As hospital and health system consolidation has increased year after year, independent hospitals are becoming increasingly rare. Upon acquisition by a health system, many hospitals must realign their financial and automation systems, including their automated medication storage and retrieval devices, to those of the parent facility. According to the 2020 Pharmacy Purchasing & Products State of Automation Survey, 41% of hospitals have adopted automated medication storage and retrieval systems—carousels and robots— with distribution across hospitals of varying sizes.1
Automated medication storage and retrieval systems have been in use since the 1990s, with adoptions consistently increasing over time. To keep up with new end-user technologies, many early adopters will need to either physically replace their units or update their software. This article explores the planning, implementation, and subsequent quality checks required when integrating the hospital carousel software with the larger health system pharmacy enterprise.
Texas Health Presbyterian Hospital Flower Mound, a 99-bed community hospital with a 24/7 pharmacy that utilizes ADCs to dispense approximately 90% to 95% of all doses required an update of its carousel system software to align with the health system pharmacy enterprise. Fortunately, the physical system was relatively modern and did not require replacement.
The pre-implementation period is the most critical stage when upgrading a carousel system, as dedicating resources during this portion of the process will prevent many challenges during both the implementation and post-implementation phases. Key areas of focus for a smooth implementation include assembling a skilled team, ensuring bar code accuracy, addressing labeling issues and design, aligning wholesaler identification numbers with site-specific IDs, carefully considering medication location, and updating pharmacy workflow.
Building a team with robust expertise is vital. Including local IT, enterprise IT, and vendor IT representatives on all calls and meetings is crucial to establishing effective back-end processes. Ensure that local pharmacy staff is proficient in the carousel software operations/workflow, as well as savvy in data organization and manipulation.
Enterprise Medication Identification Numbers
Automated medication storage and retrieval systems and ADCs are bar code-driven, as advocated by national pharmacy and safety organizations. It is likely that the existing bar codes will not be correctly associated with the new enterprise medication identification numbers. Aligning bar codes between the hospital and parent health system was the most time-consuming portion of the preparation for our conversion.
Pay special attention to the manufacturer’s outer packaging versus interior packaging, as well as bulk versus unit dose products. The new software may utilize unfamiliar nomenclature, which may cause confusion for your staff. To address this, develop a validated crosswalk to verify names and identification numbers of all medications used in the facility.
Label Printing and Design
Decide which printer will produce ADC labels, patient-specific labels, STAT orders, exception labels (for items not stored in the carousel), etc. In addition, standardize the order of priority for medication orders (ADC pulls, STAT orders, patient-specific orders, returns, etc).
Note that the existing label design may not be the standard in the new system. Items to consider when analyzing label design include state label requirements, bar code association with the hospital’s EMR, as well as any repackaging labels used in the pharmacy.
Wholesaler Identification Numbers
If your organization will change wholesalers or medication identification numbers during the standardization, work with the wholesaler to align the numbers with site-specific IDs. If using an enterprise server, be alert for preferred wholesaler products that may be different from your previously purchased products. A crosswalk is recommended to identify any differences and to create a plan for inventory turnover. Moreover, if you use the carousel for inventory control purposes, be sure that accurate pricing is loaded into the software.
Take extra care when assigning space or rearranging medications for the transition. Separating look-alike/sound-alike medications, high-alert drugs, hazardous medications, and bulk items, while simultaneously ensuring manufacturer recommended weight distribution is a time-consuming task. Work closely with your vendor and IT experts, who can recommend processes to address this issue efficiently. To ensure the longevity of the carousel and reduce the risk of mechanical failure, the ideal setup locates fast-movers close to one another to reduce spin times.
Upgrading to new carousel software may require a change to existing pharmacy workflows. It is critical to understand the constraints and expanded capabilities of the new software and how this will affect the current pharmacy workflow. The new carousel may have more or less capacity, necessitating the creation of “virtual” storage spaces that are physically outside of the system, although the items are tracked within the software. Also, note that some carousel software may have multiple locations for the same medication; these locations can be delineated based on bulk versus unit dose packaging.
Schedule the most experienced staff members to work during go-live. Identify a typically low-volume time period in the pharmacy to begin, and ensure onsite support is available in case challenges arise. The length of time required to complete the implementation process will be unique to the chosen transition approach.
Test all transmission modes. Many vendors will use a test server or test patients prior to actual implementation. Once implementation day has arrived, test inpatient orders, TPNs, chemotherapy, purchasing orders, ADC replenishments, etc. This testing should occur while the full attention and resources of the transition team are available.
Once the implementation is complete, use pre-established metrics to compare the efficiency of the new carousel software to the previous software. Consider evaluating the following metrics:
If your workflow changed or you moved locations, discuss the workflow with staff to determine if additional adjustments are necessary.
Upgrading the automated medication storage and retrieval system in any pharmacy is a substantial project that should not be underestimated. Our facility’s carousel software upgrade proceeded smoothly due to the dedication of the staff members involved and the extensive experience of the system pharmacy team. Pharmacy leadership is encouraged to dedicate all available resources to ensure a successful transition.