Applying ISMP best practices and leveraging data to drive a safe

Applying ISMP best practices and
leveraging data to drive a safe and
efficient med-use process
Marian M. Rhoads, R.Ph., M.S.
Director of Pharmacy
Saint Joseph Medical Center
Reading, PA
Objectives
Illustrate the Automated Dispensing Cabinet
adaptations to meet the ISMP guidelines for safe
use.
 Show how the Med Analytics data can be
utilized to increase staff productivity, improve
inventory control and minimize outdates and
waste.
 Provide diversion prevention tactics for
pharmacy and nursing.
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Saint Joseph Medical Center is
a 211-bed facility located in
Reading, PA
Major service lines
Cardiology
Oncology
Orthopedics
Neurosciences
Pharmacy Department
24/7 Coverage
Director
Operations Manager
Clinical Coordinator
Medication Safety Pharmacist
PGY-1 Resident
10 FTE Staff pharmacists
9.8 FTE technicians
Problem

How do you optimize workflow in the
pharmacy, maximize real estate in the automated
dispensing cabinet and integrate with the
pharmacy information system while meeting the
requirements of the various regulatory bodies in
an effort to provide safe patient care?
ISMP Guidelines
The ISMP gathered in the Spring of 2007 a
multidisciplinary group of nurses, pharmacists,
and vendor representatives which led to the
development of 12 core processes for the safe
use of automated dispensing machines.
 These 12 core processes can be found on their
website: http://ismp.org/

Ideal Conditions for the Use of Automated
Dispensing Cabinets (ADCs)
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Medication rooms are only for medication
related activities.
Changed Drawer Configurations from Carousel
drawers to Pyxis CUBIE® drawers.
There is adequate space for MARs, adequate
lighting and cabinets are secure when not in
use.
Medication rooms are accessed through a
badge reader.
Ideal Conditions for the Use of Automated
Dispensing Cabinets (ADCs)
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Eliminate interruptions from patients and
visitors.
Phone is on wall near ADC.
Refrigerator is in close proximity of ADC.
Stations are mirrored on the floor if one of the
stations would go down.
Respiratory Drawers for Nebulizers
Medication Room

Bins are used for
large volume IV
solutions and IV
meds that do not
require refrigeration.
ADC Location in Medication Room

ADCs are located in a
quiet environment with
access to a phone if a
discrepancy occurs
between the screen
and paper MAR.
Drug Removal Process

Space exists on
the AUX for the
nurse to have
the MAR
available during
removal.
ADC System Security
Password access sheets with assigned areas and
the completed tutorial for the Pyxis®
MedStation ® must be completed prior to
receiving access.
 Agency are assigned an ID but must be activated
each time they arrive for work.
 Students are activated by their instructors and
do not have access to controlled substances.
 The only physicians that have access are the
anesthesiologists and only to the Pyxis®
Anesthesia system.

ADC System Security
Automated terminations come to the Director
of Pharmacy daily from Human Resources.
 Quarterly reports to nurse managers.
 Access is limited to certain providers.
 When a person is terminated, a standard
template is used.

Use Pharmacy-Profiled ADCs
Profiled machines are located on all our nursing
floors as the drug distribution system and in our
Infusion Center, Outpatient Interventional Unit,
Radiology Department for controlled substances,
Birth Center and now working on our Emergency
Department.
 High alert medications are not on override.
 Clinical data categories are placed on certain items.

Use Pharmacy-Profiled ADCs
 The
location of the medication has
specified pockets or is grayed out if it is
refrigerated or located in the patient
specific bins in the medication room.
 There is access to Lexi-comp on each
machine so the nurse can review
administration information.
ADC Screen Information
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The two patient identifiers, patient name and
date of birth, appear on the screen in addition
to location and allergies.
Medication is identified the same way on the
Pyxis® MedStation® system screen, the MAR
and in the pharmacy system.
The dose in the pharmacy system defaults
onto the Pyxis® MedStation® system screen.
ADC Screen Information
Tall Man lettering is used as well as visual
queues are used for look-alike/sound-alike
medication pairs.
 Special preparation instructions are listed on the
full screen including any sliding scale
parameters.
 Removal by time is advocated to avoid
administration of medications at the wrong time.

Tall man lettering for insulin
Sliding scales for Insulin Orders
Look-Alike/Sound Alike
Medications
Visual queues are
used with stop signs
in both the closed
and open position.
 Tall Man lettering
appears on the Pyxis®
MedStation® screens
and the MARs to
distinguish these
medications.

Labeling of Bins in Towers
Tall Man lettering
used on bins in
Towers.
 Look-alike/soundalike drugs are not
stored behind the
same doors in a tower
but are separated.

CT Scan
Contrast Agents are
stored in a tower in
Radiology.
 Same agent in various
sizes behind single
door. Agents are not
mixed on the shelves.
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Select and Maintain Proper ADC Inventory
As part of the formulary review process,
the P&T Committee decides if a medication
will be stored in the Pyxis® cabinet or not.
 Subsequent modifications to both inventory
decisions and override reviews are reviewed by
both the Medication Safety Committee and the
P&T Committee.

Select and Maintain Proper ADC Inventory
 Chemotherapy
drugs are excluded from
the ADC.
 Drugs that are considered hazardous
pharmaceutical waste (RCRA waste) and
need to be disposed of in a different waste
stream are handled through visual cues.
Identification of RCRA Waste

Pyxis CUBIE® pocket will have a static cling
which states to dispose of contents in black
bucket waste.
Reporting to Increase Productivity
Med Analytics is used to determine medications
with low usage that can be eliminated from
storage or items that should not be stocked in
certain machines.
 The pharmacy secretary ran reports every
Thursday to document on an Excel spreadsheet
who had done their inventory and calculate the
% compliance per month. Now we distribute
the report from the Med Analytics reporting.
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Controlled Substance Inventory
Example of Use of Med Analytics
Data
On a med-surg nursing unit we found that
fenofibrate 160 mg had been loaded and
unloaded 6 times in a month in both machines
on the unit. That dose was made standard in
those machine.
 This list is reviewed each month and any
loads/unloads that exceed three per month
those items are marked as standard stock.
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Improvements in Loads/Unloads
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Reporting has shown the improvement in
loads/unloads. Units P1N1 and P1N2 have
decreased from 33 each to 24 and 25
respectively.
Meditech Customer Defined Screen to Identify
Infrequently Used Medications
Select and Maintain Proper ADC
Inventory
Limit 5 or 10 tablets in pockets that contain high
alert medications.
 Perform monthly pharmacy audits of the
machine as part of nursing unit reviews.
 Turn on outdate tracking to manage expired
drugs.

Select Appropriate ADC Configuration
There are at least three extra drawers of Pyxis
CUBIE® pockets per machine to limit access to
medications.
 Matrix drawers are used for IV solutions that are
used for diluents and items such as antacids or
guaifenesin.
 Drugs prone to diversion are in lidded Pyxis
CUBIE® pockets with blind counts.
 Paralyzing agents are in kits or boxes in the
appropriate unit.
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Matrix Drawers
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Matrix drawers
are used for bulk
items or diluents
to mix drugs
with limited
stability.
Paralyzing Agents in Emergency
Department
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Rapid Sequence
Intubation Boxes and
Anesthesia Deep
Sedation Boxes are
located in the ED
Pyxis® MedStation®
system
Select Appropriate ADC Configuration
The top drawer of each Pyxis® MedStation®
system is a matrix drawer where bulk
medications, patient’s own meds or nonformulary drugs are stored.
 Only PCA keys or refrigerator keys are kept in
the Pyxis® MedStation® to track who has
removed them last.
 The keys are a return to pocket item whereas the
meds are a return to the return bin.
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Bulk Medication And Patient’s Own
Medication Storage
The top drawer of each
machine is labeled with the
room numbers of the unit.
 Meds are accessed
through the override
function picking “Bulk
Med” as the med choice
on override.
 Allows the pharmacy to
track access to bulk meds.
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Pharmacy Process For Safe ADC
Restocking
Visual queues are used for Tall Man lettering
and hazardous waste.
 Critical lows are printed to avoid stock outs.
 Pharmacy packages and loads all ½ tablets. All
half-tabs are built as such in our pharmacy
information system also.
 Bar code scanning is utilized to refill controlled
substances and high alert medications such as
heparin vials and insulin.
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Pharmacy Process For Safe ADC
Restocking
All drug names are the same for the pick areas,
pick lists, and refill screens.
 Inventory requests for additions to the ADCs go
to the Medication Safety Committee and P&T
for approval.
 Check process includes bagging the medications
after checking.
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Pharmacy Process For Safe ADC
Restocking
Monthly nursing unit reviews and medication
error reporting are used to detect fill errors that
may occur.
 An asterisk is placed next to the generic name of
the drug if it is to be loaded in a Pyxis CUBIE®
pocket so these drugs do not get placed in a
matrix drawer.
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Identifying ISMP High Alert Meds
ISMP High Alert Category
adrenergic agonists, IV
adrenergic antagonists, IV
anesthetic agents, general,
inhaled and IV
SJMC Formulary Items
epHEDrine
epINephrine
Phenylephrine
Propanolol
Metoprolol
Labetolol
Propofol
Ketamine
Etomidate
Reference: ISMP List of High Alert Medications. http://ismp.org/Tools/highalertmedications.pdf
An asterisk is
placed after the
generic name on
the console that
prints on all load
bulletins and alerts
the pharmacist and
technician that the
medication needs to
be pended and
loaded in a Pyxis
CUBIE® pocket.
Reporting to keep Pyxis® in Sync with
Pharmacy Information System
Diversion Prevention in the Pharmacy
The locks were changed out from the standard
locks.
 Numbered pull tabs are located on the top of
the electronic panel to insure integrity and alert
us to entry through the control panel.
 Pharmacists do not have inventory capability.
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Pharmacy Diversion
Large external return bin behind the return door
for outdates and recalls and patient’s own meds
not returned on discharge.
 The slips for returns are stapled to the bags and
dropped in the outdate external bin for
reconciliation with the reverse distributor.
 Return bin emptying requires a witness.
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Nursing Diversion Prevention
Techniques
Require weekly counts of all controlled
substances.
 Distribute the Diversion Watch List and
Cancelled Transaction Report to the Nurse
Managers to observe staff ’s behaviors, charting
and pain control of patients.
 Minimize the controlled substances on override.
 Require waste upon removal with witness
actually watching the waste process.
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Printer for Bar coded Labels
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Pyxis® CIISafe
prints bar coded
labels which are
used for the
controlled
deliveries rather
than delivery
slips.
Controlled Substance Refills
Utilizing the Bar Coding Feature
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Bar coded labels are generated and the drugs are
pulled from the Pyxis® CIISafe and placed in the
zip-lock bags for refill one at a time.
Bar code scanning at station
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Bar code scanning is done at the station for
refilling of controlled substances. The technician
is not refilling from a screen selection.
Conclusions
Continue to implement safe guidelines for ADC
use in our institution by reviewing ISMP
quarterly action agendas, internal medication
errors, and data supplied through the Med
Analytics reports.
 Continue to refine policies and procedures as
diversion is detected both from a pharmacy and
nursing standpoint.
 Make adaptations to conform to new medication
management standards of TJC or National
Patient Safety goals as they emerge.
 Continue to monitor override lists as they relate
to any medication errors.

Next Steps
Convert all the ER machines from non-profile
to profile machines with pharmacist review of all
orders.
 Begin looking at making the Post Anesthesia
Care Unit a profile machine.
 Continue to utilize the Med Analytics data to
improve productivity, decrease the amount of
medications that outdate and remove items not
being utilized that are not antidotes or code
medications.
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