There is no doubt that carousel technology can greatly improve the efficiency and safety of pharmacy inventory management by automating medication storage, ordering, and distribution.1,2 But switching to a fully automated system can be complicated, especially for facilities that do not have the luxury of designing and moving into a brand new space. What follows are eight pearls of wisdom gleaned from one hospital pharmacy’s successful transition to this automation.
Technology Status Before Automating
Union Hospital in Cecil County, Maryland, is a 122-bed acute care hospital. The pharmacy, including office space and an IV room complex, is approximately 2,400 square feet. The staff of almost 23 FTEs processes approximately 25,000 prescriptions and dispenses approximately 6,200 doses monthly.
In the 8 years that preceded the carousel implementation in 2013, our hospital began using a variety of technologies to support patient safety. These included bar code medication verification, computerized prescriber order entry (CPOE), decentralized medication distribution through automated dispensing machines, and smart pump technology. What we lacked and what is essential to the viability of all of these tools, is an interconnected, orderly system for medication inventory management.
Instead, we relied on manual processes for ordering, receiving, storing, and dispensing medications. Medications for reorder were logged on paper, resulting in scarcities when staff members forgot to document supplies. Outdated stock and incorrect medications sometimes were found in the manually sorted drug bins, causing extra work to avoid dispensing the wrong drug strength or dosage form on the nursing units. In short, our system was fraught with the potential for human error.
After reviewing a number of available systems, we chose a carousel vendor that we felt offered the technology features and software updates we would need to accommodate future workflow. We looked for hardware that was dependable and that utilized a transaction information control (TIC) bar, which identified not only the location of a medication (pick-to-light technology), but also identified the medication and quantity needed (see PHOTO 1). In terms of software attributes, we looked for software that allowed for easy upgrading and that would be able to support pharmacist bar code scanning of the medication upon pulling it from the carousel.
In presenting the acquisition proposal to hospital administration, we highlighted the many projected benefits of the technology, including greater medication safety, streamlining of workflow, and a means to address potential national medication shortages. Because the carousel’s software could assist in cycle counting, we noted its capacity to improve inventory tracking and eliminate the cost of annual inventory counts.
The carousel build began in May 2013 and went live in July. Following are some of the most important lessons we learned along the way.
Avoid overlapping projects when scheduling your installation.
If possible, prioritize the carousel installation and implementation over other projects, in order to provide necessary support to everyone involved. At the time of our carousel implementation, the hospital also was replacing the information technology (IT) software. For over a year, preparing for the full IT replacement affected every department. The reach of this project was significant; its broad effects included changes to how radiology and laboratory results were ordered, nurses’ processes for documenting completed tasks, and dietary staff’s systems for ordering patient meals. This hospital-wide project took precedence over every other department’s projects.
Simultaneously, our pharmacy was in the process of implementing several other large-scale projects, including initiating software to serve as a rules generator for clinical pharmacy and an antimicrobial stewardship program. This led to overlapping tasks for employees. We sometimes felt we had taken on more than we could handle. While the carousel project was successfully accomplished, we would have preferred that it was our sole focus.
Before going live, prepare a training strategy.
We could have avoided some staff training deficits had we prepared an action plan for our super-users in advance. It is important to establish clear expectations for the super-users prior to the installation. Consider training both the super-users and the pharmacy buyers early in the process.
Implementing a competency checklist is another option to help ensure that everyone on staff is adequately trained to perform the tasks specific to their roles. Because safety is important to us, we emphasized the carousel’s safety features as part of the checklist process. With the exception of general operational items, the competencies on the checklist are delineated by specific roles, including system administrators, buyers, pharmacists, and technicians. Our organization includes individual goals in the annual personnel review process, and we incorporate the competencies in the super-users’ goals (see FIGURE 1).
Forge strong relationships with the facilities and IT teams.
Some hospitals are able to add carousel technology during the design of a new pharmacy space, but we did not have that option. Because we were building our carousel within our current place of operation, the department’s infrastructure required major enhancements. Accomplishing this required a collaborative effort among pharmacy staff and in-house facilities management and IT technicians.
Walls were torn down, and newly acquired rooms were painted. New flooring was installed where shelf removal revealed bare concrete. Refrigerators, drawers, and shelves were disassembled, moved, and reassembled. Emergency power sources, interfaces, and network connections were installed. The facilities department surveyed the floor supports to make sure the floor would support the weight of the carousel. Our IT staff reserved space on the computer server, deployed new hardware, and installed the new software. Maintaining normal service during construction also required working with infection control specialists on precautions to safeguard the staff and medication. This project was truly a collaborative effort and we were grateful for our core organizational values that guide interdepartmental efforts and allowed us to develop great working relationships with our supporting departments.
Expect occasional glitches toaccompany the latest technology.
One of the features that determined our vendor selection was a newly available option. The carousel we chose included a TIC bar that directs the user to the correct bin from which to remove a required medication while also displaying the medication name, strength, and quantity to be retrieved. Although other carousels were equipped with pick-to-light technology—a flashing light that indicates the correct location of the medication—we chose the newer option for its additional data to support patient safety.
TIC bar technology has indeed ensured that we experience few medication errors related to medication removal from the carousel. However, like any new technology, we did experience a few challenges at installation. Our pharmacy was the first in which the vendor had installed a carousel with the TIC bar, and the device was also new to our software vendor. This required the vendors to collaborate to identify any problems, such as making sure commands were programmed and sent correctly from the software. Communicating clear and concise information to the vendors was extremely important when reporting problems. Sending photos of any screen error messages related to the software helped them visualize and correct the issues we were experiencing.
Prepare for workflow changesin advance of installation.
For facilities such as ours, transitioning from manually picking medications from static shelves to a process whereby the product moves to the user, required a complete workflow overhaul. To minimize post-implementation upheaval, consider using flowcharting in advance of the installation to determine how your new workflow will proceed with the added carousel technology. This is an excellent opportunity to consider changes that will improve efficiency and contribute to a more ideal operation. Even with the creation of a highly detailed pre-implementation flowchart, a period of trial and error is likely upon go-live. We highly recommend that you solicit input from the frontline users at this point to adjust any unanticipated issues.
Keep in mind that it is not realistic to expect a vendor’s employees to understand every nuance of your pharmacy’s practice. As such, it was very useful for our team to visit other hospital pharmacies to see their carousels in operation—as opposed to visiting a factory or watching an online demonstration.
Create a list of contacts to save timewhen problems arise.
Communication during a project of this magnitude can be challenging, given the multitude of individuals and teams that need to work together. Any overlapping projects in which the pharmacy is engaged may further complicate the installation.
In our experience, having a single IT pharmacist oversee the project in the midst of competing priorities created some bottlenecks. For example, after the software company’s installation technician left, we discovered some of the interfaces were not fully implemented. A contact list of all vendors and individuals involved in the project would have allowed other employees to assist in resolving issues when necessary.
Look for opportunitiesto hardwire processes to prevent errors.
Even with the implementation of automation designed to avert human error, mistakes will still occur. It is important to try to resolve errors by critically examining how the technology works.
For example, an issue repeatedly occurred with the software when our staff attempted to add product information for new medications. Upon investigation, we discovered the mistake was easy to make, as the software defaulted to the first drug name in the library. We asked the vendor to revise the software so it would no longer auto-select a drug name when a new product was being added to the system. We also suggested changes to the location of some of the selections. The vendor understood what we were experiencing and updated the software by the end of the week.
A carousel is a versatile tool, so make the most of it.
As with many industries, health care professionals are expected to accomplish more with fewer resources. When considering automation, look to use this new tool to its maximum benefit. We rely on our carousel software to monitor inventory that is not located in the carousel itself, such as refrigerated items. Shelving and drawers near the carousel are designated for fast-moving items or for those products that are too large to allow for the par level to be stored in the carousel. Because the accessible location permits quick retrieval, the software can be utilized to manage inventory, record expiration dates, and automatically add items to the reorder list when inventory falls below minimum.
Our carousel purchase has proved easy to use and has streamlined our efficiency and workflow. While implementation of such technology can be challenging, prioritizing installation and maximizing use of other team members, as well as the technology itself, will help ensure that anticipated benefits are reaped in the end.
David Jaspan, RPh, MBA, is the director of pharmacy and materials management at Union Hospital of Cecil County, Maryland. He has previous involvement in both for-profit and not-for-profit health systems, as well as in hospital, long-term care, outpatient, and home care pharmacy. David has developed and initiated both clinical and operational programs, including antimicrobial stewardship, decentralized pharmacist models, residency programs, investigational drug services, CPOE, pharmacy automation, and bar code medication verification systems.
Ryan Caldwell, CPhT, is a pharmacy technician at Union Hospital of Cecil County in Elkton, Maryland, with the expanded role of super-user for several pharmacy IT systems. His experience includes 6 years in retail pharmacy and 3 years in hospital pharmacy.
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