Providing accurately compounded IV medications is a safety imperative at every hospital, as the consequences of improperly prepared IV drugs can be deadly. The Medical University of South Carolina (MUSC) is a regional teaching hospital with a 700-bed medical center, MUSC Health, located in Charleston, South Carolina, and includes the MUSC Hollings Cancer Center, which is designated by the National Cancer Institute. Along with its downtown Charleston facilities, MUSC offers a wide range of health care services, including cancer care, in cities throughout the region and state. MUSC Health prepares approximately 500 IV doses a day in the MUSC Children’s Hospital, with an additional 100 preparations in the cancer center.
To ensure that IV medications are prepared to the highest safety standards, as well as to improve medication tracking and thus reduce IV waste, the decision was made to add IV workflow automation to the compounding process. As the two highest risk pharmacies, the children’s hospital and cancer center were selected for MUSC’s initial implementation of IV workflow software, along with two outlying chemotherapy clinics.
Choosing an Automated Solution
We considered two automation solutions to improve the reliability of IV room production: a robotic solution and a bar code–driven solution. Since the children’s hospital requires various dose sizes, it was determined that a robotic solution would place too many constraints on dosing. Therefore, our investigation focused on bar code–driven options, which would deliver the necessary flexibility to enable the pharmacy to determine how to meet individual patient needs while ensuring that the preparation of any given dose is exactly as intended.
As a medical center with several inpatient pharmacies and a variety of patient types, MUSC had three critical requirements for its IV automation:
Planning for Implementation
Implementation planning began with a thorough evaluation of IV workflow. A failure mode and effects analysis revealed several areas for potential improvement (available online at www.pppmag.com/FMEA). First we identified the steps pharmacists and technicians followed to prepare an IV dose and route it properly within the hospital, and then tracked the time required to prepare several common types of medications. These and other data helped the pharmacy identify areas for improvement, as well as prepared the pharmacy to compare performance—before and after implementation—of the automated solution to evaluate success.
The assessment process identified 25 errors that could potentially occur in our IV room utilizing current practices; this large number immediately validated our decision to implement an automated solution that would better ensure the safety of IV doses. While many of these potential errors can be mitigated by vigilant pharmacist review, hundreds of medications are compounded in the IV room on a daily basis; this high volume and the corresponding risk of human error prompted us to quickly adopt automated technology. With appropriately designed and implemented IV workflow automation, the risk of error could be almost entirely eliminated, and patient safety maximized.
Benefits of Implementing IV Workflow Automation
Improved patient safety has been the central and most significant benefit of implementing IV workflow automation, as the technology replaced a manual system and eliminated the dangers inherent in such processes. Moreover, the technology has delivered additional benefits, including substantial cost savings as a result of reduced IV waste. Before IV workflow automation was adopted, pharmacy delivered one or two large IV batches daily. Using the new technology, our bar code system enables pharmacy to prepare an IV batch every two hours during normal daytime and evening hours, and track each dose to the hospital floor. Almost all medications are delivered on pharmacy’s normal hourly schedule. By reducing the number of doses in each batch, making more frequent deliveries, and using bar code technology to enable fast, accurate tracking, we are now saving more than $10,000 each month as a result of IV waste reduction. While the increased IV batches increased workload, we have been able to accommodate the requirements without hiring additional staff.
In addition to the safety and cost benefits, IV automation has improved both pharmacy and nursing satisfaction. Before IV workflow was automated, each missing dose notification pharmacy received from the hospital floor took approximately 30 minutes to resolve. Often, pharmacy prepared a second dose to rectify the situation in a timely manner; however, many second doses then came back to the pharmacy as waste after the first dose was located. This dynamic created tension between the pharmacy and nursing staff, as each tended to blame the other for the error, and the resolution was time-consuming. Using IV automation with bar code technology, pharmacy staff can identify the status of a missing dose within five minutes, and subsequent actions are based on solid data, rather than conjecture. Bar code technology gives the pharmacy the means to investigate and track down the dose—pharmacy sends the dose information to the nurse manager or sends a member of the pharmacy staff to the hospital floor to investigate. The cause of the problem can be easily identified and steps are then taken to prevent a recurrence.
Pharmacy now partners with nursing colleagues to locate missing medication—working together rather than assigning blame—and thus improving efficiency, accuracy, and staff relationships. In addition, pharmacist satisfaction has increased as a result of the confidence that each IV medication has been produced correctly and is error-free.
The enhanced reporting capabilities of the new technology are an additional benefit. Production reports provide detailed information on any incorrectly scanned doses and enable us to identify any patterns that emerge in mis-scans. When a pattern of problems occurs with certain doses on multiple reports, we can identify which staff require further training and on which tasks. We then provide that individual or team with the necessary support, using specific scenarios derived from report data.
Since any newly implemented system requires adjustment after the go-live, one concern is how easily these adjustments can be identified and completed. Auditing medications that do not scan correctly, as well as any doses rejected by pharmacists, ensures rapid resolution of these anomalies. The production reports provided by the IV workflow automation quickly identify specific issues that our initial automation design did not anticipate.
While the process of preparing to automate IV workflow requires time and commitment, the rewards more than compensate for that investment. In addition to improved patient safety, pharmacy stands to benefit in several other areas: cost savings, IV waste reduction, greater staff satisfaction, improved interactions with the nursing staff, higher quality reporting, and support to deliver targeted training and education. At MUSC, we have been able to accomplish these goals without adding additional staff.
Today, more than 95% of all doses prepared in the children’s hospital and cancer center pharmacies are produced using IV automation with the safety benefits of bar code technology. Two adult 24-hour pharmacies have started using the system, and are experiencing the same benefits as the children’s hospital pharmacy. In the future, we anticipate expanding use of this valuable technology in other areas of the health system, particularly in our investigational drug service and the compounding pharmacy.
Matthew Maughan, PharmD, was previously the manager of the Children’s Hospital pharmacy at the Medical University of South Carolina and is presently the director of pharmacy at Rainbow Babies and Children’s Hospital in Cleveland, Ohio. He graduated from the Philadelphia College of Pharmacy and his professional interests include medication safety, informatics and technology, and pharmacy leadership.
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