Given the time, resources, and effort required to implement large-scale technology projects championed by pharmacy, it is easy to see how additional, supportive actions can be marginalized. However, any new technology will only provide added benefit to the pharmacy if it can work seamlessly with existing technologies and processes. Therefore, when considering an improvement initiative, it is important to make sure a proper foundation is set ahead of time.
In the case of bar coded medication administration (BCMA), the technical advantages are fairly apparent, as it provides a closed-loop system for tracking and monitoring all medication administrations throughout the hospital. However, in order for this system to truly be efficient, it has to be populated with clean data and a solid inventory foundation. Performing a thorough review and audit of formulary items before adopting a BCMA system will streamline overall medication management, offer a chance to eliminate redundant or unused products, and create a succinct database for medication inventory and tracking.
Prepare Prior to Adoption
Gerald Champion Regional Medical Center (GCRMC) is a small, 99-bed, acute-care community hospital located in Alamogordo, New Mexico. Despite our relatively small size, our administration always encourages the adoption of the latest technology to continually improve operations. To this end, GCRMC has implemented considerable technology advancements in recent years, including CPOE, eMAR, automated dispensing cabinets (ADCs), and most recently, BCMA to the unit dose level.
When reviewing the multitude of steps required to implement BCMA, as well as the necessary adjustments to workflow and interfaces with cooperative technologies, these actions can be taxing enough for pharmacy resources. Thus, formulary review is often relegated to the bottom of a long list of priorities. However, it is better to look at this as an opportunity to streamline a formulary that may have become bloated. In order to allow for a smooth transition to this new technology, we determined the first logical step was to perform a line-item review of our formulary to ensure it reflected current pharmacy inventory use and needs.
Perform a Physical Review
We began by printing a copy of the full drug formulary and to our surprise, it comprised 1834 items; an inordinate amount in our estimation. We then performed a comparison between the printed formulary and the items actually on our shelves, noting all of the items that appeared on the printed list that were no longer physically stocked in the pharmacy. One pharmacist went through the remaining items listed on the formulary to mark items that could potentially be removed due to duplication, manufacturer discontinuation, lack of use, or simply because we no longer stocked that product. A group of staff pharmacists then reviewed the list to create consensus as to which items could be removed from the formulary.
Once agreement was reached, the revised formulary was approved by the P&Tcommittee and the chosen items were either immediately removed from the ADC formulary and pharmacy stock or allowed to outdate upon removal. This decision was based primarily on expiration date; items set to expire within six months were pulled immediately, while the remaining items were left until they ran out or became close enough to their expiration date to be removed. Once an item was removed from the ADC system formulary, it also was deleted from the CPOE formulary. Now, users either choose a comparable item or contact the pharmacy for an alternative.
Even though the process was somewhat tedious, reviewing our inventory item by item allowed us to remove a total of 536 items from our formulary. Of these, 25 items were removed due to lack of use, while 31 items had been discontinued by their respective manufacturers. We determined that another 166 items were effectively duplicates (ie, therapeutically similar items and multiple strengths that were not necessary). Most surprisingly, 314 items were simply no longer part of our physical inventory. Based on the inventory from the previous year and taking into account the cuts we made during our review, we were able to remove over 3,300 unit dosed products from our inventory stock enabling a total cost savings of over $7,600 (see Figure 1). In addition to the cost savings, this refinement also resulted in a reduction of the time needed for daily inventory activities including medication ordering, pharmacy inventory processing, unit dosing, and ADC fills.
By undertaking a detailed evaluation we were able to refine and reduce our formulary by 29.2% and, in doing so, reduced the costs associated with carrying an inflated inventory. We owe our success, in part, to tying this activity to the larger facility-wide goal of reducing medication errors by following a process of ordering medications via CPOE, verifying them through pharmacist review, and ultimately dispensing products from ADCs that are then scanned at the bedside through BCMA. Ultimately, we accomplished our original objective of increasing the accuracy of our inventory prior to implementing BCMA.
Theresa Waxlax, RPh, is a clinical staff pharmacist for CompleteRx at Gerald Champion Regional Medical Center. As part of a multidisciplinary team at Gerald Champion, Theresa spent over a year helping to implement bar coding at the facility.
As seen in PP&Ps State of Pharmacy Automation issue (August 2013), just 35% of facilities currently operate without a BCMA system in place, and that group is expected to shrink in the coming years. Adoptions of this important safety technology are projected to continue at a steady rate across facilities of all sizes in the next three years.
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