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Use of the automation system Medi365 has shown it to be well accepted by nursing and medical staff. With an array of services, perhaps its biggest benefit is that replenishment is driven by the use of products or stock levels, and thus clinical and patient need
Christopher Green
Director of Pharmacy and Medicines Management
Countess of Chester Hospital NHS Foundation Trust
Chester
Don Hughes
Director of Pharmacy
North Wales NHS Trust Central Area
Glan Clwyd Hospital
Rhyl
Denbighshire
UK
Ward-based automation has been in place in the United States for a number of years.[1,2] In the United Kingdom, however, while dispensary-based automation systems such as the
ROWA are almost considered de rigueur, the automation of medicines storage at ward level is very much in its infancy.[3-6]
Storage of medicines in National Health Service (NHS) institutions in the UK is generally poor, with storage facilities showing little change over the last few decades, while compliance with the standards set out nationally is variable.[7]
As access to medicines is key-controlled, when the keys are lost or staff leave the ward to accompany patients or to take breaks, patients may be denied timely access to their medicines.
Security is also a problem, because key-controlled access lacks a robust audit trail, such that, in the event of a clinical or security incident, accountability of individuals is almost impossible to establish.
There is also a less obvious human cost, in that some staff have resorted to misuse of medicines for a variety of reasons, with sometimes tragic consequences that may have been prevented had a robust audit trail been in place as a suitable deterrent.
The packaging of medicines is such that it can be difficult to accurately distinguish products from each other, and product selection is subject to well-recognised picking errors, or even errors where packets are not selected because they cannot be readily identified.
These problems lead to frustration for nursing and pharmacy staff as they blame each other for the problems associated with poor storage of medicines. And, at the end of this, it is the patient who bears the brunt of these problems because they are susceptible to the effects of missed doses, incorrect product selection and delays while medicines are acquired.
Stock control is also a problem because the traditional mechanism for restocking clinical areas is a labour-intensive process and collecting information about product expiry and batch number details is performed manually. Similarly, product recalls are also an issue because tracking individual products across the hospital in terms of expiry and batch number detail is again labour-intensive, and it is difficult to provide assurance that it is effective.
Automation of the storage and control of medicines would clearly address some of these issues, and with this in mind the Countess of Chester NHS Foundation Trust was the first in the UK to tackle them using the Medi365 automated storage system in 2005.
The system
In principle, the Medi365 system is a modular system that consists of a number of frames – in our experience between two and five – and each frame is made up of a number of drawers and storage cupboards that come in a range of shapes and sizes.
One frame contains a personal computer that controls access to the drawers via a pin number, swipe card, fingerprint scan or a combination of the three. Each drawer is divided up into sections, and the locking mechanism for each drawer is designed to limit the extent to which drawers open by stopping the opening of the drawer once it is open to the rear of the product requested. When staff come to select products from the unit, they quickly learn to select the product at the rear of the drawer, thus reducing selection errors.
Products are allocated to a drawer and a location between two dividers across the width of the drawer. Users are guided to the appropriate drawer using directional light technology, and a visual display, possibly a photograph of the product, is shown on the system’s computer display monitor. While the latter
is considered somewhat useful by staff, the vagaries of NHS procurement mean that products are subject to change in terms of supplier, and that the appearance of one drug can change periodically, potentially confusing users.
Barcode technology is used to control the stock in the system, which is intended to minimise the likelihood of selection and replenishment errors.[8,9] Medicines administration can also be supported by the onscreen option to view or print guidelines and protocols while accessing the product.
There is also the option of attaching a refrigerator to the Medi365 system, which can be controlled by a magnetic electronic lock.
Product recalls are currently a major problem because most hospitals do not have the staffing levels or the degree of sophistication in their computer systems to track products as they move around the hospital. Automation via Medi365 will enable pharmacy staff to check an entire hospital’s central stock of a product for a single batch number via the network on a desktop computer. Although this could currently be achieved by manually entering barcodes into a system, the rollout of two-dimensional barcodes is required to make this a fully automated reality.
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Benefits of the system
Experience with Medi365 has shown that it is well accepted by nursing and medical staff. Evaluative work has also shown that it reduces average acquisition time of a dose of a medicine from about three minutes to about 40 seconds. Pharmacy time saved by not having to visit the units using Medi365 is reinvested in
loading the machine such that time is saved for nursing staff who previously put stock away. Similar facilities in hospital wards and departments in the USA have shown a number of key benefits. These include significant reductions in time spent on nurse[1,2] and pharmacy medication-related activities, high user acceptability and significant reductions in medication errors.[1]
Perhaps the biggest benefit of Medi365 is that replenishment is driven by the use of products or stock levels, and thus clinical and patient need. Under the traditional system – that is, using manual systems – the traditional pharmacy top-up is usually done on a specific day of the week with nursing staff ordering
additional supplies, usually when stocks are critically low or have run out. Automation prevents or reduces the risks of stock-outs, creates automatic reorders and provides better data, with which more useful predictions of stock usage can be obtained.
Another benefit is that the system can accommodate part-packs, unlike most dispensary automation systems, and the use of ward-based cabinets may be a route to reducing levels of waste across the NHS by improving opportunities to recycle part-packs.
Uses of the system
Medi365 can be used in a number of ways, ranging from direct from the unit to patient administration in A&E, to holding patients’ own medicines or original packs, to one-stop dispensing in other wards, for example mental health, and to acting as a central stock-holding unit. Medi365 could also be used to facilitate self-medication, since fingerprint or barcode controlled entry can restrict patients from their own medicines, and the software is also able to limit access to set times during the day, and even to ration access to doses of medication, for example analgesics.
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Supporting the medicines use process
Medi365 is also able to support the safe use of medicines by reducing errors with barcode technology, allowing links to policies and procedures when products are selected, putting questions on the screen to answer before products are released and via the “kitting function”. For example, when staff withdraw a less commonly used drug, for example caspofungin, Medi365 could either ask staff to confirm that it will be mixed with sodium chloride solutions and not glucose, or the system could link the drug to a saline bag of predetermined volume.
Supporting NPSA alerts is also possible – for example, asking staff to confirm that methotrexate doses are administered weekly, or asking them to confirm the request when withdrawing high-strength opiates. Medi365 can also assist with stock-outs and facilitate a reduction in missed doses, because when products are not in stock it has a “talk” function and can
interrogate other units to locate where a dose can be found.
A learning curve
There have been some teething problems with the system. For example, staff report that Medi365 does not always recognise the drug name typed in, although spelling drug names or using International Nonproprietary Names (rINNs) correctly is the key issue. As many departments have discovered with dispensary automation, the frequent NHS contract changes that result in changes to pack sizes, and shapes and changes in barcodes, present some problems that require reconfiguration of the drawers.
Medi365 has solved a number of the problems associated with medicines storage, but it would be inappropriate, at this stage, to paint a utopian picture of its benefits, and experience from Canada with a similar concept is described elsewhere.[10]
As experience builds, there is little doubt that different models of practice will emerge based on local and shared experience. Future developments include storage of controlled drugs, and the maintenance of an electronic register that could include biometric data is also a practical option.
There is little doubt, however, that ward automation using Medi365 and similar concepts will have a massive and positive impact on working practices in hospital pharmacy.
References
1. Guerrero RM, Nickman NA, Jorgenson JA. Work activities before and after implementation of an automated dispensing system. Am J Health-Syst Pharm 1996;53:548-54.
2. Schwarz H, Brodowy B. Implementation and evaluation of an automated dispensing system. American Am J Health-Syst Pharm 1995;52:823-8.
3. Audit Commission. A spoonful of sugar – medicines management in NHS hospitals. Audit Commission; 2001.
4. Slee A, Farrar K, Hughes D. Implementing an
automated dispensing system. Pharm J 2002;268:437-9.
5. Whittlesea C, Phillips C, Roberts D, Burfield R, Savage
J, Way C. Automated dispensing – how to evaluate its impact. Hosp Pharmacist 2004;11:286.
6. Fitzpatrick R. Automated dispensing – developing a business case to support investment. Hosp Pharmacist 2004;11:109-11.
7. Royal Pharmaceutical Society of Great Britain. The safe and secure handling of medicines. London; 2004. Available at: www.rpsgb.org.uk/pdfs/safsechandmeds.pdf
8. Bates D. Using information technology to reduce rates
of medication errors in hospitals. BMJ 2000;18:788-91.
9. Anonymous. Bar coding at the bedside. Health Manage Technol 2004;25:42-4.
10. Balka E, Kahnamoui N, Nutland K. Who is in charge of patient safety? Work practice, work processes and utopian views of automatic drug dispensing systems. Int J Med Inform 2007;76s:S48-S57.
