Before I came to Tennessee in 2000, I was against Medication Automation. All during my career, I developed a Systems Design expertise that I still love to do. Also, before the much publicized Medication Error rates in US Hospitals (by the Institute of Medicine), this topic (Medication Safety) was important, but not important enough for many hospitals to spend on software and devices that would address these issues. I learned quickly to rely on automation for efficiencies and elimination of rote dispensing activities. This is not a pure and finite process.
However, over the last decade plus, I have become more and more concerned about “Rote” dispensing activities. In days when Pharmacies Compounded the majority of dispensing, there was less chance of errors ( I feel) due to the fact that when compounding, the Pharmacist used methods to check and double check calculations, ingredients, etc. That most pharmacies did not rapidly dispense the same preparation over and over again. Don’t get me wrong, errors did occur and some were very, very devastating. “Too err is human”…… But all Pharmacists, then and now, are concerned about errors and how to prevent them. Our worst nightmare is when an error does happen and it is due to “my” dispensing.
There was a saying in the 90’s that, to the effect, when computers make errors, the results are huge…..take for example the address labels for a magazine publisher. Suppose there is a “hiccup” in the labeling program, and the town on the labels become the same on all the labels printed, even though the names are quite different. This error will be found, but by the time it has, there may be thousands of labels attached to magazines that are incorrect. The net result is a delay in distribution and so on……
Back to Pharmacy, we are not heavily dependent on computerization. This will only be developed more, especially with “artificial intelligence” emerging and being refined. As manufactured medications became more available, and now more than 98% of our dispensing is manufactured, very little compounding is down in the local Pharmacy. There are still some non-manufactured drug preparations which some hospital P&T Committees (Pharmacy and Therapeutics) feel MUST be compounded and available for patient use. This is becoming less and less as true therapeutics are discussed, not necessarily a unique combination of drugs in one preparation, that is really needed. But this means that “dispensing” is speeding up and becoming more repetitive (rote activities). Even though there are other influences on medication errors, that cannot be dismissed or ignored, I will focus on “rote” dispensing.
We need to look at the areas of “Repetitive” action dispensing (rote dispensing). As dispensing volumes have increased so has the number of rote dispensings.
Some Medication errors
When a human being is providing the same cycle of activities, if their is no critical thought process needed, in theory, we should not have errors. But even “assembly line manufacturing” are susceptible to errors. So how can we expect “rote” dispensings to NOT have errors. This applies to Pharmacists and Pharmacy Technicians.
Pharmacy Technicians used to be thought of as a “gofer” for the Pharmacist. This is not true today. Our Pharmacy Technicians are becoming automation specialists. That is, they know the software, expected results and ways to monitor machines to detect and correct dispensing errors. They have become specialists in supporting Medication dispensing machines, Sterile IV compounding, Inventory control and many other activities that were the Pharmacist’s territory in the past. But our roles are evolving too.
The Pharmacist role is becoming the “interpreter”, Assessor and contributor to the Medical Teams therapy of a patient. I predict that this will change also. I was talking to a Physician friend this morning who said that in his Group’s practice with a Hospital System, he was originally forced to use a voice recognition system for Medical Records. But when saying “to”, was this “to”, or “2”, or “too”, or “two”…….the nuance of the machine interpretation could have a dire outcome for patient care. So his practice is back to dictating Medical Records who have Medical Secretaries interpret the notes. Hence, less errors are being found. This all to say, that artificial intelligent is here to stay, and will need a lot of refinement to meet complex medical needs.
In Pharmacy, the need for order interpretation is being addressed…….though it will no doubt need many a refinement, it is here to stay. We’re finding that using Medication Machines to give Nurses drugs for patient needs are more efficient and less fraught with errors. But 10 years ago, the thought of a hospitals spending this money on Medication systems, was unheard of……..
Unit Dose (U/D) dispensing was a huge improvement on previous dispensing. But it developed it’s own set of problems and eventually errors. The Pharmacy Technician would be charged with setting up the individual patient medication drawers. But this meant that in some cases they were adding ONE “pill” to TWENTY different drawers, in some cases all on the same patient care unit. Then along came the Medication Machines, which changed the Pharmacy Technician role from U/D dispensing to TWENTY “pills” in ONE medication slot of the Medication machine. And since the Machine had software to identify patient needs and prevent inadvertent use of the medications (in theory) , dramatically reduced medication errors coming out of the Hospital Pharmacy.
Present Dilemma
All these innovations are NOT going to be implemented at the same time. It’s humanly impossible. The differences in computer systems, the logic in one system that doesn’t exist in another, even though over time, t his will be a learned process and innovation for Medication Programs, we will be “dealing” with rote dispensing activities for a while.
As I mentioned earlier, there were hospitals that couldn’t afford, or didn’t have the emphasis on Medication Safety as we do today. So the spread of automation will continue, at varying rates. Our practice will need to continue to design manual systems that will help us prevent errors. This is a discipline that will be hard to do, but also, we need to look ahead to see what automation systems will be good for us, in each of our practices, and more importantly for patient care. This will be a very, very daunting development over the next several years. Standards of practice are being developed to account for the wide areas of practice settings for Pharmacies. Some of us must help to implement/transitions to new automation, some to help change automation functions and accountabilities, and some will need to continue with manual systems to constantly change so as to reduce medication errors.
I remember coming to work in one hospital I directed, and found the staff “sitting” around. On inquiry, I found that our computer systems had crashed and no orders were coming into the Pharmacy. As I looked around at the “young” faces, I realized that none of these Pharmacists had worked in Pharmacies with manual systems. I pulled up a Word processing program on an indivicual PC and started to format a label. Next we sent Technicians to the floors, hourly to pickup physician orders, then keep the Orders, with “manual dispensings” organized per patient. Today, as a standard of practice there is a requirement to have an individual hospital “down time” process. So that when the computers crash (and they do), we’re still treating patients, not the machines……..
So as we continue in the “great transition”………all members of the Pharmacy teams will have to address and keep addressing various scenarios of medication dispensing to reduce errors to the maximum. Once Rote Medication Activities “go away”…..there will be other and much more important safety plans to create and implement.
pharmacistrjs 