The Robotics 2007 meeting was held at Austin Court, Birmingham, UK, on 26 September 2007. The theme was “Shaping the future of hospital pharmacy”, and about 90 people attended.
Hospital Pharmacy Europe
The introduction of dispensing robots in hospitals in the North-West of England virtually eliminated picking errors and ensured that routine supply work was done much more quickly, according to Shoshana Bloom (programme manager, North West Hospital Automation Programme, UK). The phased programme for automation in the North West has made it possible to have multisite discounts and evaluate performance stage by stage. As a result, the North West has now purchased the most advanced system in the UK ï¿½ incorporating loading hoppers, integrated channel storage for fast-moving items and labelling facilities, she continued.
When planning the introduction of robots, it is essential to consider optimal robot design, reï¿½designing of services and evaluation of the impact of automation on existing staff roles.
Storage capacity and throughput must be conï¿½sidered. The required throughput is determined by the number of items to be issued per hour. The actual output is governed by the number of picking heads on the robot. Another useful tip is to maximise the height of the system ï¿½ removing a false ceiling may make it possible to reduce the size of the robot’s footprint, she suggested.
Process mapping is a good way to understand work patterns and the likely impact of automation. It is critical to understand how existing processes impact on each other; for example, stock replenishment may occur at the same time as dispensing, at present. As both activities would impact on the robot at the same time, the processes may have to be redesigned for optimal functioning, she explained.
Automation could change staff roles ï¿½ some tasks could become redundant and new roles, such as robot users and “super-users”, will be required.
Ms Bloom’s top tips for success were to communicate with the staff, because some would be afraid their jobs would disappear, and to visit as many automated sites as possible to learn from colleagues’ experiences.
The NHS Purchasing and Supply Agency (PASA) has a website for robotics and automation, Judie Finesilver (e-business pharmacist, NHS PASA, UK) told the audience (see Resource). The site contains a list of hospitals, the systems that each one is using and contact information. The information is sufficiently detailed to provide “a snapshot of where to go for help and support”, Ms Finesilver said. In addition, the site contains a toolkit that provides a flow diagram of processes to aid the installation of a robotic system.
Problems are still being encountered with items that cannot be put into robots because they have seven-digit instead of 13-digit barcodes (or no barcode at all) or because the packs are too flimsy, she said. When arranging repackaging it is important to ensure the repackaging unit understands the need for barcodes and “overlabelling”. Overlabelling of inappropriate barcodes must be done in such as way as to obliterate the original barcode, because many cameras can read through thin labels, she warned.
The implementation of electronic prescribing (e-prescribing) is progressing but has been held up by the lack of a common dictionary, said Ann Slee (clinical lead, e-prescribing programme, NHS Connecting for Health).
E-prescribing has been defined as “the utilisation of electronic systems to facilitate and enhance the communication of a prescription or medication order, aiding the choice, administration or supply of a medicine through decision support and providing a robust audit trail for the entire medicines-use
The definition is broad and means that ward-based e-prescribing will need to link with pharmacy systems ï¿½ and this is technically complex, Ms Slee said. One of the key priorities for planners is safety and several steps are being taken to address this. Decision support will be built in to deal with the “top 10” medicines that cause harm to patients. Another feature will be dose calculators for paediatric prescribing ï¿½ this is one of the biggest areas of error, Ms Slee noted. It will be important to ensure that the software not only calculates the dose but also checks that it is a feasible quantity to administer and rounds the dose up or down acceptably. So far no software has been evaluated for this task. There will also be a method for incorporating alerts into the e-prescribing system.
Careful attention has been paid to screen design and there has been wide consultation with all the professions involved. As a result, a way of helping to avoid selection errors with lookalike names has been devised. This involves capitalising certain syllables to give names a distinctive appearance, for example, gliBENclamide, gliCLAzide and gliPIzide.
“With medicines, you think you can predict things but you only really see what happens when you implement the new system,” Ms Slee said.
Pharmacy staff must move from managing the organisation’s medicines to managing patients’ medicines, and a fully robotised medication management system is needed to allow this to happen, according to Ron Purkiss (clinical director of medication management and pharmacy, Sheffield
Teaching Hospitals NHS Foundation Trust).
Within five to 10 years it should be possible to have a system in which fully automated prescribing, dispensing and administration systems work as a single, auditable process, he predicted. It might also be possible to automate processes related to examinations, tests, diagnoses and the reporting of results. At present, 20% of tests result in no action and 30% of X-rays are not reported to the person who requested them, so an automated system could bring considerable cost savings by preventing unnecessary orders. Good electronic communication would be essential to underpin all future developï¿½ments. In particular, communications between primary and secondary care have to be improved. Increased use of mobile and remote technology should improve access by making remote prescribing possible. Finally, failsafe systems would be critical. At present we tend to replace one set of errors with another, Professor Purkiss said.
Effectiveness of decentralisation
Work in Sheffield has shown that in a traditional system in which medicines are received into the pharmacy store, transferred to a dispensary and later issued to a ward, one pack of medicines can be handled 11 times before the patient receives a dose. “This is an inefficient process that has not changed in 38 years ï¿½ why robotise it?” Professor Purkiss asked. The ideal way to streamline the process is to install decentralised dispensing robots in ward areas, he suggested. Centralised robots offer the advantage of improved stock control but at low volumes of work they offer no advantage over manual systems. Moreover, centralised dispensing robots do not save staff time, he said. In contrast, a decentralised system provides better stock control at ward level, reduces “travelling time” for staff (in collecting/delivering medicines from the pharmacy) and improves overall efficiency. Medicines can also be issued out-of-hours by staff at remote sites. Such robots can be installed incrementally ï¿½ one has been installed annually for the past four years in Sheffield ï¿½ and space in the central pharmacy can progressively be reallocated.
One refinement that Professor Purkiss would like to see is replenishment of the decentralised robots by wholesalers, but this has not yet been achieved. Another possibility would be for all other products on wards, such as dressings, syringes, needles and catheters to be controlled by robots. “Anything with a barcode on it would be suitable”, he suggested.
A selection error that resulted in accidental administration of two doses of suxamethonium instead of syntocinon to a woman post-partum made clear to Don Hughes (then director of pharmacy, Countess of Chester Hospital, now director of pharmacy, Glan Clwyd Hospital, Conwy and Denbighshire, UK) age system. Medi-365 automated control systems were installed in the accident and emergency (A&E) department to improve medicines management.
The Medi-365 is a secure storage unit that has computer-controlled drawers. Units can be custom-built to match the needs of the clinical area. Staff access the device through a touch-screen on the front of the unit. Logging on involves both a four-digit personal code and a fingerprint scan. The pharmacy receives daily automatic orders from the system and a pharmacy assistant delivers the items and refills the Medi-365 drawers.
As a result of installing the units there have been savings in nursing time, changes in the way that pharmacy staff time is used and a reduction in the stockholding in the A&E department. The time taken by a nurse to access a medicine has fallen from 203 to 46 seconds. This saves nearly 18 minutes of nurse time per hour, or 7.1 hours of nurse time per 24 hours.
A&E staff have welcomed the system and commented that time is not wasted searching for medicines because the system can say immediately what is available and where it is. One unexpected finding was that the use of pre-packs of antibiotics and analgesics increased, and this turned out to be because in the previous system supplies always ran out during the weekend. Now, the stock matches the needs. Mr Hughes added that the system is robust, incorporates customised decision support and provides detailed management reports with full audit trails.
The RoboPharma robot was chosen at Whiston Hospital, UK, to tackle the rapid growth in the number of inpatient prescriptions and the need to reduce turnaround time for take-home medicines, explained Mike Welsby (medicines information pharmacist, St Helens and Knowsley Hospitals NHS Trust). Between 850 and 1,200 inpatient items are dispensed each day in the pharmacy, and this was causing workflow problems.
Two features of the RoboPharma robot that are particularly attractive are that it can hold bottles as well as boxes and that it includes a labelling
The robot at Whiston Hospital is equipped to handle both fast- and slow-moving items and holds 5,500 packs ï¿½ equivalent to stock for about 1.5 weeks. There are four delivery points in the dispensary and one in the night store for on-call use. This can be activated remotely and has made it possible to “dispense from the living room”, Mr Welsby explained. Liquids, cytotoxics, refrigerator items and controlled drugs have been excluded.
The RoboPharma robot is filled manually from the rear ï¿½ a process that takes just under 10 seconds per pack. Packs are identified by scanning the barcode, the appropriate channel is illuminated and loading is confirmed on the computer touch-screen.
The robot can deliver eight packs in four seconds and the delivery rate is unaffected by filling.
Currently, 82% of all dispensed items come from the robot and dispensing error rates and the turnaround time for take-home medicines have halved since it was installed. The impact on staff has also been positive, Mr Welsby noted.
Staff have been released for clinical activities and for work in the aseptic unit, overtime has gone down and staff morale has increased. â–