Proper medication management is essential to providing high-quality care and maintaining patient safety in a hospital. Key elements of a medication management system are inventory control, storage, delivery, security, integrity and safety. The Joint Commission has consistently reported MM.03.01.01 (Medication Storage) as one the most challenging standards for healthcare organizations (http://www.jointcommission.org, “The Joint Commission Perspectives,” April 2013). A critical evaluation of the systems employed by many organizations quickly identifies vulnerabilities, shedding light on why so many need improvement.
Medication is a very broad term, encompassing everything from traditional prescription drugs to I.V. solutions and contrast media used by radiologists. For many hospitals, the term medication covers hundreds of thousands to millions of transactions per year. Ensuring the integrity and security of so many products, which are completely woven into the fabric of patient care, taxes even the best systems. Several of the greatest vulnerabilities lie between the time of dispensing and administration to the patient.
Over the past 13 years as a pharmacy director, the last eight serving as the director of pharmaceutical services at Erie County Medical Center (ECMC) in Buffalo, N.Y., I have witnessed significant changes to medication distribution and administration processes.
Approximately seven years ago, ECMC’s pharmacy moved to what is referred to as a cartless dispensing model, which was cutting edge at the time. A cartless model allows for most medications required for patient care to be stored and secured in automated dispensing cabinets (ADCs) in patient-care areas. This model greatly decreases the time from prescribing a medication to administration to the patient. It also minimizes the chance a medication will be missed, and increases accountability and reporting capabilities – all issues plaguing the traditional cart-fill model.
This type of system intrinsically secures the drugs up to the point of removal from the ADC for administration, but does not address the next steps in the administration process. We needed a medication management technology that would streamline and safeguard the transportation of medications from the ADC, or medication room, to the patient’s bedside.
Earlier attempts at addressing this concern – employing mobile medication carts, commonly referred to as bedside medication verification (BMV) carts – proved challenging. The core function of BMV carts is to document the accuracy of medication administration by utilizing barcode technology to verify that the right medication (product and strength) is given to the right patient at the right time. When BMV carts first appeared in patient care areas, security was a bit of an afterthought. Many models were little more than existing computers on wheels (COWs) with a drawer attached. Drawer locks were easy to break and generally opened with a key or universal code. This meant that medications could at times be left unsecured in the cart, and that items placed in the cart by one professional could be removed from the cart by another without an audit trail. This was particularly concerning when transporting a controlled substance.
We are now utilizing a medication administration system that connects to a single medication database, creating a closed-loop process all the way to the bedside. The system includes mobile medication workstations, designed with security in mind, that serve as an extension of the ADCs, ensuring drugs remain secure as they are transported to the patient. Our current carts continue to support the BMV mission but now provide capabilities, such as individually locking drawers that can be assigned to a specific patient, secure supply drawers and user-access audit trails. We can now answer the question: “Who was in that patient’s drawer last?”
As previously stated, medication security was a key feature the organization evaluated in selecting the next-generation BMV cart. But several other factors – or shortcomings of the prior carts – were considered. We desired a platform that was flexible, one that could be configured in several ways to meet the varying needs of diverse patient populations. For example, a nurse caring for behavioral health patients would need many smaller drawers; a medical surgical nurse may need fewer but larger drawers to hold IV infusions as well as oral meds. Flexible also means adjustable, since we have nurses less than five feet tall and nurses more than six-and-a-half-feet tall.
We also agreed that the cart needed to be easily serviceable. Out-of-service carts offer no value to the user. Ideally, the cart should be repaired or serviced on the nursing unit. Battery life was also a huge nursing concern; a cart should be able to go an entire shift without charging. Durability and mobility were also evaluated. How long is the projected serviceable life? What is the projected cost per year of service? Is it easily moved from room to room? Can the cart be easily cleaned? Does it meet infection control standards? All too often, organizations focus on addressing a known issue or vulnerability with technology without fully understanding the user’s workflow. Any technology that does not meet the needs of the end user is likely to, in some way, be circumvented – in this case defeating the security enhancements.
The solution we chose fulfills as many “wish list” items as possible. Currently, we provide four core drawer configurations to meet the needs of distinct nursing populations and, most recently, our respiratory therapists. The drawer systems are modular and can be replaced or reconfigured on the nursing unit within minutes. Locking mechanisms are robust and durable. Carts are powered by a pair of lithium-ion batteries, providing up to 17 hours when fully charged; they can be hot-swapped from one cart to another when required. The carts are heavy, but they roll very easily thanks to large wheels and a low center of gravity. The drawers have hard plastic liners that can be easily removed for cleaning. The range on the powered (nurses love powered) height adjustment easily meets the needs of our tallest and shortest staff members.
| The Omnicell Savvy Mobile Medication Workstation streamlines the medication administration process and provides safe and secure transportation of medications from the automated dispensing cabinet (ADC) to the patient’s bedside. |
Since our carts integrate into the ADC platform, Omnicell, the staff benefits from a Web-based application called AnywhereRN, which allows them to remotely schedule medications for removal from the ADC; this saves time and helps minimize lines, or queuing, at the cabinet. The same application allows for remote documentation of waste for controlled substances, which was an additional security concern. Previously, two nurses would have to return to the ADC to document waste. This could result in a staff member holding on to waste while waiting for a co-worker to become available. Remote waste continues to require two professionals for documentation, but it’s done in a way that better integrates into workflow and is closer to real time.
AnywhereRN also helps us minimize interruptions in nurses’ workflow, which is a known risk for errors. According to a study published in JAMA Internal Medicine (April 26, 2010) titled, “Association of Interruptions With an Increased Risk and Severity of Medication Administration Errors,” the risk of a serious medication error doubles when a nurse is interrupted four times in the course of administering a drug. The mobile medication workstations help minimize this risk by enabling nurses to queue up medications from a quieter area, where they are less likely to be interrupted.
Here are a few helpful tips to aid with compliance:
Work as a team: In order to ensure safe medication distribution, all departments must pursue the common goal of improving patient safety. The pharmacy is instrumental in this pursuit by working with nursing, respiratory therapy, behavioral health, anesthesiology and other departments to understand each area’s medication needs. Listening to and communicating regularly with each department to determine how medication needs can be safely met will improve medication management throughout the facility. Although pharmacy drove the acquisition of the cartless medication administration system at ECMC, our nursing staff is the most directly affected as the end users of the actual ADCs and mobile workstations. Figure out how to minimize the impact on workflow while still fulfilling the regulations. You want to avoid having people circumvent safe practices.
- Involve the IT department early and often: Many of our projects are IT heavy. Earlier carts were computers on wheels with locking drawers. There was a battle as to who owned and fixed them. Since the cart involved a computer, it ended up in IT’s lap. With an ever increasing project load on IT, work needed to be prioritized; a cart needing a 10-minute repair might have stayed out of service for days due to other priorities. While obtaining feedback from grassroots people on what products to purchase, you will also want to get IT staff involved as early as possible to ensure projects receive the dedicated resources on the timeline required. When we brought the current carts into the hospital, the pharmacy agreed to own and fix any part of it other than the actual computer. Since the unit is modular, it is easy to service onsite, and we did not need a large fleet of back-up carts. Most repairs can be made on the nursing unit.
- Train, train, train: Nothing can be done without the end users. Technology specialists understand the mechanics of new technology. In the same way, nurses and pharmacists are experts in their fields; they understand the dynamic flow of patient care and medication dosing, and the frequent interactions needed between numerous healthcare providers to provide that care. It is important for nurses to understand new technology, and for technology engineers to understand how the equipment and software will need to interface with the facility’s existing systems.
- Grassroots feedback: Involving the end users throughout all phases of the process, including the implementation and evaluation phases, is an important key to success in using these technologies.
By working as a team, including the IT department, adequately training staff and listening to grassroots feedback, ECMC has been able to meet and adhere to medication management standards. The latest advances in medication tracking, storage, distribution and security help us drive efficiency and improve patient safety.
About the author
Randy Gerwitz, R.Ph., Director of Pharmacy, ECMC.
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