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Following is the most recent medDISPENSE case study. To view archived case studies, please click here.
Running a Successful In-hospital Pharmacy |
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Alliance Health Center improved their level of medication management significantly in only one year by implementing the medDISPENSE system
Improving Medication Management at Alliance Health Center
Alliance Health Center, located in Meridian, Mississippi, is a 134-bed acute care psychiatric and chemical dependency hospital. Alliance is dedicated to serving individuals with acute behavioral health disorders and chemical and substance abuse issues.
Alliance is a smaller hospital and had not initiated an automated medication dispensing system because of the capital cost. medDISPENSE leads the automated medication market in providing quality products at an affordable price, enabling smaller facilities like Alliance to implement a strong pharmacy management program.
After purchasing a medDISPENSE automated medication dispensing system in the fourth quarter of 2007, the pharmacy staff at the hospital carefully tracked the effects of the purchase. They found that many aspects of their operations were improved by initiating this particular pharmacy management system, including reduction in the number of medication errors, better inventory management, and meeting JCAHO requirements.
Following are the significant changes realized by Alliance Health Center as a result of implementing their medDISPENSE system.
Reducing Medication Errors
Measurement of four key errors - Wrong Patient, Wrong Preparation, Wrong Dose and Unauthorized Drug - all decreased significantly after implementing the medDISPENSE system.
- Wrong Patient decreased by 75% from 2005.
- Wrong Preparation decreased by 20% from 2006 to 2008.
- Wrong Dose decreased by 63% from 2005 to 2008.
- Unauthorized Drug decreased by 45% from 2006 to 2008.
Most of the decreases can be credited to information supplied by the medDISPENSE unit when the nurse is dispensing the medication. Pharmacy puts notes on the extended release medications and doses which are noted when dispensing. Patient identification is enhanced with the medDISPENSE system. The number of reported "Omitted Dose" increased because these errors are easy to detect using medDISPENSE reports.
The number of medications per patient day has continued to decrease since the implementation of medDISPENSE, with the lowest percent in six years at Alliance Health Center in the third quarter.
How Implementing medDISPENSE Reduced Medication Errors
Pharmacy is able to include messages into computer system for specific medications, including:
- High risk medications notification
- Look-Alike-Sound-Alike medication notification
- Extended release - to avoid confusion with plain formulations
- Confusing names can be corrected by pharmacy and/or the nurse can be notified
- Specific monitoring parameters can be added as a message; for example: check blood pressure prior to giving Clonidine
- Special messages can be included; for example: patient teaching is required for Coumadin
- Both generic and trade names are in the system and nurse can choose which to use as the look-up
- Pharmacy and nursing can require witness on specific high alert medications such as insulin
- Requires a witness for overrides for medications needed after pharmacy hours
- Requires a witness for waste of control substance
- Notifies pharmacy immediately if there is a discrepancy with control substances
- The computer displays a message if someone recently removed the medication for the patient
- Reports on the system and in the pharmacy tell exactly what was removed, when, and by whom, allowing for accurate opportunities for education
- If the nurse chooses a dose that is not the same as the pharmacy profile, a message will display to ask if dose is correct and the nurse must respond after checking
- If a medication is not loaded in the system on a certain unit it will tell the nurse the location of the medication
- medDISPENSE alerts the nurse to any patient allergies at time of administration
- Alert messages are displayed when patient names may be confusing or they have the same names
- At least two patient identifiers are noted on the system
Adverse Drug Reactions (ADRs)
The pharmacy utilized the ADR reporting options on the medDISPENSE software system, providing information to pharmacists and nurses. The pharmacy put a poster in the medication room explaining the process with the medDISPENSE ADR Tracking. They also put notes within the software explaining not to mark ADR as "yes" if using Cogentin or Benadryl and this prevented EPS. Any time Cogentin or Benadryl injections are used, the nurse is required by the computer to answer whether the injection is being used to treat an ADR.
Alliance only had 7 ADR reports in 2007. As of end of 3rd quarter 2008 there were 22 ADRs, the highest number of reported incidents in eight years. There wasn't an actual increase in ADRs, only an increase in reporting. This accuracy is important for monitoring the safety of patient medication management.
Medication Occurrences
After medDISPENSE was implemented in the fourth quarter in 2007, the number of errors dropped to the lowest number in years. The total number of medication errors and the level 2 (major) reports had increased significantly by 3rd QTR 2007.
Everyone was being very careful while learning the new automation system. As the staff became more familiar with the system and there were more opportunities to find errors, the numbers began to increase. This allowed for educational in-service opportunities with pharmacy and nursing.
Controlled Substance Signatures
Missing Control Substance Signatures - 2007
Missing Control Substance Signatures - 2008
Prior to medDISPENSE implementation alliance used manual Control Substance Administration Records (CSAR) for each nursing unit. Documentation on the CSAR was required when a controlled substance was administered and required a witness signature when wastage was necessary. An end-of-shift count of all control substances was required and the documentation required putting the count on the CSAR along with signatures of both nurses. This system resulted in frequently missing signatures.
After the implementation of the medDISPENSE system, there were no missing signatures. medDISPENSE requires two nurses to log-in to witness the wastage, and at shift count two nurses count only what control medications have been accessed. The time taken by nurses performing shift count has significantly decreased since implementation.
Controlled Substance Security
Since implementation of the automated system, there have been no unresolved discrepancies. medDISPENSE allows for reports to be printed with several parameters, enabling the pharmacy staff to monitor the transactions. This was not available prior to automation. A pharmacy report detailing the controlled substance administration transactions is printed each morning from the prior day. Each dose is checked and verified. Trends are easy to detect and this permits identification of drug diversion.
Nurses are required to count the controlled substance prior to its administration; therefore, any discrepancies are noted immediately. In addition, a witness nurse is required to perform a resolution.
Inventory Management
Alliance had an 8% decrease in inventory from November 2007 to May of 2008 following the implementation of medDISPENSE. The number of inventory turns increased from 9.5 in 2007 to 10.7 in 2008, which is calculated by dividing the purchases by the inventory total. The more inventory turns the pharmacy has, the better the management of the inventory. The result is a decrease in cost to the hospital by lowering the amount of medications sitting on the shelves. The automated system assists the pharmacy in their ordering due to easy tracking of the medications being used.
Timeliness of Medication Delivery
Prior to the automated system, Alliance had to enter orders into HMS and a label would be generated to fill. The technician would fill the medication and the pharmacist would check it. The average time from order received to delivery to the nursing unit was close to one hour for regular orders. Stat or Now orders were delivered immediately, although this was very time consuming for the pharmacy staff.
With automation, medications are available to the nurses within five minutes from the time the physician orders are sent to the pharmacy. Stat and Now orders are still delivered immediately within 1-2 minutes.
After Pharmacy Hours Medication
Alliance no longer has "Night Stock"; everything that is needed is loaded into the medDISPENSE drawers. The system has an override feature that allows qualified nurses with a witness to remove medications necessary for the patient after pharmacy hours. Any alerts or precautions put into the comments on a medication by the pharmacy will be displayed, prompting the nurses to check certain criteria.
The medDISPENSE software prints an Override Report the following morning which documents the medication overrides that occurred the night before. This reporting capability has eliminated the problem of medications being removed from the night stock supply without proper documentation and the double check requiring a witness. It also prints reports of all transactions for the pharmacy to check.
Billing Chart Audit
Each quarter the hospital does a billing chart audit on 10 discharged patients. The pharmacy compares the medication charges with documentation on the medication administration record and reports the variances.
A significant decrease in variances has been noted for each quarter in 2008 compared to 2007. In the first quarter of 2008 there was a 76.5% variance, in the second quarter there was a 82% variance, and in third quarter there was a 74.3% variance. The fourth quarter numbers had not been completed when this information was collected.
medDISPENSE was implemented in October 2007. The 2008 improvements are directly related to the automation.
How the medDISPENSE System Satisfies Joint Commission Requirements: Meeting Joint Commission (JCAHO) 2008 Standards
MM.1.10 Patient-specific information is readily accessible to those involved in the medication management system.
Evaluation Method and Measure of Success
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New patient information is obtained when the patient is admitted including, age, height, weight, allergies, medications, comorbidities, diagnoses, etc. Any missing heights and weights are printed in a daily report and obtained from the nursing units. The information is displayed on the medDISPENSE screen when the nurse is administering medications.
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MM.2.10 Medications available for dispensing or administration (including stock medications) are selected, listed, and procured based on criteria.
Evaluation Method and Measure of Success
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Addition or deletions to formulary is presented to P&T monthly. medDISPENSE shows the formulary medications. If a medication is not on a specific nursing unit, it will show the nurse where it is located.
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MM.2.20 Medications are properly and safely stored.
Evaluation Method and Measure of Success
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Daily medDISPENSE checks/restock and monthly nursing unit inspections. Even refrigerated medications are loaded and obtained through the medDISPENSE system. Look-Alike-Sound-Alike medications are segregated and labeled to prevent errors. High Risk Medications are labeled in medDISPENSE. Insulin's and Warfarin require a witness for removal. medDISPENSE is a secure device.
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M.2.30 Emergency medications and/or supplies, if any, are consistently available, controlled, and secure in the hospital's patient care areas.
Evaluation Method and Measure of Success
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Emergency medications are loaded in medDISPENSE. Any removal generates a report in the pharmacy to check and resupply. Monthly inspections are preformed to make sure everything is in date.
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MM.4.10 All prescriptions or medication orders are reviewed for appropriateness.
Evaluation Method and Measure of Success
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Medications needed for a patient after pharmacy hours can be removed by using the override function and this requires a nurse witness. Override reports are monitored daily. Any discrepancies are documented and monitored monthly for trends. Age specific doses are monitored. Any alerts or precautions put into the medication comments appear on the computer screen at time of removal of medications.
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MM.4.40 The pharmacy has a system for safely providing medications to meet patient needs when the pharmacy is closed.
Evaluation Method and Measure of Success
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New medications removed from drawers after pharmacy hours require a witness and the Override Report is monitored by the pharmacy daily. In addition, there is a pharmacist on call 24 hours a day, seven days a week.
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M.4.70 Medications dispensed by the hospital are retrieved when recalled or discontinued by the manufacturer or the Food and Drug Administration for safety reasons.
Evaluation Method and Measure of Success
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The pharmacy monitors the number of recalled medications each month. The computer reports show the location of each medication for easy retrieval.
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MM.5.10 Medications are safely and accurately administered.
Evaluation Method and Measure of Success
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Medications entered onto the patient profile by the pharmacy show on the medDISPENSE profile for the nurses to choose when administering the medications. Any alerts and/or precautions on the medications display on the medDISPENSE screen at the time of dispensing by the nurses. medDISPENSE reports show any inaccurate medication dispensing and allows for direct individual education.
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MM.6.20 The hospital responds to actual or potential adverse drug events and medication errors.
Evaluation Method and Measure of Success
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The medDISPENSE system prompts the nurse to report an ADR prior to administering Cogentin or Benadryl injections. This has improved the hospital's reporting system significantly.
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MM.7.10 The hospital develops processes for managing high-risk or high-alert medications.
Evaluation Method and Measure of Success
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High Alert and Look-Alike-Sound-Alike medications are flagged in HMS to print on MARs and in the medDISPENSE system. Insulin requires a witness to check dosage and type prior to administration and Warfarin requires a witness to provide a double check.
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MM.8.10 The hospital evaluates its medication management system.
Evaluation Method and Measure of Success
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medDISPENSE automation has been a success for the medication management system and the safe administration of medication since its installation, and reports are easily pulled for evaluation and remedial action, when needed.
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Conclusion
With the implementation of the medDISPENSE automated medication dispensing system, Alliance Health Center has achieved numerous cost savings and process improvements. This affordable solution resulted in significant changes, including improved medication management with a reduction in billing errors, better inventory management during and after hours, reduction in Adverse Drug Reactions (ADRs), and compliance with JCAHO requirements. These improvements not only ensure compliance, but they also result in a better quality of patient care.
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