Alliance Health Center in Meridian, Mississippi is a 134-bed acute care psychiatric and chemical dependency hospital with programs for children, adolescents, and geriatrics. Detoxification and a short-term chemical dependency program are offered to individuals ages 17 and up, and we are also home to The Crossings, a 60-bed residential treatment facility for adolescents.

Identifying Needs and Setting Goals
Prior to implementing the automated dispensing cabinet (ADC) system from medDISPENSE in October 2007, we distributed medication via weekly cart fills and maintained a unit floor stock. With this previous system we had issues with medication errors. In addition, performing inventory on controlled substances was time consuming and signatures were frequently missing at shift change. We also had to manually charge medications removed from the floor stock and nurses had to sign out medications from both the night and floor stock.

In reviewing the performance elements of the medDISPENSE ADC system, we noted that it would allow us to maintain a large number of medications, individually quantified in each cubicle. The system had great support staff at medDISPENSE, and we had no problems bringing in the new system, with nursing staff able to operate the system within one hour of training.We decided to implement the medDISPENSE ADC system with seven units. Some of the goals we set forth for the system include:

• Improved security and medication process for control substancesn

• Effective inventory managementn Reduced medication errors
• Improved medication safety
• Improved nursing-staff satisfaction with medication management
• Compliance with regulatory requirements for medication safety

Post-Implementation Effects
During the first month of using the medDISPENSE ADCs, we saw a significant decrease in medication errors—an effect we credited to staff sensitivity to a new system and the desire to be overtly careful. The following few months saw an increase in errors, which indicated an increase in our ability to detect when errors were made. We enacted a mandatory, hospital-wide medication error in-service and errors, again, decreased dramatically, as staff was able to see exactly what mistakes were being made. By the end of the first year using the medDISPENSE system, we had the lowest number of medication errors per patient day than the previous six years. We also realized a significant decrease in variances during our quarterly billing chart audits, an improvement we relate directly to the automation process.

Process and Management Changes
After implementation, we saw an 8% decrease in inventory over the seven months that followed. The number of inventory turns (purchased divided by inventory total) increased from 9.5 in 2007 to 10.7 in 2008, indicating better medication management and hospital savings in the form of lower medication overhead.

We are currently in the process of implementing an off-site, after-hours order entry program to interface with medDISPENSE, which will allow pharmacy to review orders and nurses to remove medications until 10 pm every day.

Security Improvements
With medDISPENSE we have significantly improved our controlled substance inventory management. Missing signatures have been completely eliminated. The system requires two nurses to log in to witness wastage, and during shift count, the nurses only count what medications have been accessed, thereby greatly reducing time spent on shift counts.

Medication storage safety also has improved significantly. We can document witness checks for high-risk medication removals, and as medications are clearly segregated, we have seen a decrease in errors related to the wrong medication being administered. Storing our medications in the ADCs also allows for easy identification of expired or recalled medications.

All high-risk medications kept in the ADCs are marked with alerts, as are look-alike/sound-alike medications, and medication allergies are highlighted before a medication is dispensed. Any notes we place on a medication order are then displayed on medDISPENSE units, and nurses can add comments to be sent to pharmacy. When medications are ordered in response to an adverse reaction, nurses are then prompted to document the ADR. All of these checkpoints result in fewer medication errors, allergy related issues, and an increase in ADR reporting.

Conclusions
There are always reasons not to pursue automation, especially if the only factor considered is start-up cost. The reality is that we have seen significant cost and time savings in the long term as a result of automating our medication dispensation process. These savings are immediately recognizable to our administration, and, most important, to our patients, as we are able to transfer that time to patient care.

Joanie Chesnutt is the director of pharmacy for Alliance Health Center and The Crossings in Meridian, Mississippi and the Diamond Grove Center in Louisville, Mississippi. All three facilities are part of Psychiatric Solutions Corporation based in Franklin, Tennessee. Joanie graduated from the University of Mississippi, School of Pharmacy and has worked for Cardinal Health Pharmacy Services for 23 years.