Q&A with Rebecca Schulkowski,
PharmD, MBA, BCPS
Pharmacy Purchasing & Products: What potential for error exists when sourcing drugs from ADCs?
Rebecca Schulkowski: When storing medications in ADCs, maximize the use of locked and closed drawers and minimize the use of open matrix drawers, which increase the possibility of the user retrieving the wrong medication from the ADC; this is especially vital when stocking controlled substances in ADCs. However, such precautions are not always possible when storing larger or irregularly shaped medications in the cabinets, so extra scrutiny should be used when selecting these items. If medications must be stored in open matrix drawers, be sure to avoid overpacking medications, as they could slip into the wrong pocket and potentially cause the wrong medication to be chosen.
In addition, be sure your hospital does not permit users to return medications to ADC pockets; these medications must be placed in a return bin for pharmacy to scan and reconcile prior to restocking in the main pharmacy inventory, and ultimately, the ADC. Finally, an important safety strategy is to utilize bar code scanning upon cabinet stocking to ensure medication accuracy.
PP&P: What is the best approach to developing and implementing an overall safety strategy to guide ADC use?
Schulkowski: One of the most important considerations in developing a comprehensive ADC safety strategy is including a multidisciplinary team, comprising nurses, pharmacy technicians, pharmacists, and physicians. ADCs serving different patient populations—such as, medical/surgical, critical care, or telemetry—will include a variety of different medications, so the clinical staff that regularly interact with these patients should be able to offer insight into potential ADC safety concerns.
An important component of Riverside Regional Medical Center’s (RRMC’s) overall safety strategy is our daily morning safety huddle; in fact, feedback from the safety huddle provided the impetus for the implementation of bar code scanning upon ADC refill. The 10-15 minute safety huddle takes place at the same time every morning and includes employees from every area of the hospital: department directors; nursing managers; and representatives from the ER and OR, infection control, support services, registration, environmental services, facilities, and security. The purpose of the huddle is to provide a platform for each individual to iterate any safety concerns arising from the previous day and any anticipated safety concerns for the next 24 hours. Last year, ADCs were stocked without the benefit of bar code scanning and pharmacy began to notice an increasingly common trend as nursing shared near misses involving medications stocked in the wrong ADC pocket. Because we use BCMA at the patient bedside, none of these wrong pocket errors made their way to the patient; nonetheless, pharmacy recognized that utilizing bar code scanning upon stocking the ADC would prevent these near misses. Therefore, scanning upon stocking the ADC was implemented, after which we experienced a significant reduction in drug replenishment events.
Be aware of manufacturer recommendations when evaluating how many ADCs will be required to serve different patient populations. Vendors often can provide suggestions for how many patients should be served by each cabinet based on acuity. At RRMC, we generally allocate one ADC to serve approximately 16 to 18 patients. Our strategy is to free staff from the burden of refilling ADCs too often, while simultaneously ensuring that the cabinet inventory turns over regularly. While manufacturer recommendations can be valuable in determining how many ADCs will be needed, the internal process of setting appropriate inventory levels is nonetheless central to enabling patient access to medications while concurrently preventing drug waste.
Performing continual maintenance after the initial setup period is critical to medication safety and will ensure a smooth workflow. Because practice is constantly evolving, a medication that serves as a first-line treatment one year may not be used at all the next. Moreover, with the passing of time the patient mix on the floor may change; this in turn impacts which medications should be included in ADC inventory in different areas. Ideally, minimums and maximums, the vend-to-fill ratio, and any requests to change inventory levels should be reviewed at least quarterly.
PP&P: What standardization is required to ensure safe use of ADCs?
Schulkowski: One of the most important standardization requirements is making sure that what appears on the ADC screen exactly matches the information in the pharmacy information system (PIS) and the medication carousel. The description of the drug should be identical in all hospital systems. For example, if Mag/Al/Simeth is entered in the PIS, the same medication should not be entered as Mag Al Plus in the ADC or medication carousel.
Standardized naming conventions prevent nursing confusion and help avert calls to pharmacy to check if a medication is correct. Standard nomenclature is driven by the PIS, with critical input from organizations such as the Institute for Safe Medication Practices (ISMP). For example, ISMP has recommended that TALLman lettering be consistently applied to all drug names in all databases. It is the responsibility of the informatics pharmacist to review and ensure that drug naming conventions are consistent across all databases.
A significant barrier to standardization efforts is evident anytime a change must be made, as three separate systems must be updated: the PIS, the ADCs, and the medication carousels in the pharmacy. Technology that would permit concurrent updating of all hospital automation via a single interface would be quite valuable in ensuring standardization and preventing rework.
Retaining appropriate alerts within the cabinet software, while eliminating those that are unhelpful, is an important step toward standardization. The P&T committee should assist in determining what information be included and what should be avoided, with the goal of minimizing alert fatigue. Alerts that are typically important include reminders for a second nurse to check high-risk drugs, vital allergy information alerts, and alerts specifying which medications require special waste disposal, such as the reminder to dispose of P- and U-listed waste in black waste bins.
PP&P: What is the process for determining which medications should be stored in ADCs?
Schulkowski: ADCs should be utilized to store practically all medications. At RRMC, the goal is to store 95% of our inventory in ADCs. Our guiding objective is for nurses to feel confident that when they need a medication, it will be conveniently available in the ADC, while also being afforded the safety benefits that bar code scanning provides.
The small percentage of medications that should not be stored in ADCs include drugs with special handling precautions, such as chemotherapy, and high-cost, infrequently used items. Chemotherapy is most often compounded in the pharmacy after the patient has arrived in the hospital to avoid waste, while high-cost medications that are used only rarely are consolidated in the pharmacy to save space in ADCs for more frequently used items. Consolidating low-use/high-cost drugs in the main pharmacy also decreases overall inventory costs for the hospital.
PP&P: What challenges have you encountered when implementing safety strategies?
Schulkowski: A year ago, when we made the decision to implement bar code scanning upon stocking ADCs, there was significant resistance from some pharmacy technicians who believed that the scanning step would be time-prohibitive to completing their other duties. In addition, technicians were concerned that there would be numerous bar codes that would not scan, which would further slow down workflow.
To assuage these concerns, pharmacy completed a comprehensive cleanup of all bar codes prior to initiating the scanning-upon-stocking project. All bar codes in use were downloaded from the PIS system and sent to our ADC vendor, whereupon the entire bar code file was uploaded into the ADC system. Every medication was then scanned in the pharmacy to ensure it would scan correctly at the ADC. This process demonstrated that virtually every bar code would correctly scan, and thus created confidence that technicians would not be frustrated by unscannable bar codes.
In addition, we evaluated the validity of the technicians’ concern that the bar code scanning step would negatively impact workflow. Our ADC vendor provided the results of time-motion studies that suggested implementing the bar code scanning step would actually decrease the time required to stock the ADC; however, these studies were not effective in convincing staff that workflow would be unaffected until they tested the process themselves.
Prior to implementing bar code scanning upon stocking, the restocking procedure included highlighting all of the medications that required refilling on the ADC screen and then refilling one after another until completion. Inevitably, the technician would be interrupted by a nurse who needed to access the ADC; after the nurse retrieved the required medication the technician would have to log in again, identify the point where they left off, and continue the refill process. Thus, interruptions resulted in significant wasted time as the technician regained their bearings and continued refilling the ADC. The new ADC refilling procedure does not require accessing the ADC touchscreen to highlight all the medications that require restocking; the technician simply scans the medication, scans the pocket, and replenishes the drug. As a result, the technicians found that the new process allowed much faster restocking. After experiencing the benefits of incorporating bar code scanning upon ADC stocking, the technicians’ resistance disappeared and they became advocates for the new process.
All drugs are scanned into the pharmacy carousel upon receipt from the wholesaler, so when a medication does not scan the new drug is immediately identified and added to the carousel, PIS, and ADCs.
PP&P: What collaboration with nursing is necessary?
Schulkowski: While determining cabinet location may seem to be a minor concern, it will have a significant impact on nursing. The extra steps required to walk to an inconveniently located ADC quickly add up to a substantial burden—and decreased efficiency—over the course of a day. In addition to seeking nursing feedback on ADC placement, ask for input on the location of look-alike/sound-alike medications within the cabinet, as well as the most efficient placement of pockets for commonly used medications. Nurses’ insights can be particularly useful in determining drug placement—for example, nursing can alert pharmacy if two similar vials are located next to each other in the ADC and should be separated to prevent a potential medication error. Make sure nurses know that their feedback and suggestions are welcome.
PP&P: What staff training and competency validation should be provided to ADC users?
Schulkowski: At RRMC, new users complete the ADC training module provided by the vendor prior to beginning work. In addition, during their orientation, nurses receive hands-on training to ensure they can competently complete all ADC transactions. Whenever ADC updates are implemented, staff is trained to ensure the changes are fully understood. When the ADCs were upgraded last year, pharmacy developed a computer-based learning module for all users to complete. The module outlined the changes to the system, including newly available features and changes to the content on the ADC screen. Moreover, pharmacy employees are required to complete an annual competency evaluation to demonstrate the effectiveness of such continuing education.
For more tips on how to optimize ADCs, see Managing Refrigerated Medications as ADC Inventory and Storing Assembled RTU Systems in ADCs.
Rebecca Schulkowski, PharmD, MBA, BCPS, is a director of pharmacy for Cardinal Health, supporting Riverside Regional Medical Center in Newport News, Virginia. 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, Missouri.
Managing Refrigerated Medications as ADC Inventory
Another consideration when maximizing the utility of ADCs is ensuring that refrigerated medications are managed as ADC inventory. Our medical-grade refrigerators are integrated with the ADC technology so that pharmacy is alerted through the ADC if the refrigerator goes out of range, potentially affecting the usefulness of the medications therein. The refrigerators are remotely managed by the ADCs, and include a lock so they can only be opened through ADC access. The ADCs can remote-manage many different medical-grade refrigerators, regardless of the refrigerator manufacturer. Additional hinges may need to be installed on the refrigerator to make it compatible with the ADC, but this is generally a simple process that can be handled in-house by maintenance staff. The ADCs employ a remote manager that stores data from the refrigerators, so if a refrigerator goes out of range, pharmacy will receive an alert that service is required in real time. When a nurse requires a refrigerated medication and attempts to access it through the ADC, this triggers the refrigerator to open, providing easy access. Thus, the ADC technology expands to incorporate refrigerated medications as well as non-refrigerated medications.
When moving medications from the refrigerator into the ADC, be sure to consider the effect of this change on drug expiration dates. For example, when an unopened insulin vial is stored in a refrigerator it may have an expiration date that is years away, but after it is moved into the ADC and stored at room temperature it requires a beyond-use date (BUD) of 28 days. Therefore, be sure that pharmacy applies the correct BUD to the medication prior to placing it in the ADC.
Storing Assembled RTU Systems in ADCs
By Michelle DeLuca Fraley, PharmD
At Ephraim McDowell Regional Medical Center (EMRMC) in Danville, Kentucky, the pharmacy strives to minimize medication waste while concurrently improving medication delivery time and increasing nurse access to medications. Likewise, we aim to reduce the possibility of compounded product contamination and ensure the right drug is provided to the right patient by utilizing bar code scanning prior to drug administration.
To achieve our objectives, the decision was made to adopt ready-to-use (RTU) vial adaptive systems when available per TJC’s MM.03.01.01 EP 10, which states that medications in patient care areas be available in the most ready-to-administer forms commercially available.1 All RTU systems are prepared in the pharmacy under ISO Class 5 conditions and stored in ADCs on the floors to provide safety and enhance nursing access; per manufacturer and USP <797> recommendations, RTU systems are given a beyond-use date (BUD) of 30 days, which reduces waste of expired and unused medications. Although the assembly of these systems is not considered compounding per USP <797>, and manufacturer labeling does not require assembly within ISO Class 5 environments, some USP <797> surveyors do recommend assembly occur in ISO Class 5 conditions as a best practice. Therefore, EMRMC made the decision for pharmacy to assume responsibility for assembling RTU systems within an ISO Class 5 environment.
To minimize wasted medication, a par quantity was identified through review of weekly and monthly ADC restocking reports, as well as an analysis of utilization trends, and this quantity is stored in the unit ADCs. Par level review is ongoing so that quantities can be adjusted as necessary to further minimize waste. The ADCs utilized at EMRMC include glass doors, shelving that provides adequate space for the RTU products, and compartments that can be adjusted allowing for easy storage. For products that require protection from light after being mixed, an amber bag is rubber-banded to the diluent bag. For less frequently used and very high cost products, waste is averted by assembling and dispensing those items on an as-needed basis via a 24-hour cart fill.
Nursing appreciates the easy access to medications our strategy affords. In addition, our process of assembling the RTU systems in the pharmacy in an ISO Class 5 environment and storing them in ADCs on the nursing units has minimized the risk of contamination and eliminated waste of expired and unused products, given the 30-day BUD. The RTU systems have further improved medication safety efforts by allowing bar code scanning of medication vials prior to administration to ensure the right patient receives the right drug.
Michelle DeLuca Fraley, PharmD, is a clinical pharmacist and director of the pharmacy residency program at Ephraim McDowell Regional Medical Center in Danville, Kentucky.