Medical City Dallas/Medical City Children’s Hospital is a 795-bed, tertiary care community hospital, recognized for excellence in both adult and pediatric patient care. The pharmacy department provides around-the-clock pharmaceutical care services, including sterile IV compounding production of 600-750 nonhazardous and 50-70 hazardous patient-specific compounded sterile preparations (CSPs) per day. Focused on delivering high-quality patient care in a large, complex work environment, pharmacy leadership was concerned with areas of potential error within our manual IV checking and verification process. In addition, we wanted to reduce waste and improve overall efficiencies in the IV room.

The Texas State Board of Pharmacy introduced a new requirement that a pharmacist must perform in-process IV compounding checks to validate the accuracy of the admixture process; this provided further motivation to make changes to our IV preparation practices. Thus, we embarked on a journey to convert from a manual to an automated process.

Challenges with a Manual Process

Our manual IV verification processes included the syringe pull-back method, wherein the technician would pull back the syringe plunger to show the amount of drug or diluent that was injected into the final container. The drug vial was placed next to the compounded product, and the amount of drug added was noted on the patient label. These methods are prone to human error and require the pharmacist to place a high level of trust in the technician’s skills. When multiple IV preparations are to be checked at one time, it may be unclear which syringes or bags correspond to which vials.

The 2016-2017 ISMP best practices guideline recommends performing an independent verification to ensure that the proper medications and diluents are added, including confirmation of the proper volume of each ingredient prior to its addition to the final container.³ In addition, ISMP warns against the syringe pull-back method due to reports of errors resulting in serious patient harm or death linked to this technique.⁴ Eliminating the use of all proxy methods of verification for CSPs is recommended, as is the use of technology to assist in verification.³

Benefits of Implementing IV Workflow Automation

Medication Safety

To enhance medication safety, Medical City Dallas/Medical City Children’s Hospital implemented IV workflow software in May 2017. The key features driving this decision included bar code verification, automatic calculations, and image-capture capabilities. Bar code scanning confirms that the correct ingredients have been obtained prior to beginning preparation. Automatic calculations prompted by the system reduce errors caused by incorrect doses or incorrect dilution concentrations. Digital images provide visual confirmation and documentation to verify that each step in the IV preparation process was accurately completed. Safety checks and hard stops at critical phases of the compounding process help ensure CSP accuracy and patient safety overall.

Improved Efficiency

The benefits of utilizing technology in the sterile compounding process extend beyond improving medication safety. An additional advantage of introducing IV workflow automation is that it allows any pharmacist in the hospital with access to a computer to verify CSPs without having to be physically present in the IV room. This helps distribute the burden of verifying a high volume of CSPs and reduces the bottlenecks that can occur in the IV room.

Robust Reporting Capabilities

Replacing a manual process with this technology provides the pharmacy a robust reporting system. For example, in the event of a product recall, we have the ability to easily identify any patients who received recalled products. The capacity to search for specific products, NDCs, and images makes the recall process efficient and comprehensive.

The data recorded also facilitates investigation into potential workflow improvements. Objective data helps us to analyze whether or not we are best utilizing our resources in the appropriate area and at the correct time in the IV room, allowing us to improve staff scheduling and evenly distribute workload.

Reduced Waste

IV workflow software reduces the time required for manual sorting of labels and reduces wastage of CSPs. Before implementing the technology, scheduled IV preparations were printed in batch and manually sorted and triaged prior to being compounded. Now we print to a virtual queue, and staff members are guided toward making certain compounds by priority, based on when a product is due to be administered, as well as the product’s BUD. In addition to reducing laborious batching printing, waste is minimized when a product is discontinued or a patient is transferred within the hospital. In these cases, the software sends a message to the virtual queue, and the product is either removed from the “waiting to be prepared” queue if it is discontinued, or appropriate room changes are made on the label if a patient is transferred before the final label is printed. To maximize the benefit of the real-time updates, staff is instructed to prepare products as needed and to update labels in real time, further increasing efficiency and reducing waste.

Implementing IV Workflow Technology

Medical City implemented IV workflow software over a 4-5 month period, collaborating with an implementation team from our vendor to ensure our electronic health record (EHR) system communicated appropriately with the software. The process required a significant time commitment up front to sync drug libraries, define specific compounding processes for certain drugs, update BUDs, and perform repetitive process testing to ensure accuracy.

We adopted a stepwise approach to implementation, introducing a different CSP type each week for a 4-week period. During the implementation process, it became clear that to fully utilize the IV technology, analyzing the data’s effectiveness would be vital. This analysis was begun one month into using the software. With medication safety as our top priority, we analyzed near misses recorded in the system. The results showed that in the first month, we prepared 12,479 doses through the system, with 409 doses sent back to the pharmacy technician for adjustments (a 3% error rate). However, approximately 220 of these 409 doses were returned because better pictures were required for proper viewing of the product or process. Excluding these, the remaining 189 doses correspond to a 1.5% error rate (see FIGURE 1).

It is interesting to note that after implementing the bar code scanning system, the verifying pharmacist identified 8 doses with wrong drug errors. These errors occurred after the users scanned the correct product to initiate the preparation, but then recorded a different product during the picture documentation process. The pharmacist then rejected the preparation due to a mismatch of information. This underscores the fact that while technology can be an excellent tool in advancing medication safety, well-trained staff is intrinsic to its successful implementation.

Another factor evaluated was the efficiency of automating the IV workflow process by quantifying turnaround time. The process can be broken into three steps: preparation, verification, and sorting. The drug preparation and verification steps were similar to our manual process, while the sorting step is specific to the automated process. Sorting is an important safety feature that prevents the application of a scannable bar code prior to pharmacist verification of the dose. Since nurses are required to scan a dose prior to administration, a dose without a bar code prevents administration.

Average IV turnaround time by dose type is displayed in FIGURE 2. Data was separated into hazardous and nonhazardous, which mirrors the staffing model in our IV room. One dedicated pharmacy technician prepares hazardous products for the hospital, and two to five pharmacy technicians prepare nonhazardous doses during a 24-hour period, depending on volume. The results show that on average it takes ~39 minutes for nonhazardous and ~33 minutes for hazardous doses to be completed. The average time for a technician to prepare any CSP is about 5 minutes. The pharmacist verification step requires about 9 minutes for nonhazardous and less than 2 minutes for hazardous CSPs.

Based on the data, the new sort step is the most significant factor affecting turnaround time. However, it is important to note that technicians may prepare doses that are not due for hours, and thus may delay the sorting steps for those doses in order to finish preparing STAT doses. We have since reorganized our IV workflow process to ensure that STAT doses are sorted and delivered to patients in a timely manner. Improving turnaround time is our greatest opportunity for improvement with the new IV workflow process.

Conclusion

In alignment with the pharmacy department’s goal of providing safe, effective pharmaceutical care for patients, IV workflow automation offers multiple benefits, including improving safety with bar code scanning. In addition, the software provides automatic data collection, robust reporting power, and helps reduce waste. The system’s data collection capabilities facilitate continual assessment of our IV workflow so adjustments can be made. Moreover, the system provides transparency into the IV workflow process. Our future goals are to utilize this automation to help reduce turnaround times, eliminate medication picking errors, and adjust staffing based on workflow volume.

In an acute health care setting, it is critical to adopt best practices and embrace change. The IV workflow software allows our pharmacy leadership team to focus on continued process improvements to enhance medication safety and operational efficiency.

References

1. Flynn EA, Pearson RE, Barker KN. Observational study of accuracy in compounding I.V. admixtures at five hospitals. Am J Health-Syst Pharm. 1997;54(8):904-912.
2. State of Pharmacy Automation. IV Workflow Management. Pharm Purch Prod. 2017;14(8): 54,56.
3. Institute for Safe Medication Practices. 2016-2017 Targeted Medication Safety Best Practices for Hospitals. www.ismp.org/tools/bestpractices/TMSBP-for-Hospitals.pdf. Accessed September 19, 2017.
4. Institute for Safe Medication Practices. ISMP Medication Error Report Analysis: Syringe Pull-Back Method of Verifying IV Admixtures Is Unreliable. Hosp Pharm. 2013;48(10):803-806.

SYSTEMS SCOOP
Medical City's vendors include:

• IV Workflow Software: DoseEdge
• Electronic Health Record: Meditech

Lan Cao, PharmD, is the supervisor of pharmacy services at Medical City Dallas and Medical City Children’s in Dallas, Texas. He is a graduate of the University of Texas at Austin College of Pharmacy and is currently enrolled in the Hospital Corporation of America (HCA) Emerging Leader Program. Lan’s professional interests include leadership development, pharmacy process improvement, and medication safety.

Michael Epshteyn, PharmD, MSM, is the director of pharmacy services at Medical City Dallas and Medical City Children’s in Dallas. He also serves as an adjunct professor in the Department of Pharmacotherapy at the University of North Texas System College of Pharmacy. Michael’s professional interests include pharmacy leadership development, continuous quality improvement, human resource management, and financial sustainability.

Tammy McCoy, RPh, is the pharmacy operations manager at Medical City Dallas and Medical City Children’s Hospital. She received her BS in pharmacy from Southwestern Oklahoma State University. Tammy’s professional interests include pharmacy leadership development, personnel development, and effecting continuous quality improvement via new operational technologies.

Sheila Nguyen received her bachelor’s degree in management information systems from the McCombs School of Business at The University of Texas at Austin. She is currently a fourth year pharmacy student at Texas Tech University Health Sciences Center in Dallas and is expected to graduate in May 2018. Sheila’s professional interests include data analytics, quality improvement, and health care innovation.