Manual vs Auto – Driving Medication Safety

Ken Tam

Senior Pharmacist – Electronic Medicines Management

Pharmacy Department I Fiona Stanley Hospital

ken.tam@health.wa.gov.au

FSH Medication Management System

Pharmacy

Theatres & Procedural Areas

Wards

Consult Prescribe

Resupply

Administer &

Record

Refill

Fill

Assign

Administer &

Record

Request

Standard Shelving

Standard Shelving

Picking & refill errors Manual Expiry Checks Side-by-Side Strengths

Pharmacy Robots

• Automated storage and retrieval

• Barcode scan & product library validation

• First-in, First-out + exact expiration dates

• ~75% of packs stored

Inventory Robots – Errors

Issue RCA Response

Telmisartan 80mg

output instead of 40mg

User overrode input

barcode scan

Override disabled –

every item must be

scanned

Dispensing error

caused by stock

removed from robot

jam.

User cleared a robot jam

and assumed the stock

manually removed was for

them.

Jammed stock always re-

input before dispensing

again.

• Automation is only safe if users know how to use it

Ward Imprest Shelving

Selection & refill errors Manual Expiry Checks

• Groups of dosage forms e.g. tablets in one section, vs injections

• Manual paper registers for controlled drugs

• No point of removal guidance

• Challenging recall process

Side-by-Side Strengths

MedStations

Workflow

Login with BioID

Select patient

Select drug & quantity

Initiate removal

Drawers/Doors open

sequentially one at a time

Electronic

Drug Register

Drawer Options

Cubie Open Matrix / Tower

• Individual containers per drug

• One drug at a time

• Tamper evident

• APINCH & Controlled Drugs

• Open tray with dividers

• Screen directs user to a

numbered compartment

• All other drugs

Open Matrix Drawers

43 44 45 46 47 48

37 38 39 40 41 42

31 32 33 34 35 36

25 26 27 28 29 30

19 20 21 22 23 24

13 14 15 16 17 18

7 8 9 10 11 12

1 2 3 4 5 6

48 Drugs 48 Compartments per Drawer

What is the optimal configuration to minimise picking errors?

Open Matrix Guidance Algorithm

Paired Product Comparison

• Both on ACSQHS Sound Alike List?

• Same first letter?

• Same strength?

• Same unit of measure (UOM)?

Product ACSQHS 1st Letter Strength UOM Pair Risk

Ceftriaxone 1g Vial

Ceftazidime 1g Vial

Score 1 1 1 1 4

Product ACSQHS 1st Letter Strength UOM Pair Risk

Salbutamol 100mcg MDI

Ceftazidime 1g Vial

Score 0 0 0 0 0

Product Pair Risk Score

Open Matrix Guidance Algorithm

Bag Syringe Patch

Sachet Nebule MDI Cream

Automated Imprest & Critical Low Reorders

Clinical Area

Imprest

Order

Refill

Pharmacy

1595

453

0 500 1000 1500 2000

June 2015 (Pre-Auto)

June 2016 (Post-Auto)

Number of Order Lines Submitted

Number of Stock Lines Manually Ordered by Nursing

• Weekly Imprest

• Daily Critical Low

• 20% for most drugs

• 100% for certain drugs e.g.

antidotes

Point of Removal Guidance

• Too Close Warnings

• Configurable per drug

• Requires override reason

• 2hrs for most items

• Facility wide

Point of Removal Guidance

• Dose/Volume Calculations

• Configurable per drug

• Qty to administer

• Qty remaining

Point of Removal Guidance

• Pop-up Warnings

• Configurable per drug & machine

• Interactive options

Errors with MedStations

• Medication search selection error

• Automation does not prevent transcription/selection error.

• The 6 Rights are still essential

• Is there a better way?

Electronic Prescribing

Login with BioID

Select patient

Select time – Drugs auto-

populate

Initiate removal

Drawers/Doors open

sequentially one at a time

Take Away Messages

• Automation brings many advantages

• Modified risk profile

• Technology does not replace the clinician

• The 6 Rights

• Checking of dispensed items

• Outcomes dictated by the lowest common denominator (the user)

• Staff training is essential

• Platform for ongoing safety enhancements e.g. ePrescribing

Manual vs Auto – Driving Medication Safety

Ken Tam

Senior Pharmacist – Electronic Medicines Management

Pharmacy Department I Fiona Stanley Hospital

ken.tam@health.wa.gov.au

Questions?