Even as IV workflow systems continue to offer more advanced capabilities, adoption rates of this technology remain relatively low, particularly in smaller facilities. There is a misconception that this technology is only appropriate for large hospitals. In fact, over half of hospitals with more than 400 beds utilize IV workflow systems, while just 20% of smaller hospitals use these systems.1 However, sterile compounding errors can occur in any IV room, whether they process 5 doses per day or 500.
The Medical University of South Carolina (MUSC) Health Charleston is an 800-bed academic medical center in Charleston, SC that averages 2,000 parenteral doses daily. In 2010, MUSC encountered problems when our diverse patient population required multiple concentrations for drugs such as heparin and insulin. Initially, we implemented manual safety strategies: separating look-alike and sound-alike drugs on our shelves, utilizing TALLman lettering configurations in our information systems and on our labels, and color-coded stickers to reinforce the importance of the right drug and the right concentration. In addition, we restricted certain drug concentrations from purchase, in hopes that inventory control would play a role in preventing medication errors.
Despite these practices, internal measurements suggested a roughly 5% rejection rate by pharmacists at the point of verification, for causes ranging from wrong drug to incorrect amounts in the final container. Given these significant risks, it was clear that our facility needed a better solution. Most importantly, the solution had to support all types of sterile compounds, not just high-risk drugs. Every patient deserves the right dose, not just those receiving chemotherapy or anticoagulants.
DoseEdge from Baxter Healthcare was implemented at MUSC Health in the fall of 2011, as it accommodates adult, pediatric, outpatient, and hazardous workflows within the same system. We now process more than 99% of all parenteral doses through DoseEdge and are approaching our 6 millionth dose through the system. We were able to achieve this milestone in large part due to the system’s versatility and customization options that support the vast majority of sterile preparations. DoseEdge provides our pharmacy with the certainty that the right ingredients are used and administered to the patient; further, we can prove this via the documentation captured for each sterile compound.
Features and Benefits
The DoseEdge system tracks all activity within the system, allowing visibility of issues that may not have been apparent with manual methods. The data provided by the system has given us insight to make additional improvements in our processes covering every dose, and removed the limitations of only capturing what is directly supervised in the moment by a pharmacist.
One of the greatest benefits realized is the hard stops within the system, which detect incorrect ingredients via bar code scanning before a staff member even accesses the vial. Positioning these interventions earlier in the process has decreased our drug waste and improved efficiency and turnaround time. Pharmacists continue to verify doses, and they have fewer errors to detect because the system identifies and halts them well before the verification step. In 2019, our average pharmacist verification rejection rate dropped to just 0.15%. Compared to our previous rejection rate of 5%, we are preparing more drugs quickly and efficiently, while also reducing waste.
In addition to bar code scanning, DoseEdge captures medical-quality images during dose preparation that are stored to verify the ingredients and processes used. These are especially helpful in the event that there is a question at the bedside about how a dose was prepared. Additionally, the system automatically assigns beyond-use dating based on dose specific parameters such as concentration, diluent, storage temperature, and where the dose was prepared. This feature confirms that pharmacy is maximizing in-use time without running the risks associated with manual human calculation. Each of these steps is time stamped, allowing tracking of the workflow from start to finish.
Ongoing Improvements and Success
In our years with the IV workflow system, we encountered process barriers along the way. For example, we did not initially account for ways to manage the use of 12-hour hoods versus fully compliant ISO 5 cleanrooms, or how to insert specific guidance regarding filter needles or line terminations. Recognizing that any dose is high-risk if it is compounded incorrectly, our staff has been able to address and rectify all concerns. As such, DoseEdge is automatically included in the workflow design for any new pharmacy opening within our system. After witnessing the benefits of an IV workflow system almost 6 million times, it has become the standard of care at MUSC.
Medication errors can occur in a facility of any size, and with any drug. The implementation of an IV workflow system helps reduce the occurrence of these errors while allowing visibility into the compounding process, enabling short- and long-term improvements. Pharmacists can save time on verification and can feel confident in the accuracy of the doses prepared, while working to reduce waste in the pharmacy.
Disclosure: After this manuscript was submitted and accepted for publication, the author was offered and accepted a position as pharmacy operations manager at Baxter.