CHILDREN’S HOSPITAL OF PITTSBURGH IS A 260-BED, PEDIATRIC TEACHING hospital. The topic of intravenous medication waste has generated much discussion in our institution. As a pediatric hospital, all of our IV medication doses are weightbased and unit dosed for each patient. We originally attempted to standardize our weight-based doses to alleviate medication waste; however, there were not as many “common doses” as we had initially anticipated. Therefore, IV medication waste continued to be a problem. To address this challenge, pharmacy first had to identify the origin and amount of IV waste before we could begin looking for solutions.

Medication Waste
At the time, our process was a oncedaily IV syringe exchange, wherein all of our IV medications were prepared in the morning for the next 24-hour period and exchanged at 2:30PM. We examined this process and recognized two key elements that were contributing to our waste problem: morning patient care rounds and morning patient discharges. We then hypothesized that the majority of changes and/or discontinuations of medications occurred during the morning hours.
To test this hypothesis, we generated a report identifying the times that medications were discontinued. The report showed that the majority of medication changes occurred between the hours of 10:00AM and 2:00PM. Since the pharmacy was preparing a 24-hour supply of medication in the morning, a tremendous amount of medication waste was being generated during our hours of IV preparation. Our next step was to conduct a preliminary study to quantify the amount of waste.

With our unit dose system, our objective was to quantify the amount of IV syringe medication waste that occurred with a “once a day” syringe exchange and determine if a “twice a day” syringe exchange could reduce waste. To calculate the acquisition cost savings that could result from a syringe preparation system change, we collected all of the IV medication syringes returned to the pharmacy as waste for a one-week period. For each medication, patient-specific information was accessed through our Cerner Classic PharmNet pharmacy information system to determine the start and stop times of each order. For each medication order, we calculated the current number of wasted syringes and total dosage wasted, and the number of wasted syringes and total dosage we would waste if we changed our syringe preparation times from once daily at 8:00AM, to twice daily at 6:00AM and 2:00PM. Acquisition cost data was obtained through our GPO acquisition-cost summary report. We then calculated our current cost of waste for a seven-day period and the annualized cost of waste, along with the cost-savings potential that would result from a twice-daily system.

The Potential for Savings
In a one-week period, 6,021 IV medication syringes were prepared. Of that total, 1,416 syringes (24%) were returned as wasted doses. Wasted medication syringes represented $8,907 of pharmacy acquisition cost in the seven-day period, or $463,164 annually. We calculated that twice-a-day preparation would have decreased waste by 43.7%. We estimated a medication acquisition cost savings of $4,392 in seven days, or $228,384 annualized. The source of waste was attributed to patient discharge, drug discontinuation, drug-dosing regimen changes, and missing doses. We were able to document significant waste and potential cost savings in a limited seven-day sampling. We proposed a system change to twice-daily syringe preparation to decrease waste and increase cost savings. By restructuring pharmacy workflow, our goal was to reduce waste by approximately 44%, translating to a cost savings of $231,582 per year.

In addition, while preparing for our facility’s upgrade to a Cerner CPOE system and the Millenium PharmNet computer system, pharmacy processes were examined, gaps between the two systems were identified, and processes to better serve our pediatric patients were reviewed. A gap analysis of pharmacy process and the results from our initial IV syringe medication waste study yielded the decision to change to a twice-daily IV syringe exchange.

Results
Six months post-implementation, we conducted a follow-up study to determine whether we had realized our predicted decrease in IV syringe waste and the accompanying cost savings. Our first step was to quantify our curent amount of waste.

All IV medication syringes returned to the pharmacy as waste were collected during a sample two-day period. Due to the labor-intensive nature of the study, we limited our data collection to two days, with the understanding that the twoday collection period may not have captured the total amount of waste. Once the number of wasted syringes and the total dosage wasted was determined, we obtained the acquisition cost data from the same GPO acquisition-cost summary report that we utilized during the initial study. We found that the switch to a twice-daily syringe exchange resulted in a calculated cost savings of $630 per day, or an annualized cost savings of $229,000. So the implementation of twice-daily IV syringe preparation resulted in a major cost savings for our pharmacy services department, clearly demonstrating that workflow analysis and change can significantly affect costs. We plan to repeat this waste study again, using a longer sample period, in the near future to evaluate our current amount of IV medication waste. However, thus far, we are pleased with the results of this process change.