Q Manage Health Care Vol. 18, No. 2, pp. 103–114 c 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Implementation of a Pharmacy Automation System (Robotics) to Ensure Medication Safety at Norwalk Hospital Robert J. Bepko, Jr, BS, MHA, RPh; John R. Moore, BS, MHA, RPh; John R. Coleman, PhD This article reports an intervention to improve the CURRENT INDUSTRY TRENDS quality and safety of hospital patient care by introducing the use of pharmacy robotics into the The Institute of Medicine reported in 1999 that medication distribution process. Medication safety there are more than 98 000 preventable medical er- is vitally important. The integration of pharmacy rors that occur annually in US Hospitals, that 10% robotics with computerized practitioner order entry of hospitalized patients suffer medication-related in- and bedside medication bar coding produces juries, and that more than 7000 patients die annu- ally because of medication errors.1 A recent study a significant reduction in medication errors. found that the leading cause of anxiety for patients is The creation of a safe medication—from initial the fear of suffering a medication error during their ordering to bedside administration—provides hospital stay. Evidence suggests this fear may be jus- enormous benefits to patients, to health care tified. Researchers who observed nurses delivering providers, and to the organization as well. medications to patients in 36 health care facilities in the Greater Atlantic and Denver metropolitan areas made some startling findings. Almost 1 in 5 medi- cations was given erroneously, and 7% of the mis- takes were potentially harmful.2 Investigators at Har- vard found that most medication errors occur either when a physician inaccurately ordered a medication (39%) or when a nurse administered a drug mistak- enly (38%). More importantly, the Harvard study also revealed that, luckily, almost one-half of all inaccu- rate physician orders were intercepted by nurses and pharmacists before these mistakes reached the pa- tient. In contrast, only 2% of nurses’ errors when ad- ministrating a medication were intercepted, making the risk of error far greater at the patient’s bedside.3 Multiple studies within the medical literature con- sistently demonstrate that more than 30% of all Author Affiliations: Corporate Pharmacy Services, Nor- walk Hospital, Connecticut (Messrs Bepko and Moore); and Ancell School of Business, Western Connecticut State University, Danbury (Dr Coleman). Corresponding Author: Robert J. Bepko Jr, BS, MHA, Key words: automation, bar code technology, medication RPh, Corporate Pharmacy Services, Norwalk Hospital, safety, prescription error reducing Connecticut. 103 104 QUALITY MANAGEMENT IN HEALTH CARE/VOLUME 18, ISSUE 2, APRIL–JUNE 2009 Figure 1. Dispensing error rates. medication errors and adverse drug events (ADEs) and 12 technicians to provide pharmacy services 24 occur at the administration stage of the medication hours per day, 7 days per week. The hospital has distribution process. Systems exist that use bar code a manual, labor-intensive medication distribution technology to ensure accurate medication selection and administrative process. A nationwide shortage and dispensing by the pharmacist.4 Other systems of pharmacists and increased regulatory demand exist that use bar code and wireless communication (The Joint Commission) prompted the pharmacy technologies to safely administer medications at the management team to investigate means to deliver patient’s bedside. These systems can drastically im- and improve pharmacy services to its patients. prove the accuracy of medication administration as well as automate the documentation process. Unfor- THE EVALUATION PROCESS tunately, although many such systems are marketed, very few have been effectively implemented in hos- The pharmacy department dispenses approxi- pitals to date.5–8 mately 5500 doses of medications in a 24-hour pe- riod. Pharmacy technicians used computer-generated THE SETTING OF THE PROBLEM lists to pick patient medications. These medications were then placed in a designated patient cassette. Norwalk Hospital is a private, nonprofit, acute Pharmacists using the same medication lists checked care hospital located in the southwest suburb of the patient cassettes to ensure the accuracy of the Norwalk, Connecticut. The city of Norwalk is in technicians’ work. The process was tedious and time- Fairfield County, one of the most affluent counties consuming. As highly trained professionals, the phar- in the country. Founded more than 100 years ago, macists quickly become bored when not performing the hospital serves 50 000 residents of the city and patient-centered activities (drug information, kinetic 300 000 residents in the 5 neighboring communi- consultation, and drug therapy reviews). ties. The hospital is supported by private payers As a check on this process, an additional pharma- (insurance companies and health maintenance or- cist check on the medication cassettes was conducted ganizations), federal payments (Medicare), and state over a 28-day period to measure the accuracy of the reimbursements (Medicaid) as well as by private and filling and dispensing process. The dispensing error community donations usually for a specific cause rate was calculated at the end of this period (see Fig 1 or project. The hospital employs 17 pharmacists and Table 1). The data revealed that even after a Implementation of a Pharmacy Automation System 105 Table 1 single medication travels through many steps (and health care providers) between the patient’s present- ERRORS RATE OF PHARMACIST-CHECKED a ing a condition and the time that patient actually re- MEDICATION CARTS ceives that medication. Figure 2 reviews the medi- cation use system and highlights its vulnerabilities. Day Weekday Error rate, % The left side of the illustration shows the vulnera- 1D Monday 3.00 bilities of a manual system approach to the medica- 2D Tuesday 3.50 tion process. Poor handwriting, transcription errors, 3D Wednesday 2.00 and incorrect visual checks all conspire to prevent 4D Thursday 1.00 the institution from guaranteeing that the patient re- 5D Friday 3.90 6D Saturday 4.40 ceives the Five Rights of medication administration. 7D Sunday 4.80 The right side of the illustration shows that an auto- 8D Monday 2.70 mated process has great potential to reduce errors and 9D Tuesday 2.20 guarantees that each patient receives the Five Rights 10D Wednesday 2.00 of medication administration. 11D Thursday 3.10 12D Friday 2.60 Developments in information technologies, includ- 13D Saturday 3.80 ing bar coding, computerized practitioner order en- 14D Sunday 3.40 try, pharmacy computer and automation systems, 15D Monday 3.60 analytical tools, and error reporting instruments, 16D Tuesday 3.40 provide opportunity for a system approach to pro- 17D Wednesday 2.80 cess improvement. The Agency for Healthcare Re- 18D Thursday 2.10 19D Friday 2.50 search and Quality estimates that hospitals can save 20D Saturday 3.70 $500.000 in direct costs by using these processes. Pa- 21D Sunday 2.90 tient safety must be the primary focus of any system 22D Monday 3.00 approach to process improvement. To assess the po- 23D Tuesday 2.50 tential impact (real and relative) of any solution to re- 24D Wednesday 1.20 25D Thursday 1.70 duce medical errors, the medication use process and 26D Friday 3.30 respective vulnerability points must be reviewed in 27D Saturday 3.40 the context of the entire system. 28D Sunday 3.30 The Institute of Medicine report suggests that Average 2.92 the causes of most errors are “system errors” rather than individual behaviors or intent. Therefore, solu- aConducted over a 28-day period, average 5500 doses per day. tions to medical error and their respective “system failures” must focus on identifying system failure modes and creating reliable safeguards. Tables 2 and pharmacist had done the standard check of the 3 describe various vulnerabilities in the medication medication cassettes, there were, on average, 160 use process. The percentage of ADE interceptions medication variances (2.9%). When the staffing was is based on the portion of the system with the least reduced on the weekends, the error rate was higher, redundancy and double checks. up to 264 medication variances (4.8%). After reviewing its medication variance data, the National research consistently finds that 1 of every pharmacy department decided to attempt to automate 5 doses administered results in medication error. Nor- the dispensing function, beginning with the process walk Hospital’s data revealed a medication variance of bar coding medications to facilitate point-of-care rate of 6.1 per 1000 doses billed. bar coding medication administration. The project Errors are common in health care systems because was presented as a 2-phased project in conjunction of the complex cognitive mechanisms involved.9 A with the nursing and information departments. 106 QUALITY MANAGEMENT IN HEALTH CARE/VOLUME 18, ISSUE 2, APRIL–JUNE 2009 Figure 2. Manual vs computerized practitioner order entry system. IV, intravenous. aVery vulnerable to errors. bPotential for greatly reducing errors. THE APPROVAL PROCESS a project of this magnitude should wait for the new CEO and management team. The process to recruit Once it was decided to move ahead with automa- a new CEO has not even started. The pharmacy staff tion was made, we had to find a sponsor in the institu- feared that the project would be tossed aside once tion to champion its cause. It proved to be a difficult a new management team was in place. (It was 18 task. The Board of Trustees had decided to replace months before the new CEO arrived.) The pharmacy the hospital’s CEO. Pharmacy management spoke to department managers enlisted the help of the out- several senior management members to champion going CEO, who suggested meeting with the Chair- the project; no one expressed interest, arguing that person of the Planning Committee of the Board of Implementation of a Pharmacy Automation System 107 Table 2 MEDICAL ERRORS AND ERROR RATES NATIONAL DATA SHOWING MEDICATION ERRORS, National research has found that 1 of every 5 DISTRIBUTION, AND NUMBER PREVENTEDa doses administered results in a medication error.