By Suzi Birz, principal, HiQ Analytics, LLC
The Institute of Medicine’s (IOM) 1999 publication “To Err Is Human: Building a Safer Health System” reported that medical errors attributed to between 44,000 and 98,000 deaths annually. The report included recommendations for specific strategies to reduce medication errors in an effort to reduce errors in health care and improve patient safety. A reduction in medication errors might come from improving the complex process of getting medications to patients.
The process for a single medication starts with the order and ends with the administration, but involves collection of patient specific data even before a medication is prescribed. Allergy and adverse reaction information must be collected and available. Current medication lists must be compiled and checked when prescribing a medication. Even when all of this information is available, there is a need to improve the process to ensure that providers get the “five rights” right every time: right patient, right drug, right dose, right route and right time.
Automated medication dispense devices have been suggested as a technology that can assist in reducing the rates of medication errors. If you work in a hospital, you may have seen one. They are large cabinets, not unlike vending machines, that dispense medication and track usage.
What is Automated Medication Dispensing?
Janet Harris, RN, CNAA, director of clinical improvement for Cardinal Health’s Center for Medication Safety and Clinical Improvement, compared use of an order management system and automated medication dispensing system to the manual method in the following characteristics:
- In the manual method, physician order is sent to the pharmacy via fax or courier, whereas in the automated method, the physician order is scanned and sent electronically to a computer monitor in the pharmacy.
- In the manual method, the pharmacist accepts the paper order and enters the order into the pharmacy information system, whereas in the automated method, the order is automatically available to input into the pharmacy information system.
- In the manual method, the pharmacist reviews the order, whereas in the automated method, the pharmacist reviews the order, approves it in the system and adds it to the patient’s profile.
- In the manual method, the pharmacist pulls the medication from the shelf, bags and labels it, whereas in the automated method, the system sends information about the patient, medication, dose, route and time via an interface to the dispensing cabinet on the nursing unit.
- In the manual method, the medication is tubed, or sent via courier to the nursing unit, whereas in the automated method, 90 to 95 percent of the medications are stocked in the dispensing unit, allowing the nurse to access the patient’s profile and pull the medication.
Harris called attention to some specific safety features: “A nurse cannot go home with the only keys to a narcotics cabinet, elapsed time from order to administration is measurably reduced and the most experienced person—the pharmacist—is reviewing the order,” she said.
Discontinued orders (d/c) follow a similar workflow. The “d/c” from the physician is scanned and transmitted to the pharmacy. As soon as the pharmacist reviews the discontinue order, he or she updates the patient profile, the data is transmitted to the dispensing cabinets and the medication is eliminated from the patient’s profile.
Vendors have a variety of hardware designs. Some are configured to open and allow the nurse a limited view of available medications and the nurse selects the medication and verifies the start and end counts. Others are more similar to a vending machine and the medication is presented in a drawer.
Restocking requirements are calculated using pre-set minimum/maximums for each drug selected to be stocked in that particular cabinet. Each cabinet is configured to reflect the needs of the unit. The dispensing units are restocked as required by state law, which might include pharmacists and pharmacy technicians as well as a nurse verifier.
Pyxis products from Cardinal Health offer the latest advances in health care automation technology with efforts to improve patient safety and the quality of clinical care through automation technology. The Pyxis dispensing units offer safety measures that address each of the “five rights.”
The Pyxis MedStation system delivers on all the benefits of automation described above, helping improve patient safety and providing process advantages to both pharmacists and nurses.
For instance, a nurse is presented with a list of medications, often pared to those that are due, and can select those medications. The nurse may also receive prompts about the drug, such as “do not crush,” and recent administrations, such as “too soon to give this drug again.”
The flexibility afforded by Cardinal Health’s products allows each organization to determine what interfaces are required to existing clinical systems, what drawer and pocket configuration best suits the nursing unit, what medications to stock in the cabinet and how to set the alerts.
Pyxis MedStation dispensing devices can also be configured for use in outpatient areas and emergency departments.
With an announcement last month, Cerner entered the hardware market with CareAware RxStation. Dawn Iddings, director of Cerner’s Resource Planning Device Group explained that Cerner will be “closing the loop” with nurse-centric dispensing units. All the medication and medication administration data will be stored in one database.
Cerner designed this dispensing device after studying medication workflow from order to bedside administration. The dispensing cabinet is a sealed unit that delivers the exact dose and medication through a bin. This device eliminates the manual selection. This presentation takes another step toward improved patient safety by taking away the opportunity for picking wrong medications caused by look-alike and sound-alike drugs.
The cabinet has a workstation attached, providing immediate access to all patient data stored in the system as authorized to that specific user.
Cerner’s first delivery and implementation will be this summer, with general availability in fourth quarter of 2006.
Chris Woodruff, R.Ph., enterprise pharmacy project lead at Bon Secours Health System Inc., in Marriottsville, Maryland, summarized two benefits: “The JCAHO standard to have a pharmacist review all orders is met and the nurse has near instant access to the medication.”
Woodruff identified some things to consider when implementing automated medication dispensing:
- The systems are not inexpensive.
- Sufficient space is needed in the patient care area; the convenience to the nurse and patient rooms aids in achieving the workflow benefits.
- There is a cost to maintaining inventory in the patient care areas as well as the pharmacy.
- If a patient care unit has a mixed patient population and routinely new admits require a medication that is not stored in the cabinet, room will have to be made by eliminating a drug from one of the storage spaces. The new drug is not available until that restocking is completed.
Take Away Messages
Woodruff noted: “Profile-driven automated dispensing devices are the most effective and safe medication delivery systems available today, enforcing security of the medication use process.”
Harris urged nurses to be involved. “Use technology to support yourself, your nursing processes, your patients and your facility,” she said.
© 2006. AMN Healthcare, Inc. All Rights Reserved.