Design, implementation, and evaluation of a thrice-daily cartfill process.

PURPOSE: Efficiencies achieved through a redesign of the central pharmacy cartfill process at a large academic medical center are reported. SUMMARY: In an initiative to expand clinical pharmacy services in a budget-neutral manner, pharmacists at the University of Wisconsin Hospital and Clinics (UWHC) led the transition from a once-daily to a thrice-daily medication cartfill model designed to better align pharmacy operations with patterns of medication ordering, delivery, and order discontinuation. A pre-post analysis demonstrated several benefits of the shift to thrice-daily cartfill, including a 32.7% decrease in the mean daily number of extemporaneously prepared oral doses. Overall, the new cartfill process resulted in reduction in lead times for three of four peak delivery periods, roughly a 55-65% reduction. During the postimplementation period, the frequency of requests for missing medication doses through the electronic medical record (EMR) system increased from 1.13% to 1.43%; however, this increase may have been the result of improved nurse adherence to EMR protocols for requests for missing medications. CONCLUSION: Implementation of a thrice-daily cartfill process and ancillary changes at UWHC resulted in a 2.1% increase in cartfill doses dispensed, a 44.1% decrease in first doses dispensed, and a 42.9% decrease in the number of medications returned to the central pharmacy. This resulted in a reduction in waste within pharmacy operations and allowed for redeployment of two technician full-time equivalents to expand pharmacy services.

Comparison of a hybrid medication distribution system to simulated decentralized distribution models.

PURPOSE: The results of a study to estimate the human resource and cost implications of changing the medication distribution model at a large medical center are presented. METHODS: A two-part study was conducted to evaluate alternatives to the hospital's existing hybrid distribution model (64% of doses dispensed via cart fill and 36% via automated dispensing cabinets [ADCs]). An assessment of nurse, pharmacist, and pharmacy technician workloads within the hybrid system was performed through direct observation, with time standards calculated for each dispensing task; similar time studies were conducted at a comparator hospital with a decentralized medication distribution system involving greater use of ADCs. The time study data were then used in simulation modeling of alternative distribution scenarios: one involving no use of cart fill, one involving no use of ADCs, and one heavily dependent on ADC dispensing (89% via ADC and 11% via cart fill). RESULTS: Simulation of the base-case and alternative scenarios indicated that as the modeled percentage of doses dispensed from ADCs rose, the calculated pharmacy technician labor requirements decreased, with a proportionately greater increase in the nursing staff workload. Given that nurses are a higher-cost resource than pharmacy technicians, the projected human resource opportunity cost of transitioning from the hybrid system to a decentralized system similar to the comparator facility's was estimated at $229,691 per annum. CONCLUSION: Based on the simulation results, it was decided that a transition from the existing hybrid medication distribution system to a more ADC-dependent model would result in an unfavorable shift in staff skill mix and corresponding human resource costs at the medical center.

Experience with a "tech-check-tech" program in an academic medical center.

PURPOSE: A "tech-check-tech" (TCT) program to support unit dose drug distribution at an academic medical center is described. SUMMARY: In April 2004, the University of Wisconsin Hospital and Clinics implemented a TCT program to provide validated pharmacy technicians with the opportunity to serve as the person checking unit dose medication cassettes that are filled during a 24-hour cart-fill process. This program required special authorization from the Wisconsin Pharmacy Examining Board and included detailed training and validation expectations of the pharmacy technicians, along with quality-assurance oversight by pharmacists who are completing a double check. For initial validation, the technician should attain a 99.8% accuracy rate for at least 2500 consecutive doses checked during at least five separate audits occurring over a minimum of five separate days. During the validation process, a pharmacist artificially introduces errors at a minimum rate of 0.2% (5 of every 2500 doses). A staff pharmacist performs a final check of the medications before releasing them to the inpatient units. The overall time for pharmacists spent on checking medication doses for cart fill was reduced from an average of 6 hours and 5 minutes per day to 20 minutes per day. CONCLUSION: Through the implementation of a TCT program at a university hospital, specially trained pharmacy technicians safely and efficiently checked unit dose medication carts filled by other technicians. The program reduced interruptions in the pharmacists' daily workflow and allowed pharmacists to spend more time on patient care activities.

Implementation and evaluation of carousel dispensing technology in a university medical center pharmacy.

PURPOSE: The implementation of carousel dispensing technology (CDT) at a university medical center pharmacy and the associated changes in drug distribution are described. METHODS: An evaluation of CDT was conducted in three phases: before implementation, during implementation, and after implementation. The preimplementation phase consisted of data collection and facility planning leading up to the physical installation. The implementation phase included the physical installation, carousel medication assignment, and user training. The postimplementation phase included data collection and analysis. The data collected were used to compare preimplementation and postimplementation time studies, labor requirements, inventory turns, and accuracy rates. RESULTS: The estimated labor savings comparing the preimplementation and postimplementation time studies for automated dispensing cabinet (ADC) refills, first-dose requests, supplemental cart fill, and medication procurement totaled 2.6 full-time equivalents (FTEs). After departmental reorganization, a net reduction of 2.0 technician FTEs was achieved. The average turnaround time for stat medication requests using CDT was 7.19 minutes, and the percentage of doses filled in less than 20 minutes was 95.1%. After implementing CDT, the average accuracy rate for all dispense requests increased from 99.02% to 99.48%. The inventory carrying cost was reduced by $25,059. CONCLUSION: CDT improved the overall efficiency and accuracy of medication dispensing in a university medical center pharmacy. Workflow efficiencies achieved in ADC refill, first-dose dispensing, supplemental cart fill, and the medication procurement process allowed the department to reduce the amount of technician labor required to support the medication distribution process, as well as reallocate technician labor to other areas in need.

Determining the feasibility of robotic courier medication delivery in a hospital setting.

PURPOSE: The feasibility of a robotic courier medication delivery system in a hospital setting was evaluated. SUMMARY: Robotic couriers are self-guiding, self-propelling robots that navigate hallways and elevators to pull an attached or integrated cart to a desired destination. A robotic courier medication delivery system was pilot tested in two patient care units at a 471-bed tertiary care academic medical center. Average transit for the existing manual medication delivery system hourly hospitalwide deliveries was 32.6 minutes. Of this, 32.3% was spent at the patient care unit and 67.7% was spent pushing the cart or waiting at an elevator. The robotic courier medication delivery system traveled as fast as 1.65 ft/sec (52% speed of the manual system) in the absence of barriers but moved at an average rate of 0.84 ft/sec (26% speed of the manual system) during the study, primarily due to hallway obstacles. The robotic courier was utilized for 50% of the possible 1750 runs during the 125-day pilot due to technical or situational difficulties. Of the runs that were sent, a total of 79 runs failed, yielding an overall 91% success rate. During the final month of the pilot, the success rate reached 95.6%. Customer satisfaction with the traditional manual delivery system was high. Customer satisfaction with deliveries declined after implementation of the robotic courier medication distribution system. CONCLUSION: A robotic courier medication delivery system was implemented but was not expanded beyond the two pilot units. Challenges of implementation included ongoing education on how to properly move the robotic courier and keeping the hallway clear of obstacles.

Observations on the use of ready-to-use and point-of-care activated parenteral products in automated dispensing cabinets in U.S. hospitals.

PURPOSE: The use of ready-to-use (RTU) and point-of-care (POC) activated parenteral products and their storage in automated dispensing cabinets (ADCs) in U.S. hospitals were evaluated. METHODS: A survey on the use of RTU and POC activated parenteral products, including storage and dispensing of the products, was developed and sent electronically to hospital pharmacy administrators. Survey respondents were identified using the American Society of Health-System Pharmacists' member database. RESULTS: Of the 4070 surveys sent, 965 (23.7%) were completed and returned. Most pharmacy administrators (94.7%) reported that their institution used some form of RTU and POC activated parenteral product, with 74% using ADCs to dispense these products. Efficiency was the most common reason cited for storage of RTU and POC activated products in ADCs. Facilities varied on reasons for not implementing this technology, with 47 facilities citing implementation costs, limited number of RTU and POC activated products on the hospital's formulary, lack of available pediatric formulations, and safety concerns as the main reasons. More than half of respondents noted space limitations as the greatest challenge to adding RTU and POC activated products to ADCs. CONCLUSION: Nearly three fourths of survey respondents reported using RTU and POC products in conjunction with ADCs; however, the approach to including these products in ADCs varied based on the characteristics, policies, and preferences of the individual facility. Advantages of RTU and POC products identified by respondents included enhanced safety benefits, increased dispensing efficiency, cost avoidance due to reduced waste, and improved compliance with federal and state regulations.