The implementation of an automated medication storage system, such as carousel technology, can benefit a hospital’s processes by ensuring the right drug and dose are selected, refining pharmacy workflow, improving inventory control, and maximizing cost savings. Conversely, utilizing a manual process for medication storage leaves a hospital open to possible medication errors and may prevent robust tracking of inventory and pricing data.
Riverside Regional Medical Center (RRMC) is a 500-bed, community teaching hospital located in Newport News, Virginia. Before 2013, the RRMC pharmacy department comprised a dichotomy of new technology and old-fashioned physical space. While over 95% of physicians’ orders were entered via computerized physician order entry (CPOE) and over 98% of doses were dispensed through automated dispensing cabinets (ADCs), the physical design of the pharmacy had not been updated in over 20 years, and almost all pharmacy products were stored manually. Medications were kept on curved, static shelves in alphabetical order by generic name and organized by route of administration with oral tablets arranged in one area and injectables in another. All high-alert and look-alike/sound-alike medications were labeled with fluorescent stickers on the plastic medication bins. To control inventory costs, minimum and maximum inventory levels were set on high-cost drugs. These numbers were also labeled on the front of the medication bins with stickers.
Inefficient and Error-prone Manual Processes
This manual medication storage system was less than ideal for a few reasons. A critical concern was the increased risk for medication picking errors. The shelving space was limited and medications would often fall out of their designated bin and land in the adjacent bin. In addition, it was impossible to separate all look-alike/sound-alike medications, especially among different strengths of the same drug. Moreover, the high-alert and look-alike/sound-alike stickers would sometimes fall off or become unreadable over time, defeating the purpose of the alert.
The manual storage system also negatively affected our technicians’ work efficiency. Due to limited space, products oftentimes did not fit in alphabetical order, making it challenging to maintain a cohesive storage system. This made finding medications problematic, and it was particularly confusing and time-consuming for new staff. Furthermore, because there was little room for extra stock, overstock was usually located elsewhere in the pharmacy, making it difficult to track and maintain inventory. Batch fills for the ADCs had to be pulled in order by unit rather than by drug, and this inefficient workflow required a significant amount of time to complete. The ergonomic impact from the poorly designed shelving posed another challenge for technicians: extensive bending was required for the many medications stocked on low shelves, and a stool was required to reach the medications on the higher shelves.
The pharmacy buyer’s workflow likewise was impaired by the inefficiencies of the manual system. Without minimum and maximum levels for all medications (they were only established for high-risk drugs), the buyer relied on historical knowledge while walking the shelves to determine purchase quantities. Moreover, the buyer ordered medications for each section of the pharmacy just once per week; unless a special request was made, the drug would not be ordered until its weekly review.
Finally, the system compromised our ability to accurately track inventory levels and costs. We were unable to track the amount of medications available in our inventory without physically scaling the shelves, and inventory costs were only available once per year when the full inventory count was conducted.
Creating a Successful Proposal for Automation Acquisition
After evaluating the available medication storage options, we chose to implement carousel technology. Because of the size and expense of this undertaking, it is important to conduct a full cost-benefit analysis to demonstrate the value of the project to administration and gain their support.
When creating and presenting a proposal to administration, focus on the significant gains for pharmacy, including decreased inventory costs, improved safety due to the closed-loop bar code scanning process, and increased technician and buyer efficiency. Highlight the financial and patient safety benefits. It is key to include an estimate of the inventory savings that would be generated by the carousel. Depending on the size of the facility and the annual drug spend, a carousel could increase inventory turns by greater than 12 per year. The inventory savings could then be calculated based on the potential of 12 turns per year compared to the current level.
Other key data to include in the proposal is the time staff will save as a result of carousel use. While the pharmacy may not decrease the number of FTEs required after carousels are implemented, pharmacist time may be redirected to clinical activities and technician time redirected to additional inventory control tasks to further improve inventory expenditures.
From a safety perspective, it is important to highlight the bar code scanning process to prevent medication dispensing errors. Potential cost-avoidance from preventing medication errors could be included in the proposal; however, soft costs generally do not carry as much weight in the decision-making process. We found that the easiest way to propose the implementation of carousels was to tie it to another construction project. At RMMC, the hospital was building a new wing requiring relocation of the pharmacy department, and building the carousels into this new design was identified as a viable option. Another approach is to consider using the carousel to dispense medications to other facilities within the health system.
Once the decision to implement carousel technology has been approved, workflow mapping must be conducted. A carousel implementation changes the majority of the buyer’s job duties; therefore, it is critical to involve the buyer early in the process. Creating and receiving the drug order is automated, and allows the buyer more time during the day to dedicate to other tasks. The technicians’ workflows will need to adjust as well due to the more efficient process for replenishing ADC batches. Once the staff is accustomed to having all of the medications in one location, and scanning every drug, we have found the pull times decreased by almost 50%. Replenishment batch trigger times also will likely need to be adjusted to accommodate this faster pace.
Implementation of a carousel is a complex process, and the formulary database development requires the greatest time commitment. For example, identifying every drug and its minimum and maximum level, and including destinations (ADCs, nursing units), users (employees), and distributors, must be planned for as well. In order to efficiently build and review the database, the current medication formulary was pulled from the pharmacy information system (PIS) database and edited by two pharmacists to reflect the data elements required for the carousel database. Breaking the drug list into sections allowed for more efficient review and permitted the two pharmacists to double-check each other’s work.
It is important to note that carousels may be taller than the standard hospital ceiling, thus potentially requiring adjustments to the pharmacy’s physical structure in order to accommodate the carousel. Because RRMC installed the carousels into a new space, there was no need to knock down walls or move utilities. This also permitted the carousels to be situated in the middle of the main pharmacy workspace allowing technicians access to both sides of each carousel and opening foot traffic, thus improving workflow. The carousels were also located next to the medication refrigerators. The refrigerator is considered a static storage area in the carousel software, and the computer and scanner are used to stock and dispense drugs from the refrigerator. By placing the carousels near the refrigerator, we did not need to purchase an additional computer workstation. Overall, the physical installation took approximately one week once the hardware was delivered. Each carousel also required redundant power and multiple data ports, a computer, and a printer.
The Testing and Go-Live Process
Once the carousels have been installed, the testing phase and go-live can proceed. For RRMC, there was a planned delay between the installation and go-live period, as the carousels were installed in the newly constructed pharmacy and go-live would not occur until the department was moved into the new space. It was during this delay that the testing phase was completed. This included building the server and the interfaces; interfaces are required between the carousel and the ADC system, the carousel and the pharmacy information system, and the carousel and the wholesaler. Depending on the complexity of creating these interfaces, this phase can last a few days to several weeks.
Immediately before go-live, the carousel was configured and loaded with the drug bins. All pharmacists and pharmacy technicians should be rotated through this process, as it allows them to become familiar with the carousel, moving the bins, arranging pockets, printing labels, and scanning pocket bar codes. Having hands-on experience with the configuration process was key to ensuring staff comfort with the new technology. It was also during this period that all pharmacy employees received initial training on basic carousel functions. It is recommended to use a train the trainer process, which utilizes several super-users as trainers. The super-users at RMMC were trained by the vendor, and then were able to successfully educate the rest of the pharmacy staff in carousel use.
Carousel implementation can be a considerable change for staff, and gaining their buy-in is necessary to ensure success. To encourage them to embrace the change, all staff members should be included in the process. At RMMC, the pharmacy relocation planning and carousel project were discussed at weekly meetings to allow for feedback and preparation. It is imperative to continually discuss the project and ensure that the staff comprehends not only the benefits of the new system but the reasoning behind the decision to change.
The true go-live at RRMC began with the loading of medications into the carousel. Loading required the work of three pharmacy technicians and one pharmacist for three day shifts to fill the three carousels we implemented. This process should proceed in an organized manner: load one shelf of one carousel at a time. In our case, two technicians pulled all of the medications for the specific shelf in the order that they were listed in the carousel, and a third technician loaded the shelf by scanning each medication into its designated pocket. If a bar code failed to scan, the medication was put into a problem bin. The pharmacist then mapped the bar code, updated the NDC, or otherwise fixed the issue so the drug could be properly loaded.
To further optimize the efficiency of the carousel, the medications were strategically located within the carousel. For example, fast moving medications were grouped together to help minimize the rotation of the carousel. Medications specific to ADC batch pulls for the operating room, which are pulled at a different time of day from the main ADC batches, were also all placed together in one carousel. This allows technicians to work with one carousel with minimal disruption to any dispensing activities in the other carousels.
Benefits of Automated Storage
The goal with the new pharmacy space was to correct the many inventory and workflow problems that had been identified in the old pharmacy. During the pharmacy design process, other storage options were considered, but the electronic tracking of inventory, the automated ordering process, bar code scanning technology, and the potential to expand the inventory control functionality across the health system were the key factors that led to the implementation of carousels. The carousels were implemented when the pharmacy department moved to the newly constructed department in January 2013.
Carousel technology has positively affected our distribution process in several ways, the most important being improved medication security and patient safety. One significant benefit has been the implementation of a bar code scanning process when drugs are dispensed from the carousel, ensuring the correct medication and correct dose is dispensed. The bins in the carousel are easily adjusted to the appropriate size for the amount of medication that is to be stored in each pocket. This capability decreases the likelihood that medications will spill into adjacent pockets. If a medication did fall into the incorrect bin, it would be caught during the dispensing scan. Look-alike/sound-alike medications can now be separated from each other. There is also no need for medications to be stored in alphabetical order, which drastically reduces the risk of wrong strength medication errors.
The carousel also has improved technician workflow. During ADC batch replenishment fills, the entire replenishment file is sorted to maximize efficiency and minimize the time required for stocking. The carousel also allows for medications to be relocated within the machine to create more space if the inventory level increases, which allowed us to do away with the secondary storage location for overstock. The work area of the carousel is ergonomically optimized, eliminating bending or reaching for medications, as the shelf moves to the standard counter height for each dispense.
Furthermore, the buyer’s workflow efficiency is improved through use of this technology. During the planning stage, the inventory strategy was determined and minimum/maximum levels were established for every medication stored in the carousel. The system then generates a daily order based on those levels; thus, the buyer no longer must walk the shelves to identify which medications to reorder.
Inventory counts and costs are much easier to track because the exact number of all medications within the carousel is available at any time and the carousel’s software is accessible on every computer in the pharmacy. The software also provides an inventory dollar amount based on the current inventory and the price points listed within the software.
We encountered a few unexpected challenges during implementation, for example, several drugs in inventory were expired, damaged, or not on formulary. In addition, we found it was more challenging than anticipated to manage the interface between the carousel and the ADCs. During the testing phase it was discovered that the replenishment batch messages would not flow over and stock out messages disappeared. Consequently, the go-live was delayed by two weeks while these issues were addressed.
Facilities planning to implement carousel technology should first consider a review of the formulary in the PIS. The development of the carousel’s database was more time consuming than anticipated, but this time commitment can be decreased when starting with a clean formulary. It is also important to ensure that all the involved third-party vendors are communicating with each other throughout the entire process. Building an interface between the carousels and the ADCs can be complex and requires an upfront investment of time on the interface engineer’s part to ensure proper function. Furthermore, it is key to identify at least one staff pharmacist and one staff technician to help champion the project. Positive energy and enthusiasm from multiple staff improve the ease of implementation. The buyer is also a crucial player in the success of the carousel project; ensure the buyer is invested in the project from the planning stages forward.
Reflections on the Process
Overall, the process of implementing carousel technology was both challenging and rewarding. The improvements in safety and efficiency have been noticeable throughout the pharmacy department. The beauty of carousel technology, besides the significant safety benefits gained with bar code scanning, is that an effective inventory strategy is hardwired into daily purchasing activity. The pharmacy department is generally viewed by the C-suite as a cost center, with drug inventory representing a significant expense to the hospital. The carousel helps decrease overall inventory costs by increasing inventory turns. This strategy, controlled by the minimum/maximum settings, streamlines the purchasing process and prevents padding of drug stock. Medications are ordered when they are needed, and only in quantities to meet the predetermined maximum level. The immediate access to accurate inventory information also allows pharmacy managers to keep a tight watch on inventory levels and intervene in a timely manner as necessary.
The benefit of improved inventory management encompasses a key portion of the return on investment (ROI) analysis. At RMMC, metrics such as inventory value and inventory turns continue to be monitored to justify the implementation and demonstrate ROI. Other metrics that are associated with soft dollars include safety and efficiency data. For example, the number of incident reports related to the wrong medication being sent from the pharmacy has been tracked both pre- and post-implementation. After carousel implementation, the number of those reports has decreased by 90%. The bar code scanning process has been credited with significantly decreasing this number. Turnaround time from batch pull to ADC fill is also monitored to illustrate technician efficiency gains; since implementation, the time to pull the ADC batches has been cut in half. Likewise, our buyer now has additional time to spend on other tasks, such as managing drug shortages.
Although the carousels have been in use for less than one year, both the pharmacy department and hospital administration are quite satisfied with the implementation. In the future, we plan to take advantage of package sharing capabilities among the other acute care hospitals in the Riverside hospital system. This is projected to create additional inventory reductions throughout the health system and result in decreased inventory costs.
Rebecca Schulkowski, PharmD, MBA, BCPS, is a director of pharmacy for Cardinal Health, supporting Riverside Regional Medical Center in Newport News, VA. She received her PharmD from the University of Maryland School of Pharmacy, her MBA from Wilmington University, and has completed the Pharmacy Leadership Institute at Boston University. Rebecca also completed a primary care residency with the John Cochran VA Medical Center in St. Louis, MO.
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