Sterile compounding is one of the most dangerous tasks performed in a hospital pharmacy. To best manage this risk, the Institute for Safe Medication Practices (ISMP) provides recommendations for strong processes that are bolstered by technology, which emphasize that a pharmacist’s check of the technician’s work via the syringe pull-back method is inadequate for ensuring patient safety.1 Rather, they recommend that technology be used to supplement the process, ideally including IV Workflow Software (IVWS). Furthermore, ISMP’s best practice clearly delineates that simply implementing technology is not enough to mitigate risk; once implemented, it must be maintained and improved, stating:
“When technology is in use, it is important that processes are in place to ensure it is maintained, the software is updated, and that the technology is always used in a manner that maximizes the medication safety features of these systems.”1
When utilizing a system that relies on technology there is no such thing as “set it and forget it.” The system must be managed and improved to guarantee its effective use, by engaging in robust reporting, providing access to the data produced, and continually updating the system.
The reports listed in the TABLE provide a comprehensive overview of both the processes and the outcomes of the sterile compounding services provided by the pharmacy. This data is important, but it can also be overwhelming. This is where data prioritization comes in. A key tenet in the improvement world is the Pareto Principle. Known as the 80/20 Rule, it describes the phenomenon wherein most of the delivered value results from a minority of the effort expended. An IVWS is an incredibly complicated system that houses a vast amount of data. It is overwhelming to think about improving the entire compounding system and impossible to fix everything at once, so it is necessary to prioritize where to begin.
Utilizing the correct reports will provide the data you need to focus your efforts on the highest value work. For example, we analyzed our override data and found that over half of our overrides (62%) at one facility were related to two products that were not built correctly in the system. This prompted the leadership team to correct this issue and build the system to reflect the established process. Having the report made it quite clear where to begin making improvements. Two ways to organize your reports include splitting the data into big picture reports and ad hoc reports.
Big Picture Reports
Once you have all the data, it is crucial to create a “dashboard view” of the information. Select one or two reports, distill the data to provide the information needed for an “elevator speech,” or the number(s) that would be displayed in an infographic. These statistics often include basic workload data such as the number of products compounded per month, which could be further detailed as hazardous and non-hazardous. The dashboard should also include big picture safety data, such as the override percentages or the total errors per 1,000 doses for the IVWS. These big picture reports should be run on a routine basis, usually monthly or quarterly.
Ad Hoc Reports
Some reports do not need to be run regularly but do provide helpful data when making decisions. For example, if there is concern about the workload being handled by the department, the IVWS data can be used to dig more deeply into the “right” number of staff that is needed. By reviewing very detailed data, it is possible to quantify the approximate amount of time needed to prepare a dose. This number can be extrapolated out to account for time spent in direct compounding activities. Of course, this would not capture all the preparation time (eg, gathering supplies and materials, garbing, cleaning, etc), but that one statistic may be helpful to begin quantifying the amount of work required in the IV room. Another useful ad hoc report identifies any staff members who represent a disproportionate percentage of the errors or overrides. Understanding the array of available reports provides a multitude of tools to identify problems and uncover new opportunities.
The Power of “Why?”
Another benefit of having the right reports is that it leads to great questions. When data analysis reveals an unexpected metric, it naturally prompts the question of “Why did the override rate go up?” or “Why is the volume increasing steadily?” These “Why” questions can sometimes be dead ends with no single coherent cause revealed, but other times they can launch an important dialogue that results in significant improvements.
By having facts to discuss, rather than opinions or assumptions, the different members of the team can have a more productive conversation. These conversations must include the entire team, from the technicians and pharmacists who are using the system, to the managers who directly oversee the system, and the customers who are affected by the quality of the system. The customers could be the nurses who are waiting on the sterile compounds, or the patients themselves. Alternatively, a pharmacy leader from a higher level in the organization or a leader from the quality department can speak on behalf of the patient. These conversations are most productive when everyone involved has access to accurate data.
Errors Are Opportunities
Every error represents an opportunity. When a manager dives into the data, the ideas for improvement often present themselves immediately. For example, every override represents a time where a technician or pharmacist tried to use the system but could not, resulting in a workaround. Errors can be an opportunity for the following improvements:
Using Anecdotal Evidence
While data is essential, stories are often more influential in achieving behavior change. Humans gravitate toward stories and narratives, and while it is important to make data-based decisions, often, an actual patient case can provide the human connection to the numbers. As you are reviewing the data, it is helpful to call out errors that were prevented. For example, you may find that the wrong product was scanned, and the system caught it. These stories may be sourced from the data, or from information that a technician or pharmacist shares with you. Regardless, these anecdotes help to round out the data that you acquire from a robust IVWS.
There are common pitfalls in the data mining process to watch out for, including:
My dad always says that “Most of life comes down to management.” An IVWS is a crucial component of a pharmacy’s safety system; as such, it must be well managed. Savvy use of the reports will ensure that the system is working as intended and that its utility is maximized. Implementation is the first step, but excellent management through the use of data is what will allow the IVWS to continuously improve the effectiveness of the entire sterile compounding process. By describing workload, reviewing errors, and telling stories, a successful manager can provide the safest system possible for the patients who depend on us.
This research was supported (in whole or in part) by HCA Healthcare and/or an HCA Healthcare affiliated entity. The views expressed in this publication represent those of the author(s) and do not necessarily represent the official views of HCA Healthcare or any of its affiliated entities.
Nathan Hanson, PharmD, MS, BCPS, is the division director of pharmacy operations for the HealthTrust Purchasing Group. He holds a doctor of pharmacy degree from Drake University, and a master’s degree in pharmacy administration from the University of Kansas. Nathan completed his Health System Pharmacy Administration PGY1/PGY2 residency at the University of Kansas Health System. In his current role, he serves the seven Kansas City hospitals in the HCA MidAmerica Division in the areas of controlled substance management, sterile compounding, Joint Commission readiness, pharmacy distribution, and leadership development.
To recognize the value of reporting data, it is essential to understand three key terms:
To provide daily QC, monthly QA, and continual QI, a broad constellation of reports is required.