At the 180-bed Spaulding Hospital in Cambridge, Mass., a member of the Boston-based Partners Healthcare, Joe Sacco, R.Ph., the hospital’s director of pharmacy, has been helping to lead his colleagues forward on a multi-phase journey toward automation and improved patient safety and care quality.
The work that the clinician leaders at Spaulding Hospital have been leading has been strongly motivated by the recent changes in medication management standards coming out of the Joint Commission. In July 2010, the Joint Commission issued more rigorous standards on the management—including the labeling—of multi-dose medications, including certain types of injectibles. Because of a mandate requiring all stored medications to be labeled with an expiration date, many hospitals have ended up adopting ad hoc processes involving nurses hand-writing expiration dates on labels, ironically leading to new medication administration errors and other issues, including problems around handwriting illegibility and incompleteness of information.
Over the past several years, Spaulding Hospital’s clinician leaders have experimented with different strategies in this area, ultimately moving from a hybrid to a fully decentralized medication distribution model that allows nursing staff to print individual, patient-specific labels for medications accessed and removed from automated medication cabinets on patient care floors. Sacco and his colleagues have been working with solutions from the Mountain View, Calif.-based Omnicell. Sacco spoke recently with HCI Editor-in-Chief Mark Hagland regarding his team’s work in this area. Below are excerpts from that interview.
What led you to move forward on this initiative?
We had already had automation here since I came in. We had had Omnicell since 2002, and had expanded it in 2003. And a year ago, we embarked on expanding our use of the Omnicell product in the Windows 7 environment, including with new equipment and products. We expanded the number of medication cabinets we were using, so that we could provide an adequate number of stations for the nurses. We purchased AnywhereRN™, the company’s remote medication management solution, as well as the SinglePointe™ patient medication management system [together, the two solutions provide nurses with automated access and management of medications].
The reality, though, is that you can only get about 80 percent of your medications in a cabinet. It’s the remaining medications, including multi-dose inhalers, bulk liquids, and so forth, where the problems come in. SinglePointe allows you to create a bin for medications within the Omnicell cabinet, assign a patient to it, assign multiple medications to it, and make it a part of your regular restock system; while AnywhereRN allows nurses to remotely access medications from their cart or nurses’ station, and build their lists of meds they’re going to issue. It’s a good time-saver, because it prepares the cabinets to open.
So we started to get this equipment in, and one of the things I was concerned about was, we wanted to expand the number of medications the nurses could have on the floors in the cabinets. But some of that involved things like single-use antibiotics, and multi-dose inhalers. In the past, some of those medications would come out of the pharmacy IV room, and we [pharmacists] would label them. But the recently revised Joint Commission regulations on proper labeling, which require complete labeling, including the patient name, the room number, and the drug and dose, to be on the label, created a problem with certain medications.
Do you have barcoded medication administration?
We’ve just rolled that out, but even with such a system, you still have to make sure you’ve hung an IV on the right patient, for example. And at the time when we started this, we were still a year away from barcoding. The challenge is that anything that isn’t a single unit of use like a tablet—anything that’s an IV or an ointment or a multi-use inhaler, has to have a label on it, as spelled out by the Joint Commission standards.
So what did you do?
I spoke to the director of nursing and said, we want to have these meds available as soon as possible to the nurses. But how are we going to put a label on that product? We could produce labels and have nurses hand-write on them, but that’s not a perfect system. But one of the things I noticed was, I happened to open the new cabinets one day, and noted that there’s a spot for the receipt printer, and noticed this other spot marked for a label printer, and I asked Omnicell about this, and they told me it was a future enhancement. And I said, if there’s a beta test on this, we’d love to be involved.
So that the nurse could print the label upon removing the medication from the cabinet?
Actually, it’s a lot better, because you can pre-configure to auto-print, by drug, in the Omnicell database. If we choose to select an item in our database, for example, a vial of penicillin that’s been ordered, when the nurse selects the med, it’s set to auto-print a label. A second option is that if a nurse wanted a label for any reason, for any product, he or she could just select to print that label. Another great safety feature, and you have to have the hardware piece—but we added this onto our system—is an option called “confirm med.” Let’s take our vial of penicillin option: when the nurse selects that item, the menu will say, “scan item,” because some of our items are in cabinets on individual shelves. So this feature requires the nurse to scan the item; then the label will come out, but not until they confirm the med.
So you’re saving time, also?
Yes. And you’re also able to put expiration dating on the label. The confirm-med function was something we wanted to utilize. And we do have barcoding now, but barcodes are not always foolproof. Any IT person would realize they’re not a perfect system, either, because sometimes, barcodes don’t read. And your Omnicell system might be your dispensing system; but your documentation system might be Siemens or McKesson or Meditech, or whatever. Since we’ve gone with scanning, I’ve never heard a nurse say it’s a problem to scan twice.
When we first started this project, we hadn’t yet included training; but the benefit was huge, and nurses thought it was great. They liked that they didn’t have to hand-write labels; and they thought scanning was a good thing, and they thought that that second check was always a good idea. So they’re really embraced this process. And I say, really, cabinets should not be sold without having this built in. Just as you can’t buy a cabinet without a receipt-printer, this should be a standard feature now, just as you can’t buy a car without an air bag now. And labeling is very important, unless every single item will be unit-of-use.
Have medication administration error rates gone down?
Yes, overall, we’ve seen decreases. And I haven’t heard of anybody who’s put up the wrong the antibiotic since this was implemented. And I can’t say it was a huge problem in the past; the potential was there, but we never identified that as being a big problem for us.
What have been the overall l lessons learned in all this, so far?
In this environment, it was very important that if you do something like automated dispensing cabinets, you’ve got to remember that you still have to satisfy all the standards of the Joint Commission and CMS [the federal Centers for Medicare and Medicaid Services], and you really have to develop your systems ahead of time. It most likely didn’t really dawn on me until we had decided to go forward with the cabinets and we started to build the inventory for the cabinets, that when we sent antibiotics up to the floors, they were going there without labels. And of course, we immediately got calls from the nurses on that account.
So you have to think about how a new system will impact everyone compared to what you’re doing now. We were so excited about having the nurses have antibiotics right at the point of administration, that we lost sight of the fact that we had always sent up labels from the IV room. So that was a huge lesson learned; think of everything you’re going to put into that cabinet.
What would your advice be for CIOs, CMIOs, and other healthcare IT leaders, with regard to process issues?
A lot of this trickles down to the pharmacy directors; one of the things that CIOs need to remember is to work with the pharmacy directors to make sure they look at their workflow, and really talk about what’s going to change.
So they have to be involved in discussing workflow at a somewhat granular level, in planning, correct?
Exactly. Because that’s one thing that I was a little bit taken back by, in going from medication carts to a cart-less system. And CIOs don’t know medications, but they know systems, and can be instrumental in helping to facilitate change.
