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Published on 23 September 2008

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Automating the hospital medicines supply chain

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The benefits of automated dispensing have been demonstrated by fewer errors and greater efficiency. How can such systems be used to support ward-based teams delivering decentralised services?

Ray Fitzpatrick
PhD FRPharmS

Clinical Director of Pharmacy
Royal Wolverhampton Hospitals

Professor of Pharmacy
Wolverhampton University

UK

The medicines supply chain in hospitals is more complex than in community pharmacy, since medicines are not only dispensed directly to patients but also supplied via wards and clinical departments. In the average UK acute hospital, an estimated
7,000 doses of medicines are administered each day.[1] There is therefore considerable potential for things to go wrong. In fact, in the UK, medication-related incidents are the second most common adverse incident reported to the National Patient Safety Agency after slips, trips and falls.[2] There are potential benefits to be gained from automating the various steps in the medicines supply chain, including safety, although there are
other drivers depending on the step in the process.

The main drivers for automating the dispensing process are minimising dispensing errors and improving efficiency in a very labour-intensive activity. However, the most important driver in automating management of ward stocks is having a clear audit trail for the medicines, since a large number of individuals are involved. Hitherto, the focus regarding automation has been on
its application to dispensing medicines in pharmacy.

Automation in pharmacy
Automated dispensing systems tend to fall into three main categories: unit-dose dispensing, random storage systems for original packs, and channel storage systems for original packs. In the UK, where original-pack dispensing is common, the random storage and channel-storage systems are the two systems in general use.[3]

In the random-storage systems, the picking head puts the stock into a location within the machine determined by the system computer, whereas in the channel system the stock is manually loaded into predetermined channels. Figure 1 shows an example of a channel automated dispensing system.

The main advantage of the random-storage system is that loading is done by the machine itself rather than manually, as is the case for the channel system.[4] The main advantages of channel-storage system machines are that they are very space-efficient and require less complex mechanics so are less likely to break down.[4]

More recently, hybrid systems have been developed that combine the automated loading of the random storage systems with a front-end channel system.[5]

Benefits of automating the dispensing process
As stated, the main drivers for automating the dispensing process have been the desire to reduce dispensing errors and to improve efficiency. The various systems in use in the UK have been evaluated. Studies have shown a reduction in dispensing error rates following the introduction of random-storage[6] and channel-storage systems[3] in hospitals in the UK. These individual case studies have been followed up with a multicentre
evaluation, which confirmed a reduction in error rates following the introduction of automation.[7] Not surprisingly, the dispensing errors most commonly minimised as a result of automation were picking errors.[3,8]

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Introducing automation has also been shown to have a positive impact on the efficiency of dispensing, primarily as a result of faster product selection times. In the two main case studies in the UK, the improved efficiency resulted in the equivalent to a reduction in staff time of 2.4-3.5 whole-time-equivalent staff respectively.[3,6] In both cases, this improved efficiency allowed the redeployment of staff to more patientfocused activities.

Clearly, the case has been made for automation in the pharmacy. There are now more providers of automated systems, offering a variety of solutions. This offers real advantages for hospital pharmacies, since competition results in better value for money and hospitals can choose a system based on their individual needs, such as space, activity and configuration of the department. Furthermore, systems are becoming more sophisticated, with the ability to store temperature-labile medicines and controlled drugs and handle
inline labelling. There is now the potential for the application of automation to ward and clinical areas as well as to the pharmacy.

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Automation outside the pharmacy
As hospital pharmacy has developed more ward-based services, with clinical pharmacists supported by wardbased technicians and “one-stop” dispensing services,[9] the concept has emerged of decentralised satellite pharmacies that serve a cluster of ward areas.

Using small automated dispensing machines offers benefits in these situations as they offer secure storage of medicines and safe dispensing with minimal staffing, allowing pharmacy staff to be permanently based on wards.[10] However, although the cost of automated systems has decreased in recent years, the
cost of investing in multiple units for use across a hospital may be prohibitive unless the geography of the hospital dictates otherwise.

The use of semiautomated systems in ward and clinical areas should also be considered. These are not miniature automated dispensing stations but electronically controlled medication storage systems. The main purpose of this approach is to provide a secure system for the storage of medicines in clinical areas that will provide a full audit trail for all medication used and facilitate better stock control. One such system, the
Medi 365, has been successfully implemented in the surgical admissions unit and accident and emergency department of an acute hospital.[11] The system (see Figure 2) uses fingerprint recognition to ensure controlled access and can produce automatic stock usage reports to facilitate better ward stock management as well as detailed inventory reports.

The future
The availability of a wide range of different types of automated and semiautomated medicines storage and dispensing systems, coupled with the development of electronic prescribing, opens up the possibility of a fully integrated medicines management system in hospital. The following scenario is now not just a
possibility but a reality.

The doctor (or pharmacist) prescribes the medicine on a laptop at the patient’s bedside. The ward-based pharmacy technician creates the label on computer on the ward, and the whole electronic medication record is clinically checked by the ward’s clinical pharmacist who authorises dispensing (see Figure 3). The electronic prescription is sent via the hospital network to the pharmacy (or satellite unit), where it is dispensed automatically by the robot, and a label is printed out and applied automatically or manually, depending on the system.

The dispensed medicine is finally checked by an accredited checking technician and sent up to the ward, where it is stored in the patient’s medication locker (see Figure 4). The nurse administers the medicine from the locker or, for medicines not yet stabilised, from the ward’s secure electronic storage system for stock medicines. All administration is recorded on the patient’s electronic medication record. The ward’s electronic secure storage system sends an order automatically to the pharmacy when stocks fall below the predetermined minimum, and stocks are replenished by the pharmacy team.

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By using technology in this way, paper is eliminated from the process, the number of transcriptions is reduced, and mundane tasks are automated (see Figure 5). Not only is there a complete audit trail for all medicines used, but nursing and pharmacy staff can concentrate on the professional aspects of their work.

Over the last few decades in the UK, there has been progressive development of the pharmacist’s clinical role on the wards. More recently, ward-based technicians have undertaken reviews of patients’ own medicines and undertaken “one-stop” dispensing. Developments in technology, as described here, facilitate the creation of pharmacy teams on wards delivering a comprehensive pharmaceutical service. Thus, the concept of a “pharmacy without walls” – previously described in this journal[12] – is now a reality.

References
1. Healthcare Commission. The best medicine: the management of medicines in acute and specialist hospitals. London: Healthcare Commission; 2007.
2. Patient Safety Observatory. Safety in doses: medication safety incidents in the NHS. London: National Patient Safety Agency; 2007.
3. Fitzpatrick RW, et al. Evaluation of an automated dispensing system in a hospital pharmacy dispensary. Pharm J 2005;274:763-5.
4. Swanson D. Automated dispensing: a review of the types of system available. Hospital Pharmacist 2004:11:66-68,77.
5. Goundrey-Smith S. Pharmacy robots in UK hospitals: the benefits and implementation issues. Pharm J 2008;280:599-602.
6. Slee A, Farrar K, Hughes D. Implementing an automated dispensing system. Pharm J 2002;268:437-8.
7. Whittlesea C. What did the research reveal about the effects of introducing automation? Hospital Pharmacist 2004;11:453.
8. Clarke C. Pharmacy automation. Pharm J 2003;271:590-1.
9. RPSGB Hospital Pharmacists Group. One-stop dispensing, use of patients’ own drugs and self-administration schemes. Hospital Pharmacist 2002;9:81-6.
10. Purkiss R. Decentralising services: a pharmacy
without walls. Hospital Pharmacist 2007;14:318.
11. Green C, et al. Automation at ward level: installing a Medi 365 system. Hospital Pharmacist 2006;13:333-5.
12. Fitzpatrick RW. A vision for tomorrow: hospital pharmacy without walls. Hosp Pharm Eur 2007;33:7.



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