Applying ISMP best practices and leveraging data to drive a safe and

efficient med-use process

Marian M. Rhoads, R.Ph., M.S.Director of Pharmacy

Saint Joseph Medical CenterReading, PA

Objectives

Illustrate the Automated Dispensing Cabinet adaptations to meet the ISMP guidelines for safe use.

Show how the Med Analytics data can be utilized to increase staff productivity, improve inventory control and minimize outdates and waste.

Provide diversion prevention tactics for pharmacy and nursing.

Saint Joseph Medical Center is a 211-bed facility located in Reading, PA

Major service linesCardiologyOncologyOrthopedicsNeurosciences

Pharmacy Department 24/7 CoverageDirector

Operations ManagerClinical CoordinatorMedication Safety PharmacistPGY-1 Resident10 FTE Staff pharmacists9.8 FTE technicians

Problem

How do you optimize workflow in the pharmacy, maximize real estate in the automated dispensing cabinet and integrate with the pharmacy information system while meeting the requirements of the various regulatory bodies in an effort to provide safe patient care?

ISMP Guidelines

The ISMP gathered in the Spring of 2007 a multidisciplinary group of nurses, pharmacists, and vendor representatives which led to the development of 12 core processes for the safe use of automated dispensing machines.

These 12 core processes can be found on their website: http://ismp.org/

Ideal Conditions for the Use of Automated Dispensing Cabinets (ADCs)

Medication rooms are only for medication related activities.

Changed Drawer Configurations from Carousel drawers to Pyxis CUBIE® drawers.

There is adequate space for MARs, adequate lighting and cabinets are secure when not in use.

Medication rooms are accessed through a badge reader.

Ideal Conditions for the Use of Automated Dispensing Cabinets (ADCs)

Eliminate interruptions from patients and visitors.

Phone is on wall near ADC. Refrigerator is in close proximity of ADC. Stations are mirrored on the floor if one of the

stations would go down.

Respiratory Drawers for Nebulizers

Medication Room

Bins are used for large volume IV solutions and IV meds that do not require refrigeration.

ADC Location in Medication Room

ADCs are located in a quiet environment with access to a phone if a discrepancy occurs between the screenand paper MAR.

Drug Removal Process

Space exists on the AUX for the nurse to have the MAR available during removal.

ADC System Security Password access sheets with assigned areas and

the completed tutorial for the Pyxis®

MedStation ® must be completed prior to receiving access.

Agency are assigned an ID but must be activated each time they arrive for work.

Students are activated by their instructors and do not have access to controlled substances.

The only physicians that have access are the anesthesiologists and only to the Pyxis®

Anesthesia system.

ADC System Security

Automated terminations come to the Director of Pharmacy daily from Human Resources.

Quarterly reports to nurse managers. Access is limited to certain providers. When a person is terminated, a standard

template is used.

Use Pharmacy-Profiled ADCs

Profiled machines are located on all our nursing floors as the drug distribution system and in our Infusion Center, Outpatient Interventional Unit, Radiology Department for controlled substances, Birth Center and now working on our Emergency Department.

High alert medications are not on override. Clinical data categories are placed on certain items.

Use Pharmacy-Profiled ADCs

The location of the medication has specified pockets or is grayed out if it is refrigerated or located in the patient specific bins in the medication room.

There is access to Lexi-comp on each machine so the nurse can review administration information.

ADC Screen Information

The two patient identifiers, patient name and date of birth, appear on the screen in addition to location and allergies.

Medication is identified the same way on the Pyxis® MedStation® system screen, the MAR and in the pharmacy system.

The dose in the pharmacy system defaults onto the Pyxis® MedStation® system screen.

ADC Screen Information

Tall Man lettering is used as well as visual queues are used for look-alike/sound-alike medication pairs.

Special preparation instructions are listed on the full screen including any sliding scale parameters.

Removal by time is advocated to avoid administration of medications at the wrong time.

Tall man lettering for insulin

Sliding scales for Insulin Orders

Look-Alike/Sound Alike Medications

Visual queues are used with stop signs in both the closed and open position.

Tall Man lettering appears on the Pyxis®

MedStation® screens and the MARs to distinguish these medications.

Labeling of Bins in Towers

Tall Man lettering used on bins in Towers.

Look-alike/sound-alike drugs are not stored behind the same doors in a tower but are separated.

CT Scan

Contrast Agents are stored in a tower in Radiology.

Same agent in various sizes behind single door. Agents are not mixed on the shelves.

Select and Maintain Proper ADC Inventory

As part of the formulary review process, the P&T Committee decides if a medicationwill be stored in the Pyxis® cabinet or not.

Subsequent modifications to both inventory decisions and override reviews are reviewed by both the Medication Safety Committee and the P&T Committee.

Select and Maintain Proper ADC Inventory

Chemotherapy drugs are excluded from the ADC.

Drugs that are considered hazardous pharmaceutical waste (RCRA waste) and need to be disposed of in a different waste stream are handled through visual cues.

Identification of RCRA Waste

Pyxis CUBIE® pocket will have a static cling which states to dispose of contents in black bucket waste.

Reporting to Increase Productivity

Med Analytics is used to determine medications with low usage that can be eliminated from storage or items that should not be stocked in certain machines.

The pharmacy secretary ran reports every Thursday to document on an Excel spreadsheet who had done their inventory and calculate the % compliance per month. Now we distribute the report from the Med Analytics reporting.

Controlled Substance Inventory

Example of Use of Med Analytics Data

On a med-surg nursing unit we found that fenofibrate 160 mg had been loaded and unloaded 6 times in a month in both machines on the unit. That dose was made standard in those machine.

This list is reviewed each month and any loads/unloads that exceed three per month those items are marked as standard stock.

Improvements in Loads/Unloads

Reporting has shown the improvement in loads/unloads. Units P1N1 and P1N2 have decreased from 33 each to 24 and 25 respectively.

Meditech Customer Defined Screen to Identify Infrequently Used Medications

Select and Maintain Proper ADC Inventory

Limit 5 or 10 tablets in pockets that contain high alert medications.

Perform monthly pharmacy audits of the machine as part of nursing unit reviews.

Turn on outdate tracking to manage expired drugs.

Select Appropriate ADC Configuration

There are at least three extra drawers of Pyxis CUBIE® pockets per machine to limit access to medications.

Matrix drawers are used for IV solutions that are used for diluents and items such as antacids or guaifenesin.

Drugs prone to diversion are in lidded Pyxis CUBIE® pockets with blind counts.

Paralyzing agents are in kits or boxes in the appropriate unit.

Matrix Drawers

Matrix drawers are used for bulk items or diluents to mix drugs with limited stability.

Paralyzing Agents in Emergency Department

Rapid Sequence Intubation Boxes and Anesthesia Deep Sedation Boxes are located in the ED Pyxis® MedStation®

system

Select Appropriate ADC Configuration

The top drawer of each Pyxis® MedStation®

system is a matrix drawer where bulk medications, patient’s own meds or non-formulary drugs are stored.

Only PCA keys or refrigerator keys are kept in the Pyxis® MedStation® to track who has removed them last.

The keys are a return to pocket item whereas the meds are a return to the return bin.

Bulk Medication And Patient’s Own Medication Storage

The top drawer of each machine is labeled with the room numbers of the unit.

Meds are accessed through the override function picking “Bulk Med” as the med choice on override.

Allows the pharmacy to track access to bulk meds.

Pharmacy Process For Safe ADC Restocking

Visual queues are used for Tall Man lettering and hazardous waste.

Critical lows are printed to avoid stock outs. Pharmacy packages and loads all ½ tablets. All

half-tabs are built as such in our pharmacy information system also.

Bar code scanning is utilized to refill controlled substances and high alert medications such as heparin vials and insulin.

Pharmacy Process For Safe ADC Restocking

All drug names are the same for the pick areas, pick lists, and refill screens.

Inventory requests for additions to the ADCs go to the Medication Safety Committee and P&T for approval.

Check process includes bagging the medications after checking.

Pharmacy Process For Safe ADC Restocking

Monthly nursing unit reviews and medication error reporting are used to detect fill errors that may occur.

An asterisk is placed next to the generic name of the drug if it is to be loaded in a Pyxis CUBIE®

pocket so these drugs do not get placed in a matrix drawer.

Identifying ISMP High Alert MedsISMP High Alert Category SJMC Formulary Items

adrenergic agonists, IV epHEDrineepINephrinePhenylephrine

adrenergic antagonists, IV PropanololMetoprololLabetolol

anesthetic agents, general,inhaled and IV Propofol

KetamineEtomidate

Reference: ISMP List of High Alert Medications. http://ismp.org/Tools/highalertmedications.pdf

An asterisk is placed after the generic name on the console that prints on all load bulletins and alerts the pharmacist and technician that the medication needs to be pended and loaded in a Pyxis CUBIE® pocket.

Reporting to keep Pyxis® in Sync with Pharmacy Information System

Diversion Prevention in the Pharmacy

The locks were changed out from the standard locks.

Numbered pull tabs are located on the top of the electronic panel to insure integrity and alert us to entry through the control panel.

Pharmacists do not have inventory capability.

Pharmacy Diversion Large external return bin behind the return door

for outdates and recalls and patient’s own meds not returned on discharge.

The slips for returns are stapled to the bags and dropped in the outdate external bin for reconciliation with the reverse distributor.

Return bin emptying requires a witness.

Nursing Diversion Prevention Techniques

Require weekly counts of all controlled substances.

Distribute the Diversion Watch List and Cancelled Transaction Report to the Nurse Managers to observe staff ’s behaviors, charting and pain control of patients.

Minimize the controlled substances on override. Require waste upon removal with witness

actually watching the waste process.

Printer for Bar coded Labels

Pyxis® CIISafe prints bar coded labels which are used for the controlled deliveries rather than delivery slips.

Controlled Substance Refills Utilizing the Bar Coding Feature

Bar coded labels are generated and the drugs are pulled from the Pyxis® CIISafe and placed in the zip-lock bags for refill one at a time.

Bar code scanning at station

Bar code scanning is done at the station for refilling of controlled substances. The technician is not refilling from a screen selection.

Conclusions Continue to implement safe guidelines for ADC

use in our institution by reviewing ISMP quarterly action agendas, internal medication errors, and data supplied through the Med Analytics reports.

Continue to refine policies and procedures as diversion is detected both from a pharmacy and nursing standpoint.

Make adaptations to conform to new medication management standards of TJC or National Patient Safety goals as they emerge.

Continue to monitor override lists as they relate to any medication errors.

Next Steps Convert all the ER machines from non-profile

to profile machines with pharmacist review of all orders.

Begin looking at making the Post Anesthesia Care Unit a profile machine.

Continue to utilize the Med Analytics data to improve productivity, decrease the amount of medications that outdate and remove items not being utilized that are not antidotes or code medications.