State University of New York at Buffalo. Madalyn has 22 years of experience within the UPMC organization, focusing on pharmacy informatics for the last 12.
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