As the resident medication experts, pharmacists must play a pivotal role in preventing medication errors throughout the hospital. Accordingly, it is vital to thoroughly evaluate the medication-use process and identify areas where the potential for error exists. Studies suggest that half of all harmful medication errors occur during drug administration, and of these errors, two-thirds involve injectable medications.^1,2 Because so many medication errors occur during drug administration, minimizing the opportunity for error during this critical process is necessary. ASHP recommends that pharmacists dispense medications in ready-to-administer (RTA) forms whenever possible to avoid having the nurse manipulate drugs prior to administration. Utilizing RTA prefilled injectable medications can reduce the possibility of medication error, increase standardization, help control costs, reduce waste, ensure that items are properly labeled and bar coded, and improve nursing satisfaction.

Norwalk Hospital is a 328-bed, not-for-profit, acute care, community teaching hospital that serves a population of 250,000 in lower Fairfield County, Connecticut. The pharmacy provides clinical pharmaceutical services and pharmacy supply chain distribution management, and is staffed 24/7 by 11 pharmacists, four clinical specialists, and 12 technicians. The inpatient pharmacy follows a centralized distribution model, utilizing robotic dispensing, a medication carousel, and bar code–ready inventory, which is about 98% CPOE- and 90% bedside bar code–compliant. We have utilized commercially available RTA products for many years, including controlled substances (eg, morphine and hydromorphone), rescue medications for code carts (eg, sodium chloride, lidocaine, epinephrine, dextrose, etc), and a few miscellaneous medications (eg, vitamin K and low–molecular weight heparin). As more products have become commercially available, we have been adding them to our inventory. Most recently we added ondansetron, metoclopramide, and diphenhydramine, which are typically ordered by prescribers on an as-needed basis.

Considerations for Increasing Use of RTA Products
To determine which products should be provided in prefilled RTA syringes, the pharmacy department must begin by evaluating the products that are commercially available, the safety profile of these medications, the volume of these items used by the facility, and the relative costs. Prior to incorporating use of RTA products, pharmacy must work closely with the quality improvement team, infection control team, regulatory team, and medication safety personnel to evaluate the hospital’s capacity to incorporate RTA injectables into existing workflow. A collaborative effort to increase use of these products can improve safety and mitigate risk during the medication administration process. 

Benefits of RTA Prefilled Injectables
At Norwalk Hospital, we have realized multiple benefits by increasing use of RTA dosage forms, including:

• Improved safety. Because RTA medications require fewer manipulations—multiple injections, vial transfers, and repackaging are not required—there are fewer opportunities for the introduction of contamination, which reduces the likelihood of medication errors to occur. For example, RTA dosage forms do not require cleaning the vial or ampule, opening a separate needle and syringe, and drawing the medication into the syringe to prepare for medication administration
• Enhanced pharmacy and nursing workflow. Pharmacy department workflow is usually unaffected by the switch to RTA prefilled injectables; however, because they are larger products, there may be space considerations for storage in automated dispensing cabinets (ADCs). If your facility is considering using RTA injectables, conduct a careful evaluation of the available ADC storage space. RTA medications improve nursing workflow by reducing the number of manipulations of equipment required to prepare a medication for administration, thus saving time and allowing nurses to focus on other patient care activities
• Improved nursing satisfaction. Because RTA medications require less time to prepare for administration and allow nurses to perform clinical work, nursing satisfaction increases as more of these products are incorporated into use
• Compliant labeling and bar coding. RTA prefilled injectables are received from the manufacturer properly labeled and bar coded, thereby improving and ensuring standardization. 
• Reduced training requirements. Additional staff training for use of RTA syringes is only required if there is special packaging, security devices, or safety needle applications. If a new device or safety needle is introduced, pharmacy and nursing staff refer to the package insert and the nurse educator may do an inservice training class for staff. Moreover, the vendor’s training brochure is posted on the units, managers are informed of the change, and any questions are fielded in the main pharmacy
• Costs. When comparing costs of RTA syringes vs vials or ampules, be sure to consider the costs of additional supplies that are required to administer these drugs, as well as the time required to properly label them. At Norwalk Health, we determined that use of RTA prefilled injectables was not cost-prohibitive once we accounted for the time and costs associated with preparing these medications for administration 

Future Goals
The key benefits of utilizing these products—including increased nursing satisfaction and more time for nurses to spend on patient care, reduced number of steps required to administer medications, lower risk of medication errors/cross contamination, and increased standardization through proper labeling and bar coding—illustrate the value of incorporating RTA prefilled injectables into pharmacy practice. Looking forward, we anticipate incorporating additional RTA products into our inventory as they become commercially available, particularly in the anesthesiology arena.

References

1. Bates DW, Cullen DJ, Laird N, et al. Incidence of adverse drug events and potential adverse drug events. Implications for prevention. ADE Prevention Study Group. JAMA. 1995;274(1):29-34.
2. Bates DW, Spell N, Cullen DJ, et al. The costs of adverse drug events in hospitalized patients. Adverse Drug Events Prevention Study Group. JAMA. 1997;277(4):307-311.

Keith P. Shuster, RPh, MBA, the manager of acute care pharmacy services at Norwalk Hospital in Connecticut, has over 25 years of clinical and management experience. He received a BS in pharmacy from the University of Connecticut and an MBA from the University of New Haven. Keith’s professional interests include pharmacy management/operations, medication safety, regulatory/quality improvement, and emergency management.