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Clinical Director of Pharmacy/Senior lecturer
Royal Wolverhampton Hospitals Trust
At the beginning of the new millennium, the Department of Health (DOH) issued pharmacy’s response to the NHS Plan in “Pharmacy in the Future”.(1) This document praised the work of hospital pharmacy in developing new areas of work. However, the document also had a clear message for hospital pharmacies to modernise systems of work. The Audit Commission report on medicines management in hospitals, “A Spoonful of Sugar”,(2) contained many examples of how hospital pharmacies were already modernising their work practices, including automation. Over the last two years there has been a growing interest in automation, and there are now four systems on the market and over 20 hospitals that have implemented automation or have well progressed towards this. So why automate the dispensing process?
Automation offers the potential for improved service delivery in four key areas:
All systems currently available have a mechanical picking head, which is able to pick a medicine in <10sec and deliver it either directly to a dispensing station or via a conveyor belt (conveying systems take longer, with an additional 2.5sec/m of conveyor belt). This speed of operation is faster than a human being can achieve for the same task, which involves walking to the storage shelf, locating the stock, picking the medicine and returning to the workstation. It has been estimated that approximately 3.5wte (whole-time equivalent) pharmacy staff time can be released by introduction of automation.(3) Staff can then be utilised in more patient-centred activities.
There is clearly a potential for any member of staff to select the wrong medicine during the dispensing process, especially if packages look the same and at times of high workload. According to the US National Academy of Science, >78% of dispensing errors could be avoided by the use of automated dispensing systems.(4)
Automation can help improve stock rotation and, as a result of better inventory management within the dispensing machine, improve overall stock control.
Stock that is stored on traditional shelving or drawer systems needs space between shelves for the operator to access the stock. In automated systems, the mechanical picking head does not require as much space, which means a large amount of stock can be stored efficiently. This leads to a better, less cluttered working environment. Furthermore, there is less staff movement around the dispensary area, further improving the overall environment.
For staff in the pharmacy, automation takes the stress out of working in a busy, congested and overcrowded dispensary. However, adequate training on the use of the systems is essential, and accuracy-checking procedures must be implemented to ensure that automation itself does not change the quality control processes that were already in place. All three systems available in the UK are based on the use of original packs of medicines, since original pack dispensing represents the majority of dispensing in primary care and is growing in hospital pharmacy. Therefore, to gain the maximum benefit from using automated dispensing systems, hospital pharmacies must also be modernising other elements of the medicines management chain, such as using patient packs in outpatients and on discharge, and implementing one-stop dispensing, which utilises original packs. If the hospital has, or plans to implement, computerised prescribing and electronic health records, the impact of automating the pharmacy processes will be much greater. Computerised prescribing and electronic health records alone eliminate nearly three-quarters of medication errors. As well as knowing why the dispensary needs to be automated and where it fits into the overall modernisation programme, hospital pharmacy managers need to undertake careful planning to ensure successful implementation of an automated dispensing system.
Implementing the CONSIS system at Royal Wolverhampton Hospitals
The Royal Wolverhampton Hospitals (RWH) NHS Trust is an acute teaching hospital with 912 beds, which will grow to 1,120 in 2004. There is a single dispensary at New Cross Hospital serving both inpatient and outpatient needs. The pharmacy dispenses over 200,000 packs each year, and space in the dispensary is at a premium. The pharmacy has recently moved to original pack dispensing for all discharges and outpatients, and one-stop dispensing is in the process of being implemented across the whole hospital. The whole service has been reorganised, and a comprehensive clinical pharmacy service is being established in all clinical areas. Therefore, the key reasons for wishing to automate the dispensary were: first, to improve the efficiency of the dispensary process; and, second, to improve the environment through improved storage and reduced clutter.
From the outset, it was important to establish a project group to steer the introduction of the new system and critically review the workflow and the impact of automation. The project team comprised: a Clinical Director of Pharmacy, a Deputy Director of Pharmacy, a Chief Technician Patient Services, Senior Technicians in inpatient and outpatient dispensing, and Senior Technician Directorate Support. The Clinical Director focused on the business issues and procuring the system, the Deputy Director led on the operational issues around implementation, and the Directorate Support Technician liaised with IT suppliers and hospital IT support.
The first step was to process-map our dispensing to understand how automation would contribute. Figure 1 shows the dispensing process before and after automation. Since we were already increasing clinical input at ward level, the clinical check by the pharmacist, either on the ward or in the dispensary, was less of a rate-limiting step. Before automating the process, the labelling and picking steps were the rate-limiting steps. However, following implementation, the rate-limiting step has now shifted to the checker technician element of the process, such that we have had to reorganise the staffing of this step.
Selecting the system
At the time of selection, there were three automated dispensing systems marketed in the UK. Two of them can be classified as random storage systems, whereby the machine allocates the storage location for each medicine. The CONSIS system from Baxter is a channel storage system in which the location of stock in the machine is determined before installation. As part of the tendering procedure, a clear specification was developed to reflect our needs. All three systems were fast at picking medicines. However, as space was at a premium in the department, efficient storage was a major factor in helping to determine the system of choice.
Analysis of the stock holding of each system in relation to the footprint the machine occupies showed the following:
Following a tendering procedure on the basis of these key specification points and price, the CONSIS system was selected.
Analysis of stock usage
Having decided on the channel storage system, it was necessary to undertake an analysis of stock usage so that the space advantage of the system was not undermined by storing infrequently used items in the machine. Although there were >4,000 lines on our computer system, only 1,400 were active and only 900 had been used in the last 12 months. Analysis of usage by line showed that 700 lines represented >90% of the activity in the dispensary. Therefore, working with Baxter, these 700 lines were allocated locations within the CONSIS dispensing machine.
With the selection made, the project team was expanded to include three staff from Baxter, which included the project manager, the automation lead from Europe and the IT lead for automation in Baxter. The team then worked with the IT supplier of the pharmacy labelling and stock control system to develop a two-way interface. This was crucial, as the dispensing machine needed to respond to an order from the pharmacy system to dispense a medicine.
From the outset, staff were kept informed of the whole process. The concept was initially “sold” to staff on the basis of improving efficiency, improving the environment and ultimately improving their working life. It was emphasised that this was not a threat to jobs but an opportunity to develop roles and provide an improved level of service. The technician members of the project team kept the staff informed on progress with regular updates, meetings and videos, all of which were supported by Baxter. As a result, there was a high level of expectation and excitement among staff. This proved invaluable: as the implementation date loomed, volunteers were needed to undertake additional training and work extra hours in preparation for the implementation.
One of the major advantages of the CONSIS system is that it does not occupy a large amount of space. We installed two modules each measuring 1.2m ¥ 1.4m and holding a total of up to 11,000 items. This gave us a lot of flexibility, and the expanded project team were able to consider the best location for the machine in the dispensary, where they felt it would make the maximum impact on workflow. The only enabling works required were minor in nature and consisted of moving electrical sockets and IT terminals, and moving shelving and free-standing benches.
The new system was installed over one weekend in September 2003 (ie, only six months from tender to installation.) The simultaneous dispensing and reloading allows restocking at any time. It also employs a first in–first out principle, which ensures stock rotation and, importantly, allows easy access for product recall if necessary.
The introduction of CONSIS into the pharmacy has already made a tremendous impact. All staff were impressed with the speed of picking (an item can be picked in <10sec). We have also noticed that the flow of work has smoothed out, and efficiency has certainly improved. The machine itself is space-efficient, is not obtrusive and is easy to use (see Figure 2). The environment in the pharmacy has improved, and walking time (an estimated 3 miles/day/person before we introduced CONSIS) has been minimised.
The CONSIS system incorporates barcode scanner checking whereby, after dispensing the patient’s prescription, details can be called up on screen and each dispensed item scanned to check that the correct medicine has been dispensed. We are currently using this at the assembly stage for operators to self-check before passing on to the final check stage.
A formal evaluation is currently underway to compare a range of parameters before and after introduction of the system.
The next phase will be the introduction of barcodes on medication labels, carrying data on the medication and dosage instructions. This will allow the scanner checking system to validate that the correct medicine has been dispensed and that the label carries the correct information and correlates with the dispensed item. The department also expects the introduction of electronic prescribing, which could then be directly linked to the automated dispensing system after authorisation by a pharmacist.