By David Grant, RPh, MBA

CHAMBERSBURG HOSPITAL, AN AFFILIATE OF SUMMIT HEALTH, LOCATED in south-central Pennsylvania, is a 248-bed, JCAHO-accredited, not-for-profit community hospital that provides comprehensive medical services to about 130,000 residents in surrounding Franklin County. Specialty areas include bariatric (gastric bypass surgery), cardiology, pediatric care, orthopedic surgery, physical medicine and rehabilitation, and total cancer care.

In 1996, I joined Chambersburg Hospital as a staff pharmacist. From my first day on the job, it became clear to me that the hospital leadership was aware of the national discussion about medication errors and was engaged actively in taking steps toward improved patient safety. In the mid-’90s, we brought in a consultant from the Institute for Safe Medication Practices (ISMP) and subsequently implemented their recommendations. At that time, there was little technology available that effectively reduced medication-use process errors.

My awareness of the need to focus on medication errors was sparked in 2002, when I became the director of pharmacy and respiratory care. I recognized how error-prone health care can be, and I began attending the National Patient Safety Foundation’s Patient Safety Congress. Along with the hospital board, CEO, and others, I saw a need to improve patient safety, and I felt we could thoughtfully apply technology to reduce medication errors. As part of our on-going discussions about patient safety, our CEO invited me to make a presentation to the hospital’s board of directors.

New Resources
Resources and the priority for improving the medication-use process developed immediately, once the issue came into sharper focus. We were directed to form a medication safety team comprised of nurses, pharmacists, doctors, and information services specialists. In weekly meetings, we set our goals for medication error reduction and increased patient safety. We were guided by the publication “Pathways to Medication Safety,” a cooperative project involving the American Hospital Association, the Health Research and Educational Trust, and the Institute for Safe Medication Practices.

Our intention was to do everything we could do on paper, in the form of policies, procedures, goals, and changes in the culture, before looking at technology solutions. The team felt that without the basic changes in approach to the problem and the culture, automation alone would not solve the problem. For nursing, one change of process was simple, but effective: taking the MAR (medication administration record) to the bedside to verify they were administering the right medication to the right patient. Nurses quickly adapted to the change.

Our culture began to transfrom as the nurses realized it was the right thing to do. Next, we built a medication information guide that is readily accessible to everyone on our intranet and includes a calculator to determine drip rates for drugs, such as cardiac medications, which when done manually often led to errors.

Action List
The medication safety team developed an action list of 180 items from the “Pathways to Medication Safety” guidelines. We began implementing them one at a time, holding “medication safety day” seminars that were mandatory for anyone handling or dispensing medications. While working on the paper systems, we were also keeping an eye on technology to help us achieve our goal of reducing medication-use errors. We wanted to dispense medications more efficiently, reduce errors, and place bar codes on all medications so nurses could verify them at the patient bedside. We would repackage oral solids with bar codes and rely on FDA rules for bar coding all other medications.

Everything in Place
Once the policies and cultural changes were in place, we began shopping for vendors and processes. This search ultimately led us to Omnicell’s WorkflowRx automation solution to help us manage our centralized cart fill system. We chose the Omnicell PharmacyCentral carousel for automated picking and the SafetyPak unit for packaging oral solids with bar codes.

Implementation of WorkflowRx was part of a process that began in January 2005. In February 2006, we formed a new, expanded medication safety team. The new 40-member team included existing members of the medication safety team, plus representatives from all disciplines involved in the handling, dispensing, or accounting for medications (nursing, pharmacy, respiratory therapy, diagnostic imaging), as well as our partners from information services and accounting. We met every week, and by April 2006 our first automation project went live. By December 2006, we will have initiated end-to-end medication-use automation, from physician order scanning to electronic bedside verification.

Reduced Inventories
Although decentralized cartless medication-use systems work well for many hospitals, we chose a hybrid approach with large cabinets in some areas and with cart fill centralized in the pharmacy. As a result, we get 24 hours of medications without the need for extra stock on the floors. If you look at how we worked before installation of the Omnicell WorkflowRx system, and how our system works today, the results are dramatic.

Before WorkflowRx, we had a shelving area which served as a pick station. Each day, we literally generated a ream (500 sheets) of paper with medication orders. A technician would divide the list by nursing unit, and then pick by hand every tablet and every dose, which amounted to 1,200 to 1,400 doses per cart fill.

Then a pharmacist would directly follow the technician, go down the paper medication list, pull out every drawer in the cart, and check for accuracy. This took approximately 16 hours per cart fill (eight for the technician and eight for the pharmacist). Let me describe one particular day to better illustrate this process.

We would run the medication list on the 14th of the month at 8 PM. The technician and pharmacist would work to fill as much of the carts as possible, before the end of the evening shift. Beginning at 7 AM the next morning, the technician and the pharmacist would finish filling the carts and verifying the medications by 1 PM. At 1 PM, we would run a catch-up report of all the new orders and changes since 8 PM the previous night. This required going through a long list of changes (from morning physician rounds) and pulling and replacing or adding medications. By 2:15 PM, we ran another catch-up report to identify changes that occurred between 1 PM and 2:15 PM. We then rushed to have it completed by 3 PM for delivery to the floors.

A Big Change
With Omnicell WorkflowRx driving the process, an electronic refill report is run at noon. The orders are picked and filled with all medications and oral solids, and bar coded with patient name on the package by 1:30 PM – in just 90 minutes. Now when we run the change report, there are rarely any changes, and those take only a few minutes to update.

SafetyPak picks 700 to 850 individually wrapped bar coded tablets or capsules in 90 minutes. What SafetyPak does not pick, Omnicell PharmacyCentral does, with both systems communicating with one another. Most of our pharmacist checks have become automated. This new process has mitigated the workload that a high census would create. Even an increase in the daily census by 30 or 40 patients does not slow down the automated cart-fill process. With the extra time, our pharmacists can now attend morning rounds with the hospitalists, consulting on patient medication needs. Also, the pharmacists have become involved in medication reconciliation. Our oncology pharmacist can attend to the special needs of patients, instead of spending time assisting with verification of the cart fill.

All of these positive changes have helped reduce medication errors, increase patient safety, improve staff efficiency and satisfaction, and reduce our annual pharmacy budget. The initial goals our team, board, and administration set for patient safety are being achieved. Meanwhile, we will keep looking for ways to continue the process of providing quality health care at Chambersburg Hospital.

Conclusion
The success of any medication-use improvement process hinges on support from senior leadership and the board. Establishment of clear patient safety goals by a multi-disciplinary team that believes in the importance of first creating policies, procedures, and a staff culture to support automation is key. Merely installing technology will not guarantee the reduction of medication-use errors. Healthy relationships between patient services, information services, allied health providers, finance, and the back office are paramount to an initiative’s success. Working out needed organizational changes with staff acceptance is critical for automation to work. Following this process will lead to improved patient care, enhanced employee satisfaction, and cost savings for the organization.

David Grant, RPh, MBA, has been the director of pharmacy and respiratory care for Chambersburg Hospital since 2002. He earned his BS in pharmacy from Duquesne University and his MBA from the University of Phoenix.