Automated Medication Preparation for Chemotherapy [PP&P December 2013]

The December 2013 issue Pharmacy Purchasing & Products features a Q&A session with Anne McDonnell, PharmD, BCOP; Caryn Belisle, RPh; and Josephine Leung, PharmD, MBA from Brigham and Women’s Hospital, Department of Pharmacy

I had the opportunity to visit Brigham and Women’s Hospital earlier this year while doing some research for a project I’m working on. It’s a very interesting facility that makes use of a lot of pharmacy automation and technology. Based on what you read below you’d think that everything was perfect. What I saw was interesting, but far from perfection.

Worth noting in the Q&A session is that the products being used are never defined, i.e. what technology is being used. There’s mention of a robot, but which robot? They speak of gravimetic analysis, but don’t say what system they’re referring to. I know because I’ve been there, but other people might like to know as well don’t you think?

Here are some of the questions and responses I found particularly interesting in the PP&P article.

PP&P: What were the primary safety concerns with a non-automated process for chemotherapy production?

McDonnell: Non-automated processes for chemotherapy production are rife with potential error points. Transcription errors in particular often lead to medication errors and misadventures. Fortunately, our current system provides prescribers with templates, which include default doses, frequencies, infusion rates, and administration times for chemotherapy preparation. By entering a patient’s height and weight, the template will populate the necessary dosage fields, thereby providing both pharmacists and nurses with clear, complete, and accurate chemotherapy order information. Although it is not an error-proof system, it is certainly safer than non-automated processes.

The response really never answers the question. The question was focused on “safety concerns with a non-automated process for chemotherapy production”. The answer appears to be focused on order entry. No? I’d like to hear more about the actual chemotherapy production process, and where automation has created fewer opportunities for error.

PP&P: How do your automated systems affect batch production and extended BUD?

Leung: At BWH, we produce all of our doses daily on a per-patient basis. We do not outsource any chemotherapy production at our institution and we do not use any extended use dating for our chemotherapy products either. However, we do perform batch production of high-use, non-chemotherapy items using robotic technology; roughly 60% of our batch production is robotic and our technicians produce the remaining 40%. We follow USP <797> guidelines for all BUDs and we only apply extended BUD to products for which samples have been sent in for sterility testing per USP <71>. We also have a quarantine program for all products that have an extended BUD….

Emphasis is mine. This is an interesting little tid bit of information. Only 60% of batch production is performed via robotics. I would really like to know what has prevented the facility from using their robotics to batch more items.

PP&P: How does interconnectivity improve your processes?

Dose Tracking
Josephine Leung and Caryn Belisle: Our dose tracking, CPOE, pharmacy order approval system (POAS), and eMAR are all interconnected and communicate with each other. Patient-specific doses are documented in the eMAR as given or not given, and that information is linked to the order in the POAS, which can be queried. In our POAS, we are able to view information on whether a dose was prepared and sent to the patient. If we receive a call about a missing medication, we can see the time it was made across all shifts, who made it, and whether it should have been delivered to the floor. Our nurses also are able to view medication workflow through their computers. This ability to track medications from multiple points reduces calls regarding missing doses and streamlines the delivery process.

Dose tracking is important, and something that most facilities do poorly. I expect this to change in 2014 as interest in this area seems to be growing. On that note, I believe interconnectivity of systems can be the difference between a good system and a great system. When systems talk to each other everyone benefits.

Workflow Management
Leung and Belisle: Everything made in the SPR comes through the POAS and is listed on a computerized dashboard for verification. When a new order is received, a bar-coded order label is printed and the medication (along with its expiration date and lot number) and diluent are scanned into the dashboard. Once scanned, a preparation label prints out with information on how to prepare that specific bag. The order will be placed into the SPR intake window with the medication, diluent and preparation label. After the dose is made, the pharmacist will retrieve it from the SPR outtake window.

In addition, our robotic and IV workflow software allows us to track the times it was started, completed, and verified. The verifying pharmacist can see the exact quantity of medication in each preparation and determines the pass/fail status by comparing it to a theoretical weight based upon each drug’s specific gravity. The pharmacist scans a system-generated bar code and all the information about the preparation is displayed on a screen including who made it, the expected dose, the actual dose, and any percentage of error. These numbers are supported by photos of all medications used.

Workflow management in the IV room is good stuff, and a focal point of many acute care pharmacies. Their system obviously uses bar code scanning and gravimetics (“…theoretical weight based upon each drug’s specific gravity…”), but unfortunately neither PP&P or the Brigham and Women’s staff mention what IV workflow systems are in use.  Just in case you were dying to know, Brigham and Women’s was using i.v.SOFT workflow management system and an i.v.STATION robot in their IV room when I was there.

PP&P: How has the introduction of automated IV workflow impacted safety and efficiency in your SPR?

Belisle: Our pharmacy system allows us to see all pending, patient-specific medications that are due within four hours of administration time. This enables us to prepare, verify, and send medications up to the nurses for just-in-time dosing. Although waste is not completely eliminated, our waste has decreased 20% since we switched to an every-four-hour batch schedule. The enhanced safety is attributed to bar code scanning verification on all medications and diluents as well as verification via gravimetric control.

Asked, but not answered. The impact on patient safety? Has your facility experienced fewer medication errors? I’d really like to know.