Clinicians at smaller hospitals around the country share the same commitment to quality care as their colleagues at major medical centers, and Great Plains Regional Medical Center in Elk City, Oklahoma, is no exception. A 62-bed, not-for-profit hospital, Great Plains has in recent years dedicated much time and effort to upgrading its systems and technologies, focusing on improved nursing workflow and a higher quality of care for our patients.

Two developments that have benefited our overall patient care model are the implementation of bar coded medication administration (BCMA) and the use of automated dispensing cabinets (ADCs) for medication distribution. Prior to implementing ADCs, our facility used old-fashioned cabinets made from pegboard, with hooks and bags to hold urgent medications for use after pharmacy hours. The cabinets would be locked and the nursing house supervisor kept the only key to the med/surg cabinet after pharmacy hours, which meant nurses often had to wait to get medications, thereby disrupting workflow and increasing the risk for potential medication errors. We needed to create a more efficient system that would offer better tracking of medications, improve patient safety, and provide easier access to medications for nurses while also improving our compliance with TJC standards. We realized that improving our system would require a few different types of technology, and that the order in which we implemented them would have an impact on training and proper usage. In order to ensure that we would have transparent and open interoperability among our systems, we sought an electronic medication management platform with BCMA capabilities that eventually could be interfaced with an automated storage and dispensing solution. We began to implement an electronic medication management platform with integrated BCMA capabilities in 2007.

Starting with BCMA
When we began to research bar coded medication administration, we were looking for a software solution that also would provide an intuitive and efficient bar code scanning process for our nurses and pharmacy technicians during the continuum of medication distribution. Our search focused on systems that would fall within our available budget, interface with our existing operating platform, and meet the unique needs of a small hospital.

Because of our size, we are often forced to acquire new technologies and automation in individual components, so interoperability among vendors is key to our upgrades. After several months of research and selection, we began implementation and then training of our staff on BCMA in order to detect potential medication errors while streamlining workflow. To rollout this new system, the hospital initiated a tiered approach, training the smaller nursing units that handled fewer formulary drugs first. These units were then broken down into small training groups, allowing the nurse manager and myself to concentrate on individual training. We started this process in March 2007 with the women’s services unit. After performing a detailed demonstration using the new system, including the various warning signs that could appear during a medication delivery, we then spent several months working with each patient care area. It was here, during this hands-on time, that we were able to effectively troubleshoot any issues and ensure each nurse was comfortable and familiar with the new system.

Following the women’s services unit, we moved on to the geriatric psychiatric unit in July 2007, followed by the intensive care unit in August 2008 and finally the largest unit, medical/surgical, in September 2008. By the end of 2008, Great Plains’ nursing staff was fully trained on how to effectively use the software platform for bedside medication verification, and was comfortable using scanners as part of their day-to-day routine.

Following Up with Automated Dispensing Cabinets
As we anticipated, by introducing BCMA first, and allowing our nurses to become comfortable with the system, incorporating automated dispensing cabinets—designed to provide secure, 24/7 access to medications via bar code scanning—was seamless and easy. As a smaller facility, it can be difficult to budget for expensive technologies—such as ADCs—even though they are shown to reduce medication errors, enhance security for controlled substances, and streamline operations. Fortunately we were able to work with our vendor to acquire a cost-effective option at Great Plains.

We started our ADC implementation with the med/surg unit, as it demonstrated the highest need for such a system. This unit has the largest patient population and had housed the largest medication storage cabinet for after pharmacy hours usage. Prior to this, nurses could not gain access to the medication cabinets during after hours without the house supervisor. They also had to count all controlled substance medications following each shift. With the new ADCs, the nurses are able to quickly access medications while ensuring secure and safe access, as all medications are automatically accounted for.

Following the med/surg rollout, which included simple and straightforward training for the nursing staff, we then provided ADC units to our emergency department, which also had a longstanding need for better drug storage and access. The pharmacy began stocking the ADC with the current emergency department formulary and expanded the number of medications because more storage capacity was available in the ADC. The nursing staff was initially concerned about being able to access emergency medications in a timely fashion but quickly adapted to the new technology. Given the success of both rollouts, we integrated ADCs in the remaining units, including women’s services, labor and delivery, ICU, senior care, radiology, and surgery.

We were able to leverage the flexibility of our ADCs to customize the base systems, auxiliary storage, and accessories to meet our specific needs. For instance, we were able to configure different drawer sizes and arrangements depending on the inventory each of our units required. Ultimately, our administrative team realized the benefits of ADCs on patient safety through medication tracking, medication control with security, accountability, availability and closing the medication administration loop.

Key to the success of both the BCMA and ADC implementations was working quickly to reorganize workflows. Fortunately, the new ADC system was easy to learn and the vendor did a good job training our staff, including the night shift nurses most affected by the benefits of the new ADC system. It was not long before we could not imagine working without our ADC and BCMA systems. Feedback has demonstrated that many of our staff members, from technicians and pharmacists to nurses, view the ADCs and the attendant functions of BCMA as a safety net to their operational practices, and this fosters a sense of confidence and assurance in their activities.

Streamlined BCMA and ADC Processes
Today, our ADC technology and scanning software are integrated seamlessly into the medication distribution workflow and we have established a cycle for ordering, stocking, and using medications. First, a pharmacy technician uses the scanners to ensure medication is properly placed in ADC drawers during stocking. When a specific medication needs to be administered, the nurse will scan the medication at the ADC to double check for accuracy and then scan again at the bedside to ensure the medication is being administered properly. The ADC system is interfaced with patient profiles through our medication management platform. After medication is removed from the ADC, the nurse scans a patient’s wristband, his or her medical information is displayed, and the nurse can easily evaluate any restrictions or warnings prior to delivering the medication. These warnings are always linked directly with a patient’s profile, helping the nurses ensure they are administering the five rights.

In addition to improving safety, the nursing staff now has faster access to medications, including stat doses—an especially critical issue for patient care after pharmacy hours. Tracking of controlled substances also has improved. In surgery, for example, our ADCs have increased charge capture for dispensed pharmaceuticals. As well, our clinicians obtain almost all medications, including some anesthesia, through the ADC system to ensure accountability and control.

Operational efficiency also has improved in a variety of areas. End-of-shift medication counts are dramatically streamlined, as nurses only need to count drugs that were accessed during the shift. As a result, nurses can now spend more time where it matters most—providing patient care. Pharmacy technicians also are saving time and money, as the new system eliminates the need for manual debits and credits during cart fills. Tracking drug expiration dates also is streamlined because our ADCs offer fast, easy reporting on medications that need to be replaced, listing specific expiration dates for each drug. These tracking features also help streamline physical inventory procedures; a once time-consuming process for the pharmacy team. Through these systems, we have realized significant time-savings, especially in the surgical unit. One part of the inventory process—the physical count of all medications stocked in surgery including outpatient surgery, pacu/recovery, and anesthesia—that once would have required a day’s labor is now completed in five minutes because we simply run a report through the ADC.

Conclusion
Since the acceptance of BCMA and ADC processes within our facility, our system for stocking, distributing, administering, and documenting medications is more efficient, safe, secure, and accurate. We are able to provide a higher quality of care to our patients while also providing our nurses with peace of mind. We are thrilled with the results, not the least of which is the tremendous feedback we receive from our staff on the ease of using the new system. We have been so pleased, in fact, that we are now in the process of building a physician care management (PCM) module in our information system that is expected to go live in January 2011. The PCM will include computerized provider order entry (CPOE) for inpatients as well as outpatients. This implementation will help create a closed-loop medication management system within the hospital. Also in the spring of 2011, we plan to begin the implementation of new smart IV pumps that use a server-based suite of applications designed to connect data from the hospital’s drug information library to infusion devices throughout the hospital to monitor, control, and provide reports at the device, group, or system-wide levels. As with BCMA and ADCs, these will be progressive installations that will continue our mission of making informed automation and technological advancements that protect and serve both our staff and our patients.

Theresa Garner, RPh, is director of pharmacy at Great Plains Regional Medical Center in Elk City, Oklahoma. Theresa has been in this position for more than 11 years and has worked at Great Plains for over 21 years. She also serves as a preceptor for Southwestern Oklahoma State University College of Pharmacy, and received the Distinguished Institutional Preceptor of the Year award in 1999 and 2006. Theresa received her BS in pharmacy from Southwestern Oklahoma State University.