Most hospital pharmacy practitioners are undoubtedly aware of ASHP’s Pharmacy Practice Model Initiative (PPMI) and its vision of enhancing the pharmacist’s role to that of a primary medication therapy manager. By collaborating with health care providers at the patient bedside, pharmacy is challenged to provide high quality clinical services while continuing to maintain oversight of medication distribution. To meet these challenges, it is clear that technologies are required to gather, organize, and present both clinical and operational information to pharmacists in meaningful ways.1
Applying the PPMI to your specific practice requires some thought, as the initiative’s goals for medication distribution can be understood to imply that pharmacists should govern, but not actually perform the actions of medication distribution. While advanced technician training and credentialing roles are rapidly expanding in the health care setting, it is evident that many hospital pharmacists continue to play a more traditional role in the practice of medication distribution. Therefore, in order to decentralize the pharmacist from the pharmacy, it is necessary to acquire software systems and automation that provide assurances that technicians have performed distribution tasks correctly and in an auditable fashion.2 Furthermore, those systems must be capable of perpetuating safety throughout the medication distribution and administration process via bar code identification. Transferring thorough medication identification via bar codes from source products to compounded products and on to the final delivery device used by nursing at the bedside is the best way to ensure the integrity of medication orders and proper patient care.
At Children’s Mercy Hospital (CMH)—a 301-bed, regional teaching hospital located in Kansas City, Missouri—the pharmacy department is a 24-hour-a-day provider of both distributive and clinical patient care services. Inpatient pharmacy services are provided out of the central pharmacy, as well as four satellite pharmacies. In order to advance the goals of the PPMI and maintain proper control and supervision over medication preparation, distribution, and administration, CMH now utilizes an automated workflow management system with bar code verification and remote video supervision that dramatically transformed our medication preparation and dispensing practices for the better. However, this was a process that required several steps in order to mature properly.
Automation Adoption and Integration
In recent years, many hospital pharmacies have embraced the benefits of automated dispensing cabinet (ADC) technology to streamline and safeguard the distribution process; 89% of all hospitals reported utilization of these devices in a 2011 ASHP national survey of dispensing and administration practices. Furthermore, nearly two-thirds of surveyed hospitals reported using ADCs as the primary method for dispensing first doses.3 While this strategy may represent the ideal dispensing model for adult-centric facilities where the majority of medications are acquired in ready-to-use, standardized dosage forms that can be easily dispensed from ADCs, pharmacies caring largely for pediatric populations are consistently challenged to provide high volumes of injectable and oral, patient-specific, manually prepared medications.
When medication selection and preparation activities must be performed by hand, these activities are best directed by systems that provide extensive, in-process controls to minimize opportunities for error.1 Unfortunately, in the same 2011 survey, just 11.9% of hospitals used bar code verification during IV medication preparation, and only 3.6% of hospitals used remote video to supervise pharmacy technician IV medication preparation activities.3
Gap Analysis Through Improved Technology
As part of CMH’s efforts to increase automation in the pharmacy in the late 2000s, we implemented a fully integrated electronic health record, a medication carousel-to-ADC interface, and an automated medication packager in 2008. However, shortly after these technologies were implemented, we experienced an increase in dispensing errors related to injectable medications. Although these errors varied in root cause, they consistently led to the identification of weaknesses in our manual dispensing practices. As a pediatric hospital, we perform high volumes of batch compounding and dilutions of injectable medications, so an error in the compounding process could potentially reach multiple patients. With no form of electronic clinical decision support, these processes simply relied on the knowledge and skillfully trained eye of our technicians and pharmacists. Furthermore, lacking a bar coded trail from product production to administration, there was no way to determine with certainty which patient received which medication.
By this point, we had acquired automation solutions, such as smart pumps, for the delivery of parenteral nutrition, but continued to rely on the manual skills and training of our pharmacy staff to ensure the safety of other injectable medication preparations. Simultaneous to these automation adoptions, we also were beginning to evaluate and implement the USP <797> requirements for sterile compounding practice and were struggling with the overall physical disorganization of our cleanrooms. At that time, it was common to have labels strung together throughout the IV room and there was no formal dose prioritization. Doses were sometimes lost and if a dose or label went missing, everyone would stop working to look for it. It also was very difficult to communicate the status of the IV room workload to anyone outside the pharmacy, especially to pharmacists working in the patient care areas.
In order to address this disorganization and fill the gaps in our dispensing workflow, we chose to add an automated workflow management system to our compounded medication preparation and distribution process. This allowed us to take advantage of the safety benefits afforded through the use of bar code technology to correctly identify medications, as well as the organizational benefits it provided for our cleanroom operations. Another advantage of the system that we thought would specifically assist in attaining the goals of the PPMI is that it permits pharmacists to remotely verify medication preparations via the system’s automated image capture program. Little did we know that over time, this system would dramatically change our entire pharmacy practice.
Integrating Automated Dose Tracking
We began to integrate the automated workflow management system into our central pharmacy cleanroom by preparing portions of our fill batches three times a day. In the beginning, we focused the system primarily on large volumes of compounded antibiotics. As our staff became more comfortable with the automation, we continued to add more medications to the system, focusing next on smaller volume compounded solutions, and after approximately six months, the majority of our fill batches could be completed using the system.
During the early months of use, our staff often struggled with its perception of the system, as after initial implementation, there was a lull in production as familiarity grew. During that early phase, pharmacists were remotely verifying only about half of the injectable medications prepared; we still relied on a pharmacist to physically be present in the cleanroom to verify the remaining doses. It was the next big step—incorporating first doses—that would begin to affect a positive change in this perception. After our staff became comfortable with the technology, we rapidly incorporated first doses into the system, including PCAs, epidurals, and continuous infusions, until all injectable medications (with the exception of chemotherapy) were actively prepared under the system’s guidance and support. During the course of this process, we saw that our decentralized pharmacists began to rely on the system when triaging medication problems and expediting the preparation of STAT medications. Eventually, as all staff became comfortable with the system and its workflow, we were able to maximize the remote verification potential. With our pharmacists fully able to remotely verify medication preparations throughout the hospital, we removed the pharmacist from the cleanroom. While we do still staff a pharmacist in the main pharmacy at all times to perform specialized verification tasks that cannot be done through the system, the vast majority of our compounded doses are verified by pharmacists working remotely in patient care areas.
A Change in Perception
One of the first indications that we were creating a positive perception among staff for the adoption of automated workflow management, bar code tracking, and remote verification was when they began to lament the temporary loss of these systems due to scheduled maintenance. When we had to take the system down temporarily for maintenance, our technicians took issue with the formerly common scenario of having labels spread throughout the cleanroom and no clear direction as to the priority or status of the workflow. Likewise, having become used to decentralized activities and remote verification, our pharmacists disliked having to leave patient care units to reenter the cleanroom and physically verify medications as they had prior to the implementation of these automated systems.
While system downtime events have always been rare, they became indicative that the mindset of the staff was changing; they first accepted and then came to prefer these automated systems over prior routines. As this sentiment grew, both pharmacists and technicians began to inquire about adding more medications to the system, which motivated us to develop automated solutions through the system for chemotherapy and parenteral nutrition. This led us to our current volume of preparing nearly 1000 injectable doses daily within the system.
Data-driven Process Improvement
In the weeks and months following implementation, beneficial evidence of the data-capture value these automation systems had on pharmacy operations became apparent. By reviewing and analyzing workflow and throughput, we were able to assign workgroups to focus on improving medication turnaround times and reducing the incidents of missing medications. Data derived from the system also allowed us to embrace a Lean-methodology-inspired, just-in-time production model that includes fill batching every two hours for injectable medications. This directly helped to reduce overproduction and medication waste (see Table 1). The ability to review stored production images retained within the system (which includes information for all products used in any given compounded dose and their lot numbers) assisted staff with root cause analysis reviews and rapid identification of recalled medications.
Expanding Automation to Oral Medications
Despite the number of compounding preparation improvements we were able to make using scanning, tracking, and verification technology, our ability to safeguard dispensing practices did not stop at the cleanroom. After the aforementioned standardization of our injectable medications, we began to look at other areas of our pharmacy practice that might benefit from this technology. In particular, we sought to improve dispensing practices in the preparation, handling, and administration of oral liquid medications.
As a pediatric pharmacy, we dispense nearly 600 oral liquid patient specific doses each day. Prior to the introduction of workflow automation, the majority of these doses were prepared in a once-daily fill batch. However, a significant portion of these medications were often wasted due to the frequent dosage and route order changes that occur in a pediatric facility, as well as the poor production model we employed at the time. After adopting our new system, we became one of the first institutions in the US to utilize an automated workflow system for the production of oral liquid medications. By incorporating bar code scanning to correctly identify medications used to prepare oral doses, we have greatly reduced the number of production errors involving the wrong drug. As with our injectable medications, this technology has allowed us to provide just-in-time dispensing (utilizing a fill batch every two hours) for our oral liquid medications, thereby reducing oral medication overproduction by 37%.
By optimizing our production, dispensing, and administration model for IV and oral medication processes, we have enabled our staff to expand into more clinical roles throughout the institution—a direct intention of the PPMI. Furthermore, reliable bar-code-driven medication identification strategies support safe dispensing practices while remote medication verification and bar-code-backed medication administration make it possible for pharmacists to become decentralized from their once intimate roles in the pharmacy, and be able to participate in patient-centric care at the bedside. Embracing the goals of ASHP’s pharmacy practice initiative, our pharmacists now regularly participate in clinical rounds throughout the institution and are able to devote more time to medication use evaluations, therapeutic drug monitoring, and medication reconciliation while still upholding their preparation and distribution responsibilities.
Given the current state of regulatory pressure and the clear need to safeguard medication preparation, distribution, and administration processes, health-system pharmacists would be wise to immediately begin researching and implementing change management techniques and processes that will facilitate the transition from current IT systems to systems that will enable and drive our future practice models.1 For pediatric facilities, this includes developing and implementing bar coding and monitoring technology to safeguard dispensing and administration processes while also supporting expanded clinical roles for pharmacists.
Sarah Bledsoe, PharmD, is the pharmacy manager for quality and medication safety at Children’s Mercy Hospitals and Clinics in Kansas City, Missouri, where she manages the inpatient pharmacy operations and technician staff. Sarah graduated from the University of Missouri-Kansas City School of Pharmacy.
Wendy Hoebing, RPh, is the director of medication information management at Children’s Mercy where she provides direction for the institution’s pharmacy informatics team, electronic medication processes, and medication reconciliation programs. Wendy graduated from the University of Missouri-Kansas City School of Pharmacy.
Jack Lemanowicz, RPh, MS, is the former director of pharmacy at Children’s Mercy. His hospital pharmacy experience includes operations management and improving medication safety through automation, the goals of which include the development of clinically oriented pharmacy departments that utilize automation, streamline distribution, and take advantage of Lean techniques. Jack received his BS in pharmacy and MS in pharmacy administration from The Ohio State University.
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