IV workflow management systems (IVWMS) have been identified by ISMP since 2013 as the preferred way for verifying compounded medication preparation.1 These systems help safely streamline several processes. Bar code scanning, consistent medication preparation, volumetric and/or gravimetric preparation verification, beyond use date standardization, and remote verification are some benefits of IV workflow implementation.2 Given these benefits, St. Jude Children’s Research Hospital (SJCRH) made the case for implementing IV workflow based on the need for increased safety checks for high-risk, chemotherapy preparations.
IV workflow management software was first implemented for all chemotherapy preparations in the inpatient areas and the outpatient infusion center in 2010. In 2016, SJCRH implemented a separate IVWMS in non-hazardous IV compounding areas for preparation of stock bags and medication tracking. This same technology was also used for nonsterile compounding verification documentation. It was eventually expanded for verification of non-hazardous patient specific compounding in 2021. The decision to use two disparate systems was driven initially by the tracking system implementation, but then later retained as an interim measure while our hospital began the process of an electronic health record conversion that would lead to conversion to another IVWMS. Despite using two systems, SJCRH created universal policies and procedures for IVWMS identification and implementation that can be used across a multitude of IVWMS.
Evaluating System Options
IVWMS on the market provide a variety of options for compounded product verification. When determining which IVWMS will best fit your organization, the following elements should be central to your evaluation3, 4:
Once a system is identified, it may be necessary to justify the cost of the technology, in which case a multidisciplinary approach is recommended. At SJCRH, the operations team worked closely with the medication safety team, patient care, and the quality department to overcome any barriers related to cost of implementation.
Education and Training
After choosing an IVWMS, it is essential to create standard operating procedures (SOPs) prior to implementation to guide workflow and delineate expectations (see TABLE 1). Most likely, these SOPs will require updating post-implementation; however, having a uniform process for all staff to use as a reference at the time of go live is essential.
SJCRH previously created a list of expected photographs and documentation with the implementation of our initial IVWMS. When expanding to non-hazardous patient specific medications, we utilized those existing expectations. This standardization helped to ease the transition to a new system and streamlined verification procedures.
When planning education and training for our most recent implementation of IVWMS for nonhazardous patient specific medications, we reviewed and shared existing literature on implementation to ensure that we were addressing key points in system workflow build and in education/training.1-6 In the weeks leading up to implementation, our team utilized training videos and live demonstrations to familiarize staff with the process. During the first week of go live, we had key staff placed with the pharmacists and with the technicians to help provide just in time training on the process and to help manage any issues. TABLE 2 describes the change management steps that were used during implementation.
Impact of Workflow
Having utilized IV workflow for chemotherapy for 11 years, our staff had already incorporated remote product checking into their process. However, as we expanded the scope of IVWMS, we had to address the following workflow impacts:
Cleaning and Environmental Monitoring
As part of the process for creating and updating SOPs, we outlined the cleaning requirements for the IVWMS equipment. Based on the manufacturer’s recommendations, the iPads could only be cleaned using sterile isopropyl alcohol, but more stringent cleaners could be used for some of the other equipment. We used smoke studies to assign compounding and IVWMS documentation zones within the primary engineering controls. Additionally, as part of our USP <800> compliance plan, we conduct hazardous drug surface sampling (eg, wipe sampling) every 6 months on our IVWMS equipment.
Leveraging IVWMS Data
The data from both types of IVWMS feeds into a dashboard. Since we have disparate systems, the preparation and verification volumes feed into this one dashboard to showcase collated data, but it also allows for data to be filtered by system and by compounding area. We use this data to review staffing alignment with workload, evaluate if workload can be safely completed by pharmacy technicians based on prep time per product per hour, and to report to our executive leadership committee on preparations, medication costs, and waste.
Our hospital is in the process of transitioning to a new electronic medical record which will lead to a third IVWMS implementation. We will execute the eight phases described above for workflow planning. The conversion also spurred our teams to complete additional evaluations of hardware and product design.
As there are several IVWMS available, it is important to carefully review each system to determine the best fit for your facility’s needs. In some cases, more than one system may be appropriate. Developing a strong set of SOPs and training procedures prior to implementation is the key to a successful implementation regardless of the technology chosen.
Cindy Brasher, PharmD, MS, BCPS, BCSCP, is the manager of compounding at St. Jude Children’s Research Hospital (SJCRH). She received her PharmD from the University of Tennessee College of Pharmacy, completed the health systems pharmacy administration PGY1/PGY2 residency program at Mission Hospital in Asheville, North Carolina, and a master’s in pharmacy administration through the University of North Carolina Chapel Hill. Currently, Cindy is serving on the ASHP Section Advisory Group on Compounding, ACCP Clinical Administration PRN, and the UT Alumni Association Board of Governors.
Kevin Smith, PharmD, HMBA, BCPS, is an EHR application analyst for Epic’s Willow Inpatient at SJCRH. He earned his PharmD from the University of Tennessee College of Pharmacy, completed a PGY1 at The Regional Medical Center at Memphis, and earned his Master of Business Administration in Healthcare Management from Christian Brothers University.
Calvin C. Daniels, PharmD, PhD, BCPPS, DPLA, is an EHR application analyst at SJCRH. He received his PhD in microbiology at the University of Alabama at Birmingham and his PharmD from the University of Tennessee College of Pharmacy. He completed a PGY1 Pharmacy Practice residency at Children’s of Alabama and a PGY2 Medication-Use Safety Residency at SJCRH.