Automated drug storage and retrieval technology helps organizations ensure medication safety, dispensing accuracy, and inventory efficiency. According to Pharmacy Purchasing & Products’ 2017 State of Pharmacy Automation Survey, one-third of hospitals currently utilize pharmacy carousels or robots for medication storage.1
Texas Health Flower Mound, a 99-bed community hospital with a 24/7 pharmacy, utilizes ADCs to dispense approximately 90% to 95% of all doses. Medications are stored in the pharmacy in a medication carousel and on static shelves; controlled substances are maintained in a controlled substances safe. Our primary motivation for utilizing automated medication storage in the pharmacy is to ensure medication safety, supported by bar code scanning to verify that medications and strengths are correct during both the carousel stocking and dispensing process. Another significant safety benefit is that the carousel restricts access to a single row of medications, reducing the chance of selecting an incorrect drug. Carousel use has increased efficiency in the medication-use process, enhanced inventory control and tracking, and reduced waste.
The Carousel Stocking and Dispensing Procedure
Medications are bar code scanned at the outset of the stocking process, and the carousel software specifies where to load the drug within the carousel. If the bar code is unreadable or missing (eg, a new medication that is not yet in the system), it cannot be stocked until a pharmacist has added it to the system. Considering the large number of generics and auto substitutions provided by wholesalers, it is critical to add new medications on a daily basis. An efficient carousel operation requires the creation of a process wherein new medications are added to the system in a timely manner.
When medications are dispensed, the software identifies the correct location for the technician. Because our hospital utilizes both the carousel and static shelving, the carousel specifies the medication’s location within the carousel, or indicates that it is located on the pharmacy shelves. After the medication is retrieved, it is scanned again for accuracy. Bar code scanning is a requirement, although overrides are allowed in some situations, such as when supply items do not come with a usable bar code. By reviewing override reports quarterly, we can monitor that the function is used only when authorized. The quarterly override reports are divided by user and are reviewed with each staff member to create an awareness of their override percentage and to identify those who are using the override function incorrectly. The entire team’s override percentages are blinded and shared with each staff member, showing how they compare to the other team members, which motivates staff with high override percentages to improve. Holding staff accountable reinforces good practices and has reduced our override percentage to close to zero.
When utilizing carousel technology, it is critical to ensure that all products are bar coded. Our hospital prohibits stocking any medication with a missing or incorrect bar code, to ensure that all medications in inventory are accurately labeled. If a medication does not scan, the technician sets it aside and consults with a manager or the pharmacist on duty to identify the problem. Only pharmacists are permitted to add bar codes into the system. We have found that having pharmacists manage this process standardizes workflow and ensures medications are managed safely and efficiently.
Because carousel space is limited, we must carefully consider which medications to store in the carousel and which to store on pharmacy shelves. Typically, the smaller, unit-dose products, high-alert medications, and look-alike/sound-alike medications are stored in the carousel. Large-volume IV bags (eg, 500 mL or larger) are typically not stored in the carousel, as they are too heavy for the shelves. Storing fluids in carousels can cause the machine to become off balance, and over time, cause hardware failure. We also avoid storing tall medications in the carousel, as the shelves have height limitations. Medications stored in the carousel are stocked and dispensed more quickly than other medications, so we attempt to store as many as possible inside. Similar-appearing products are stored away from each other, to avoid look-alike errors. Some products—including GI lavage preparations in 3-gallon bottles—simply will not fit in the carousel and are stored on pharmacy shelves.
Carousel Maintenance and Downtime
Carousel maintenance is performed every 6 months. Since the carousel was implemented 6 years ago, it has only required unscheduled maintenance a few times, and the vendor always rectifies any problems quickly. Unintentional downtime is extremely rare; nonetheless, each staff member receives annual training on how to access the carousel gears if they become inoperable, which is a time-consuming process.
Upon implementation, the vendor trained a few employees on carousel use, who then trained their fellow employees. This train-the-trainer approach has been extremely effective. A checklist is utilized to ensure new staff competency (see CHECKLIST).
Collaborating with IT
The carousel, bar code scanner, and computer must be connected to ports and to the pharmacy network, so close collaboration with IT is critical to the success of the implementation process. In addition, the carousel software must connect with every computer in the pharmacy. Our configuration permits only one user to control the carousel via their computer at a time. Because each computer requires a slightly different setup process, the initial steps can be time-consuming. However, since the initial setup, our vendor created a link on our network that allows us to add computers easily, which significantly improved the process for changing or updating computers.
Gaining Administration Buy-In
Presenting the benefits of carousel implementation to administration is critical to gaining their support. Focus on the safety benefits of automating medication storage, as well as the inventory control and waste reduction improvements. If your hospital has had a few recent event reports, these are excellent tools to help administration understand the value of pharmacy automation. Conduct a random sampling, over a month’s time, of the medication doses dispensed by pharmacy, to identify possible errors. It also may be valuable to compare your error rate to a similar hospital that is using a carousel, to highlight the benefits of automation.
Choosing a Vendor
When choosing a vendor, it is important to identify your organization’s goals for the technology. Carousels are available in various widths, heights, and configurations. If space is at a premium in the pharmacy, choosing a carousel that fits within that space is a critical consideration. If your organization utilizes a number of refrigerated medications, purchasing a refrigerated carousel may be advantageous. Some carousels open into both the pharmacy and the IV room; this option is advisable if IV room access is necessary to optimize your workflow.
Reliability and the carousel’s service/maintenance plan are also crucial concerns. What is the vendor’s response time in the event of a problem? What type of service agreements are offered? Be sure the contract spells out the specifics for both the hardware and software maintenance plans. If your organization switches to a software system provided by a different vendor, the carousel vendor will not be able to cover the software under the warranty or a maintenance plan. In this situation, a separate maintenance agreement must be obtained through the software vendor.
Consider the compatibility of the carousel and software with other IT systems, including ADCs, as well as the compatibility of any additional features offered by the vendor with your organization’s workflow. Interfacing the carousel with our hospital’s ADCs was critically important. We programmed the ADCs to drop refills to the carousel software at various times throughout the day; by staggering refills of items below the minimum inventory par levels, we can ensure a smooth workflow. Software vendors offer hospitals varying levels of configuration, so be sure that the selected vendor offers your organization the options it requires.
Benefits Realized and Future Goals
Overall, we are quite satisfied with our carousel technology. It has proven dependable and requires little maintenance. In addition, we are confident that our inventory is managed proactively and that we are avoiding waste wherever possible. Lot and expiration dates are tracked, and we can run reports to review par levels whenever necessary.
The most important benefit realized is the peace of mind that medications are managed with bar code technology, ensuring that the correct medication is chosen. This was underscored recently when the bar code scanner became inoperable, requiring that every carousel transaction be overridden for 2 days. In this time, we identified two errors made by pharmacy staff during the dispensing process. One of these errors was a wrong Heparin concentration—the exact type of potentially deadly error we are trying to avoid by automating medication storage. This experience reinforced the importance of the technology organization-wide.
One of our future goals is to add a second, refrigerated carousel. Two years ago, we added all of the supplies stored outside of the carousel on static shelving to the carousel software, which has significantly improved inventory management and facilitated proactive reordering for these items. Moving some of these items into the existing carousel would also free up additional room in the pharmacy.
We look forward to further optimizing carousel use within the pharmacy to increase safety, improve inventory management, and reduce waste. n
Todd K. Connor, PharmD, MS, is the director of pharmacy at Texas Health Presbyterian Hospital Flower Mound in Flower Mound, Texas. Todd earned his PharmD from the University of Houston College of Pharmacy, and also obtained an MS in Health-System Pharmacy Administration from The Ohio State University College of Pharmacy during a 2-year residency at Riverside Methodist Hospital in Columbus, Ohio. Todd’s professional interests include leveraging pharmacy automation to reduce risk in the medication-use process.
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