Coalition’s white paper offers blueprint for pharmacy automation
State of the industry, future goals detailed in white paper
If you ever wondered where automation was headed, how it might fit into your workplace, or if vendors would adopt standards that would make it practical for your facility to invest the megabucks necessary to install such systems, rest easy. Some definitive answers are here. The White Paper on Automation in Pharmacy has been released, the first of its kind, both in terms of scope, comprehensiveness, and support across the pharmacy field (see box, below). While it doesn’t offer solutions for every problem, it does stand as a benchmark from which pharmacists across the continuum will be measuring progress for some time to come.
Commissioned by a broad coalition of pharmacy groups, the paper details information on available and new technologies, medication errors, and system approaches and their necessary and desirable components. It also calls for national automation standards already drafted by pharmacy organizations.
"The main challenge for users is the complexity of automated systems resulting from computerized controls," the paper’s preamble states. "This complexity makes it exceedingly difficult to diagnose, much less anticipate and understand, the various types of system failures." Because of the complexity, someone must take responsibility for each major process of the system, and the best person to do that is the pharmacist, the white paper states.
Indeed, the paper’s authors say pharmacists stand to gain the most as the use of automation increases. "Pharmacists feel that automation has, and can, really free them up. That is one of the major benefits," says the white paper’s lead author, Ken Barker, PhD, head of the department of pharmacy care systems at Auburn (AL) University’s school of pharmacy. He also notes in the paper that even "turnover and on-the-job stress may be reduced when pharmacists are freed from count and pour’ dispensing for more rewarding, patient-centered tasks."
One prime example, he says, comes from the Veteran’s Affairs system, where con solidated mail outpatient pharmacies across the country are filling some 8,000 to 10,000 prescriptions a day.
With freedom comes a price
But first things first. While automation may free pharmacists from many tedious duties, he says, that freedom comes with a price of responsibility: "The crucial new skills for the pharmacist will encompass: (1) how to operate automated pharmacy systems in order to produce the outcomes desired, (2) how to recognize when a system failure occurs or is imminent, (3) how to compensate to protect patient safety when failures occur, and (4) how to get failures corrected expeditiously."
The paper also details what types of systems have been available and what’s newly available, before delving into matters of medication error and national automation standards. "[The white paper] is intended to be educational for practitioners and the environment for which they practice. It’s to inform the pharmacist and nurses and physicians," he says.
The paper focuses on two main types of pharmacy automation: those that repackage medications from bulk, and robotic systems utilizing overwrap of unit-dose medication. The paper deals with elements such as bar coding and bedside administration, calibrated drug-specific canisters, and video imaging of drugs inside the bottles, among other recent technologies. One section includes "a new comprehensive and electronically sophisticated pharmacy system that not only counts, packages, and labels patient-specific medications in unit-of-use envelopes at the time of medication administration, but also sorts the envelopes by patient in the order in which the medications are to be administered. It can be used centrally in the pharmacy or in decentralized patient care areas." Barker says he’s seen these types of systems unveiled at conferences like the recent 1998 American Society of Hospital Pharmacists midyear clinic in Las Vegas.
The human side of errors
In the paper’s section on medication errors, Barker and his colleagues repeatedly make reference to the cautions against automation complacency, as well as analytical approaches to system errors. "A compartmentalized approach to the evaluation of a complex human-machine system ignores the possibility of secondary effects, such as when the presence of automation makes the humans complacent in the performance of their own tasks," it states. The errors section details an array of automation-error studies and observational studies comparing automated and human drug handling. In one observational study, the authors note that nurses typically would administer drugs from automated devices without checking them, while they would check drugs manually taken from patient drawers.
The paper makes good use of history, detailing early automation and re-engineering efforts dating to the 1960s, including envelope systems that cut errors from 13% to 1.9% in one instance. "Interest in such envelope systems has been rekindled today because they can be bar-coded inexpensively," the paper notes. Other studies follow automation’s evolution through the 1970s, 1980s, and early 1990s.
One major stumbling block detailed in the paper is the lack of national automation standards. Along with decrying the overall "variety and unpredictability" of state standards and definitions that do exist, the authors state there is even a need for a specific standard definition of dispensing to simply allow the use of automated systems.
"Language concerning automation that is enab ling rather than restrictive, and that focuses on outcomes rather than process, is needed," the paper states. To that end, the Automation in Phar macy Initiative and the National Association of Boards of Pharmacy have drafted a model of what national standards should look like while urging national pharmacy associations to get involved.
The final draft is included in the white paper in full and outline form, along with comments and background material. It begins by detailing the "duties and responsibilities" of the pharmacist-in-charge, covering quality assurance programs, documentation, policies, and records security and access, along with drug packaging, filling, stocking and dispensing, among other sections.
The guidelines also stress that all policies and procedures should be in place before a system is installed, and in general they leave some flexibility for individual state considerations.
"The model was done to prompt the [state] boards to do something, and a number of them have used it as a departure point to develop their own versions, which in my opinion have been valuable on balance. I would urge your readers to check with their own state board to see if anything is in place or being done," Barker says.
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