White Paper

Hospital Automation Solutions Hospital automation | Optimizing safety and efficiency

INTRODUCTION

Preventing a incident in an often chaotic hospital environment is a key concern for doctors, administrators and governments. Patient safety and wellbeing may be dependent on the accurate and timely dispensing of a treatment regimen that is often contingent upon effective therapy.

With thousands of at the disposal of practitioners, many of which are varying compounds of the same medication, error in the type and dosage of medication is not uncommon within a hospital pharmacy.

Thankfully, not all errors result in an adverse event for the patient; however, ineffective treatment can result in AcuDose-Rx® prolonged illness, side effects or the presence of new symptoms. fluids frequently causes harm to patients curtailing financial losses due to inventory, in Canadian hospitals ii and harmful dosage and dispensing issues. In a recent survey, nearly one in ten adult medication incidents have received Canadians with health problems reported extensive media coverage. In fact, in the Canadian Hospital Pharmacy receiving the wrong medication or the 2015 (CSHP 2015) Goals and Objectives wrong dose when filling a prescription at a Protecting the patient’s health is the for Pharmacy Practice in Hospitals and pharmacy or when hospitalized within the number one concern of hospitals and their Related Healthcare Settings to Be Achieved previous two years. i across the country. , by 2015 document, Goal 5 has been set at when used effectively, can reduce increasing the extent to which hospitals The Canadian Adverse Events Study found medication errors and improve operational and related healthcare settings apply that the administration of and efficiency in the health care system, while technology effectively to improve the safety of medication use. iii By examining the chief demands affecting represents close to over 60% of the hospital pharmacies, this white paper remaining cost, must work with the will propose a scalable solution that will hospital’s given medication processing improve the capacity of Canadian hospital system. Unfortunately manual pharmacy pharmacies and increase their resilience in management operations experience an over-extended health care system often inherent losses when medications expire dependent upon medication to sustain or dosage issues require disposal of patient health. medications that would otherwise have benefitted hospital patients. Misplaced, The intent of this white paper is to present lost or stolen medications on the ward or in an integrated pharmacy automation the pharmacy not only affects the hospital solution that will help overcome the financially, both in drug cost and personnel challenges in hospital pharmacy operations time, but can also be dangerous to users. for doctors to prescribe, the drug managing and alleviate the possibilities of human and ordering process is a complex, yet critical error by automating processes in areas Resource Issues element in the efficiency of where patients will benefit most. patient care. As effective members of the health care CURRENT HOSPITAL PHARMACY team, are educated to play Ensuring the right medications are in stock and CHALLENGES a key role in the care and treatment of available and in the correct doses when and patients admitted to health care facilities, where they are necessary, can sometimes mean Throughout the country greater demands however, according to a 2008 study by the difference between effectively treating a are being made on our health care system. the Canadian Association of Pharmacy patient and delaying their care. Medical facilities are being asked to do Students and Interns (CAPSI), only 19.2% vi more with less. A shortage of qualified of their time was related to direct patient Efficient inventory control and intuitive ordering medical staff, an overextended medical care. According to the Hospital Pharmacy can often prevent the negative results of a drug infrastructure and a growing population in Canada 2011/2012 Report released in shortage. needing care are developing into the perfect 2013, over 50% of hospital pharmacists’ storm. time continued to be involved in non- In the 2010 Canadian Drug Shortages Survey patient centered activities. Significant Final Report, 93.7% answered yes on a national Hospital pharmacies, within the health gaps still exist in medication management, level to the question “In the last week, did care system are also navigating through counselling and reconciliation towards you have trouble locating medications to fill a a sea of challenges as a result of the high CSHP 2015 targets. prescription?” vii. Of those respondents 69.8% cost of medical treatment. The inefficient noted that their patients were adversely affected use of resources (personnel, space and Time and personnel restraints are causing by the shortage in the following ways: technology), managing their inventory resource issues that if unmanaged, result and the availability of certain drugs while in a reduction in patient care and possible • Patients are stressed, confused, angry, frustrated, ensuring patient safety, are key areas of errors in their treatment. Pharmacists and and experience a loss of trust in medication and concern. technicians are often underutilized in their the areas of expertise due to administrative and • Disruption in the continuity of care Health Care Costs logistical tasks that consume their time. • The alternative drugs have been less effective, especially as 3rd or 4th line alternatives are used The Fraser Institute noted in 2011, “across Inventory and availability of medication Canada, government spending on health • Antibiotics and anesthesics have been in short has grown faster (8.1% annually) on average With less hospital space attributed to supply than GDP (6.7% annually) since 1975. As of storage and inventory and the vast array • There have been no alternative medications 2011, provincial health spending in Ontario of medications and compounds available available and Quebec currently consumes more than • Alternatives cause side effects, allergies, and/or 50% of total revenues.” iv adverse events An adverse event • Patients have stopped taking the medications With limited resources available, hospitals are being asked to optimize their resources, represents an Patient safety without jeopardizing the safety of their unintentional patients. Hospital pharmacy operations The traditional hospital pharmacy model is are a significant component of a hospital’s harm to a patient prone to human error that may result in an service and, as such greatly impact their adverse medical event. Defined as an error that costs. arising from any causes an injury to a patient as the result of a aspect of healthcare medical intervention rather than the underlying Supplies and drugs account for medical condition, it represents an unintentional approximately 30-35% of a hospital’s management. harm to a patient arising from any aspect of operating budget. v Staffing, which healthcare management. 2 According to David E. Attarian, MD, Simply fixing parts McKesson Automation Solutions are “Most adverse events are multifactorial, completely modular, integrating or resulting from an overlap of system and of the supply chain is interfacing respectively with McKesson’s human errors. Some adverse events may and other vendor’s product lines; allowing be new or unanticipated, due to changing not the solution. all previous investments to be fully utilized; . Systems failures—such as a feature unique to the McKesson solution. poor management decisions, dysfunctional intrinsically reinforces medication corporate cultures, poor communications, The following products comprise the safety at each step of the medication inadequate resources, poor staffing, poor McKesson suite of automation solutions use and supply processes. By increasing documentation, or a lack of safeguards and and can function together or separately, communication between nursing and the check points—generally facilitate human and can be interfaced with most competitor hospital pharmacy, improving medication errors. Human errors may be knowledge- systems to develop an effective hybrid safety and optimizing productivity, costs based, skill-based, fatigue-based, or solution: in hospitals of all sizes are significantly may result from a failure to follow rules, reduced. technical mistakes, and/or an inability to AcuDose-Rx® automated medication cope with the complexities or demands of dispensing cabinets offer smart choices Through the use of robotics, bar-code the healthcare system.” viii for medication storage, balancing safety, scanning automation, and Web- accountability, accessibility and economy based virtual technologies, McKesson Hospitals and their pharmacies must do for drug dispensing on the ward or unit. Automation’s array of pharmacy solutions all to ensure exemplary patient safety Medication is there when needed. The enhance medication ordering, dispensing, and remove elements that contribute to exclusive RightStock™ feature monitors administration, charge capture and shortages or errors. Human fallibility and and dynamically adjusts inventory levels, inventory management processes. errors caused by a misunderstanding of a per medication and per cabinet. doctor’s prescriptions due to handwriting The functionality and features of each or other factors can be eliminated when PACMED® packager brings intelligent, product drive the medication safety process technology is used to order and dispense formulary level management capabilities deeper into the normal workflow patterns medication. to high-speed, oral solid medication of pharmacists, technicians, nurses and packaging. The multi-tasking PACMED® clinicians. McKesson Automation Solutions MCKESSON’S PHARMACY AUTOMATION Server Plus software could standalone, free them from time-consuming, repetitive, SOLUTIONS interface with other existing pharmacy manual tasks so they can focus on clinical automation equipment or be integrated activities and improve the quality of Simply fixing parts of the supply chain is with the McKesson Connect-Rx® software patient care; an issue that plagues medical not the solution. It requires a concerted platform to electronically process orders for professionals across the country. effort throughout the entire process: specific patients, for AcuDose-Rx® cabinets, and for the MedCarousel®, ROBOT-Rx®, and The McKesson suite of automated solutions • Decision support –There is a need MedShelf-Rx systems. can enhance the performance of any for collaboration and connectivity in hospital pharmacy, whether the system the continuum of care to ensure best is fully centralized, decentralized or a outcomes for patients and optimal use of hybrid combination of the two. Moreover, time and human resources. • Accountability – Recording and tracking of medications throughout the supply chain to ensure proper dispensing, administering, and availability of medications and to identify and eliminate diversion. • Safety – By automating supply, storage, inventory and dispensing of medication, human errors and drug shortages are minimized, thereby improving patient outcomes and safety. • Inefficiencies – Financial losses, time spent by pharmacists and nurses checking, dispensing, ordering give rise to inefficient operations and management of time and resources. McKesson Canada offers a suite of automation solutions that dramatically improves workflow, reduces costs and AcuDose-Rx® 3 • Adverse Events Based on a study evaluating preventable adverse event rates by Norton and Baker in 2004 and comparing case studies of similar sites, NHS would attribute $2.5M yearly in added expense as a result of adverse drug events and increased length of hospital stay. ix

• Inventory and Tracking 40% of all drugs distributed came from a traditional ward stock, and was manually accessed by nurses with little to no tracking. No inventory intelligence was acquired, resulting in inconsistent drug fulfillment and frequent overstock situations.

• Inefficient Use of Resources –– Nursing staff spent anywhere from 50-70% of their time dealing with medication MedCarousel® related tasks. This included skilled nursing staff in the OR and ICU where there was MedCarousel® system automates the CASE STUDY already an acute shortage of personnel. management of restock, first dose, and –– Ward clerks and nursing staff performed scheduled medications with as much as a Niagara Health System (NHS) : Ontario’s manual order transcription onto the 60% reduction in footprint requirement. largest multi-site hospital amalgamation medication administration record and The bar-code-based scanning and pick- comprised of six sites across the 12 checking while 85-90% of drug orders were to-light technologies increase picking municipalities making up the Regional already processed by the pharmacist in the accuracy and speed. By prioritizing orders Municipality of Niagara. for technicians to user specifications, the Pharmacy Information System. MedCarousel® increases staff efficiencies Managing a hospital pharmacy drug –– Standard medication administration times and decreases unit-based cabinet stock distribution system, ensuring that correct were used but there was an opportunity outs. medication is available when and where to improve pharmacy and nursing it is required and in the proper dosage, is communication. There were multiple The ROBOT-Rx® system is the world’s a manpower intensive exercise prone to medication locations for nursing staff to leading hospital pharmacy robotics system. human error. Proper medication tracking, access for any single patient’s medication Using bar-code scanning technology, recycling or disposal of expired or unused administration. ROBOT-Rx® automates the storage, picking, unit dosages and standardized drug returning, restocking, and crediting of more distribution practices are required by In need of a systems-based (or system-wide) than 90 percent of a hospital’s daily unit- Canadian government bodies. solution, the Regional Director solicited the dose medications. expertise of McKesson Canada to propose a Recommendations made by Accreditation solution that would integrate with their Meditech The McKesson suite of automated solutions Canada in 2006, prompted the NHS to clinical software. will provide decision support to ensure review its drug distribution system. safety and availability of medication to The goal was to support hospital staff with improve patient outcomes with a high The Regional Director of Pharmacy of recognized state of the art proven technology level of accountability while reducing Niagara Health Services, had a critical to reduce human and drug costs and reinvest inefficiencies and freeing clinical staff to situation on hand: savings to continually improve pharmacy use their time where it is needed most; with services by centralizing purchasing and the the patient. In fact, we are the only vendor • Financial Losses provision of a 24- hour unit dose cart fill at the with the complete solutions set to ensure a In their current traditional, multi-day St. Catharines General, which would service the closed loop. dispensing system it was estimated NHS. that over $100,000 worth of non-unit Moreover, efficiency gains, reductions dose oral solids were not recyclable Additionally, the selected solution needed to of expired or wasted drugs and costs and discarded. A substantial cost, this support decentralized nursing practices on associated with medication shortages result amount did not include the costs of the ward for first dose, narcotic/controlled drugs in a rapid return on investment (ROI) that overstocking in a manual, stock-on- and PRN, as needed medication dispensing. is sure to be of interest to any hospital demand system, which would add over By investing in pharmacy automation that administrator. $200,000 worth of medication waste a maximized the utilization of nursing and year due to expiration and loss. pharmacist clinical skills while improving the staff’s quality of work life, recruitment and

4 retention, NHS would reap the benefit of In order to ensure the greatest impact in electronically process orders for specific exponential pay back in improved nursing resolving the identified issues, McKesson patients, for AcuDose-Rx® cabinets, efficiency and patient outcome. proposed the unit dose packaging of the and for the MedCarousel® and crediting top 10 expensive non-ward stock oral drugs functions systems. Finally, the solution needed to bring to cut down on discard costs immediately. • AcuDose-Rx® cabinets decentralized on NHS’ pharmaceutical service level to the This was done as a stop-gap before any critical care, expensive or high narcotic forefront of best practices and be prepared proposed automation equipment was usage areas including OR, with up to 15 to set the stage in closing the loop on brought in. This was soon followed by drawers with three security levels that medication safety within a three year the roll out of NHS’s first PACMED-500, allowed for decentralized medication time frame, as identified in the Canadian IntelliShelf-Rx (replaced by MedShelf-Rx dispensing for nurses to administer first Hospital Pharmacy 2015 (CSHP 2015) Goals today) and 48 AcuDose-Rx throughout dose, narcotic/controlled substances and Objectives for Pharmacy Practice in NHS. or PRNs, with secure tracking and Hospitals and Related Healthcare Settings. accountability. With the initial implementation By reviewing NHS’s actual processes, operational, NHS augmented their Together, this integrated solution allowed analyzing acquired data and discussions investment to deliver a solution that was for the automation necessary to improve about the alignment of their vision of an able meet all of NHS needs and offer both the efficiencies of hospital resources effective distribution system, McKesson centralized and decentralized capabilities through centralized decision support, proposed a hybrid solution that would to the pharmacy and to the ward. In 2013 inventory management and accountability centralize purchasing, medicine tracking when a new hospital site was opened in St. while assuring patient service and safety on and distribution to the wards, while Catharines, the following components were the ward. decentralizing a controlled access for first implemented in this hybrid solution: dose, narcotic/controlle and PRN nurse According to Susan Cubelic, the current dispensing. • Two MedCarousels®, which allowed Regional Director of Pharmacy of Niagara for the centralized automation and Health System, this scalable solution This proposed solution maximizes the management of restock, first dose, provided outstanding results to our effectiveness of their Meditech clinical and scheduled medications. The bar- hospital sites. “From a medication safety software by interfacing it with a single code-based scanning and pick-to-light perspective, pharmacy automation has automation backbone, Connect-Rx®, that technologies increased picking accuracy put us on a successful path to meet our would keep manual process to a minimum. and speed while managing the hospital’s overall goal of an integrated medication medication inventory in real-time. management system that closes the loop McKesson’s approach was to share and • A second PacMed 500®, which provided from when a patient medication order communicate the strategic plan with key centralized intelligent, formulary level is obtained to when that medication is stakeholders to obtain their requirements, management capabilities to high-speed, administered.” input and buy-in to the new methods being oral solid medication packaging. proposed. • The multi-tasking PACMED Server Plus The return on investment (ROI) was less software integrated with the McKesson than three years with the initial phase, Connect-Rx® software platform to which allowed us to reinvest in additional components to further automate our pharmaceutical practices, improve patient outcomes and allow our staff to perform more valuable activities more directly related to patient care.”

CONCLUSION

Almost 10 years ago the Baker Norton Canadian Adverse Events study uncovered several shocking statistics:

• The three most common areas for adverse events to occur include surgery, medication, and infection. • 1 out of 13 adult patients admitted to a Canadian hospital encounter an adverse event. • 1 out of 9 adults will potentially be given the wrong medication or wrong medication dosage.

5 • 187,500 out of 2.5 million patients Bibliography About McKesson Canada admitted annually to acute care hospitals Founded more than 100 experience an adverse event. i Commonwealth Fund 2008 International • Between 9,000 and 24,000 patients die Health Policy Survey of Sicker Adults. May years ago, McKesson Canada per year due to adverse events. 2008 is dedicated to delivering • 37% of adverse events are ‘highly’ http://www.commonwealthfund.org/~/ vital medications, supplies, preventable. media/Files/Surveys/2008/The%20 2008%20Commonwealth%20Fund%20 information technologies • 24% of preventable adverse events are International%20Health%20Policy%20 related to medication error. x and clinical care Survey%20of%20Sicker%20Adults/ management that enable IHP2008_CMWF__DSQ_for_web%20pdf.pdf The effective use of technology can the health care industry to considerably improve these statistics ii Baker GR, Norton PG, Flintoff V, et al. provide patients better, safer by reducing human intervention in the The Canadian Adverse Events Study: care. ordering, packaging and dispensing of the incidence of adverse events among medication. With the implementation of hospitalized patients in Canada CMAJ proven automation technology, medication 2004;170 (11) Our solutions empower errors can be significantly reduced. pharmacies, manufacturers, iii Canadian Hospital Pharmacy 2015 (CSHP Better yet, precious medical resources such 2015) Goals and Objectives for Pharmacy hospitals and other health as nursing staff, hospital pharmacists and Practice in Hospitals1 and Related care institutions by enabling technicians can be more effectively used Healthcare Settings to Be Achieved by 2015 in the direct treatment of patients. The them to get closer to the quality of their work lives, as well as better iv Brett J. Skinner and Mark Rovere. millions patients they serve patient outcomes are important end results “Canada’s Medicare Bubble- Is Government every single day, while of hospital pharmacy automation. Health Spending Sustainable without User- contributing to the quality based Funding?” April 2011 Moreover, scarce hospital space is and safety of care in Canada. maximized in the inventory and storage v Versha, K (May 2009) Developing an of medication, allowing it to be most Optimal Distribution Model, Amrita effectively used by stocking medication that Institute of Medical Sciences is required for immediate patient care and providing the decision support necessary vi Ascentum Inc.Dr. Neil J. MacKinnon. for just in time delivery. Moving Forward-Pharmacy Human Resources Challenges and Priorities:The These benefits not only result in better Perspective of Canada’s Pharmacy Students patient care and outcomes, better April 2008 utilization of human and real estate resources, but also produce important vii Canadian Pharmacists Assn,Canadian financial savings for the institution by Drug Shortages Survey FINAL REPORT McKesson Canada eliminating misplaced, improperly dosed December 2010 Head Office or expired medication, maximizing use of 4705 Dobrin Street available space and by reducing hospital viii David E. Attarian, MD, What is a Saint-Laurent, Québec patient stays by providing a more accurate preventable adverse event? H4R 2P7 level of care. ROI, in most cases, is rapid http://www.aaos.org/news/aaosnow/may08/ and the solution can be implemented in managing6.asp phases, to ensure budget constraints are For inquiries, please contact us: respected and hospital finances remain on ix Dr. Norton and Dr.Baker CMAJ May 25, [email protected] track. 2004, 170 (100)

x Hospital News July 2004 www.mckesson.ca

Copyright © 2013 McKesson Canada All rights reserved. August 2013