The opportunity for medication errors to occur is prevalent when using a manual approach to sterile compounding. Even a small discrepancy can result in devastating consequences. Transitioning from a manual method of IV preparation to an automated IV workflow system dramatically increases safety, standardizes processes, and reduces waste. In fact, IV workflow systems are increasing in popularity; per Pharmacy Purchasing & Products’ 2019 State of Pharmacy Automation survey, 63% of facilities with more than 200 beds plan implementations in the near future. This is not surprising, as this technology engenders strong satisfaction ratings; 90% of pharmacists surveyed are satisfied with their IV workflow systems and 72% rate their systems good or excellent.1
SBH Health System is a 422-bed, non-profit hospital in the Bronx, New York. In 2018, the hospital made the decision to implement an IV workflow management system. Prompting this implementation was a near-miss event that would have been immediately identified had the organization been utilizing IV workflow automation. A pharmacist noticed a discrepancy in the weight of the IV medication solutions; therefore, the batch was immediately sequestered. A root cause analysis revealed that the IV pharmacist had been interrupted during the preparation of the IV medication solutions, which led to the inaccuracy in production. In an effort to improve their internal processes, SBH began the search for a gravimetric IV workflow management system as a corrective action plan.
Report Near Misses
At SBH Health System, Patient Safety Friday occurs weekly, a multidisciplinary, facility-wide event where one department presents a patient safety issue and a solution. When pharmacy was selected to present, the topic of medication safety was chosen, focusing on preventing medication errors with an emphasis on the strategic goal of reporting near misses.
To reinforce the potential for serious consequences that can result from medication errors, pharmacy engaged a nationally known speaker and advocate for medication safety who had lost his daughter due to a preventable medication error. Physicians, nurses, pharmacists, and administrators attended the presentation. Response to the presentation was overwhelming, as professionals heard a personal account of how a medical error can impact not only a patient and their family but also the health care team caring for the patient. The grand rounds presentation justified the pharmacy department’s determination to implement an IV workflow system that would serve multiple areas of the hospital.
Choosing an IV Workflow Software System
In coordination with the patient safety presentation, pharmacy invited IV workflow management vendors to provide hands-on demonstrations of their products to the nurses, physicians, and administrators that attended the presentation. The workflow systems were set up in a conference room to allow staff members to handle and manipulate the workflow products in a show-and-tell experience to see how a medication product would be prepared and checked using the system. Hospital executives were also invited to interact with the technology so they too could fully understand the system’s error prevention capabilities.
SBH was already utilizing IV robotics to prepare a large number of IV medication solutions; therefore, implementing IV workflow software was the next obvious safety step. Often hospitals acquire IV workflow technology after a tragic event has occurred. The focus at SBH was to improve internal processes before a patient was harmed and to enhance our IV preparation automation by implementing a workflow system that would further ensure patients’ safety. The hands-on experience proved valuable for both staff and the executives to understand the importance of the IV workflow software system.
Ultimately, we chose and purchased an IV workflow system that fulfilled all our desired requirements, which included the following features:
Once the drug is prepared by a pharmacist using the IV workflow system, a second pharmacist checks the preparation to validate that it is correct.
SBH purchased six IV workflow software system workstations to serve multiple areas of the hospital. The workstations were placed in the following locations:
The Implementation Process
Implementation of the IV workflow systems required a significant time investment to build the drug library. Although the process was labor intensive, making certain all medication products in the library were accurate was critical to ensuring medication safety. Our strategy included breaking down the compounding process piece by piece in order to build each step into the IV workflow system correctly. As we were one of the first health systems to adopt this particular IV workflow management solution, we had to build the entire drug library from scratch.
The library build began with about 25 drugs, which were primarily fast movers, and then we went live with the system for those drugs so pharmacists could familiarize themselves with using the system. Thereafter, we gradually introduced additional drugs.
The process was slow at first, and it became necessary to gain pharmacists’ buy-in to using the technology, as some initially believed they could prepare the product faster using a manual process. However, pharmacy leadership made it clear that the IV workflow systems would ensure accuracy and ultimately patient safety. Even though the new process required slightly more time than a manual system, the certainty that the system would catch preparation errors was unparalleled. After reiterating our vision of uncompromised patient safety and seeing the system in training, the pharmacists fully supported its use.
Until the library was completely configured, pharmacists could use the system for medications that were in the library, but had to rely on a manual process for medications not yet added. Managing the IV preparation process at this point was challenging, as pharmacists had to switch back and forth between using the IV workflow system and manual preparation. However, we have now built approximately 90% of the formulations into the drug library. Each area’s library is customized to suit the needs of that area and to restrict drugs that are not used in that environment. For example, a pharmacist working in the infusion center does not have access to the drugs used in the non-hazardous inpatient workflow library.
Note that with USP <800> on the horizon, it is important to review safe handling processes for all hazardous drugs, not just chemotherapy. For example, oxytocin is on the NIOSH list of hazardous drugs. At SBH, these medications are prepared in a designated HD cleanroom, separate from the chemotherapy HD cleanroom, using the IV workflow system. As more non-chemotherapy drugs are likely to be classified as hazardous, implementing IV workflow technology will be increasingly advantageous.
IV Workflow Training
IV workflow training for all staff who would use the system was provided by the vendor, presented as 12 modules that cover the entirety of the IV workflow process, with each module taking about 2 to 2.5 hours to complete. In addition, the vendor provided hands-on training to all staff. We designated some staff members as superusers, who have an enhanced understanding of the system and can field questions from other staff members.
To ensure staff are utilizing the IV workflow system as intended, the facility utilizes Lean Daily Management processes and Gemba walk-throughs, where pharmacy IV workflow system utilization is measured daily (see SIDEBAR). As of January 2020, 90% of IV medication products are prepared utilizing the IV workflow software system.
It is not uncommon for each health care worker to prepare IV medications in slightly different ways. A significant benefit of implementing the IV workflow system is that the device standardizes how IV medications are prepared, so we have the assurance that every pharmacist is preparing medications identically. Utilizing a standardized process also protects against practice drift, which can occur when pharmacists prepare IV medication manually and infrequently.
Looking to the future, we would like to have bidirectional communication between the IV workflow system and our IV robot. We discussed the possibility with both vendors and are currently working with them on attaining a bidirectional interface.
In addition, we would like to further standardize the drug library. Hospitals typically have between 2000 and 4000 formulations in their formularies; each of these entries may have multiple line items, so it is not unheard of for a formulary to become as large as 20,000 items. Ensuring the accuracy and managing the size of the drug library is an ongoing effort.
Utilizing a manual IV preparation process creates an opportune environment for medication errors to occur. IV workflow management systems, which automate the processes of preparing and verifying sterile IV preparations, are an important tool to enhance safe sterile compounding. Not only do these systems help prevent medication errors, but implementing IV workflow software provides pharmacy with peace of mind that patients’ IV medications are accurate and prepared safely.
Ruth E. Cassidy, BS, PharmD, FACHE, is senior vice president of clinical support services and chief pharmacy officer at SBH Health System in the Bronx, New York.
Joshy Joseph, BS, RPh, is the associate director of pharmacy at SBH Health System.
Lean Daily Management
Our hospital participates in Lean Daily Management, which is a set of principles and tools used to create a culture of continuous improvement. Approximately 20 hospital departments are currently utilizing this process, which is part of the Quadruple Aim. The goals of the Quadruple Aim are:
Lean Daily Management helps support these goals, with each department following its own set of metrics to accomplish them.
The pharmacy department is one of the facility departments that participates in this organizational performance improvement program. Vice President to Executive Vice President-level administrators walk different routes to converse with staff and discuss whether the department metrics are being met. These Gemba walks are completed daily from 9AM to 10AM. Walk-throughs are valuable for both the frontline staff, as well as the facility’s senior leadership, as everyone has the opportunity to observe collaborative efforts to improve care.
For pharmacy, providing better care also means expanding the IV workflow software library, and ensuring that the IV workflow system is consistently used during the production process.
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