hospital dispensing

Published: 10/10/2002, Volume II2, No.5826 Page 26 27

An automated dispensing system has halved errors and incresed technicians'availability for other work.

Keith Farrar and colleagues report

Effective medicines management is the responsibility of all staff, not just the pharmacy department.

The costs involved are significant.The NHS spends£1.5bn on medicines in hospitals and this figure is increasing by around 12 per cent a year.Last year's Audit Commission report, A Spoonful of Sugar, highlighted the importance of effective medicines management in reducing the financial pressures on the NHS and the risk to patients from ineffective or incorrect drug treatment.

A key to greater efficiency is better use of IT.

A modest investment in automation has the potential to release staff to provide patient-centred services - and provide an impressively short payback on investment, as well as reduce the national shortage of pharmacists and technicians.

The risks from medication error are increasingly obvious.

Studies in the US and Australia indicate that almost 7 per cent of all admissions suffer from an 'adverse drug event' (ADE).

1These events can lead to significant morbidity or even mortality, but at the very least are associated with sizeable financial consequences resulting from delayed discharge and/or additional, corrective treatment (estimated at up to $4,500 per event).

2A recent report from the UK showed that 10.8 per cent of patients suffered an adverse event as a result of medical error while in hospital; medication errors account for 16 per cent of all errors.

3 Significantly, each error led to an average increase in length of stay of 8.5 days, with a third of patients suffering disability or death.

Apart from the effect on individual patients,£500m is spent annually by hospitals treating patients who have been made sicker as a result of medication errors.This estimate does not include the cost of medical negligence litigation to the NHS, where 20 per cent of cases stem from medication errors.

4Regardless of the clinical benefit to patients, reducing medication errors would have a significant impact on the availability of hospital beds.Taking a conservative estimate of an ADE resulting in one extra day in hospital, it is only necessary to reduce the incidence of medication errors by 10,950 (365 days x 30 beds) to free up a fully staffed, 30-bed medical ward.

This might seem ludicrous, but it is achievable.There are 7,000 administrations in the average district general hospital per day.

The average error rate, based on a number of studies, would be about 5 per cent, which gives us 350 errors per day from drug administration alone.

If only 25 per cent of these errors resulted in one extra day in hospital, this would mean nearly 90 extra days as a result of errors each day in each hospital.While this has an impact on demand management within hospitals, the impact on patients must not be underestimated.

Though not all of these errors will cause an adverse drug event resulting in prolonged stay, one in 1,000 of these will be potentially fatal, putting one patient at risk of a fatal error every three days in each hospital in the country.

Pharmacy staff can reduce these clinical risks to patients associated with the use of medicines.

5But, like many healthcare professionals, pharmacy is suffering a recruitment crisis, with fewer pharmacists and technicians currently in training than existing vacancies.

Based on Audit Commission figures collected as part of the acute hospital portfolio review of medicines management, at 31 March 2001 nearly 11 per of pharmacist posts and 8 per cent of technician posts were vacant.Because of the vacancy rate, over half of hospital pharmacy departments have withdrawn some services in recent years.Clearly we need to make better use of those that we have, and this is where IT can have an impact.

At Wirral Hospital trust, work has been done to evaluate the impact of the introduction of automated dispensing.We have found automation reduced dispensing errors by almost 50 per cent and released 31 per cent of dispensing technician time for other duties.

6This technology, though rare in the UK, is in widespread use in continental Europe.

The automation system cost£350,000 and took two weeks to build and a weekend to fill and test before going live in January 2001.The system was well received by pharmacy staff who had already been trained to take on new responsibilities at ward level, managing medicines at the patient's bedside.

The medicines are loaded into the automated system by scanning the barcode on the packs and placing these on a conveyor belt.The packs are then put away by the robot in a designated space.When a pharmacy technician types in a request the machine picks the appropriate pack and delivers it via a conveyor belt and a helter skelter-type carousel.The carousel reduces the momentum and ensures that the pack arrives on the bench undamaged.The computer system generates a label which is stuck on the dispensed pack.The pharmacy technicians' time can then be redeployed to ordering drugs on the wards, thus reducing the nursing workload.

But automation remains a largely untested innovation in UK pharmacy. Indeed, automation only became a realistic option with the introduction of 'patient packs'.

The use of barcodes on original packs is a prerequisite to the use of automation.This is becoming more widespread, but it is still not in standard use across the pharmaceutical industry.

Before submitting a business case for the project, we tried to engage all pharmacy staff, particularly technicians, with the benefits to be gained from automation.

This included developing an alternative role for technicians at ward level and including technical staff in the selection process, visiting working sites on the Continent and feeding back our findings to the rest of the staff in a formal meeting.Technicians were also influential in determining the necessary changes to the design of the dispensary and the changes in workflow that might result from implementation.

Planning for the project involved a culture change within the pharmacy department.All the staff supported the introduction of automation, and indeed without the entire department's effort it would have proved impossible.

We found that automation freed up 122 hours of technicians' time over the five-day week. It has reduced the time spent by nurses in drug administration by 7.5 per cent.As up to 40 per cent of ward nursing time is spent dealing with medicines, this can significantly reduce pressure on staff.

The main benefits of automation are:

A reduction in dispensing error rate.

Better managing of the dispensing process - manage the demand and get medicines out to wards quicker (slow dispensing is a perennial gripe of ward staff ).

Staff have time to provide a more proactive service.

Helping throughput by reducing errors and speeding up discharge.

The benefits from implementing this approach at other hospitals would be significant.Based on the results of the Audit Commission's acute hospital portfolio national data review, in many trusts a quarter of pharmacists' time is spent on dispensing and supply.

Trusts in England and Wales spent£30m in 2000-01 on pharmacists' time in this area, with a further£46m on technician time.

Reducing pharmacists' dispensing and supply time in line with good-practice sites would release around 635 whole-time equivalent pharmacists to provide clinical pharmacy services, greater than the total vacancies for trusts at 31 March 2001.

A 25 per cent reduction in technician time spent dispensing would again release staff numbers greater than the vacancies.Based on these figures, the return on initial investment would be only two years.

The Audit Commission review presents a compelling case for the introduction of automation across the country - one that could resolve the shortfall in recruitment, which is unlikely to be met in the short to medium term by the entry of more staff into the pharmacy and technician professions.

The findings from the Wirral show that better use of staff time will improve the ability of pharmacy services, and also trusts, to manage the demand for their services. It will also enable more time to be spent with patients.

Key points

An automated dispensing system installed in an acute hospital has halved dispensing errors and released more than 30 per cent of technicians' time for other duties.

Reducing medication errors can have a considerable effect on reducing pressure on hospital beds.

Automation has considerable advantages in light of the continuing shortage of pharmacists and pharmacy technicians.

REFERENCES

1Bates DW, Cullen DJ, Laird N, Petersen LA, Small SD, Servi D et al.

Incidence of adverse drug events and potential adverse drug events. JAMA 1995; 274:29-34.

2Bates DW, Spell N, Cullen DJ, Burdick E, Laird N, Petersen LA et al.

The costs of adverse drug events in hospitalised patients. JAMA 1997; 277:307-11.

3Vincent C, Neale G, Woloshynowych M.Adverse events in British hospitals: preliminary retrospective record review.Br Med J 2001; 322:517-519.

4An Organisation with a Memory, Department of Health, 2000.

5Hawkey CJ, Hodgson S, Norman A, Daneshmend TK, Garner ST. Effect of reactive pharmacy intervention on quality of hospital prescribing.Br Med J.1990;300:986-90.

6Slee A, Farrar K, Hughes, D.

Implementing an Automated Dispensing System.Pharm J 2002:268;437-438.

Keith Farrar is chief pharmacist, Wirral Hospital trust. Ann Slee is chief pharmacist, Glan Clwyd District General Hospital, Conwy and Denbighshire trust. Michael Yeats is research manager, Audit Commission.