A case study of the benefits of combining electronic prescribing directly to a dispensing robot at a UK hospital pharmacy is presented
Rod Beard BPharm MSc MBA MProf MRPharmS
Sunderland Royal Hospital, Sunderland, UK
Hospital pharmacies across Europe are faced with ever-more demanding workloads, and tighter budgets to manage the demands placed on them. Many hospitals seek to utilise technology to improve efficiencies, and there are a range of technologies that can be utilised to improve the efficiency of a department.
City Hospitals Sunderland has the following profile: it serves a general population of 350,000 and a sub-regional population of 750,000; 1000 acute beds; 5000 staff; income of approximately £300 million. The hospital operates two dispensaries, including a smaller discrete outpatients pharmacy, dispensing around 5000 items per month.
In 2005, the Department of Health in the UK issued a report authored by the Chief Pharmacist, entitled ‘Building a safer NHS for patients. –‘Improving medication safety’.(1) This was a detailed paper on medication errors, the causes, and potential remedies, and stemmed from the paper ‘An Organisation with a Memory’.(2) ‘Building a safer NHS for Patients’ made many suggestions to design out errors through use of a systems approach to medication systems. Electronic prescribing (EP) and robotic dispensing were put forward as potential tools to help reduce dispensing errors. However, the advantages of EP and robots are not systematically documented in the literature, and it remains unclear as to what features provide the greatest safety. There is a variety of design in EP and robotic dispensing systems and it is important when surveying the literature to consider the context of the medication system in a hospital.
The Chief Pharmacist of England quoted a study from the dispensing error analysis scheme (DEAS) published by Cardiff and Vale NHS Trust.(1) The paper analysed errors from 66 contributing hospitals from 1991 to 2001, and looked at 7000 errors. As such, it represents one of the biggest surveys of its kind in the UK. The errors as recorded by frequency are shown in Table 1.
The pharmacy at Sunderland has been operating an integrated EP system for over 10 years (a Meditech system from the US). This system has modules for pharmacy, pathology, radiology, patient entry, electronic prescribing and medicine recording, and is the main recording system of the hospital. The pharmacy installed a robotic dispensing machine. The machine chosen was a triple-headed ROWA machine, with an automated labeller for each picking head. This machine stores products chaotically within itself, using product bar codes. A loading hopper and automatic loader for the machine were also purchased (approximately 10 metres long). The business case for the machine anticipated efficiencies, and it was estimated that four whole-time equivalent (wte) technical staff would be released to re-deploy in other areas.
The pharmacy at Sunderland is open 80 hours a week, so the staff savings were estimated across this time frame. Medication safety was a feature of the business case. The crucial element was the writing of the interface software that linked the unique product code in the Meditech EP/Pharmacy system to the ROWA product system because the links had to be exclusive for each individual product. With this software, the EP system linked directly to the robot, and it is this linkage that yields benefits. A second, smaller robot was included in the separate outpatient department. The impact of linking technology on dispensing errors, staff efficiencies and other efficiencies was assessed. Using EP and robotic dispensing as implemented at Sunderland, we can regard medication errors prevention in the same way as described in the DEAS study (Table 2).
It follows that, provided EP and robotic dispensing are integrated in a specific way, many dispensing errors can be ‘designed out’ by skilful application of technology.
Dispensing errors per month were plotted on a control chart for before and subsequently to the installation of the dispensing robot (October 2009). This is illustrated in Figure 1.
Control charts have been used in industry for many years as a means of assessing process control.(5) One difficulty in assessing processes with small numbers of deviations (for example, dispensing errors) is the haphazard nature by which they occur. This may require assessing if a small cluster of errors (deviations) is chance, or whether there is something flawed in the processes. Control charts are useful to determine if it is more likely that there is a more systematic flaw occurring. The technique looks at the number of errors over a time frame, and calculates the standard deviation. Deviations above one standard deviation consistently would suggest that there were more fundamental system flaws occurring. The control chart for errors shows that the process was no worse regarding dispensing errors than those determined using standard interpretations.(5)
Skill mix changes
The outpatient pharmacy is open 45 hours a week, Monday to Friday. The business case for the outpatient robot required releasing for re-deployment around £70,000 in staff terms.
On installing the robot in 2009, band 5 technical staff could be replaced with lower-band dispensing staff without adversely affecting the quality of the dispensing process. The change in skill mix was 50% (Table 3); this was 16% more efficient than planned for in the business case. After installation, staff was reduced by 1.4 wte, and the skill mix was also adjusted to meet overall operation needs of the department. All NHS Hospitals in the UK pay staff on a banding system that equates all jobs to their value; the higher the job band, the more highly skilled the post. The job band and wtes for staff were determined, and used as a measure of the ‘quantity of skill’ to run the Outpatient pharmacy. The monetary value of the ‘skill quantity’ changes is calculated from the mid-point salary scale. The business case identified savings of around £35,000 per year for outpatients. The ability to reduce skill mix with regards to technicians gave an additional benefit.
Skill mix and quantity changes
The business case for the in-patient robot required four wte staff to be released for other deployment to offset the £750,000 purchase costs. It was possible to release these staff, and deliver further economies, through a series of changes in working practices. Because the EP robot system only triggered after the pharmacist had checked the prescription, and because the electronic links could not be interfered with, the previous ‘two dispensing checks’ were deemed unnecessary. In effect, there was no need for higher skilled pharmacy technicians (band 5) to be based in the dispensary, and so four were re-deployed to expand medicines management at ward level. This did not affect the 80 hours per week opening time for this dispensary. The dispensing and accuracy checking in the main pharmacy was carried out mainly by band 3 staff (dispensing assistants, not technicians). Technicians are used in a managerial capacity in the dispensary.
The dispensing processes, by being instantaneous, meant that staff needed to walk about less in the dispensary. The ROWA /ARX dispensing machine at Sunderland compacts around three kilometres of shelving into area of approximately 10m2. Using automated loading meant that staff time used to replenish shelves was reduced significantly. The discipline of having one location for product, and only being able to retrieve stock by using the standard processes, meant that inventory was reduced by two weeks, equating to around £500,000 in savings that were additional to the business case stock reduction of £250,000. Table 4 shows this.
The integrated EP means that, when the clinician prescribes the medicine on the computer, he/she is also writing the label to attach to the medicine. This means the label is always what the clinician requested. Because the label is always accurate to the prescription, there is no transcription error. Drugs can only be stored in the robot by barcode identification. There is a direct electronic link between the medicine, barcode, the item selected on the electronic prescription and the label that the robot applies. These are the crucial links in deriving safety benefits from technology. To design in these links is to design out potential errors. Once designed, the system works from anywhere in the hospital; this allows 60% of dispensing activity to be triggered outside the pharmacy at Sunderland. Automatic labelling is a critical component of this system.
Another important consideration is avoidance of part packs wherever practical. The robot does not handle these well in the way Sunderland operates the system, so avoidance of part packs is vital. Part packs cannot be entirely eradicated from use (for example, steroid courses, chemotherapy) but minimising the number from the robot is important. Once medication has been checked by a pharmacist (usually at ward level at Sunderland), the dispensing becomes nearly instantaneous (on EP). The remaining part of the process is to get the medication from the pharmacy to the ward. In achieving ‘instantaneous dispensing’ with EP and the robot, the role of the dispensary pharmacist changes. No longer are pharmacists directly in control of the whole dispensing process. It is akin to craftsmen producing goods being replaced by production lines where quality control is through process control, and each individual is responsible for a part of the overall process, not all of it.
The prior use of EP at Sunderland for eight years meant that the integrated medicines management processes were well established. The delivery of products to the wards links with these processes. Typically, most wards (30 of 36) receive a medicines management service. Each ward can expect of 0.75 wte pharmacist, and 0.5 wte technician time per week. Changes in skill mix in the outpatient department equated to an additional saving on top of staff reduction more than the business case by 16%. Data from the control chart suggests de-skilling the dispensary workforce using robots has a no worse impact on dispensing errors.
A previous paper(6) listed the different types of dispensing methods at CHS, and the error rates associated with them.
Significantly, we have found zero errors for the robot plus EP system combined, based on around 800,000 items per annum, which is potentially a great safety benefit. However, dispensing is not risk-free, because not all items are supplied and labelled from the robot, although clearly the opportunity for errors is significantly reduced.
The stock figures for 2008/09 represent values effectively pre-robot. The business case required that besides re-deploying four staff, inventory value would be reduced by £250,000. This was achieved, but over time, and the reduction in number of weeks stock held has fallen by more than two weeks, representing an additional saving of around £500,000 above the business case requirement. The cost of the robotic programme was around £750,000 over ten years. This was achieved because the EP-robot system allowed continuous reviewing of internal processes to yield better stock control.
Turnaround time for prescriptions
Speed of turnaround time taken from the pharmacist’s clinical check is nearly instantaneous. At very busy periods, dispensing times can rise to up to 20–30 minutes, but this situation tends not to last beyond about half an hour. Normally, dispensing times using traditional methods can often be up to four hours for non-urgent dispensing.(4) These authors show that, by using lean processes, the dispensing time of the prescription was reduced from four hours to approximately two hours. (These times include the time it takes a signed prescription to get from ward to pharmacy.) This is not untypical of non-EP robotic system. The concept of instantaneous dispensing is not currently part of hospital pharmacy culture, nor is dispensing triggered from over 30 different points in the hospital.
Whittlesea quotes a Welsh benchmark of ten items per person per hour.(7) The main Sunderland robot dispenses a maximum of 360 items per hour, equating to 36 dispensing staff. The in-patient pharmacy operates with around ten dispensary staff. Sunderland’s robot chute 24 issues 60% of the dispensing activity, which is from the ward-based pharmacy staff. Ours is not a directly comparable situation, but the efficiency is apparent.
There are clear benefits in using electronic prescribing and robotic dispensing, and these will be realised so long as the following conditions are met. The first is that the EP system used be integrated with all other hospital software systems (transfer of information). The second is that the robotic dispenser be integrated to the EP system, and the third is that there be automated labellers for those items dispensed robotically. When the above conditions are applied, several advantages become apparent, based on the principle of not needing to retype information. For items in the robot, there is no scope to make a dispensing error, thereby improving patient safety; the process is much more efficient, and the skill mix of staff can be adjusted within the dispensary; as a consequence of all of the above, the speed of the prescription dispensing process increases dramatically.
There is also a change in the professional model at Sunderland, as the dispensary pharmacist is no longer in complete control of the dispensing carried out in the dispensary. The professional dispensing expertise is replaced to some extent by a systems approach. This allows flexibility where dispensing is triggered (ward or dispensary). It also allows pharmacists to maintain being at ward level rather than having to return to the dispensary to help dispense. The ability to have ‘instantaneous dispensing’ means there is more time for pharmacists to devote to the clinical care of the patient, and thereby performing more ‘value added’ clinical roles.
- Because EP is integrated, when the doctor prescribes the medicine on the computer, he is also in fact writing the label to attach to the medicine. This means the label is always what the doctor requested therefore there is no transcription error.
- Drugs can only be stored in the robot by bar code identification. There is a direct electronic link between the medicine, bar code and item selected on the electronic prescription and the label that is printed. This is the most crucial step in deriving safety benefits from the technology. It is achieving this direct link through integration of the technology that delivers safety benefits. To design in these links is to design out potential errors.
- The system works from anywhere in the hospital. This allows 60% of dispensing activity to be triggered outside the pharmacy, but this only occurs if there is a direct electronic link between prescription, label and robot.
- Automatic labelling is a critical component of this system.
- Once discharge prescription has been checked by a pharmacist (usually at ward level at Sunderland), the dispensing becomes nearly instantaneous.
- Smith JM. Building a safer NHS for patients. Improving medication safety. Department of Health 2005.
- Donaldson L. An Organisation with a Memory www.doh.gov.uk
- Beard RJ. Master’s thesis. University of Sunderland:2009.
- Beard J, Wood D. Application of lean principles can reduce inpatient prescription dispensing times. Pharm J 2010;(284):369–71.
- Lynn KD. How to Use Control Charts for Healthcare. ASQ Quality Press. ISBN 0-87389-452–9;1999.
- Beard R, Candlish CA. 2004 Does electronic prescribing contribute to clinical governance? BrJ Healthcare Comp Information Manag 2004;21:27–9.
- Whittlesea C et al. Automated dispensing – how to evaluate its impact. Hosp Pharm 2004;11:283–5.