Managing a patient’s medications as patients move into or out of hospital requires careful planning in order to prevent unintentional medication errors and to ensure patients receive all doses of medication as intended. There is a large body of local and international evidence that medication error is common at these points. Evidence from the Collaborative Pharmaceutical Care at Tallaght Hospital (PACT) study demonstrates that engaging the services of a pharmacist working as an integrated part of the multidisciplinary team managing medications at admission and discharge improves the quality and safety of care (1-4).
Following the successful realignment of the Clinical Pharmacy Service to PACT in early 2015, clinical pharmacists are now deployed to each of ten specialties in Tallaght Hospital as part of the PACT service. The intended benefits of this realignment are:
- 78% reduction in medication errors at admission and discharge.
- 1,066 inpatients avoid potentially severely harmful errors at discharge each year.
- Reduced bed pressures on the hospital.
A limitation of the service is the time Pharmacists are available each day to provide the PACT model of care. All clinical pharmacists are required to support the dispensary service in the supply of medicines to wards. Furthermore, there are not enough clinical pharmacists available to see all patients in each specialty.
This improvement project intends utilising skill mix and technology to increase the time available to pharmaceutical technicians and clinical pharmacists to participate in the PACT service and direct patient care.
Pharmacy Dispensary Service for Adult Inpatients
Each ward carries a range of the most commonly prescribed medications as ward stock. The ward stock top-up service is provided by pharmaceutical technicians twice weekly. Nursing staff order Non-Stock medicines which are not available as ward stock using the 'carbon copy (NCR) system' from the In-patient Prescription Chart. In 2015 the Dispensary will process 320,000 medication orders. About 50% (160,000) will be supplied as stock whilst the remainder will be supplied as non-stock (individually dispensed and labelled) items. About 100,000 non-stock items will be supplied to the 11 adult wards. Currently we supply medication to cover the duration of the inpatient episode but do not issue any supply on discharge.
Delivering this model of care in the Dispensary, including procurement and stock management, currently requires Pharmaceutical Technicians (14 WTE) and Pharmacists (4 WTE)
If the 100,000 non-stock items were dispensed as original packs (28 days’ supply) without labelling, dispensary workload could be reduced significantly. However, redeployment of pharmaceutical technicians to wards would be required to ensure medicines are managed effectively including ordering and storage of medicines on the ward.
As Nurses are no longer expected to order medicines this project is also proving beneficial to their work load on ward.
Service Development and planning - Ward Based Technician intervention
This project builds on the PACT model to include Pharmaceutical Technicians. With training and redeployment, Pharmaceutical Technicians, based on the ward, work collaboratively with the PACT Pharmacists and ward team to support management of medicines including:
- Ordering and maintaining medicines from pharmacy for up to 28 day supply to be used for the duration of the inpatient episode
- Managing ward stock including stock list and shortages
- Facilitating use of patients’ own medicines, where appropriate, during the inpatient episode
- Arranging for disposal and/or return of medicines to Pharmacy
- Managing non-stock storage
- Utilise the pharmacy software system Cliniscript on a laptop on the ward to facilitate transmission of medication orders directly to Pharmacy.
A full pilot of this system, including the use of a notebook computer to allow access to the pharmacy software system, Cliniscript was successfully completed on Osborne ward beginning in February 2015 and is feasible. As of September 2015 Lynn ward became the fourth ward to receive this service and the pharmacy plans to roll out to all adult inpatient wards by Q1 2016.
Benefits and evaluation of the improvement project
We anticipate that this improvement programme will improve the medication supply process to all adult inpatients. This project has the potential to release an additional Pharmacist from the dispensary service to the PACT service. An additional 800 patients would benefit from the PACT model of care.
To date there has been a reduction of orders to Pharmacy by about 10%, Monday to Friday and 25% at weekends. In addition a non-stock order requiring 20 items would typically take 2 hours to complete (Pharmacist and Technician time) can now be turned around in about 15 minutes. The resource gained is being redistributed to direct patient care i.e. the PACT and WBT service.
Audit has demonstrated
- A 45% reduction in missed doses for patients
- A 25% reduction in interruptions during drug rounds
- A 20% reduction in time taken to complete drug rounds
- A high degree of nurse satisfaction - 100% agreed that the WBT service has
- saved nursing time
- improved time taken for ordered medications to reach the ward
- made locating medications on the ward easier
This project would significantly benefit from an Automated Dispensing System (Robot) as this this would fully automate both the stock and non-stock processes. A separate business case is in development for the next phase of this project which incorporates a robot.
Future Development - Implementation of an Automated Dispensing System (Robot)
An Automated Dispensing System (Robot) will help us improve patient care/safety in the Pharmacy department, particularly in Clinical Pharmacy Services (PACT) and WBT service. In brief the key benefits of implementing an ADS in the Pharmacy at AMNCH are:
a) Avoid the need to employ 3 FTE Pharmacists and Pharmaceutical Technicians at an annual pay-cost of €105,000 (mid-point of scale going forward for the implementation of Medication Reconciliation).
b) Release 1 FTE Pharmacist currently rostered in the Dispensary for clinical work.
c) Reduce need for a capital building project to further expand the Pharmacy department to meet space and staffing requirements
d) Improved service to nursing staff on wards through the expansion of the Ward Based Technician Service, in particular easier drug administration rounds.
e) A 60% reduction in dispensary errors.
2) The proposed solution is an Automated Dispensing System, the procurement and installation cost of which will be approximately €470,000 including acquisition costs and the associated building works.
Mr John O’Byrne, Deputy Head of Pharmacy, AMNCH
who has operational responsibility for the completion of this project.
John O’Byrne Deputy Head of Pharmacy