The natural extension of the use of robots to dispense medicines in a pharmacy is the use of electronic ward cabinets to automate the supply of medicines at ward level. These cabinets provide secure individual storage for medicines used on a ward, and are able to control and record access to medicines by ward staff [ 22 ] .
Parameter Evaluation recommendation Other comments Dispensing incidents Data on dispensing incidents should be collected, as error rate will be low Distribution incidents Distribution incidents should be monitored on two separate 1 week periods pre- and post-implementation Dispensary turn-around times Turn-around time data should be collected for inpatient, outpatient and discharge prescription items It is dif fi cult to get accurate timings for all inpatient dispensed items Out of hours dispensing Use of the robot remote dispensing function by on-call pharmacists should be analysed The out of hours cost analysis should take into account cost of travel to hospital and time off in lieu (TOIL) Stock control Staff resources (cost and time) spent on stock-taking activities should be analysed pre- and post-implementation Dispensing rate Dispensing rate data should be collected on three consecutive days pre-implementation and on two intervals of three consecutive days post-implementation Distribution workload Data on time spent on different distribution-related activities should be collected for a 1 week period pre-implementation and a 1 week period post-implementation
Workload survey results should be compared with issue statistics Support staff attitudes The attitudes of pharmacy support staff should be surveyed by questionnaire and/or other methods The design of the survey and methodologies used should be customised to the needs of the department Ward staff attitudes The attitudes of ward staff should be surveyed by questionnaire 6 months pre-implementation and 6 months post-implementation Outpatient satisfaction Outpatient satisfaction should be surveyed by anonymous question- naire for two periods of 2 weeks, pre-and post-implementation
Table 4.2 Guidelines for quanti fi cation of pharmacy robot bene fi ts
108 4 Pharmacy Automation
There is considerable experience of the use of these cabinets, which have sometimes been referred to as “magic cupboards”, in US hospitals, but their use is very much in its infancy in the UK. However, their use has the potential to resolve a number of the problems associated with pharmacy stock control at ward level.
Traditionally, the process of pharmacy stock control in a hospital ward or depart- ment has involved a regular top-up by a pharmacy technician or assistant. Each ward would have an agreed stock list, with an agreed stock level of each item. On a regular basis (daily or twice weekly), the pharmacy technician would visit the ward, review stock usage and arrange for the stock on the ward to be topped up. The stock would be sent to the ward in a ward box, and it would be the responsibility of the nursing staff to unpack and put away the stock.
There are, however, many fl aws in this system. Different nurses might put medicines away in different places, so the actual stock level for the ward might not be apparent to either the nurse administering medicines, or the pharmacy technician arranging supply. Medicines may not always be stored in the most appropriate places. Nurses may not be able to fi nd the item they are looking for, and call the pharmacy department – sometimes out of hours – to rectify the situ- ation. Orders are made for the “missing” items and the ward then has duplicate stock. In addition to this, if cupboards are untidy, there may be errors in the selection of the medicine (especially if there are similarities in name and pack design). These factors lead to an increased risk of patients receiving an incorrect medicine or missing a dose of a medicine altogether, accumulation of unneces- sary stock on a ward and a lack of information about what stock is on a ward, therefore making it hard to conduct medicine use audits and to identify medi- cine theft.
Electronic ward cabinets have the potential to address a number of these issues.
1. They have individual drawers for each medicine and access to the device is via PIN, swipe card, fi ngerprint ID or a combination. They therefore facilitate secure storage of medicines.
2. Many cabinets have a signi fi cant capacity and can hold typically 150–200 prod- uct lines.
3. They facilitate correct product selection by clearly identi fi able compartments, with visual identi fi cation of the medicine on the front of the drawer and possi- bly barcode veri fi cation of the medicine placed in the drawer. Draws may be modular and can be built to different designs to fi t different products. Stock locations, therefore, are clearly de fi ned.
4. They will draw patient demographic and allergy information from the hospital patient administration system (PAS) , and can therefore provide decision sup- port for allergies at the time of medicine use. Cabinets may also be used to enable barcode medicines administration (BCMA) , using a barcode scanner at the point of issue.
5. Cabinets enable accurate stock control in a ward location. The cabinets are topped up by pharmacy assistant staff, in a similar way to a traditional ward top-up, but they provide accurate control of stock due to the individualized issue of items and the de fi ned locations. They therefore have the potential to
prevent stock-outs and inappropriate ordering by ward staff. They will also enable pharmacy staff to do a full, periodic stock check, and this is advisable at an interval depending on the stock turnover on the ward.
6. Cabinets have functionality to monitor expiry dates , if barcode product infor- mation is scanned at the point of cabinet stock-up. This is a useful feature to prevent product waste.
7. Cabinets can provide audit trails and reports on the booking out of items (what and by whom), which can be useful in dealing with incidents and resolving disputes.
8. Cabinets can provide medicine use support , providing additional instructions and warnings concerning the medicine at the point of issue.
9. Many units are able to store controlled drugs and other drugs of abuse.
10. These units can also be used to enable and control dispensing of TTO/discharge pre-labeled packs of commonly used medications such as analgesia, laxatives and antibiotics, depending on the specialty of the ward. This is a common prac- tice on surgical and day case wards in the UK.
Electronic ward cabinets may be con fi gured in a number of different ways to sup- port medicines management on a ward:
1. They can be used to issue the stock for a ward to a traditional drug trolley from which medicines would then be administered to patients.
2. They might be used to administer medicines directly to a patient.
3. They could be used to support patient self-administration , where the cabinet would be con fi gured to have a PIN or access code for each individual patient.
The mode of use of the cabinet would depend on the type of ward and the types of patients on the ward. Surgical wards require a smaller number of commonly used medicines, and a cabinet is often straightforward to stock and run on this type of ward, while providing a signi fi cant bene fi t in error reduction in product selection.
On the other hand, medical wards will have a wider variety of stock medicines, and this may be more challenging for the stocking and maintenance of the cabinet.
Cabinets have obvious bene fi ts in emergency departments , in terms of preventing product selection errors in urgent situations, but staff may have concerns about speed of access to medicines.