Using a variety of automation technologies for drug distribution can improve patient safety and free up staff time to focus on clinical roles. The implementation of an integrated automation system that eliminates many of the traditional centralized pharmacy drug distribution duties is a prudent course of action that enables decentralized pharmacists to use hybrid medication distribution methods to improve quality of care.

Martha Jefferson is a 176-bed community hospital that is part of the Sentara Healthcare 10-hospital system. In 2006, Martha Jefferson began planning a move to a replacement hospital as we had outgrown our facility in downtown Charlottesville, Virginia. During the planning process to move to the new hospital, pharmacy and facility leaders completed a review to determine how to best care for patients in the new environment, including what processes would need to change and what equipment would be required to support these processes. We had been using a hybrid distribution method in conjunction with a decentralized pharmacy model, and this combination—with a few enhancements and upgrades—also was determined as the ideal model to utilize going forward at the new facility. 

An Integrated Automation System 
At that time, we had already been using a central robot for cart fill and unit-based ADCs for PRN medications and controlled substances, and have had ADCs implemented since the early 1990s. Our robot had been installed in 2000; prior to implementing the robot we used a manual cart fill process that was highly labor-intensive for both technicians and pharmacists. A carousel and high-speed packager were added in 2007. This automation served as a foundation for BCMA, which was implemented in May 2008 on the inpatient units; since then, we have added BCMA to day surgery, postanesthesia care, the ED, and a freestanding ED. The ADCs in the inpatient units have been set to profiled dispense since their inception; once BCMA was added, both ADCs in the EDs also became profile units. 

Addition of Nurse Servers
As a result of our process evaluation, the nursing department, in consultation with pharmacy and materials management, decided to implement nurse servers in the new design, which would house medications, supplies, and linens. These nurse servers are located at each patient room and are accessible from both inside and outside the room. They are stocked from the hall, and pharmacy and nursing can access the contents from inside the patient room. The goal of using nurse servers was to reduce the amount of time nurses were hunting and gathering medications and supplies and increase time spent at the patient’s bedside. The nurse servers were installed at the new facility, which we occupied in August of 2011. 

Automation Supports an Integrated, Decentralized Practice Model
Pharmacy leaders at Martha Jefferson have always supported a hybrid distribution model, even before the decision was made to add nurse servers in the new facility. We believe that using a central fill for standing medications and ADCs for controlled substances and PRNs provides the best support for nursing in our hospital. The addition of the nurse servers has dramatically reduced the amount of walking the nurses have to do to administer medications, and more time at the bedside has allowed more time with patients, better quality of patient care, and increased patient satisfaction. 

Increased Efficiencies
The space we gained in the new hospital pharmacy allowed the addition of another medication carousel, which greatly expanded the number of drugs that could be housed in automation. We have paid particular attention to optimizing the use of all of our technologies, and have recently achieved near 100% efficiency; less than 1% of our non-IV doses are dispensed without the benefit of bar code scanning. 

This robust automation system has translated into fewer regulatory barriers as well. We have petitioned the Board of Pharmacy twice for waivers for the 100% pharmacist check requirement for both robot- and carousel-dispensed medications. Because the Board has more confidence in the safety processes surrounding robot and carousel technology, we are now only required to perform a random 5% check for doses dispensed by automation. This reduction in pharmacist check requirements has allowed reallocation of pharmacists to the patient care units, where they can have a more significant contribution to medication-related health outcomes. Additionally, we have been able to delegate the management of much of our distribution activities to our well-trained technicians. We have also created enhanced roles for several of our technicians, again freeing pharmacists for more direct patient care activities. 

Enhanced Roles for Technicians
In addition to the significant role our technicians play in managing pharmacy processes, we have expanded their responsibilities in other areas as well, increasing support for the hybrid distribution method and decentralized pharmacy practice model. All technicians are required to have PTCB Certification within 6 months of hiring, and also must be registered by the Board of Pharmacy. Technicians are an integral part of a successful, effective pharmacy team and every effort should be made to encourage them to work to the top of their license. Some of the enhanced roles that have been developed for pharmacy technicians at Martha Jefferson include the following:

• Keeping our automation optimized requires a considerable amount of daily attention, and technicians are responsible for performing much of this maintenance. Two technicians have moved into application specialist positions to support our technology, keeping the automation running efficiently by reviewing utilization patterns and adjusting inventory when necessary. 
• Technicians also increase safe drug distribution by ensuring look-alike/sound-alike medications are not stored near each other in ADCs to prevent picking an incorrect medication. 
• Pharmacy technicians assist in managing the security of ADCs by adding and deleting staff access. 
• They have supported all of the relocation and reallocation of medications within the automation required as a result of recent drug shortages. Technicians help scan-test inventory as it is received, prior to placement into inventory, to ensure that there are no NDC changes that would affect scanability at the bedside or within the automation. 
• One technician serves as our packaging expert and maintains all of our packaging equipment, helping ensure that required drugs are ready for use.
• Our inventory coordinator is a long-tenured technician who evolved into the role. She ensures the appropriate amount of inventory is on hand, paying careful attention to drugs on shortage. 
• Another technician runs our IV room and is responsible for all of our USP General Chapter <797> compliance. 
• An infusion center technician is responsible for all chemotherapy ordering and preparation for our cancer center patients. 

These specialized roles and increased technician responsibilities have made our technicians’ work lives more meaningful. They are accountable to patients and view their role as a career, not simply a job. As a result, Martha Jefferson has experienced very low technician turnover. 

Benefits and Results of the Enhanced Process
Our journey to increase distribution efficiency and accuracy through the application of automation technology was driven by the need to free pharmacists from rote tasks in order to spend more time on patient care units providing effective clinical services, and meeting this objective has been highly successful. 

In addition, medication safety has increased as a result of BCMA expansion. The confidence in our BCMA process allowed an expansion of technician roles and decreased the requirements of pharmacists in distribution tasks. Currently, only two pharmacists work in the central pharmacy, checking IV compounding, performing order entry (soon to be order verification), and checking the rare manual picks that may arise. Five decentralized pharmacists work on various patient care units and in the ED, performing clinical consults for drug dosing, medication histories, assessing immunization status, ordering vaccines as needed, and participating in interdisciplinary rounds. In addition, many of our pharmacists precept the two PGY1 residents that we host. All pharmacists, with the exception of our oncology specialist, rotate through the central pharmacy, as we want all clinicians aware of every aspect of the medication use process. 

Our activities on the patient care units help ensure appropriate therapeutic decisions, help support the medication reconciliation process, and contribute to compliance with the process of care measures for value-based purchasing. We have finally achieved 100% compliance with immunization measures, and are currently involved with a readmissions reduction project. 

Future Initiatives
Despite the success of our practice model, improving processes is an ongoing requirement at Martha Jefferson. We continue to evaluate novel ways to utilize our technicians and technology to support clinical care. Future goals include evaluating IV automation to expand the value of our distribution model, and we will be going live with CPOE on September 8th of this year. We expect to incorporate additional enhancements to our model after CPOE is implemented. 

The appropriate use of technology and technicians has enhanced the ability of the pharmacist to positively impact clinical care as part of the health care team. Both pharmacy and nursing have been extremely pleased with the results of utilizing automation to drive a hybrid distribution model and decentralized pharmacy practice.

Janet A. Silvester, RPh, MBA, FASHP, is the director of pharmacy and emergency services at Martha Jefferson Hospital, and also serves as one of the preceptors in the pharmacy practice management rotation. She received her BS in Pharmacy from the Medical College of Virginia/Virginia Commonwealth University and her MBA from James Madison University. Janet is currently a Doctor of Pharmacy candidate at Creighton University. She is a former president of ASHP.