At Penn Presbyterian Medical Center (PPMC), a 350-bed medical facility located in Philadelphia, the pharmacy department consists of 60 employees and meets the medication management needs of the institution by providing medications for the inpatient pharmacy, two outpatient retail pharmacies, and two infusion centers. The pharmacy is also responsible for managing medications for over 25 physician practices. Given this centralized medication distribution model and the volume of medication requests fulfilled every day, one of our top priorities is enabling a proficient, secure, and precise process for maximizing medication throughput. Although this process can be performed manually, doing so introduces multiple opportunities for errors that can waste time and jeopardize patient safety. It is with this in mind that we began to seek a fully automated system in early 2009. 

Challenges of a Manual Process
For over three decades, Penn Presbyterian’s medication distribution model was largely a centralized, manual system. We ran a cart fill process, the entirety of which took an average of 12 to 16 hours per day, conducted by 2.5 FTE technicians who also were responsible for replenishing ADCs and anesthesia cabinets, checking for expired medications, managing recalls, and returning unused medications to the pharmacy. Likewise, first doses and stat medications also were processed manually by a technician and checked by a pharmacist. 

This process was not only labor and resource intensive, but it also created a significant amount of waste as evidenced by unnecessarily high inventory levels and extensive medication expirations. This is notwithstanding the significant medication safety risks inherent in manual processes. 

In order to help eliminate manual medication dispensing and provide a safer environment for patients and products, the PPMC pharmacy evaluated multiple automated systems in an attempt to foster a multi-tasking distribution environment with a goal of attaining 99.99% dispensing accuracy. To bolster our case, we provided our administration with a presentation on the failures of existing practices and the potential benefits of automating our process. A five-year ROI was presented that included redeployment of pharmacist FTEs to more direct patient care, as well as the benefits of a system that included BCMA functions in terms of safety and quality initiatives. 



Introducing Automation
After an evaluation period, we decided to implement Swisslog’s PillPick, an automated unit dose packaging, storage, and dispensing system, in February 2012. We determined it would provide us with a one-stop option for packaging and dispensing bar coded medications from a single unit. Each medication is packaged individually and then placed alphabetically on a pick ring, with the patient information listed on the front. The bar code printed on each medication package allows for easy tracking of lot numbers to reconcile expiration dates and recalls. In April 2013, we decided to also incorporate Swisslog’s BoxPicker, an automated, high-density storage system, so that all medications, especially those not housed in the PillPick, could benefit from the same tracking mechanisms and bar code capabilities. With this addition, the entire pharmacy is ready for our future implementation of bar code scanning through to the patient bedside.

How the System Works
Medication orders for oral solids are sent to the PillPick via CPOE. The requested medications are packaged into unit dose and then are labeled, bar coded, and placed on pick rings. PillPick handles all higher-volume oral solids and tablets for the central pharmacy (with the exception of chemotherapeutic agents and half-tablets), whereas items with low utilization are housed within the BoxPicker.

The BoxPicker houses and dispenses bulk products, injectables, liquids, and topical products and features a unique loading and dispensing portal allowing the user to remove medications from a single drawer. The system is interfaced with both our CPOE and ADC systems to alert for proper filling, and to enable wholesale orders to be placed automatically based on par levels and cabinet replenishment needs. 

Implementation was not without its challenges, as the entire process required a year of planning and pre-implementation phases, pharmacy construction to make space for both units, and interaction with our IT department for the development of medication formularies, interfaces, and integrated testing. Due to their sophistication, managing these robots requires comprehensive training and troubleshooting education. Fortunately, Swisslog provided extensive training on system operation to all our pharmacy staff.

Increased Efficiency, Safety, and Savings
In the first six months of using PillPick and BoxPicker, we have been able to decrease our inventory overhead by $350,000 and missing doses by 40% due to a change in the presentation to nursing. Furthermore, our cart fill can now be completed within four hours and our ADC fills take about an hour each. We are far more confident in the safety of our medication distribution and our pharmacists also have more time to spend in patient care. After a six-month stabilization period expires, we are planning to go live with BCMA pilot units in August in order to further optimize our distribution and safety initiatives. 

Nishaminy Kasbekar, PharmD, FASHP, is the director of pharmacy at PPMC. She received her BS in pharmacy and PharmD at the Philadelphia College of Pharmacy and Science.