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Director of Pharmacy
Senior Pharmacy Technician
Ward Manager, Ward 4
Chris O’Brien Williams,
Sister, Haematology Transplant Unit
The Christie NHS Foundation Trust
The Christie NHS Foundation Trust in Manchester, UK, is the largest single-site oncology centre in northern Europe. The unit comprises 190 beds and is dedicated to oncology diagnosis and treatment. It also serves as a key research facility and is a leader in clinical trials worldwide.
In the summer of 2009, two automated medicine-dispensing cabinets (Omnicell) were installed in two ward areas: one in the haematology transplant unit and the other in a clinical oncology ward.
This article describes the benefits realised from using the new automation and reports the results of data collected before and after the installation to demonstrate inventory reduction and staff time savings.
The Christie pharmacy operates Monday through Friday as well as Saturday morning and includes an outpatient and inpatient dispensary aseptic and clinical services. It is staffed by more than 50 pharmacists and pharmacy technicians with automation installed in the dispensary, including an electronic queue-management system. Electronic prescribing is used in all of the outpatient chemotherapy clinics.
The traditional ward stock replenishment or ‘top-up’ process occurs once a week on the clinical oncology ward and twice a week in haematology.
Prior to the installation of the automated dispensing cabinets, the pharmacy staff would travel to the ward to check the cupboard for stock levels of each drug required and manually record what needed to be replenished. This was a very time-consuming process.
In addition, the open ward cupboards were often in disarray, several medicine packs had often been part-used and stock was not always in the correct place.
After checking stock levels on the ward, the pharmacy technician would return to pharmacy, where the required medicines would be placed in a ward box and delivered back to the appropriate ward. Upon receiving the ward box, the nursing staff became responsible for putting the medicines away in the cupboard.
Streamlined top-up process
After the Omnicell-automated dispensing cabinets were installed, the top-up process became much more efficient. Since the drug inventory in the cabinets was automatically and electronically tracked, the dispensary staff could run a computer report from the pharmacy, which details exactly what items need to be restocked on each ward. There is no need to physically visit each ward to count the inventory first.
The pharmacy staff make a single trip to the ward, taking exactly what is needed to restock the automated dispensing cabinet. The cabinet also stores all medicines in a much more ordered fashion. This system not only saves pharmacy staff time, but saves nurses time as well, because the nurses no longer have to put the medicines away in the cabinet – with the exception of controlled drugs, which nurses retain responsibility for putting into the Omnicell cabinets.
Comparison study: time and inventory savings
To evaluate the saving in time and reduction in inventory resulting from the Omnicell system, we conducted time and motion studies on the two wards and collected inventory data before and after installation.
The Omnicell-automated medicine cabinets were installed in the haematology transplant unit (HTU) and clinical oncology unit (Ward 4) in July 2009. Data was collected three months before installation and for three months afterward. Nurse and pharmacy staff time were analysed in addition to the amount of stock issued.
A stringent review of the data collected was conducted to ensure the results of the analysis were robust. For example, if data was missing from a form or the signature of a witness was absent, that data was eliminated from the analysis.
External support was provided by Omnicell to facilitate the time and motion analysis, and forms were designed to collect data (see Figure 1). To analyse pharmacy staff time, data was collected on days the pharmacy conducted top-ups on the wards. For controlled drugs, nursing staff were shadowed to assess workflow and time spent on medicine administration.
The evaluation of the data prior to and after using the automated dispensing cabinets demonstrates a significant saving in decreased stock issued as well as a reduction in time spent on top-up and drug administration. The savings demonstrated for Ward 4 are assumed to be typical of a clinical oncology ward. On this ward, a reduction in inventory issued of £889, or a 61% reduction, was observed.
The savings in pharmacy staff time of 159 minutes (2.65 hours) per week has enabled pharmacy technicians to be redeployed to improve dispensary turnaround times. The savings in nursing time compared well with other UK published data and have allowed nursing staff to spend more time on patient care.
In addition to the time and monetary savings, there is a benefit from the increased security and audit trail for controlled drugs. Prior to the installation of automated medicine dispensing cabinets, the traditional controlled drug cupboards required key access, which often meant that nurses needing to administer controlled drugs would spend time searching for the nurse holding the keys. Once the cupboard was accessed, then the sole audit trail was the controlled drugs register.
With the Omnicell system, fingerprint identification is required to access the system. Access is much more restricted, and a full audit trail exists for general stock as well as controlled drugs. The pharmacy can see exactly what has been issued, by whom, and how much. Nursing staff no longer waste time searching for keys to access controlled drugs.
Potential for fewer drug administration errors
One unique feature of the Omnicell automated cabinets is the ‘guiding lights’ that guide nurses to the drawer of the cabinet for the specific medicine they have requested. This speeds up the process of issuing medicines from the cabinet and, more importantly, helps to reduce the likelihood of nurse error. In a disorganised cupboard, it can be difficult to find items and easier to mis-select among similar-looking medicines.
However, hospital data collected for clinical incidents is on a voluntary reporting basis and no impact was detected on medicine administration errors after installation of the automated cabinets. Nevertheless, the nurse managers felt that the new system was safer and has resulted in fewer errors.
Additional benefits may be realised from using automated dispensing cabinets on the wards. Part-pack wastage was reduced by the cabinets being programmed to remove doses solely from one open pack rather than multiple packs being opened.
Although not formally looked at in the pilot, the cabinets can potentially enable a greater range of discharge medicines to be stored on the ward, which would help ensure medicines can be given to patients in a more timely manner to free up valuable bed time.
The automated dispensing cabinet will also help identify low turnover stock that can be removed to improve efficiency. Storage of items in the cabinet resulted in the overall release of valuable storage space in the treatment rooms, plus they can be used for storage of non-medicinal high-cost items. The ability to track drug and non-drug usage and the subsequent production of reports will help to highlight any anomalies. An electronic record is available showing all the items dispensed by each nurse and which patients they were administered to.
The key to implementation
Proper planning and communication with colleagues and staff are critical aspects of successfully implementing new technology. It was critical to the success of the project to gain the support of nurse colleagues from the outset and involve them throughout the transition.
Prior to initiating the system at The Christie, a visit was made to an A&E department in a nearby hospital where automated dispensing cabinets were in use. The staff were very positive about the technology, and although the facility was not an oncology centre, the nurses were able to see at first hand the technological capabilities of the automated dispensing cabinet, and were encouraged sufficiently to agree to a pilot study, despite some initial reservations.
While there is some queuing at the automated cabinet during busy times, the reaction of the nursing staff has been overwhelmingly positive. One of the nurse managers commented that the fingerprint identification is very user-friendly and noted that there was “no more searching through cupboards” and “more time spent with patients at the bedside”.
Installing the automated dispensing cabinets has saved time for pharmacy and nursing staff, and significantly reduced the amount of stock kept on the wards. From the time saved, pharmacy personnel have been redeployed to support outpatient dispensary turnaround times, and nurses have more time to spend on direct patient care. Additionally, the nurses feel they are less vulnerable to making medicine errors with the new system, which means increased patient safety. Involving nurse and pharmacy colleagues at the outset and keeping them informed throughout the implementation process ensured a smooth transition and a successful project. Other wards at the Christie are now considering installation of the automated dispensing cabinets.