Laying the foundation for your technology implementation team

I’ve been thinking a lot lately about the right way to go about putting new technology into a pharmacy. Making the decision to add technology doesn’t mean running out and purchasing a million-dollar piece of equipment and shoving it in a corner. It’s much more complicated than that. You must first lay the foundation for the work to be done.

Here are some things that I think should be considered before putting new technology in the pharmacy:

Give everyone fair warning of what you plan to do. No one likes to be surprised and people fear change. The best policy is to give people plenty of warning before making a change, which will allow them to get used to the idea. This will go a long way in gaining support for the project. Being aware of what’s coming is always preferable to being surprised by what has already been done.

Gauge user beliefs and feeling. It’s best to take the temperature of pharmacy personnel prior to getting started. Is it going to be an uphill battle? Are the pharmacists and technicians open to the idea of implementing new technology? Is the pharmacy morale where it should be? Does your department fear change?

The success of the implementation depends heavily on how well the department is warned and prepared for the change. People often see technology as a threat to control over their work environment, resulting in pushback. Helping staff understand what it is you hope to accomplish, how it will help them, and offering opportunities for staff to become vested in the project can go a long way in ensuring a successful implementation.

Get support/buy-in for the project. Support for any project is a must. Recruit from the top of the organization to the bottom. Failure to do so may result in a failure to launch.  Whenever possible it is best to have support from the highest level of the organization, executive sponsor or someone from the board if you have one.  Influence matters. And don’t forget to involve all departments that will be impacted by the change, including nurses and physicians when appropriate.

Create a buzz. Create some excitement. Don’t act like the project is required, but rather a choice that’s going to make things better.  This is the power of advertising. We fall for it all the time, from cars to smartphones.

User involvement and participation. When individuals believe that the implementation of technology is relevant, they are much more likely to have a positive attitude toward the project. The best way to get individuals to believe in the technology is to get them involved and allow them to participate in all phases of the project. “Increasing user participation … enhances post-development user involvement and attitude”.(1)

Involve as many people as possible as often as possible. When people are involved, it gives them a sense of ownership, making them vested in the project’s success. It also helps deal with negative vibes that may come from others.

Volunteers only. It is important that all participants be volunteers as mandated participation has been shown to be ineffective and potentially detrimental to the success of this type of project. (2)

Champions. Champions are the people that go above and beyond the general participant. Champions believe in the technology and the benefits it will provide. They can often have a contagious zeal about the project, and are sometimes referred to as “evangelists”, or in extreme cases “zealots”. Whatever you call them, you need them. When it comes to implementing new technology in the pharmacy, champions can be your best source of support and are often useful in putting a spotlight on the project in a positive way while swaying negative feelings about the project. 

Finding Champions shouldn’t be too difficult. There are usually early adopters in every group. They will often present themselves while taking the initiative to learn more about the project without being asked.

Develop rules for participation. This is really quite simple. It is important that the rules for participation be laid out well in advance, and that each member of the team signs off on them. There should be no surprises for what’s expected from participants once the project is underway. The following rules are examples:

  • Be willing and able to engage in the project
  • Be willing to be positive about the project
  • Be willing to work with others to advance the project
  • Be willing to commit to attending meetings
  • Be willing to commit to handling extra work, even if it means staying late or doing some reading at home in the evenings or on the weekends. I understand that no one wants to put in a bunch of unpaid overtime on these projects. However, on occasion, a little extra work needs may need to be done to keep things moving forward. One should enter into participation with the understanding that this could happen.
  • Be willing be engage in every aspect of the project, not only the items that are assigned. It is vitally important that each participant has at least a basic understanding of the overall scope of the project and what each member of the team is assigned to do. Things happen. People get sick, quit their jobs, move to another state, and so on. Such unforeseen events should not completely derail the project timeline or goals. 

Sway the naysayers. Every project has its opposition. As the saying goes, you can’t please everyone all the time. Unfortunately, naysayers tend to be the most vocal personalities in any group. They’re not afraid to say what’s on their mind; whether positive or negative. The downside is that outwardly negative comments about a project have a way of spreading like wildfire. They’re caustic and often seep into the minds of even the staunchest supporter without warning. And once planted, negative thoughts grow like a cancer.

Naysayers and their negative comments have their place. They often point out things that others fail to see, helping avoid pitfalls along the way. The trick is to use the information to your advantage and allow naysayers to offer their thoughts in an environment that won’t bring down the rest of the pharmacy. Give them space to vent, and then do your best to use the information to flip them. If you can show the naysayers in the group that you’re willing to listen to them and take their concerns seriously, you may be able to get them on your side. That’s a huge victory for any project. On the other hand, never force change on a naysayer. Forcing change or mandating them to join your side rarely works. It’s like dealing with a donkey, the harder you pull, the harder they resist.

Build a team with high potential for success. According to Harvard Business Review’s (HBR’s) 10 must Reads On Emotional Intelligence (3), the source of great success lies with teams that can achieve high levels of participation, cooperation, and collaboration among members.

Team members must be chosen carefully and meet three basic conditions:

  1. Mutual trust of one another
  2. Have a sense of group identity – a feeling that they belong and the project is worthwhile
  3. Have a sense of group efficiency – belief that the team can perform well and that the group is better than the individual members.

Collectively, HBR refers to this as the groups “emotional intelligence” (EI). And while the knowledge and experience among group members is important, EI may be more important still. Keep this in mind when you begin building the project team.

Chose a project leader. Being “the leader” is a burden that many well-qualified individuals shy away from. With that said, someone has to be in charge. Someone has to be given authority over the group. Someone has to be willing to make the tough decisions and hold people accountable.

Not everyone is cut out to be a leader. I am of the opinion that leaders are born, not made. You either have it or you don’t. I know because I’ve tried many times to lead and failed. It wasn’t for lack of knowledge or desire, but rather a lack of natural leadership and charisma. On the flipside, I’ve been around many people that just have “it”; “it” being a knack for getting people to follow them and do what they say, i.e. they’re natural born leaders.

What distinguishes good leaders from great leaders is “a group of five skills that enable the best leaders to maximize their own and their followers’ performance.” (3)

The five skills are:

  • Empathy
  • Motivation
  • Self-regulation – controlling negative impulses
  • Self-awareness – knowing strengths and weaknesses
  • Social skill – being able to build a rapport with others to get desired results

Find a project manager. As ridiculous as this may sound, the project manager is an often overlooked position when discussing project teams. Let me go on record now as saying that a good project manager is absolutely vital to the success of any project; arguably the most vital consideration to the success of a project.

It is the job of the project manager to manage all aspects of the project, including the scope, the timeline, the cost, the quality, and the people. They apply their knowledge, skills, tools, and techniques to help projects be successful.

“The role of the project manager is that of an enabler. Her job is to help the team get the work completed, to “run interference” for them, to get scarce resources that they need, and to buffer them from outside forces that would disrupt the work.”(4)

Things to consider when selecting a project manager:

  1. The person must have leadership qualities, have good self-management and time management skills, and be a taskmaster.
  2. The project manager cannot serve two masters. Individuals that serve as a project manager must not be required to do any of the actual work in the project. According to Lewis (4), “as team sizes increase, it becomes impossible to work and manage both[the work and the team], because you are constantly being pulled away from the work by the needs of your team members”. Having project managers attempt to manage the project in addition to working on the project is a recipe for disaster.
  3. The person must have a proven track record. We all know people that can’t manage the paper piles in their office much less a multi-faceted project requiring meticulous attention to detail.

I encourage everyone involved in a large project to read a book or two on project management. Being a project manager is not as easy as it sounds and should be given the respect it deserves.

That’s it. Piece of cake. Go forth and build your implementation team.

  • Vaughan PJ. Internal Report of Information Technology Services. University of Colorado at Boulder. 2000.
  • Hunton, J.E. and Beeler, J.D., Effects of User Participation in Systems Development: A Longitudinal Field Experiment. MIS Quarterly, 21(4), 1997, pp. 359-388.
  • Hbrʼs 10 Must Reads On Emotional Intelligence. 1st ed. Boston (Massachusetts): Harvard Business Review Press, 2015. Print.
  • Lewis, James P. Fundamentals Of Project Management. New York: American Management Association, 2007. Print

Thoughts on my time with DoseEdge Pharmacy Workflow Manager 

Yesterday, I had a great opportunity to spend the day using DoseEdge in its native environment. That is to say, I staffed at a facility that was using DoseEdge in its cleanroom to prepare CSPs, including patient-specific products as well as stock bags, TPNs, etc. I’ve used DoseEdge for brief periods in the past. I’ve also spent time with the engineers that have worked on the product, product managers, sales people, marketing folks, and various other Baxter employees at conferences like ASHP midyear. But, this is only the second time that I have worked an entire  “staff pharmacist” shift using the product. And as one might imagine, using a system in its native environment can often provide a new perspective.

DoseEdge System at Boston Children’s Hospital

I’ve written about DoseEdge, and systems like it, extensively on this site over the years.  A quick search of jerryfahrni.com revealed several articles mentioning DoseEdge, dating back to 2010. I’ve also written about DoseEdge and similar products extensively elsewhere.

With over 300 installs in the U.S., DoseEdge is one of the most popular IV workflow management systems on the market and is still the most widely implemented product of its kind in the U.S. It’s a very good system, certainly in my top five. There are several things that I really like about the system, such as how it controls labels, its ability to track partial vials, and the fact that it talks. Seriously, it speaks to the user. Pretty cool.

However, there’s always room for improvement. For example, after using the system, I found that I don’t really care for the user interface (UI). I found it to be rather unintuitive and a bit clumsy. The UI is stuck somewhere between a legacy system and a modern web-based system. It’s not good. Too many clicks, things in weird places, naming conventions that simply don’t make sense in my mind, just to name a few. With that said, it’s still quite usable, and honestly, it’s likely as good as any other UI on any other product that I’ve used in the pharmacy.

The other thing that hit me yesterday was just how terrible the process of using images is to verify the accuracy of compounded products. I don’t care for it. As good as the images are – and they’re quite good in DoseEdge – there are still shadows in strange places that make reading syringe volumes difficult at times. This is especially true for small volumes. There were times yesterday when I simply made educated guesses to the exact volume and assumed that the volume was accurate, as I couldn’t quite see the exact location of the plunger. Don’t get me wrong, this is still way better than the syringe-pullback method, but image-assisted verification isn’t optimal. I would have liked to have had the gravimetric option available to me yesterday. DoseEgde offers gravimetrics, although it isn’t widely used.

So, good system, but not perfect. Better than the manual process, but room for improvement. Imaging better than pullback, but not great.

Does charge-on-chart hurt or help medication chain of custody?

Historically, hospital pharmacies have used a charge-on-dispense (COD) model for medications. The model charges the patient for a medication when it is dispensed from the pharmacy and credits the medication if it’s returned to the pharmacy unused. Simple, but labor-intensive. The model itself has been around for a long time.

The introduction of electronic health records (EHRs) and electronic medication administration records (eMARs) has pushed the COD model aside in favor of the charge-on-chart (COC) model; sometimes referred to as “charge on administration” (COA). In the COC model, the patient isn’t charged for a medication when it is dispensed from the pharmacy because the charge is captured when the medication is scanned by the nurse and administered to the patient. When the nurse scans the medication, the information is captured by the eMAR and charted, hence the name. There are several benefits to this model, including no need for the pharmacy to credit medications that go unused. Unused medications are simply returned to the pharmacy and folded back into the inventory.

Put simply, the COC model eliminates the need for pharmacies to charge and credit medications as they are dispensed and returned to the pharmacy. But here’s a little untoward side effect of the COC model, it eliminates much of the pharmacy audit trail for medication movement into and out of the pharmacy.

The old COD model wasn’t perfect, and there were plenty of discrepancies, but I wonder if the COC model has created even less transparency regarding inventory reconciliation and the movement of medications throughout the hospital.

Inventory management systems like AutoPharm from Talyst and Pyxis Pharmogistics from Carefusion should, in theory, give pharmacies real-time inventory numbers. But the promise of these systems has fallen short. Both utilize barcode scanning to track inventory, which unfortunately requires humans to be diligent when scanning items in and out of inventory. Human laziness usually prevails, and numbers are frequently inaccurate.

Medication tracking systems are available from a couple of companies, but also utilize barcode scanning, thus fall prey to the same weakness mentioned above. These systems also fall short when following medications throughout the medication distribution process as they typically stop as soon as the medication is delivered to the nursing unit, i.e. they don’t track the return of the medication.

Track and trace regulation, which will require serialized barcodes and tracking from manufacturer to patient, could potentially help with this issue. However, that process has the same weaknesses as those mentioned above, namely human intervention.

RFID technology would surely be better than barcode scanning, except that RFID tags are too costly for use on all medications and drug manufacturers are nowhere near ready to do anything like this.

Currently, the only medications that receive enough scrutiny in a pharmacy to determine location and quantity at any given moment are controlled substances, i.e. morphine, fentanyl, oxycodone, and so on. And this falls short on some level once the medication leaves direct oversight of the pharmacy.*

It’s interesting to think that as much time as we spend managing inventory in a hospital pharmacy, we still have a long way to go.

———–

*This includes leaving the pharmacy itself as well as storage devices like automated dispensing cabinets (ADC). When a medication leaves the ADC we assume it has been administered to the patient once it has been charted. We cannot confirm this, however. For all we know, the healthcare provider that removed the medication and documented the administration, simply put it in their pocket and walked out with it. You never know for certain.

Use of digital pills to measure opioid ingestion [article]

Here’s an interesting article from the January 13 issue of the Journal of Medical Internet Research (JMIR): Digital Pills To Measure Opioid Ingestion Patterns In Emergency Department Patients With Acute Fracture Pain: A Pilot Study (1)

A group of researchers out of Boston utilized digital pills (eTectRx, Newbury, FL, USA) to observe the ingestion patterns of oxycodone for patients discharged from the hospital following an acute extremity fracture.

Eighteen patients met inclusion criteria for the study, but only ten consented and were enrolled. Of the ten, eight had usable data. Not exactly a large number, but you gotta’ start somewhere.

Study drug was dispensed in capsule form. The digital pill was compounded with oxycodone tablets using a standard capsule-filling machine by the hospital’s investigational drug services pharmacy. Compounded digital pills were dispensed in blister packages.

When ingested, the gastric chloride ion gradient in the stomach activates the digital pill, transmitting a unique radiofrequency signal that is captured by a hip-worn receiver. The ingestion data is then transmitted to a cloud-based server where it can be viewed and analyzed. Because each digital pill emits a unique frequency, the system can record multiple simultaneous ingestion events, which is very cool.

It turns out that the digital pill did a pretty good job of recording the patient’s ingestion of their pain meds. It wasn’t perfect, and they had some technological issues along the way, but overall it results look promising. Imagine being able to see how your patients are taking their medication in real-time. You could even use the data coming from the digital pill to determine if a patient had ingested too many capsules at once.

The use of digital pills definitely has potential.

From the abstract:

Results: We recruited 10 study participants and recorded 96 ingestion events (87.3%, 96/110 accuracy). Study participants reported being able to operate all aspects of the digital pill system after their training. Two participants stopped using the digital pill, reporting they were in too much pain to focus on the novel technology. The digital pill system detected multiple simultaneous ingestion events by the digital pill system. Participants ingested a mean 8 (SD 5) digital pills during the study period and four participants continued on opioids at the end of the study period. After interacting with the digital pill system in the real world, participants found the system highly acceptable (80%, 8/10) and reported a willingness to continue to use a digital pill to improve medication adherence monitoring (90%, 9/10).

Conclusions: The digital pill is a feasible method to measure real-time opioid ingestion patterns in individuals with acute pain and to develop real-time interventions if opioid abuse is detected. Deploying digital pills is possible through the ED with a short instructional course. Patients who used the digital pill accepted the technology.


  1. Chai, Peter R et al. “Digital Pills To Measure Opioid Ingestion Patterns In Emergency Department Patients With Acute Fracture Pain: A Pilot Study”. Journal of Medical Internet Research1 (2017): e19.

Someone please disrupt controlled substance storage technologies

Management of controlled substances(1) inside acute care pharmacies is a mess. It’s difficult for me to stress how utterly disappointed I am by this area of pharmacy technology.

  • The technology has been around for a long time. The controlled substance area of the pharmacy was one of the first areas to start using technology as part of routine medication distribution.
  • More pharmacies use technology to manage controlled substances than any other area of the pharmacy. It’s probably considered “best practice” to use technology in this area of the pharmacy.
  • There’s a fair amount of technology being used to deal with controlled substances: inventory management software, barcode scanning, biometrics, analytics and reports, remote access refrigeration and “vaults”.
  • It’s the worst technology in the pharmacy, hands down.

I haven’t been in a pharmacy in years that wasn’t using technology to manage these drugs. This is likely due to the amount of fear and regulation swirling around controlled substances. These drugs have the highest level of control and are more regulated than any other drug class; at least until USP <800> goes live. The paranoia around these medications is crazy. The man hours dedicated to their management is obscene.

Based on my observations, the technology is outdated, difficult to use, and has failed to improve the process in any appreciable way. It remains unclear to me what advantage these systems offer. I don’t think it would be difficult for someone to argue in favor of ditching the technology in lieu of replacing it with two people locked inside a room using pen and paper. Crud, it might even be more efficient.

Consider that in a majority of instances the inventory management system used to manage controlled substances is separate from the system used for other inventory, and almost never tied directly to the EHR. Yes, it means you have to maintain a separate database for one area within the pharmacy.

Also consider that at least one of the major players in this area cannot handle partial doses, i.e. half-tablets or increments of mL’s. That’s right, software designed to keep detailed records for controlled medications chokes on something as simple as 7.5 mL.

This is an area of the pharmacy that needs an enema. Someone out there must have a better way. If you have any ideas, please give them up.

And for the companies playing in this space, you really need to do a better job. Go sit in a pharmacy for a day or two and observe how utterly terrible these systems are to use.

——————-

  1. The term ”controlled substance” means a drug or other substance, or immediate precursor, included in schedule I, II, III, IV, or V of part B of the Controlled Substances Act http://www.fda.gov/regulatoryinformation/legislation/ucm148726.htm . This includes medications like morphine, fentanyl, hydromorphone, etc.

Cool Technology for pharmacy – Linked Visibility Inventory System (LVIS)

The Intelliguard® Linked Visibility Inventory System™, or LVIS for short, is an RFID-enabled anesthesia cart designed for use by anesthesiology providers in the OR. I spoke about this briefly in my last podcast.

LVIS is a free-standing cart with three drawers – one large and two small. The cart looks quite different from any of the current anesthesia carts on the market. Take a look at the image below taken at the ANESTHESIOLOGY 2016 conference for a better understanding of what I’m talking about.

Intelliguard LVIS Cart

 

LVIS utilizes RFID technology to track medications in real-time. Items placed inside the cart are labeled with RFID tags – attached by the pharmacy or pre-tagged from some third parties like PharMEDium – and placed in a drawer. Once the cart is unlocked via one or a combination of locks – RIFD reader, biometric scanner, keypad for PIN (see image below) – the user has access to any medication in any of the drawers. Each time a drawer is closed, the system scans the contents and captures data on every medication, including item, quantity, user identification and time stamp. That’s it. If you take something out, the system knows. If you place something back in the drawer, the systems knows. The user is not required to debit or credit any item or scan the drug on removal or return. That’s a win for anesthesia providers and for the pharmacy. The provider gets access to medications without interring with their workflow, and the pharmacy gets real-time inventory numbers and complete transparency for what’s being used.

LVIS Access

I like how the system was designed. There are several little things that show how much thought went into the product. For example, offering three different methods to log into the cart, or giving users the ability to configure access to each drawer individually, or offering an “in process” area to track items that have been removed but not documented as used (little green area on top of the machine), and so on. I also like how the system was designed with minimal impact on workflow in mind. Because LVIS uses RFID technology, most of what’s happening is transparent to the user, i.e. their workflow remains intact.

Not all is perfect, however. I’m not completely sold on the physical design of the system. I would like to speak to others that have seen the unit to get their feedback. The other questions I have are around integration with existing systems, especially EHRs and AIMS. That’s the elephant in the room with every small company trying to play with the big boys. Only time will tell, but I am encouraged by LVIS. I like the technology and I’m impressed with the thought that went into the product’s design.

I’m looking forward to learning more at ASHP Midyear in Las Vegas.

Couple other random images below:

 

MEPS LVIS Keypad

20161023_141315

JerryFahrni.com Podcast | Episode 14: Update from ASA 2016

Show Notes:
Host: Jerry Fahnri, Pharm.D.

Just a quick update from Jerry’s visit to Chicago for ANESTHESIOLOGY 2016, October 22-25, 2016.

Items discussed in podcast:
Intelliguard Linked Visibility Inventory System (LVIS)
BD Intelliport (I’ve written about this before here)
Codonics
ePosters

Current setup:
Blue Microphones Yeti USB Microphone – Blackout Edition
Dragonpad Pop Filter
Sony MDR-V150 Headphones

JerryFahrni.com Podcast | Episode 13: HCP Chicago

 

Show Notes:
Host: Jerry Fahnri, Pharm.D.

This is actually Episode 13. My apologies, but the volume is very low for some reason.

A brief discussion of Jerry’s presentation at Health Connect Partners (HCP) in Chicago on October 18, 2016, followed by a brief overview of some of the products he saw while at the conference.

Items discussed in podcast:
Swisslog
BD Cato
DoseEdge
MEPS Real-Time Inc Intelliguard LVIS

Current setup:
Blue Microphones Yeti USB Microphone – Blackout Edition
Dragonpad Pop Filter
Sony MDR-V150 Headphones

Sensor-enabled medication inhalers

I recall being really excited about sensor-enabled asthma inhalers several years ago. I even remember giving a presentation in 2013 on “the future of pharmacy” that included two such products: Asthmapolis and GeckoCap. Each was an add-on device for existing inhalers. They were marketed as tools for improving medication adherence, and by default helpful in controlling patient’s asthma symptoms. Each had a very different approach but were both pretty cool in their own way.

Asthmapolis is still around, as far as I can tell, but at some point, the product was rebranded as the Propeller Sensor by Propeller Health. The only reason I know this is because earlier this year the Propeller Sensor received FDA 540(k) clearance. I always thought the approach used by Asthmapolis was interesting because the product utilized crowed-sourced data to generate “Asthma risk maps” to help keep patients with asthma informed about potential hot zones in and around their area. It appears as though not much has changed. While the Propeller Health website doesn’t offer many details, a quick search of the web generated several articles that lead me to believe the mission remains the same. I’m still impressed with the Propeller Sensor and would love to see it in action sometime. It seems like it would be well suited for use by ambulatory care pharmacists.

Propeller

The other product, a little doohickey known as GeckoCap was a glowing “smart cap” that used a blinking light and gamification to remind patients when to use their inhalers. Data collected by the device was transmitted to a database via Bluetooth connection where family members and physicians could access it. I thought the use of gamification was rather clever, especially for kids. Parents could set goals with accompanying rewards to encourage kids to remain compliant. In this day and age, that made sense to me.

Similar to Asthmapolis, it appears that at some point GeckoCap became CareTRx [pronounced care-tracks]. However, it doesn’t appear that the product is actively being developed at this time. The last few reviews on the Google Play Store included complaints about server issues, and those were from December 2015. Based on information at the CareTRx website, the company was acquired by Teva in September of 2015. I’m not sure what that means. I don’t know if the product is dead or alive.

 

CareTRx

I wonder why these products never took off? Seems like these little devices would fit right into the up and coming Internet-Of-Things era.

The scope of IV room errors

There’s an interesting article in Pharmacy Practice News this month (In the IV Room, Robots Come to the Rescue). While the title of the article is a bit misleading – I think ‘rescue’ is a bit strong – it does contain quite a bit of good information.

The article discusses some of the technology being used at Brigham and Women’s Hospital (BWH) in Boston, and the University of California, San Francisco (UCSF) Mission Bay pharmacy. I’ve been in both pharmacies. BWH and UCSF both make extensive use of technology, but believe me when I say that they have very different approaches. Anyway, the article is worth a few minutes of your time.

Deep in the article, the author, Rajiv Leventhal spends a few paragraphs discussing the scope of the problem in the IV room, and some of the challenges of using robotics. Rajiv acknowledges that the iv room is a dangerous place for a host of reasons.

Regardless of the technology chosen, the need to automate IV compounding to at least some degree is hard to dispute, given the relatively high rate of errors that occur when technology is limited. In 1997, when many of the recent advances in robotics were not available, the error rate for IV compounding was 9%—or one mistake in every 11 medications coming out of the IV room.

As for the main cases [sic] of those errors, many factors have been identified, including sterility and other drug safety issues, according to a safety alert released last year by the Institute for Safe Medication Practices. The alert identified five core causes: 1) depreciating importance of the compounding and dispensing processes in pharmacy practice; 2) lack of knowledge and standardization around best practices; 3) training based on traditions handed down from one pharmacist to the next; 4) learned workplace tolerance of risk and routine practice deviations that persist; and 5) a reluctance to learn from the mistakes of others.

It seems intuitively obvious that the use of technologies like iv workflow management software, barcode scanning, gravimetrics, imaging, and even robotics can potentially decrease errors described in the article referenced above (Am J Health Syst Pharm1997;54[8]:904-912 ). However, of the causes identified in the second paragraph, only #2 can really be addressed with the use of technology alone. The rest of the items listed are symptoms of a deep-seeded problem growing in pharmacies today, and that is the failure to understand the need for our profession to provide patients with medications in the most efficient, safe, and economical way possible. Sounds ridiculous, I know, but it’s true nonetheless.

Most (all?) pharmacies I visit these days tout initiatives to improve patient care through increased ‘clinical activities’ of pharmacists, including electronic chart review, ADE follow-up, rounding with the medical team, monitoring and adjusting medications, antibiotic stewardship, and so on. However, I rarely, if ever hear directors talk about efforts to improve operations through streamlined processes, automation and technology, standardization, and heaven forbid, increased use of technicians and non-pharmacist personnel.

Examples of this can be found within open job listings at various healthcare systems. Recently I visited an acute care pharmacy with a large budget for several open ‘clinical pharmacist’s positions’ but no budget for improving operations or automating processes. In this particular case, a fraction of the money being allocated for open clinical pharmacist positions could be used to make significant improvements to the medication distribution process.

It’s an interesting dilemma for pharmacy directors. While spending tens of thousands of dollars on automation and technology to improve operations may not seem sexy, it goes without saying that a vast majority of care for a hospitalized patient involves getting the right drug at the right time. A majority of that falls to nursing staff, but the pharmacy owns a piece of the medication distribution/administration process. Nurses can’t administer medications if they’re not readily available, or wrong.

Regardless of what direction the profession wants to go, it is important that we understand that pharmacy is, at this time, tied to distribution. We must find ways to extricate ourselves from the medication distribution process first before we can begin to truly realize the benefits of pharmacists in patient care. Each time an error occurs for lack of focus, training, or sheer disinterest, the profession suffers. Preventable medication errors involving the pharmacy causes both the public and other healthcare practitioners to lose trust in our ability to get the job done. It’s difficult to recover from lack of trust. Think about it.