Automation of in-hospital pharmacy dispensing: a systematic review

Studying waiting time in pharmacy: A strategy for improving patient satisfaction

This study analyzes waiting times for compounded and non-compounded medication services and identifies factors influencing prescription delays in public and private hospitals in Surabaya. Using a quantitative cross-sectional design, the study collects data in two phases: the first focuses on outpatients and their prescription data sheets, while the second involves pharmacists and pharmacy technicians through a questionnaire. The average waiting time for compounded prescriptions was 80 min in public hospitals and 36 min in private hospital. For non-compounded prescriptions, the averages were 64 min in public hospitals and 43 min in private hospital, with some cases as low as 28 min. These results exceed the Ministry of Health standards of 60 min for compounded drugs and 30 min for non-compounded drugs. The main factors influencing waiting times were the high workload of pharmacy staff during peak hours, the number of items in prescriptions, and insufficient pharmacy staff. Patient satisfaction in the outpatient division is associated with•Information technology,•Standard operating procedures, and•Human resources.

Benefits and challenges associated with implementation and ongoing use of automated dispensing cabinet for medicines: A scoping review

When deciding whether to adopt a digital healthcare technology, there is a need to fully grasp the benefits as well as understand any potential challenges from the outset, to enable appropriate mitigations to be considered as part of implementation plans. Automated dispensing cabinets (ADCs) have been increasingly used in hospitals as a means of streamlining medicines use workflows, facilitating medicine management, saving costs, and improving patient safety. Manufacturers commonly reference the benefits of ADCs but rarely outline the challenges. It is important that senior leaders in healthcare understand both the benefits and challenges of ADCs prior to implementation, to ensure the technology is implemented in areas where the benefits can be most maximally achieved and the challenges mitigated in so far as possible. A scoping review methodology was used to map existing literature focussing on the benefits and challenges of ADC use with medicines. Following a preliminary search to identify key terms, extensive literature searches were conducted in Medline, PubMed, CINAHL, Embase, Global Health, and Web of Science. Among 234 articles identified from the search, 54 articles were included for full data extraction. Extracted information included publication date and origin, study aims & objectives, study setting, medication distribution model, technology infrastructure, overarching category, area of focus, and key findings. The findings were discussed in terms of implications for broad trends and future research directions. Although results indicate that there is an abundance of published literature on benefits and challenges associated with ADC use with medicines, there are only a handful of UK studies. Differences in settings, distribution models, workflows and technology infrastructure limit the overall ability to generalise findings. Further UK-based studies carried out in different settings with varying levels of technological infrastructure is imperative to not only track the impact of ADCs but also to inform practice to ensure the continued delivery of benefits. Further studies focusing particularly on the impact of stock optimisation and the management of CDs (Controlled drugs) would be key areas of focus.

Innovation in hospital pharmacy: Modeling the installation of automated dispensing systems based on an oncology hospital experience transfer

ObjectiveThis study explores automated dispensing systems (ADS) implementation in hospitals, focusing on experience transfer between the National Institute of Oncology of Rabat (NIO) and the specialties hospital of Rabat (SHR) to develop a transferable ADS installation and management model.MethodA retrospective implementation and experience data analysis of 3 years ADS implementation at NIO and a prospective planification for SHR new implementation on 6 months were employed. Data collection included pharmacist team reports, personnel interviews, direct observations, and information system data exports. The study focused on identifying challenges a plan-do-check-act (PDCA) cycle.ResultsThe analysis revealed overestimation in ADS needs at NIO about 42%, leading to: Resource exhaustion; Challenges in timeline installation staff training and management, Disruptions in data integration and Incident Reports. These issues underscored the importance of a phased, well-planned implementation process.DiscussionThe study highlighted the crucial role of many comprehensive strategies. In accordance with the results of several studies, this work demonstrates the benefits of ADS in reducing medication errors and enhancing resource management, while also pointing out the necessity for accurate system sizing, effective integration with hospital information systems, and comprehensive staff training.ConclusionThe experience transfer between NIO and SHR provides a valuable model for ADS implementation in hospital pharmacies, proposing optimizations on: Implementation process; Timelines and mapping; Risk management and incident reports; Staff training, sensibilization and change control.

Introducing Unit Dose Dispensing in a University Hospital - Effects on Medication Safety and Dispensing Time

Purpose

Unit dose (UD) medications reduce manual steps in the medication management and use process and enable electronic documentation by barcode scanning. This study aimed to explore the effects of introduced unit doses on medication safety and time spent on medication dispensing.

Patients and Methods

Direct before-and-after observations were conducted in an inpatient internal medicine ward at Helsinki University Hospital. The prevalence of medication and procedural errors and time nurses spent dispensing medications at patient-specific doses were observed 10 weekdays before and after introducing unit doses of selected medications. To complement the observations, a separate survey was used to investigate nurses' perceptions of medication dispensing. Quantitative analysis was performed.

Results

During the observations, medications were dispensed for 208 patients (n=1359 medications) before and 221 patients (n = 1171) after introducing unit doses. After UD implementation, 45.3% (n=530/1171) of the medications were dispensed as UDs. Medication and procedural errors were reduced (from 3.2% to 1.7% and 37.4% to 13.9%, respectively; p<0.05). Barcode scanning-related problems decreased from 21.4% to 1.8% (p<0.05) after implementation. The unit doses did not change the median time used to dispense medications to the patient, although the time used to dispense a single medication increased. In the survey, nurses reported improvements in barcode scanning but also indicated problems with handling unit doses and were worried about increased plastic waste.

Conclusion

Piloted unit doses decreased medication and procedural errors. Barcode scanning improved, which supported electronic closed-loop medication management in the study hospital. Unit doses in a fully automated process should be further studied for their effects on the dispensing time. In addition, controlling the amount of plastic waste in the unit dose dispensing should be considered.

Assessment of Automation Models in Hospital Pharmacy: Systematic Review of Technologies, Practices, and Clinical Impacts

Medication management in hospitals is a complex process that encompasses every step from prescription to administration, involving multiple healthcare professionals. This process is prone to various errors that can compromise patient safety and generate significant human and financial costs. Automation in hospital pharmacies represents a major advancement, enhancing patient safety, optimizing professional practices, and reducing hospital expenses. This study aims to analyze the different types of automation systems used in hospital pharmacies, assess the impact of automation, and explore its benefits as well as the challenges and limitations associated with its implementation. A literature search was conducted using the ScienceDirect, PubMed, and Scopus databases, covering the period from 1992 to 2024. A total of 129 relevant articles related to the automation of medication preparation and distribution, as well as its challenges and perspectives were included in this study. Automated technologies significantly contribute to reducing medication errors, strengthening traceability, optimizing inventory management, and alleviating the workload of healthcare professionals. However, challenges persist, particularly in terms of costs, integration with existing processes, and staff training. The use of artificial intelligence offers promising prospects for improving the accuracy and operational efficiency of automation systems.

Unit dose drug dispensing systems in hospitals: a systematic review of medication error reduction and cost-effectiveness

BACKGROUND

Medical errors pose significant risks to patient safety and public health. Automated unit dose drug dispensing systems (UDDSs) have emerged as valuable tools to reduce medication errors while optimising economic and logistical resources.

OBJECTIVES

This systematic review aims to evaluate studies specifically focused on the impact of automated UDDSs in reducing medication errors and streamlining processes.

METHODS

A literature search was performed on PubMed, Scopus, and Web of Science, focusing on peer-reviewed articles published between 2019 and 2024. The search, concluded on 24 September 2024, included studies conducted in inpatient hospital settings that assessed automated UDDS effects on medication errors, therapy management and inventory control. Outcomes examined included effects on patient safety, cost-effectiveness and inventory management. Results were synthesised qualitatively.

RESULTS

From 3346 references, four studies met the inclusion criteria: a cost-effectiveness analysis, an uncontrolled before-and-after study, and two observational studies. UDDS improved medication processes, reducing drug-related problems, medication handling and dispensing time by 50% per patient per day. Integrated with barcode scanning, UDDS lowered medication administration errors (MAEs) from 19.5% to 15.8% and harmful MAEs from 3.0% to 0.3%. Overall, medication errors dropped by 45-70%, enhancing safety and reducing manual handling risks. UDDS demonstrated cost-effectiveness by significantly reducing MAEs. The study estimated a reduction in MAEs, with a cost-effectiveness ratio of €17.69 per avoided MAE. For potentially harmful MAEs, the cost-effectiveness ratio was estimated at €30.23 per avoided error. These findings suggest substantial long-term savings potential, though the exact magnitude may vary depending on hospital size and implementation specifics CONCLUSIONS: Automated UDDSs improve patient safety by significantly reducing medication errors and delivering cost savings through better inventory management. Challenges such as high initial costs and workflow adjustments can be mitigated through gradual implementation and staff training. Further integration with other healthcare technologies, such as barcoding, real-time tracking, artificial intelligence (AI)-driven error prevention tools and fully automated restocking systems could enhance UDDS benefits and further support hospital processes.

Digital technologies in nursing: An umbrella review

BACKGROUND

Digital technologies promise to reduce nurses' workload and increase quality of care. However, considering the plethora of single and review studies published to date, maintaining a comprehensive overview of digital technologies' impact on nursing and effectively utilizing available evidence is challenging.

OBJECTIVE

This review aims (i) to map published reviews on digital nursing technologies, based on their aims and the specific technologies investigated, to synthesize evidence on how these technologies' uses is associated with (ii) nurses' work-related and organizational factors, professional behavior, and health and work safety and (iii) ethically relevant outcomes for people in need of care.

DESIGN

Preregistered overview of reviews (PROSPERO-ID: CRD42023389751).

SETTING(S)

We searched for systematic reviews in eight databases, five key journals, and reference lists of included reviews published in English until May 21, 2024.

METHODS

We used the AMSTAR 2 checklist to assess the methodological quality of included reviews reporting associations with nursing outcomes. The extracted data were analyzed by their frequency and narratively synthesized.

RESULTS

We identified 213 reviews on digital technologies' uses in the nursing sector. Most of these focused on information and communication technologies. The most frequently reported research objectives encompass technology usage and/or general experiences with it and technology-related consequences for care recipients. Regarding work-related and organizational factors, beneficial impacts were found for the execution of nursing tasks, information management and job control. Depending on the technology type, reviews reported mixed effects for documentation activities, communication/collaboration and mainly negative effects on nurses' workload. Concerning occupational safety and health-related and further nurse outcomes, reviews reported mostly positive effects on nurses' job satisfaction and professional competence. Adverse effects related to mental and physical strain, such as increased frustration, fatigue, and burnout. Regarding ethically relevant outcomes, robotic and telecare technologies had the most reported findings. Most evidence concerned effects on the principles of beneficence/non-maleficence and respect for autonomy.

CONCLUSIONS

Digital nursing technologies' legitimacy hinges on their impact on patient outcomes and nurses' work, safety, and health. This review identifies a diverse array of these technologies, with both positive and negative effects. However, due to narrative limitations, meta-analysis was impractical. Future research should quantitatively assess the effects of various digital nursing technologies on work, safety, health, and ethical outcomes.

TWEETABLE ABSTRACT

Research on digital tech in nursing lacks focus on key work factors, occupational health and ethical outcomes. #NursingTech #ResearchGaps.

Effectiveness of Pharmacy Automation Systems Versus Traditional Systems in Hospital Settings: A Systematic Review

Medication errors (MEs) in hospital settings remain a significant global healthcare challenge, resulting in adverse patient outcomes, increased healthcare costs, and reduced operational efficiency. Traditional pharmacy systems (TPS) are particularly vulnerable to human error, inefficient inventory management, and workflow bottlenecks. While pharmacy automation systems (PAS) have emerged as a potential solution, there is a notable gap in the literature regarding comprehensive comparative studies between PAS and TPS across multiple outcomes and settings. This systematic review addresses this gap by evaluating the comparative effectiveness of PAS versus TPS in hospital settings, focusing on MEs, operational efficiency, cost-effectiveness, and patient outcomes. We conducted a systematic literature review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, searching PubMed and Cochrane Library databases for studies published between 2010 and June 2024 that directly compared PAS with TPS in hospital settings. The review examined various PAS technologies, including centralized pharmacy robots, automated dispensing cabinets (ADCs), and hybrid systems incorporating centralized and decentralized technologies. Of 1,085 studies initially identified, 32 met the inclusion criteria for comprehensive analysis. The overall mean effect size was 0.505 (95% confidence interval (CI): 0.487 to 0.523), indicating a moderately positive effect of PAS implementation. Key findings demonstrated that PAS significantly reduced MEs, particularly in automated dispensing systems (ADS) and computerized physician order entry (CPOE) systems. While initial implementation costs were substantial, long-term operational costs were significantly lower due to reduced labor requirements and medication wastage. Workflow efficiency improvements enabled pharmacists to dedicate more time to clinical activities. Patient outcomes improved through enhanced medication safety and reduced adverse drug events. This review provides robust evidence supporting PAS implementation in hospitals. It demonstrates that despite significant initial investment requirements, the long-term benefits in error reduction, operational efficiency, and patient safety justify implementation. Future research should focus on detailed cost-benefit analyses across various hospital settings and assessments of staff satisfaction to optimize implementation strategies.

Integrating automated dispensing cabinets into the medication dispensing process: feedback from the practice in European hospitals

OBJECTIVES

Automated dispensing cabinets (ADCs) offer improved medication safety, greater efficiency and return on investment. However, integrating ADCs into medication dispensing processes can be challenging in complex hospital environments. This study aimed to draft suggestions to help hospitals adopt ADCs.

METHODS

Two-day visits were organised in seven European hospitals operating ADCs. Investigators used an observational grid, a questionnaire and interviews, each divided into the themes of medication processes before and after the introduction of ADCs, the major steps followed and the resources involved, ergonomics and staff perceptions.

RESULTS

ADCs were integrated into four global hospital medication dispensing systems (packs of drugs are distributed from the central pharmacy to wards for dispensing) and three nominative systems-that is, patient-specific ones (drug doses prescribed for individuals are distributed from the central pharmacy to wards with ADC as supplementary stock). A general ADC project implementation timeline was shaped: main drivers of automation to initiate the project, visit of other sites, pilot test (with IT integration and staff training), and evaluation phase (satisfaction, safety, efficiency) to justify a possible expansion. Users (7 pharmacists, 21 nurses, 7 data engineers) identified facilitators (such as a dedicated project manager, a pilot phase, an intuitive device), barriers and any improvements needed (training for incoming staff, reorganisation of ward workflow, dynamic inventories).

CONCLUSIONS

Despite their diverse pharmacy organisations, each hospital raised similar challenges and reported analogous major steps in project implementation. Although integration processes are complex, ADCs rapidly provide users with benefits. By following the practical advice and recommendations from these hospitals, new adopters might reduce the risks of failed ADC projects and accelerate their integration.

Nursing home staff's experiences with the implementation of an automated blister packaging system for solid, orally ingestible drugs: a qualitative study in Northern Italy

OBJECTIVES

To explore nursing home (NH) staff's experiences implementing an automated blister packaging system for solid, orally ingestible drugs.

DESIGN

This was a descriptive qualitative study. Semistructured interviews were used for data collection, and qualitative content analysis was applied for data analysis.

SETTING

Four NHs in a region in Northern Italy participated in the piloting of an automated blister packaging system.

PARTICIPANTS

The purposive sample comprised 40 NH staff (seven registered nurses, 11 certified nursing assistants, three nursing aids, seven nursing managers, four directors and eight physicians) RESULTS: Six main categories emerged from the data analysis: (1) impacting safety, including improved medication process, perceived insecurities and remaining error sources; (2) creating free spaces, including time, individualised care and drug storage and logistics; (3) serving residents, (4) meeting expectations, including met and unmet expectations; (5) generating efforts and (6) producing waste. They all merged into one theme 'It pays off!'

CONCLUSIONS

As experienced by NH staff, the automated blister packaging system improved medication safety and reduced the workload of registered nurses, but it is not an 'all-around carefree package'. Continuous quality improvement and risk management strategies are recommended to accompany and sustain implementation, as well as further clarification of roles and duties among the different care workers involved in medication management. Further research is needed to gain a better understanding of the impact of an automated blister packaging system on registered nurses' competencies in NHs regarding medication management and residents' therapies and safety.

Evaluating the impact of an automated drug retrieval cabinet and robotic dispensing system in a large hospital central pharmacy

PURPOSE

To determine the impact of implementing 2 technologies in succession, the Carousel system and XR2 robot, in a hospital central pharmacy. The study examined the technologies' impact on workload shifted from fully human-involved, labor-intensive filling from shelves to Carousel and/or XR2, prevention of filling errors, and efficiency.

METHODS

Implementation occurred in 3 phases from August 2021 through October 2022. In phase I, medications were manually filled from the shelves for immediate doses and automated dispensing cabinet stock. RobotRx was used for unit-dose (UD) carts. In phase II, the Carousel system was introduced, while RobotRx was used for UD carts. In phase III, the XR2 robot was added and RobotRx was decommissioned. Epic data and time studies were utilized and analyzed with ANOVA.

RESULTS

Over the 3 phases of implementation, workload shifted away from filling from the shelves, with 2,479, 1,044, and 864 orders filled from the shelves for phase I through phase III, respectively. The Carousel workload was 1,234 orders (phase II) and 348 orders (phase III). Nearly 71% of the workload was shifted to the XR2. The overall filling error (prevented) rate did not significantly change from phase I to phase II, remaining at 0.5%. In comparison, the error rate significantly decreased to 0.41% in phase III. Use of the Carousel system resulted in a significant reduction in filling errors compared to manual filling from the shelves. Use of the XR2 robot resulted in a filling error rate of 0%. The savings in time when using both Carousel and XR2 led to a decrease in full-time equivalents of 0.77 for pharmacists and 1.76 for pharmacy technicians.

CONCLUSION

Carousel and/or XR2 significantly shifted workload from manual filling to automated technologies, decreased filling errors, and improved efficiency, reducing pharmacist and technician workload. Time saved could allow staff to spend more time on patient-centric tasks.

Comparing nursing medication rounds before and after implementation of automated dispensing cabinets: A time and motion study

Nursing medication administration is an integral, albeit time consuming component of a nursing shift. Automated dispensing cabinets (ADCs) are a medicines management solution designed to improve both efficiency and patient safety. This study aimed to evaluate the time taken to undertake a medication round including the number of locations visited to retrieve medicines, across four different clinical specialties within one hospital. Studies to date have investigated the effect of ADCs on nursing medication rounds centred around one clinical specialty, in hospitals with varying levels of digital maturity. This study adds to the existing body of evidence by investigating multiple clinical specialties where EPMA in use throughout the study period. In this study, prior to ADC implementation nurses retrieved required medicines from shelves in the medication room, mobile medication carts, and patients' own drug (POD) lockers. Post-ADC implementation, medicines were retrieved exclusively from the ADC and POD lockers only. Nurses were observed on each ward completing medication rounds, using the data collection tool designed for this study. Pre-implementation data was collected between February and June 2023, and post-implementation data collected between July and September 2023. There was a statistically significant reduction in the time required for medicines retrieval on the surgical ward only, post- ADC implementation. The time taken to retrieve each medication went from a mean of 98.1 s to 47.2 s (p = 0.0255). When comparing all four specialties as a whole, there was a reduction in the mean time required to issue each medicine preversus post-ADC implementation, from 83.3 s to 62.6 s respectively, however this difference was not shown to be statistically significant. The mean number of locations visited to obtain all required medicines for each patient reduced significantly from 1.73 to 1.04 (p < 0.01). There is potential for improved efficiency as nurses become more familiar with new workflows. It may be of benefit to repeat this study to ascertain whether time savings have been further improved.

Pharmacist roles in the Medication Use Process: Qualitative analysis of stakeholder perceptions

BACKGROUND

Pharmacist roles in the Medication Use Process (MUP) have advanced along with new healthcare delivery models and interprofessional collaborative practice. It is unclear whether stakeholder perceptions of pharmacist roles have evolved simultaneously.

OBJECTIVES

Examine patient, pharmacist, and physician perceptions of pharmacist roles in the MUP.

METHODS

This institutional review board-approved study used a cross-sectional design with Qualtrics panels of patients, pharmacists, and physicians. Role Theory was used as a framework to develop 12-item surveys to study pharmacist role perceptions in the MUP: prescribing, transcribing, dispensing, administration, and monitoring. Content analysis was performed on the responses to open-ended questions.

RESULTS

From 1004 patients, a total of 7217 comments were obtained on 9 questions (740-1004 comments), resulting in an average of 802 comments per question or 0.8 comments per question per respondent (CQR). Similarly, 1620 comments from 205 pharmacists on 11 questions (121-205 comments) averaged 0.72 CQR; and 1561 comments from 200 physicians on 11 questions (136-200 comments) equated to 0.74 CQR. Content analysis revealed recurring themes across the stakeholders: "pharmacists," "physicians," "insurance," "technology," "collaboration," "time," "communication," and "patient's responsibility." Some role congruence was seen regarding pharmacist roles by all 3 stakeholders; noting pharmacist roles in improving all steps of the MUP, except transcribing. Pharmacists highlighted professional challenges such as staffing issues, burnout, and competing demands; which were not acknowledged by patients and physicians indicating the need to increase awareness.

CONCLUSION

This study showed increased visibility and awareness of pharmacist roles in the MUP by all stakeholders, compared to previous research showing pharmacist roles limited to dispensing. Known barriers to pharmacy practice such as lack of provider status and reimbursement were not reported by any of the stakeholders in this study. There is a need to continuously inform stakeholders about pharmacists' expanding roles in the MUP through advocacy and marketing.

Assessing Similarity in Production from Organizational and Department-Level Financial Accounting Statements

Hospitals are complex organizations which provide a wide array of health care services. This complexity creates challenges for stakeholders who wish to use financial accounting statements to make inferences about the productive choices made by a hospital's management. These challenges are especially salient when using data reported at the department (or cost center) level, or where the provision of care is coordinated across hospital departments. This study applies information entropy-based comparability analysis techniques to overall and department-level hospital financial data to identify hospital peer groups. Hospitals peer groups not only exhibit similar financial positions overall, but are also likely to exhibit operational similarities at the department level. Data for this analysis are drawn from the financial statements of Washington State critical access hospitals in the fiscal year 2019. The medical laboratory and pharmacy departments were specifically assessed because their services impact or support virtually every other revenue-producing department in the hospital. Findings suggest both departments significantly impact the formation of peer groups, with the pharmacy department contributing the largest impact.

Enhancing Operational Efficiency and Service Delivery through a Robotic Dispensing System: A Case Study from a Retail Pharmacy in Brazil

Drug dispensing in retail pharmacies typically involves several manual tasks that often lead to inefficiencies and errors. This is the first published quality improvement study in Latin America, specifically in Brazil, investigating the operational impacts of implementing a robotic dispensing system in a retail pharmacy. Through observational techniques, we measured the time required for the following pharmacy workflows before and after implementing the robotic dispensing system: customer service, receiving stock, stocking inventory, separation, invoicing, and packaging of online orders for delivery. Time savings were observed across all workflows within the pharmacy, notably in receiving stock and online order separation, which experienced 70% and 75% reductions in total time, respectively. Furthermore, customer service, stocking, invoicing, and packaging of online orders, also saw total time reductions from 36% to 53% after implementation of the robotic dispensing system. This study demonstrates an improvement in the pharmacy's operational efficiency post-implementation of the robotic dispensing system. These findings highlight the potential for such automated systems to streamline pharmacy operations, improve staff time efficiency, and enhance service delivery.

Analyzing override patterns in profiled automated dispensing cabinets at a tertiary care hospital in Saudi Arabia

BACKGROUND

Inappropriate automated dispensing cabinet (ADC) overrides pose a significant risk to patient safety. Bypassing pharmacist review during these overrides removes a vital safety check, leaving nurses to review complex medication orders alone. This can lead to overlooking incorrect orders and significantly increasing the potential for medication errors. While Institute for Safe Medication Practices (ISMP) guidelines promote profiled ADCs and safe override practices, there is no national standard for acceptable override rates.

OBJECTIVES

Assessing the appropriateness of ADC overrides of profiled ADCs at a tertiary hospital in Saudi Arabia in accordance with ISMP guidelines (third core safety process).

METHODS

This retrospective observational study reviewed all override transactions for 13 profiled ADCs over a 3-month period, from 1 October 2022 until 31 December 2022. The target override rate was set at no more than 5%. After applying exclusions, the relevant data fields were extracted from electronic records of 2 integrated systems: the Omnicell dashboard and the BESTCare hospital information system. The study assessed whether the override transactions complying with the standard elements required for appropriate ADC overrides in accordance with ISMP recommendations and hospital regulations.

RESULTS

Six hundred sixty-four override transactions from profiled ADCs were reviewed and evaluated. Although the overall override limit for profiled ADCs was met (1.9%), multiple inappropriate override practices were revealed. These inappropriate practices are missing physician orders (33.7%), undocumented verbal orders (31.5%), nonurgent physician orders (11%), missing (8.4%) or delayed (33.7%) administration records, and unrecognized override errors (5.3%). Only 3 (0.5%) met all the standard elements required for ADC overrides.

CONCLUSION

The target override threshold of 5% is inadequate to demonstrate sufficient adherence to the standard elements of appropriate overrides or effectively prevent medication errors. Consequently, a significantly lower target threshold override limit, well below 5%, should be considered, especially with 24-hour pharmacy services and fully integrated computerized physician order entry with ADC system. A multidisciplinary override surveillance team is considered essential.

Automated dispensing cabinets and their impact on the rate of omitted and delayed doses: A systematic review

Use of automated dispensing cabinets (ADCs) is increasing in hospital settings. ADCs bring various potential benefits, among which are improvements to patient safety and reduction of medication errors. A core function of ADCs is to prevent medication stock outs by triggering an order when stock is reaching low levels. A quantifiable patient safety measure is the occurrence of omitted or delayed doses, which can range in severity from being negligible, to potentially fatal. The purpose of this review is to identify and synthesise the existing evidence regarding the impact of ADCs situated in secondary and tertiary care inpatient settings, on the rate of omitted and delayed doses as a specific subsection of medication errors. In April 2024 searches were conducted in Embase, PubMed and CINAHL, with additional articles discovered through citation searching and from colleagues. A total of 375 articles were returned from the search. Nine articles met the inclusion criteria. The most common reason for exclusion was due to lack of relevance. The included papers were focused on centres which had implemented six or fewer ADCs. The studies mostly presented findings which suggest ADCs have a positive impact on the rate of omitted or delayed doses, although crucially only two papers correlated missed doses due to unavailability of medications The studies highlighted other factors which should be considered prior to the implementation of ADCs. Factors included staffing requirement, type of stock held in the cabinets, and interoperability with other systems. Studies only reported omitted or missed doses, none reported results on delayed doses. It is widely accepted that ADCs can prevent medication unavailability but there is a paucity of evidence linking the improved availability of medications through the utilisation of ADCs with the perceived impact on missed or delayed doses. Further multi-centre studies are needed to determine this causality.

Leveraging code-free deep learning for pill recognition in clinical settings: A multicenter, real-world study of performance across multiple platforms

BACKGROUND

Preventable patient harm, particularly medication errors, represent significant challenges in healthcare settings. Dispensing the wrong medication is often associated with mix-up of lookalike and soundalike drugs in high workload environments. Replacing manual dispensing with automated unit dose and medication dispensing systems to reduce medication errors is not always feasible in clinical facilities experiencing high patient turn-around or frequent dose changes. Artificial intelligence (AI) based pill recognition tools and smartphone applications could potentially aid healthcare workers in identifying pills in situations where more advanced dispensing systems are not implemented.

OBJECTIVE

Most of the published research on pill recognition focuses on theoretical aspects of model development using traditional coding and deep learning methods. The use of code-free deep learning (CFDL) as a practical alternative for accessible model development, and implementation of such models in tools intended to aid decision making in clinical settings, remains largely unexplored. In this study, we sought to address this gap in existing literature by investigating whether CFDL is a viable approach for developing pill recognition models using a custom dataset, followed by a thorough evaluation of the model across various deployment scenarios, and in multicenter clinical settings. Furthermore, we aimed to highlight challenges and propose solutions to achieve optimal performance and real-world applicability of pill recognition models, including when deployed on smartphone applications.

METHODS

A pill recognition model was developed utilizing Microsoft Azure Custom Vision platform and a large custom training dataset of 26,880 images captured from the top 30 most dispensed solid oral dosage forms (SODFs) at the three participating hospitals. A comprehensive internal and external testing strategy was devised, model's performance was investigated through the online API, and offline using exported TensorFlow Lite model running on a Windows PC and on Android, using a tailor-made testing smartphone application. Additionally, model's calibration, degree of reliance on color features and device dependency was thoroughly evaluated. Real-world performance was assessed using images captured by hospital pharmacists at three participating clinical centers.

RESULTS

The pill recognition model showed high performance in Microsoft Azure Custom Vision platform with 98.7 % precision, 95.1 % recall, and 98.2 % mean average precision (mAP), with thresholds set to 50 %. During internal testing utilizing the online API, the model reached 93.7 % precision, 88.96 % recall, 90.81 % F1-score and 87.35 % mAP. Testing the offline TensorFlow Lite model on Windows PC showed a slight performance reduction, with 91.16 % precision, 83.82 % recall, 86.18 % F1-score and 82.55 % mAP. Performance of the model running offline on the Android application was further reduced to 86.50 % precision, 75.00 % recall, 77.83 % F1-score and 69.24 % mAP. During external clinical testing through the online API an overall precision of 83.10 %, recall of 71.39 %, and F1-score of 75.76 % was achieved.

CONCLUSION

Our study demonstrates that using a CFDL approach is a feasible and cost-effective method for developing AI-based pill recognition systems. Despite the limitations encountered, our model performed well, particularly when accessed through the online API. The use of CFDL facilitates interdisciplinary collaboration, resulting in human-centered AI models with enhanced real-world applicability. We suggest that rather than striving to build a universally applicable pill recognition system, models should be tailored to the medications in a regional formulary or needs of a specific clinic, which can in turn lead to improved performance in real-world deployment in these locations. Parallel to focusing on model development, it is crucial to employ a human centered approach by training the end users on how to properly interact with the AI based system to maximize benefits. Future research is needed on refining pill recognition models for broader adaptability. This includes investigating image pre-processing and optimization techniques to enhance offline performance and operation on handheld devices. Moreover, future studies should explore methods to overcome limitations of CFDL development to enhance the robustness of models and reduce overfitting. Collaborative efforts between researchers in this domain and sharing of best practices are vital to improve pill recognition systems, ultimately enhancing patient safety and healthcare outcomes.

Impact of Pharmacist-Led PDCA Cycle in Reducing Prescription Abandonment: An Action Research from China

Purpose

Taking medicine as prescribed in time plays an important role in the treatment of diseases. However, some prescriptions have not picked up in time for various reasons. To analyze the influencing factors in patients with prescription abandonment and the role of pharmacists in Plan-Do--Check-Act (PDCA) cycle, we conducted a study in our hospital of Hangzhou, China.

Methods

Based on the prescription abandonment from October 1, 2021 to March 31 2022, we collected and analyzed the possible causes. According to the PDCA management method, we conducted improvement measures and supervised the implementation of measures from April 1, 2022 to September 30, 2022. The number, the proportion and the amount of prescription abandonment before and after establishment of the PDCA cycle were analyzed.

Results

Three measures were proposed and applied to improve the prescription abandonment:(I) Enhancing the education and training to the staff. (II) Improving the medical environment for patients, especially the environment for taking medicine. (III) Updating the computer information software. After the implementation of PDCA, the number of prescription abandonment decreased from 2030 to 775, there was significant reduction in the proportion of prescription abandonment (4.75‰ vs 1.77‰, P<0.05), and the amount of prescription abandonment decreased from $36,161.11 to $17,041.59. The target compliance rate was 108.36%.

Conclusion

The implementation of pharmacist-led PDCA can effectively reduce the number, the proportion and the amount of prescription abandonment, Moreover, Pharmacists play an important role in improving the management quality of outpatient pharmacy, and PDCA is a feasible and effective management tool for reducing prescription abandonment.

Automation of the medication process in Swiss hospitals: results of a survey

OBJECTIVES

Medication management is a core process in hospital administration. The safety, timeliness and efficiency of medication distribution may be improved by automating logistical and administrative aspects of the process. Forming an accurate high-level picture of current practices may help decision-makers to better advance the state of automation. This study aims to identify which systems for automating the medication process are currently in use in Swiss hospitals, and to what extent each system is used.

METHODS

A 27-question survey was developed and distributed to Swiss Association of Public Health Administration and Hospital Pharmacists (GSASA) members. The survey focused on enterprise resource planning (ERP) systems, automation of in-hospital distribution and dispensing of pharmaceutical goods, bedside scanning, and the management of drug master data.

RESULTS

The response rate was 98% (58/59 hospital pharmacies). All institutions had an ERP system in use, most frequently SAP (n=23, 39%). Electronic invoices from suppliers were fully processed by 37% and partially processed by 17% of respondents. Twenty-five percent of respondents reported performing bedside scanning for the purpose of medication administration. Automated medication distribution systems were available in 20 hospitals (34%), of which 13 were central robots and seven were decentralised systems.

CONCLUSION

A considerable gap remains to achieve closed loop processes between multiple systems. The present results provide an inventory of existing systems and current trends for use by decision-makers in hospitals and hospital pharmacies.

Automated unit dose dispensing systems producing individually packaged and labelled drugs for inpatients: a systematic review

OBJECTIVES

Pharmacy automation is increasing in hospitals. The aim of this systematic review was to identify and evaluate the literature on automated unit dose dispensing systems (UDDS) producing individually packaged and labelled drugs for inpatients.

METHODS

The search was conducted on eight electronic databases, including Scopus, Medline Ovid, and Cinahl, and limited to peer reviewed articles with English abstracts published 2000-2020. Studies were included in the review if drug dispensing was performed by an automated UDDS where individually packaged and labelled unit doses were subsequently assembled patient specifically for inpatients. All outcomes related to UDDS functionality were included with specific interest in medication safety, cost-efficiency and stock management. Outcomes were categorised and results synthesised qualitatively.

RESULTS

664 publications were screened, one article identified manually, resulting in eight included articles. Outcomes of the studies were categorised as medication administration errors (MAEs), dispensing errors, costs and cost-effectiveness. Studies showed that automated UDDS reduced significantly MAEs of inpatients compared with traditional ward stock system (WSS), especially when UDs were dispensed patient specifically by unit dose dispensing robot. Patient specific drug dispensing with automated UDDS was very accurate. Of three different automated medication systems (AMSs), patient specific AMS (psAMS) was the most cost-effective and complex AMS (cAMS) the most expensive system across all error types due to the higher additional investments and operation costs of automated dispensing cabinets (ADCs). None of the studies investigated the impact on the medication management process such as efficiency, costs and stock management as primary outcome.

CONCLUSIONS

UDDS improved patient safety. However, automation is a costly investment and the implementation process is complex and time consuming. Further controlled studies are needed on the clinical and economical outcomes of automated UDDS to produce reliable knowledge for hospital decision makers on the cost-benefit of the investment and to support decision making.

Questionnaire survey on pharmacists' roles among non- and health care professionals in medium-sized cities in Japan

Although the scope of pharmacists' work has expanded in Japan, people's perception of this is unclear. To contribute to medical care together with non- and health care professionals, clarifying the perceptions of these groups is important to best utilize pharmacist professionals. We conducted a cross-sectional questionnaire survey among non-health care professionals (n = 487) and nurses (n = 151), medical doctors (n = 133), and pharmacists (n = 204) regarding the work of pharmacists. The questionnaire comprised 56 items in four categories associated with the roles of pharmacists. For each questionnaire item, we performed logistic regression analysis to compare pharmacists' opinions with those of other professionals and non-health care professionals. Opinions were similar between pharmacists and nurses or medical doctors regarding "collecting patient information" and "providing drug information to patients." However, there were differences in perceptions regarding "medical collaboration" (nurses; 8/23 items, physicians; 11/23 items) and "community medicine" (nurses; 9/15 items, physicians; 11/15 items), and pharmacists themselves perceived greater roles related to health care collaboration and community health care. Perceptions of non-health care professionals were poorer than those of pharmacists in all categories (47/56 items). These results suggest that pharmacists must actively communicate to help others understand their specialty and build trusting relationships to improve patient care.

The Impact of Hospital Pharmacy Operation on the Quality of Patient Care

This paper presents the role, tasks, and place of a hospital pharmacy in the structure of the entire facility. The role of hospital drug management and pharmacy seems to be extremely important in providing patients with high-quality care. Particular emphasis was placed on the distribution systems of medicinal products and medical devices in the hospital. The advantages and disadvantages of the classical distribution system and modern systems such as unit-dose and multi-dose-and the most important differences between them-are presented. Difficulties related to implementing modern distribution systems in hospitals were also discussed. The information provided is presented in the context of the legal regulations in Poland.

Drug closed-loop management system using mobile technology

BACKGROUND

Drug closed-loop management reflects the level of hospital management and pharmacist service. It is a challenge for hospital pharmacists to realize the whole-process closed-loop management of drugs in hospital pharmacies. Therefore, this study aimed to evaluate the operational effect of using mobile technology to build a closed-loop drug management system.

METHODS

Using mobile technology, replacing the traditional paper dispensing model and constructing a multinode information collection system according to the Healthcare Information and Management Systems Society Standard, we reformed the hospital information system and inpatient pharmacy workflow and then evaluated the new approach using statistical methods.

RESULTS

After the transformation, the entire process of drug data can be traced. Closed-loop management, as well as real-time data verification and control, thereby improves the work efficiency and reduces the drug dispensing time. By reducing the work error rate, the number of dispensing errors decreased from 5 to 1 case/month. The comprehensive dispensing process can achieve the whole workflow of paperless operation and reduce the use of paper A4 by 180,000 pieces per year.

CONCLUSIONS

Mobile technology can improve the service level of pharmacies, enhance the level of drug management and hospital quality management, ensure the safety of medication for inpatients, and significantly reduce the amount of paper used.

A Survey of Near-Miss Dispensing Errors in Hospital Pharmacies in Japan: DEPP-J Study-Multi-Center Prospective Observational Study

The aim of this study was to determine the proportion of near-miss dispensing errors in hospital pharmacies in Japan. A prospective multi-center observational study was conducted between December 2018 and March 2019. The primary objective was to determine the proportion of near-miss dispensing errors in hospital pharmacy departments. The secondary objective was to determine the predictive factors for near-miss dispensing errors using multiple logistic regression analysis. The study was approved by the ethical committee at The Institute of Medical Sciences, University of Tokyo, Japan. A multi-center prospective observational study was conducted in 20 hospitals comprising 8862 beds. Across the 20 hospitals, we assessed data from 553 pharmacists and 53039 prescriptions. A near-miss dispensing error proportion of 0.87% (n = 461) was observed in the study. We found predictive factors for dispensing errors in day-time shifts: a higher number of drugs in a prescription, higher number of quantified drugs, such as liquid or powder formula, in a prescription, and higher number of topical agents in a prescription; but we did not observe for career experience level for clinical pharmacists. For night-time and weekend shifts, we observed a negative correlation of near-miss dispensing errors with clinical pharmacist experience level. We found an overall incidence of near-miss dispensing errors of 0.87%. Predictive factors for errors in night-time and weekend shifts was inexperienced pharmacists. We recommended that pharmacy managers should consider education or improved work flow to avoid near-miss dispensing errors by younger pharmacists, especially those working night or weekend shifts.

Economic Analysis of Patient's Own Medication, Unit-Use and Ward Stock Utilization: Results of the First Pilot Study

BACKGROUND

Medication wastage is causing a cost burden to the healthcare system that is worth millions of dollars. An economic and ecological friendly intervention such as using a patient's own medications (POM) has proven to reduce wastage and save the cost spent by the hospital. The potential benefits of using POM in inpatient settings have yet to be explored in a country with universal health coverage. This study aimed to pilot test the POM intervention in an adult ward setting and to perform the economic analysis of using POM and ward stock during hospitalization.

METHODS

A prospective cross-sectional observational study was conducted among the patients admitted to the medical and surgical wards in a public hospital located in Brunei Darussalam between February 2022 and April 2022. Hospitalized adults above 18 years old with regular medications with a minimum length of stay of 48 h and a maximum length of stay of 21 days were included in the study. These eligible patients were divided into a POM group and a non-POM group. The economic analysis of using POM was performed by calculating the direct cost per unit of medication used during admission (from unit-use, ward stock and POM) and comparing the cost spent for both groups. Expired ward stock deemed as medication wastage was determined. Medical research ethics were approved, and all participating patients had given their written informed consent before enrolling in this study.

RESULTS

A total of 112 patients aged 63.2 ± 15.8 years participated in this study. The average cost of medication supplied by the inpatient pharmacy for the non-POM group was USD 21.60 ± 34.20 per patient, whereas, for the POM group, it was approximately USD 13.00 ± 18.30 per patient, with a mean difference of USD 8.60 ± 5.17 per patient (95% CI: -3.95, 27.47, p ≥ 0.05). The use of POM minimized 54.03% (USD 625.04) of the total cost spent by the hospital for the POM group within the period of the study.

CONCLUSION

The pilot study showed that the supplied medication cost per patient was not significantly different between the POM and non-POM groups. Nevertheless, the utilization of POM during hospitalization is capable of reducing at least 50% of the total cost spent on inpatient medications by the hospital. The use of POM during hospitalization also helped in reducing the total time spent on the medication process per patient.

Automation of a tertiary hospital pharmacy drug dispensing system in a lower-middle-income country: A case study and preliminary results

Background

Methods

Results

Conclusion

The Introduction of Robotics to an Outpatient Dispensing and Medication Management Process in Saudi Arabia: A Pharmacy-led Multidisciplinary Six Sigma Performance Improvement Project. (Preprint)

Background

Outpatient pharmacy management aims for improved patient safety, improved quality of service, and cost reduction. The Six Sigma method improves quality by eliminating variability, with the goal of a nearly error-free process. Automation of pharmacy tasks potentially offers greater efficiency and safety.

Objective

The goal was to measure the impact that integration of automation made to service, safety and efficiency, staff reallocation and reorientation, and workflow in the outpatient pharmacy department. The Six Sigma problem definition to be resolved was as follows: The current system of outpatient dispensing denies quality to patients in terms of waiting time and contact time with pharmacy professionals, incorporates risks to the patient in terms of mislabeling of medications and the incomplete dispensing of prescriptions, and is potentially wasteful in terms of time and resources.

Methods

We described the process of introducing automation to a large outpatient pharmacy department in a university hospital. The Six Sigma approach was used as it focuses on continuous improvement and also produces a road map that integrates tracking and monitoring into its process. A review of activity in the outpatient department focused on non-value-added (NVA) pharmacist tasks, improving the patient experience and patient safety. Metrics to measure the impact of change were established, and a process map analysis with turnaround times (TATs) for each stage of service was created. Discrete events were selected for correction, improvement, or mitigation. From the review, the team selected key outcome metrics, including storage, picking and delivery dispensing rates, patient and prescription load per day, average packs and lines per prescription, and lines held. Our goal was total automation of stock management. We deployed 2 robotic dispensing units to feed 9 dispensing desks. The automated units were integrated with hospital information technology (HIT) that supports appointments, medication records, and prescriptions.

Results

Postautomation, the total patient time in the department, including the time interacting with the pharmacist for medication education and counseling, dropped from 17.093 to 11.812 digital minutes, with an appreciable increase in patient-pharmacist time. The percentage of incomplete prescriptions dispensed versus orders decreased from 3.0% to 1.83%. The dispensing error rate dropped from 1.00% to 0.24%. Assessed via a “basket” of medications, wastage cost was reduced by 83.9%. During implementation, it was found that NVA tasks that were replaced by automated processes were responsible for an extensive loss of pharmacist time. The productivity ratio postautomation was 1.26.

Conclusions

The Six Sigma methodology allowed for rapid transformation of the medication management process. The risk priority numbers (RPNs) for the “wrong patient-wrong medication error” reduced by a ratio of 5.25:1 and for “patient leaves unit with inadequate counseling” postautomation by 2.5:1. Automation allowed for ring-fencing of patient-pharmacist time. This time needs to be structured for optimal effectiveness.

Participation of pharmacy technicians in clinical and patient-centered care practices: A state-wide survey in Nigeria

BACKGROUND

Identifying the involvement of pharmacy technicians (PTs) in nonclinical and clinical duties will provide insight for improved pharmaceutical services.

OBJECTIVES

This study assessed the involvement of PTs in nonclinical tasks, patient-centered services, and more specialized patient care services and the difference in practice between hospital and community PTs.

METHODS

A cross-sectional survey was conducted using a 5-point Likert scale, and an analysis of data was performed using IBM SPSS version 21.0 (IBM). Descriptive statistics was done, and P ≤ 0.05 was considered statistically significant. The study was conducted in community and hospital pharmacies in Ogun State, Nigeria, among 100 PTs. Outcome measures were the involvement of PTs in clinical roles and other pharmaceutical care practices.

RESULTS

A total of 73 (73.0%) participated in the study, 45 (61.6%) and 28 (38.4%) practiced in hospital and community pharmacies, respectively. From the 11 listed nonclinical activities, only stocking of medications 61 (83.6%) and processing clients' or patient's charges 48 (65.8%) were often or very often performed. More than half of the participants often performed each of all 7 listed patient-centered activities, particularly empathy and confidentiality 62 (84.9%), providing information and referrals to patients or clients 56 (76.7%), and identifying patients or clients for counseling 51 (69.9%), respectively. No statistically significant difference was observed between the practice areas (P > 0.05). Only 2 of the 11 listed specialized clinical activities were performed by more than half of the respondents: screening prescriptions for completeness and authenticity 43 (58.9%) and alerting the pharmacist of drug therapy problems 46 (63.0%). Differences in the practice of specialized tasks was statistically significant for consultations (P = 0.002) and resolution of clinical conflict (P = 0.040) between the practice areas.

CONCLUSION

Study participants were less frequently involved in nonclinical activities but often involved in clinical activities. They also participated in specialized clinical tasks at lesser frequencies. Differences were observed between the practice areas in performance of nonclinical and specialized activities. Strategies to fill in the observed gaps should be explored for improved practice.

Implementation of distributed automated medication dispensing units in a new hospital: Nursing and pharmacy experience

AIMS AND OBJECTIVES

To explore the structures, processes and outcomes involved in an Automated Medication Dispensing system implementation and its impact on patient safety.

BACKGROUND

Increasing digitalisation of medication prescribing, dispensing, administration and stock management has occurred over the past two decades. While automated medication dispensing units aim to provide safe, high-quality, patient-centred care, the implementation may result in unintended consequences leading to suboptimal outcomes.

DESIGN

This study uses a qualitative approach guided by Donabedian's structure, process and outcome framework.

METHODS

Twenty-six registered nurses and pharmacy assistant staff, from clinical areas equipped with automated medication dispensing cabinets, participated in semi-structured interviews. In-depth, thematic analysis explored the structures and processes. Together with interview data, content analysis of text data generated by internal risk management and critical incident reporting systems was undertaken to evaluate outcomes. Findings were considered in light of the Interactive Sociotechnical Analysis approach to health information technology. The COREQ checklist was used in preparation of this article.

RESULTS

Pharmacy assistants reported better satisfaction with the system at implementation than nurses. Training provided for nurses and their involvement in system implementation was reported as insufficient; however, nurses' use of and satisfaction with the system improved over time. A recursive relationship between the changes imposed by the system and nurses' creative problem solving (workarounds) used to manage these changes, impacted work productivity for nurses and safety for patients.

CONCLUSIONS

The individualised nature of "workarounds" employed offered both risks and opportunities which require further identification, investigation and management.

RELEVANCE TO CLINICAL PRACTICE

Nurses are the majority of the health workforce. Digitalisation of traditionally paper-based activities in health care, impacting nursing work, requires similar strategies to any practice change.

Identification and safe storage of look-alike, sound-alike medicines in automated dispensing cabinets

OBJECTIVES

Automated dispensing cabinets (ADCs) are used in hospitals to improve medication safety and decrease costs. However, ADCs do not completely eliminate the risk of mistakes between look-alike, sound-alike (LASA) medicines. The aim of this study was to identify the characteristics of LASA medicines and determine the factors related to their safe storage in ADCs.

METHODS

The medication selection of one hospital pharmacy's ADC located in an intensive care unit was observed. The study consisted of five parts: a determination of criteria to identify LASA medications, an analysis of an ADCs' inventory reports, assessment of the storage of identified LASA medicines, a visual observation of the medicine packages stored in the same storage compartment and qualitative analysis of the medication-use process from prescribing a medicine to removing it from an ADC.

RESULTS

Approximately 70% (n=355/488) of the ADCs selection had a LASA risk with at least one product. Moreover, 20% (n=84/355) of the LASA medicines identified were high-alert medications. Approximately 16% (n=58/355) of the identified LASA medicines were stored unsafely close to at least one other LASA medicine. Less than 4% (n=13/355) of the LASA medicines were unsafely stored high-alert medications.

CONCLUSIONS

ADCs reduce the risks of LASA medication errors when used correctly, but automation can also increase them, for example, when placing multiple LASA medicines in the same storage compartment. Attention should be paid to the identification and safe storage of LASA medicines to promote safe use of ADCs in hospitals.