Automation in PharmacyAutomation in Pharmacy

Lobna Al Juffali,MscLobna Al Juffali,Msc

IntroductionIntroduction

Automation Automation

any technologyany technology , machine or device linked , machine or device linked to or controlled by a computer and used to to or controlled by a computer and used to do workdo work

Automation is designed to streamline and Automation is designed to streamline and improve the accuracy and efficiencey of improve the accuracy and efficiencey of the the medication use processmedication use process

IntroductionIntroduction

As the profession has accepted increased responsibility for As the profession has accepted increased responsibility for improving patient outcomes through implementation of improving patient outcomes through implementation of pharmacists patient care services , automation has been pharmacists patient care services , automation has been relied upon to free the pharmacist from technical tasksrelied upon to free the pharmacist from technical tasks

IntroductionIntroduction

Use of these automated medication management systems have been shown to reduce medication errors by between 26% and 81% depending on the setting in which the machines are used.

(These high rates of error reduction are achieved when medication orders are reviewed and profiled by pharmacists prior to administration).

Goals for the use of automationGoals for the use of automation

Reducing costs Reducing costs

Improving operating efficienciesImproving operating efficiencies

Growing revenuesGrowing revenues

Enhancing safety and qualityEnhancing safety and quality

Integrating and managing dataIntegrating and managing data

Providing outstanding customer serviceProviding outstanding customer service

Factors that led to AutomationFactors that led to Automation

Shortages of qualified pharmacists and Shortages of qualified pharmacists and technicianstechnicians

Shrinking operating budgetsShrinking operating budgets

Automation

Advantages:Improve efficiency( Reduce pharmacy staff and work load)Reduce pharmacy staff and work load)Improve accuracy, reduce errorsImprove documentationAuthorized access only, enhance security Reduce job stress and staff turnover Shorten med pass time for nurses/ caregivers

Disadvantages:Additional training and technical helpDowntime, system failure and inflexibility Cost and space issues

Medication use processMedication use process

Consists of five domains:Consists of five domains:

1.1. Purchasing/ inventory managementPurchasing/ inventory management

2.2. Prescribing/medication determinationPrescribing/medication determination

3.3. Medication preperation, dispensing, and Medication preperation, dispensing, and counseling counseling

4.4. Medication administrationMedication administration

5.5. Patient monitoring /assessment Patient monitoring /assessment

Technologies And Automated Technologies And Automated Devices Applied Throughout The Devices Applied Throughout The

Medication –Use ProcessMedication –Use ProcessPrescribingPrescribing

Clinical descion support soft wareClinical descion support soft wareComputerized prescriber order entryComputerized prescriber order entry

DispensingDispensingCentrilized robotic dispensing technologyCentrilized robotic dispensing technologyCentralized narcotic dispensing and inventory tracking devicesCentralized narcotic dispensing and inventory tracking devicesDecentrilized automated dispensing devicesDecentrilized automated dispensing devicesUnit dose medication repacking systemsUnit dose medication repacking systems

AdministrationAdministrationBar code medication administration technologyBar code medication administration technology

MonitoringMonitoringElectronic clinical documentation systemsElectronic clinical documentation systems

Unit Dose System

First used in hospitals in 1960’s

Used to decrease medication administration errors by nursing staff, and reduce medication waste

Standard of practice in hospital setting today

Used in some skilled nursing facilities

Unit doseUnit dose

Medication Medication that is dispensed in a package that is that is dispensed in a package that is ready to administer, directly, to the ready to administer, directly, to the patient.Medication/Products currently being unit patient.Medication/Products currently being unit dose packaged and bar coded:dose packaged and bar coded:

1.Solid dose pouches1.Solid dose pouches 2.Power fill pouches2.Power fill pouches 3.Strip packs3.Strip packs 4.Oral dose syringe fill 4.Oral dose syringe fill 5.Sterile Injectable syringe fill5.Sterile Injectable syringe fill6.Liquid unit dose6.Liquid unit dose

Unit Dose Systems

Unit Dose examples:

Manufacturer’s unit dose packs/cards

Medication cassettes

Unit Dose Systems

Advantages:Improve accuracy, less errorsEasy to track usageLess nursing time at dispensingLess wastage, savings to facility and patient

Disadvantage:More pharmacy processing time and equipment costRequires more storage space and cassette costNo cost savings to pharmacyLimit nursing processing and checking ability

Decentralized Automated Decentralized Automated Dispensing DevicesDispensing Devices

unit base dispensing cabnits, are secure unit base dispensing cabnits, are secure storage cabinets capable of handling most storage cabinets capable of handling most unit dose and some bulk (multiple –dose) unit dose and some bulk (multiple –dose) medications.medications.

Automated dispensing systemsAutomated dispensing systems

are drug storage devices or cabinets that electronically are drug storage devices or cabinets that electronically dispense medications in a controlled fashion and track dispense medications in a controlled fashion and track medication use.medication use.

Their principal advantage lies in permitting nurses to Their principal advantage lies in permitting nurses to obtain medications for inpatients at the point of use. obtain medications for inpatients at the point of use.

Automated dispensing systemsAutomated dispensing systems

These automated dispensing systems can be stocked by These automated dispensing systems can be stocked by centralized or decentralized pharmacies.centralized or decentralized pharmacies.

Centralized pharmacies prepare and distribute Centralized pharmacies prepare and distribute medications from a central location within the hospital.medications from a central location within the hospital.

Decentralized pharmacies reside on nursing units or Decentralized pharmacies reside on nursing units or wards, with a single decentralized pharmacy often wards, with a single decentralized pharmacy often serving several units or wards. serving several units or wards.

These decentralized pharmacies usually receive their These decentralized pharmacies usually receive their medication stock and supplies from the hospital’ s medication stock and supplies from the hospital’ s central pharmacy. central pharmacy.

Do we centralize or decentralizeDo we centralize or decentralize

centralized storing and packaging and centralized storing and packaging and decentralized distribution.decentralized distribution.

Automated Medication Dispensing Automated Medication Dispensing DevicesDevices

Small systems:Pyxis medstationBaxter ATCScript-pro 200

Larger systems:Baker cellsBaxter international

The Baxter ATC-212 dispensing The Baxter ATC-212 dispensing systemsystem

uses a microcomputer to pack unit- dose uses a microcomputer to pack unit- dose tablets and capsules for oral tablets and capsules for oral administration.administration.

It is usually installed at the pharmacy. It is usually installed at the pharmacy.

The Baxter ATC-212 dispensing The Baxter ATC-212 dispensing systemsystem

Medications are stored in calibrated canisters that are Medications are stored in calibrated canisters that are designed specifically for each medication. designed specifically for each medication.

Canisters are assigned a numbered location, which is Canisters are assigned a numbered location, which is thought to reduce mix-up errors upon dispensing. When thought to reduce mix-up errors upon dispensing. When an order is sent to the microcomputer, a tablet is an order is sent to the microcomputer, a tablet is dispensed from a particular canister. dispensed from a particular canister.

The drug is ejected into a strip-packing deviceThe drug is ejected into a strip-packing device

where it is labeled and hermetically sealed.where it is labeled and hermetically sealed.

The Pyxis Medstation, Medstation The Pyxis Medstation, Medstation Rx, and Medstation Rx 1000Rx, and Medstation Rx 1000

are automated dispensing devices kept on are automated dispensing devices kept on the nursing unit.the nursing unit.

These machines are often compared to These machines are often compared to automatic teller machines (ATMs). automatic teller machines (ATMs).

The Pyxis Medstation, Medstation The Pyxis Medstation, Medstation Rx, and Medstation Rx 1000Rx, and Medstation Rx 1000

The Medstation interfaces with the pharmacy computer.

Physicians’ orders are entered into the pharmacy computer and then transferred to the Medstation where patient profiles are displayed to the nurse who accesses the medications for verified orders.

Each nurse is provided with a password that must be used to access the Medstation.

Currently ,nurses select the patient required and then select the drug required from a list of all drugs available in the unit. The units can also be run in ‘profile mode’ where the pharmacist reviews medication orders and profiles a list of medications currently prescribed for the patient and nurses then select from that list.

The Pyxis Medstation, Medstation The Pyxis Medstation, Medstation Rx, and Medstation Rx 1000Rx, and Medstation Rx 1000

Pharmacists or technicians keep these Pharmacists or technicians keep these units loaded with medication. Charges are units loaded with medication. Charges are made automatically for drugs dispensed made automatically for drugs dispensed by the unit.by the unit.

Earlier models had sufficient memory to Earlier models had sufficient memory to contain data for about one week, and contain data for about one week, and newer models can store data for longer newer models can store data for longer periods.periods.

Advantages of the Pyxis® System

1. Nursing staff are guided to the correct drawer and pocket to access required medicine. Medicines which sound similar or have multiple strengths are loaded indifferent drawers of the machine. Access is restricted to only one drawer/door at a time.

2. Increased stock holdings close to patients

3. Ward stock levels are monitored by the pharmacy computer and stocks topped up before drugs run out, reducing delay to patients and staff frustration.

4. Management of controlled medication.

Advantages of the Pyxis® System

5. Possible to add additional safety features for individual high risk drugs for example,must be authorised by two staff, soft lock outs to prevent duplicate administrations (reduces risk of multiple administrations when staff forget to sign for medications), advice given or required information recorded at time of dose removal.

Advantages of the Pyxis® System

6.Use of profile mode enables constant monitoring by pharmacist of drug dosages/interactions.It also reduces the amount of interpretation required by nursing staff at time of dose removal.

7. Real time data collection for drug usage which can be advantageous for audit and other quality improvement processes.

Disadvantages of System

1. May be frustrating to get drugs in an emergency.

2. While there are incremental safety benefits running in non-profile mode, most of the research has been at sites where the machines have been run in profile mode.

Script-pro 200

Usually installed in the pharmacy

Fills vials directly from dispensing cells

Can print prescription and auxillary labels

Baker cells

In pharmacy system

Counts a 30-count vial in 3-5 seconds

Option to use software that dispenses medication after a prescription is canned

The medication administration record (MAR):

Monthly record of dispensed medications for each specific patientList of medications with administration timesMedication dispensing nursing/ facility staff initials/ signaturesMay include list of prn medicationsTracks missed doses and changes in medications

Bar Code Medication Bar Code Medication Administration (BCMA)Administration (BCMA)((

is a pointis a point--ofof--care software solution that care software solution that addresses the serious issue of inpatient addresses the serious issue of inpatient medication errors by electronically medication errors by electronically validating and documenting medications validating and documenting medications for inpatientsfor inpatients..

Bar Code Medication Bar Code Medication Administration Administration ((BCMABCMA))

It ensures adherence to the “5 Rights” of It ensures adherence to the “5 Rights” of medication administration (Right Patient, medication administration (Right Patient, Right Route, Right Dose, Right Time, Right Route, Right Dose, Right Time, Right Medication). and visually alerts staff Right Medication). and visually alerts staff when the proper parameters are not metwhen the proper parameters are not met..

Bar coding in the pharmacyBar coding in the pharmacy

Pharmacist Review & Verification

Order Fulfillment Order Fulfillment & Verification& Verification

Final scan

Bar Code Medication Bar Code Medication Administration (BCMAAdministration (BCMA

AA.. Patient name Patient name

B.B. Medication name Medication name

and strengths and strengths

C.C. Time of Time of

administration administration

D.D. Bar code for Bar code for

bedside scanning bedside scanning

At bed sideAt bed side

DisadvantageDisadvantage

Bar codes mismatch with drug, dose and Bar codes mismatch with drug, dose and patient at timespatient at times

Bar code sometimes function erroneouslyBar code sometimes function erroneously

Unable to scan bar codes properly at Unable to scan bar codes properly at timestimes

Unreadable bar codesUnreadable bar codes

Time consuming Time consuming

Computerized Physician Order Computerized Physician Order Entry (CPOE)Entry (CPOE)

clinical information system that enables a patient’s care clinical information system that enables a patient’s care provider to enter an order for a medication, clinical provider to enter an order for a medication, clinical laboratory or radiology test, or procedure directly into the laboratory or radiology test, or procedure directly into the computer. computer.

The system then transmits the order to the appropriate The system then transmits the order to the appropriate department, or individuals, so it can be carried out. department, or individuals, so it can be carried out.

Computerized Physician Order Computerized Physician Order Entry (CPOE)Entry (CPOE)

The most advanced implementations of The most advanced implementations of such systems also provide real-time such systems also provide real-time clinical decision support such as dosage clinical decision support such as dosage and alternative medication suggestions, and alternative medication suggestions, duplicate therapy warnings, and drug-drug duplicate therapy warnings, and drug-drug and drug-allergy interaction checking." and drug-allergy interaction checking."

AdvantagesAdvantages

Replaces hand-written orders (legibility, completeness, Replaces hand-written orders (legibility, completeness, readily and quickly accessible, improved communications readily and quickly accessible, improved communications between physician and pharmacist; no delay or loss ...) between physician and pharmacist; no delay or loss ...)

Supports ready access to patient data and patient Supports ready access to patient data and patient assessment assessment

Can help improve patient safety and prevent medical Can help improve patient safety and prevent medical errors and adverse drug events by checking the dosage errors and adverse drug events by checking the dosage etc. etc.

Supports improved recording, data trails, quality Supports improved recording, data trails, quality assurance and error awareness and reporting assurance and error awareness and reporting

AdvantagesAdvantages

Potential to improve efficiency and resource usage by Potential to improve efficiency and resource usage by integrating different departments - laboratory, imaging, integrating different departments - laboratory, imaging, nursing and medication recordsnursing and medication records

Cost-effectiveness benefits: Cost-effectiveness benefits:

Can reduce additional and often avoidable costs (clinical, Can reduce additional and often avoidable costs (clinical, litigation ...) that can result from medication errors; litigation ...) that can result from medication errors;

Can show test and medication costs - potential to reduce Can show test and medication costs - potential to reduce prescription costs; prescription costs;

Can reduce the number of duplicate tests; Can reduce the number of duplicate tests;

disadvantagesdisadvantages

CostCost

Risk of a system generating medication errors Risk of a system generating medication errors ee..gg. . through incorrect configuration or physician through incorrect configuration or physician input input

Systems may need medical terminologies not in Systems may need medical terminologies not in local use local use

User resistance to introduction of computerUser resistance to introduction of computer--based technologies based technologies

Clinical Decision Support Systems Clinical Decision Support Systems (CDSSs)(CDSSs)

Clinical Decision Support Systems are Clinical Decision Support Systems are ""active knowledge active knowledge systems which use two or more items of patient data to systems which use two or more items of patient data to generate casegenerate case--specific advicespecific advice"  "  [Wyatt J, [Wyatt J, SpiegelhalterSpiegelhalter D, 1991] D, 1991]..

Clinical DSSs are typically designed to integrate a Clinical DSSs are typically designed to integrate a medical knowledge base, patient data and an inference medical knowledge base, patient data and an inference engine to generate case specific advice. engine to generate case specific advice.

Clinical Decision Support Systems Clinical Decision Support Systems (CDSSs)(CDSSs)

drug doses, routes, and frequencies. drug doses, routes, and frequencies. drug allergy checksdrug allergy checksdrug-laboratory value checks,drug-laboratory value checks, drug-drug interaction checks,drug-drug interaction checks, providing reminders about corollary providing reminders about corollary orders (eg, prompting the user to order orders (eg, prompting the user to order glucose checks after ordering insulin) glucose checks after ordering insulin) drug guidelines to the physician at the drug guidelines to the physician at the time of drug orderingtime of drug ordering

Functions of CDSSFunctions of CDSS

Four key functions of electronic clinical decision support systems are Four key functions of electronic clinical decision support systems are outlined in outlined in ::

1.1. "Administrative: Supporting clinical coding and documentation, "Administrative: Supporting clinical coding and documentation, authorization of procedures, and referrals. authorization of procedures, and referrals.

2.2. "Managing clinical complexity and details: tracking orders, referrals "Managing clinical complexity and details: tracking orders, referrals follow-up, and preventive care.follow-up, and preventive care.

3.3. "Cost control: Monitoring medication orders; avoiding duplicate or "Cost control: Monitoring medication orders; avoiding duplicate or

unnecessary tests.unnecessary tests.

4.4. "Decision support: Supporting clinical diagnosis and treatment plan "Decision support: Supporting clinical diagnosis and treatment plan processesprocesses

Role of Pharmacist

Develop policy for dispensing, delivery and storage of medication in facilities

Formulate quality assurance policy for drug distribution

Track usage and monitor medication usage and returns, including initial doses, house supply stock

Monitor the use of controlled substance: record keeping of supply, usage and disposal

Role of Pharmacist

Provide patient specific recommendations on drug therapy and medication needs

Ensure accuracy of Medication administration record MAR and documentation

Provide drug information to staff, residence, family and other health care providers

Ensure compliance with all applicable laws and regulations governing drug distribution