160310 automated pharmacy distribution system new rah

Issued: March 2016

Consultation

Paper

Automated Pharmacy Distribution System in the new RAH

SA Pharmacy

Central Adelaide Local Health Network

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TABLE OF CONTENTS

TABLE OF CONTENTS 2

1. INTRODUCTION 3

2. PURPOSE 3

3. CURRENT MODEL AT THE RAH 4

4. RATIONALE FOR CHANGE 4

5. FUTURE MODEL 5

5.1 Scope of the future model at the new RAH – Day One 5

5.2 The Automated Pharmacy Distribution System (APDS) 6

5.3 Physical design 8

5.4 Pharmacy Workforce considerations 11

5.5 Benefits of the future model 11

5.6 Implementation of the future model 12

5.7 Related change processes post Day One 15

5.8 Implications for not undertaking the change 16

6. FEEDBACK 17

7. ATTACHMENTS 17

8. GLOSSARY 17

Consultation Paper Automated Pharmacy Distribution System

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1. Introduction

The Central Adelaide Local Health Network (Central Adelaide LHN) is one of five Local Health Networks (LHNs) in South Australia. The population of the Central Adelaide LHN is estimated to represent 27 percent of the total State’s population. According to the recent Department of Planning and Local Government projections, the population is likely to increase to approximately 471,000 by 2016, to 488,000 in 2021 and 503,000 in 2026. The Central Adelaide LHN brings together four hospitals: Royal Adelaide Hospital (RAH), The Queen Elizabeth Hospital (TQEH), Hampstead Rehabilitation Centre and St Margaret’s Rehabilitation Hospital, and a significant number of Mental Health (including Glenside Campus) and Primary Health Care Services. Central Adelaide LHN also governs a number of state-wide services including SA Dental, BreastScreen SA, DonateLife SA and Prison Health Care Services. The Central Adelaide LHN is committed to delivering the highest quality health care possible and taking active steps to continuously review and improve its services. Since the release of South Australia’s Health Care Plan 2007-2016 (SA Health Care Plan), it has been widely acknowledged by the Central Adelaide LHN that we would need to change some key aspects of our day-to-day business and service delivery to ensure that we can continue to provide services to our community into the future. Increasing pressures that Central Adelaide LHN is faced with as part of the public health system include:

- an ageing population with growing health care needs - rises in chronic disease - pressure to ensure we have enough clinicians and support staff to deliver

services effectively - delivering sustainable services with a limited health budget resource.

The Central Adelaide LHN is committed to achieving the vision set out in the SA Health Care Plan and in particular ensuring that we provide the best services possible to patients and that we find innovative ways of achieving this. Given the pressures we are facing and the need to make sure we can continue to provide services to the community, we have no choice but to change. To this end, and consistent with the vision articulated in the SA Health Care Plan, Central Adelaide LHN has embarked on a journey to change its approach to health care and the way it delivers health care services into the future. SA Pharmacy was formed as a state wide clinical support service in July 2012 and provides a single governance body across pharmacy services in South Australian public hospitals. SA Pharmacy aims to provide a comprehensive, efficient, professional and cost-effective approach to meeting the requirements of all staff and consumers of its constituent pharmacy services.

2. Purpose

The purpose of this paper is to describe the Automated Pharmacy Distribution System (APDS) as available on Day One of operation for the new RAH, and implications for the affected workforce. The APDS will be situated in pharmacy,


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clean utilities (clinical storage areas on the clinical wings) and technical suites (including operating theatres, interventional rooms and procedural rooms) in the new Royal Adelaide Hospital (new RAH). This paper starts the consultation process about the implementation of the APDS.

3. Current Model at the RAH

Pharmacy imprest in wards

The pharmacy imprest stocks approximately 40 percent of medications. Nurses can access non-patient specific medication from the pharmacy imprest, normally situated in a drug room. This imprest is replenished on a weekly basis by pharmacy staff.

Dispensing The remaining 60 percent of medication not found in the pharmacy imprest, is dispensed by pharmacy against a specific patient. Nurses request this medication by faxing a request to pharmacy, from where it is manually picked, validated and brought to the ward by pharmacy staff. This medication is handed to the nurse and stored in the patient’s bedside cabinet. Once the patient leaves, the nurse empties the cabinet and leaves it in ‘return bags’ in the drug rooms for pharmacy staff to sort. Any non-labelled or unusable medication (e.g, dose and strength not visible on strip) is discarded.

Current delays in first dose

Currently, when looking for a medication, the nurse needs to check pharmacy imprest on the ward, or the patient bedside cabinet. If the required medication is not there, they need to fax the order to pharmacy, and then check at intervals if the medication has arrived. There can be a delay to the patient receiving their first dose as this process is manual and has many steps.

Drugs of dependence

Controlled drugs (drugs of dependence and restricted RS4s) must be stored in a drug safe, with a nominated member of staff holding the keys. Before a nurse can collect a restricted medication, they must first locate the key holder.

Three counts of controlled drugs a day is required to reconcile the numbers. Advice from nursing is that this takes about half an hour a day (over a 24 hour period).

4. Rationale for Change A key component of the agreed model of care to support the new RAH is to ensure access to appropriate clinical support, including pharmacy, across the patient journey. The new RAH Functional Brief incorporates the model of care and design objectives. The Functional Brief emphasises the requirement for safe care incorporating the reduction of medication errors through the use of technology and automation. The new RAH Model of Care emphasises right care, right time,


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right place by the right person/team. The APDS has been designed to reflect these principles, as well as the eight rights of medication management:

- Right patient - Right medication - Right dose - Right time - Right route - Right documentation - Right reason - Right response

Current in-pharmacy processes are labour intensive, with multiple manual checkpoints to ensure safe delivery. Nursing management of ward inventory, drugs of dependence and restricted medications is time consuming and has many regulated checks and balances. In-Pharmacy Robotic equipment is increasingly used in hospital and community pharmacy settings to achieve:

- Accurate dispensing - Fast dispensing - Efficient stock control

Automated Dispensing Cabinets provide a safe and efficient means of delivering and tracking medication used, to the individual patient.

5. Future Model

5.1 Scope of the future model at the new RAH – Day One The model of medication distribution is moving from an imprest system stocking 40 percent of first dose medications within business hours to a distributed model providing 24/7 access to 90 percent of first dose medications through secure storage of medications within clinical areas.

At the new RAH, pharmacy services are located in the following key areas:

Inpatient Pharmacy - Dispensary with in-pharmacy robotics. Also houses production pharmacy and clinical trials.

- Located on Level 1.

Outpatient Pharmacy - Dispensary for outpatient and discharge medications, with in-pharmacy robotics.

- Located on Level 3.

Clinical areas - Automated dispensing cabinets (ADCs)

- Secure storage for patient medications in each hospital wing. Includes associated auxiliary storage.

- Located in clean utilities throughout the new RAH.

Technical Suites - Anaesthetic Automated Dispensing Cabinets

- Secure storage for anaesthetic and surgical drugs in theatres.

- Located in technical suites on Level 4.


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(AADCs)

Clinical areas - Clinical Pharmacy

- Clinical pharmacists and pharmacy assistants supporting inpatient and outpatient services.

- Clinical pharmacists will be assigned to inpatient wings for on the ground support.

5.2 The Automated Pharmacy Distribution System (APDS)

The APDS describes a suite of automation equipment that ensures the safety and quality of medication distribution. The APDS includes:

- Automated stock management using in-pharmacy robotics - Unit dose systems - Automated Dispensing Cabinets (ADCs) located in clean utilities on each

floor. Automated stock management In-pharmacy robotics will increase the speed of dispensing medication, and improve stock control and auditability. The complete in-pharmacy robotics will automate:

- Individual patient dispensing - Imprest order picking - Storage and stock management including inventory loading.

The in-pharmacy robotics will also interface with the pharmacy inventory management system. Figure 1: In-pharmacy robotics

In-pharmacy robotics can automatically load up to 5,000 packs of medication a day. Stock can also be loaded manually. Transporting stock to inpatient floors Stock will be moved from the pharmacy to the inpatient floors via multiple means, including:

- Automated Guided Vehicles (AGVs) - Pneumatic Tube System - Pharmacy and Spotless staff.


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Pharmacy staff will load the ADCs in the clean utilities with the medications. Nursing staff may be required to help with the loading of controlled drugs.

Automated Dispensing Cabinets (ADCs) ADCs will be situated in clean utilities across the hospital. ADCs provide nurses with instant information and access to stocked medication 24 hours a day, 7 days a week. Over 90 percent of patients’ first dose of medications will be available in the ADC. The ADCs will interface with the pharmacy inventory management system, meaning orders are automated and delivered by pharmacy staff to cater for the individual wing’s stock requirements. Par levels can be tailored for each ADC. ADCs will be stocked with the following items:

Common-use medications

For the usual range of drugs, ADCs will stock non-patient specific pack doses.

Patient-specific medications

For selected, patient-specific medications, ADCs will stock individual unit doses.

Controlled substances

The ADCs will also store drugs of dependence and restricted schedule 4 medications.

Bulky items Bulky items can be stored in large drawers in the ADCs or in auxiliary column linked to ADC.

Refrigerated medications

Refrigerated medications will be stored in secure fridges linked to the ADCs.


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Figure 2: Selection of pharmacy storage options wit hin the Clean Utility

Medication can be removed by an appropriate registered health practitioner after submitting a user ID and password or biometric identification. There are regulatory constraints which will dictate the mix of workforce that are permitted to supply and load controlled drugs (drugs of dependence and restricted schedule 4s) into the ADCs. Pharmacy and nursing staff will work together to meet regulatory requirements. ADCs will be configured for different users (e.g. pharmacy and nursing staff) to restrict the type of access and changes that can be made on the ADC (e.g. restrict access to controlled drugs where required, or provide temporary access to agency staff).

5.3 Physical design

Automated Dispensing Cabinets The ADCs will be situated in clean utilities across the hospital. Each clean utility will service a wing – a group of 16 inpatient beds. The number of auxiliary cabinets in each wing will depend on the medication requirements of the unit. The ADC will be restocked as required to maintain par levels. Par is the minimum level of stock to be held in the ADC. Par levels are currently being determined in discussions between pharmacy and nursing services.

Automated dispensing cabinet Auxiliary cabinet Fridge Lock


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There are a variety of drawers in the ADCs, varying from secure storage for controlled drugs to larger, open matrix drawers containing a broad range of medications. These drawers will be configured so that no sound-alike, look-alike medications will be stored adjacent to each other. Figure 4: Sample drawers in the ADC


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Anaesthetic Automated Dispensing Cabinet (AADCs) Technical suites will be located on level 4 at the new RAH, and include operating theatres, interventional rooms and procedural rooms. There will be ADCs in the clean utilities on level 4, and an AADC in each technical suite. The AADC is a modified ADC, tailored to the needs of anaesthetists within the operating room. The AADC will store the drugs required in the technical suites, and the medications can be tailored to meet the need of each technical suite and/or the anaesthetist. The AADC will be used by anaesthetists and anaesthetic nurses. The AADC can be configured by the anaesthetist to contain medications specific to a patient or specific to a procedure.

Figure 5: Anaesthetic Automated Dispensing Cabinet

In-pharmacy robotics The physical space for the in-pharmacy robotics is within the dispensary area of the inpatient and outpatient pharmacies. The in-pharmacy robot on level 1 is the main store and comprises a tandem robot over 10 metres long. This robot will handle medications required for inpatients. Attached to the robot are an automatic loader, which can load multiple packs concurrently, and a ‘box picker’ which will fill tote boxes containing inpatient imprest orders. These imprest orders will then go via AGV to each inpatient wing, where they will be loaded into the ADCs.

Figure 6: Floor plan of level 1 in-pharmacy robot


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The in-pharmacy robot in level 3 is smaller and contains a small fridge. This robot will handle outpatient and discharge medications.

5.4 Pharmacy Workforce considerations The model of medication distribution is moving from a centralised imprest system stocking 40 percent of first dose medications within business hours to a distributed model providing 24/7 access to 90 percent of first dose medications through secure storage of medications within ADCs in clinical areas. Pharmacy will support this model through the provision of pharmacy assistants in clinical areas to receive delivered medications from the AGVs, and load the ADCs. Pharmacy assistants will receive the necessary training and support to enable them to undertake these roles.

5.5 Benefits of the future model Benefits for patients As over 90 percent of first doses will be stored in the ADCs, there will be reduced time from medication order to provision of first dose for inpatients. The time taken to dispense prescriptions will also be shorter, which will reduce the length of time outpatients and patients being discharged will be required to wait for their medication. This latter benefit supports the model of care around timely patient discharge. Benefits for nursing staff Immediate access to 90 percent first dose of medications will allow nurses to spend more time with their patients. The automated checks and balances of the APDS mean that pharmacy will have better line of sight of medication usage for each inpatient wing. This will enable pharmacy to restock what is needed more often. As a result, stock outs will be minimal. One of the key elements leading to time savings relates to the management of controlled drugs. There will be one system for the supply of medications, including drugs of dependence and restricted schedule 4 medications. All medications will be stored in the ADCs, meaning there is a significant reduction in access time. There will be no drug keys to find – all appropriate nursing staff will have access to the controlled medications they require for their patients. As is currently the case, the removal of a controlled drug will require two nurses. The ADC can securely store and account for controlled medications, and therefore there will be a reduction in the number of drugs of dependence reconciliations required. Drugs of dependence discrepancy resolution will be a more straightforward and transparent process. As the ADC records which nurse removes the drug, there is increased visibility and protection for nursing staff regarding medication transactions. Benefits in Technical Suites The AADC streamlines the anaesthetists’ access to medications and ensures medications are readily available. They help eliminate time-consuming manual reporting of dispensed medications. The AADCs are highly configurable, and anaesthetists can use it to maximise


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their workflows and practices. Benefits for Pharmacy For pharmacy staff, the APDS will mean that a cohort of pharmacy assistants will be based on the inpatient and outpatient floors, supporting the distribution of medication to the wings. There will be a cohort of pharmacy assistants based within the two pharmacies working with the in-pharmacy robotics and supporting medication distribution outside of the robotics. The in-pharmacy robotics will mean the dispensing of medication will not be as manual as the current process. A large proportion of stock will be stored in the in-pharmacy robotics. Stock management of items in the in-pharmacy robotics will be easier, with the ‘count’ within the robot being ‘source of truth’. The physical space within pharmacy will be larger, and the automation will help provide an innovative and exciting workspace.

5.6 Implementation of the future model The APDS will start at the new RAH on Day One, as soon as the hospital opens. On Day One, the following components will be in place:

- ADCs, Auxiliary Cabinets, fridge locks and AADCs will be in place - ADCs will interface with the pharmacy inventory management

system, meaning requests for restocking of the ADCs will happen automatically.

- Over 90 percent of first doses will be available to nursing staff in clinical areas.

- Medication ordering (prescribing) will be as per the current process – using the National Inpatient Medication Chart.

- In-pharmacy robotics will be in place, providing efficiencies in the dispensation of medication.

- AGV and Pneumatic Tube System will be in place to facilitate the efficient movement of medication around the facility.

- Within business hours, some pharmacy assistants will be based on the inpatient floors and will be a resource for the rest of the staff around the use of ADCs.

APDS governance The implementation of the APDS is guided by a comprehensive governance structure, comprising a Steering Group with nursing, pharmacy and medication safety representation, and working groups specific to pharmacy, technical suites and nursing (with representation from each directorate).


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Figure 7: APDS Governance Structure.

APDS Implementation Steering Group

Working Party – Nursing Representatives from each

directorate

Working Party -

Pharmacy

Working Party –

Technical Suites

General staff

Senior User

Senior User

Dissemination DisseminationDissemination

Senior User

Guiding Principles The Steering Group developed the new RAH Guiding Principles for the use of ADCs in Clinical Areas. These 12 principles are based on the Institute for Safe Medication Practices (ISMP) Guidance on the Interdisciplinary Safe Use of ADC and mimic practices at the vast majority of national and international sites in which ADCs are employed. The Guiding Principles have been endorsed by Central Adelaide LHN Executive and form the framework in which nursing, pharmacy and technical suites will develop their ADC workflows. A copy of the Guiding Principles is at Attachment 1. Workflow workshops In early December, the ADC vendor hosted a series of workflow workshops, including a nursing workshop (attended by nominated nursing representatives from each directorate), pharmacy and technical suites workshops. The purpose of these workshops was to explore the functionality available with the ADCs and consider how they may integrate with their workflows. The outcome was that participants felt comfortable to develop the workflows around medication distribution, as specific to their clinical area, from the ADC to administration at the patients’ bedside, within the framework of Central Adelaide LHN’s Guiding Principles for the use of ADCs in clinical areas. The vendor was also able to demonstrate functionality to facilitate implementation of the system in line with the Guiding Principles. One such option was to enable ‘pick slip’ or transaction slip to print automatically after the removal of a patient’s medications. This allows the nurse to identify which medications they have removed and they can bring this to the patient’s bedside as an extra safety measure. The use of this transaction record will be considered as part of the development of workflows from the ADC to the bedside. Given the confidential nature of the printed material, the disposal or subsequent use of the slip will also be addressed.


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Figure 8 Proposed transaction slip.

Next Steps The next step is to configure the server to allow system testing. Decisions pertinent to clinical groups are being brought to the Steering Group and relevant working parties. These groups will also develop policies and procedures around the use of the ADCs. Hospital-wide policies will go through normal Central Adelaide LHN governance protocols.


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Training A comprehensive training program will be provided to staff. To facilitate training a number of ADCs have been ‘installed’ in training areas of the current hospital including the new RAH Skills Centre and the Anaesthetic Simulation Laboratory. Training is scheduled to occur in a number of stages: 1. System Administrator training

This training aims to provide nominated system administrators with the skills and knowledge to set up the ADCs for use within the new RAH. This includes configuration of medications within drawers, workflow configuration and basic troubleshooting. This training was provided by the system vendor and occurred in early December 2015

2. Super User training – coordinated by the new RAH training program.

The vendor of the ADCs will provide ‘super user’ training to 200 staff. These super users will be comprised of staff from nursing, pharmacy and anaesthetics. Their role will be to provide training to the remainder of the staff and to support the implementation of the ADCs across the new RAH. This training will occur in the new RAH Skills Centre and the Anaesthetic Simulation Laboratory.

3. General Staff training – coordinated by the new RAH training program.

The remainder of staff will be trained by the ADC super users and will be planned in conjunction with other training required for the move to the new RAH. Training will be supported by a range of resource materials available to staff including quick reference guides attached to each ADC.

The implementation of in-pharmacy robotics will also be supported by vendor supplied training and will be supplemented by a number of system managers within pharmacy.

5.7 Related change processes post Day One While the hardware of the APDS will be available Day One, the staged implementation of EPAS and the timing of the following interfaces will govern when the APDS can be used to fully roll out Closed Loop Medication Management. Closed Loop Medication Management The APDS lays the foundation for the new RAH to move to a Closed Loop Medication Management (CLMM) system. Once implementation is complete, CLMM means that all the steps of the medication cycle are supported in one electronic system – ordering, verifying, preparing and administering – with decision support where relevant. The key elements in a typical CLMM model area illustrated in Figure 8 below:


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Figure 9 Closed Loop Medication Management Cycle.

At the new RAH, implementation of the CLMM will be incremental. As ICT interfaces are implemented; staff will be trained and supported in each new system. In particular, CLMM cannot be achieved at the new RAH until electronic prescribing is implemented by way of EPAS. Any workforce impacts for electronic prescribing and future CLMM changes will be considered in a separate consultation process, as required closer to the implementation of these initiatives. Electronic prescribing Following the implementation of the required ICT interfaces, electronic medication ordering and ‘patient profiling’ on the ADCs will be possible. Patient profiling means the patient’s medication list (or profile) will be available on the ADC; the nurse will only be able to access the list of medications ordered for that particular patient. Full integration will also allow nurses to ‘queue’ their patient’s medication from any PC. This means that once they approach the ADC, they only need to log in and the drawers containing the medications required for the particular patient at the relevant time will open automatically. As the ICT interfaces become available to support CLMM in the future, more efficiencies and electronic safety checks will be possible. Unit dose Within pharmacy, there is an array of specialised equipment used for the cutting, repacking and automatic identification of medication packs for hospital use. This equipment makes it possible to cut and pack the unit dose of the drug, while also conserving the manufacturer’s original packaging. The use of this equipment will be limited on Day One, but provides options for the future, should the RAH decide to move to unit dosing as standard.

5.8 Implications for not undertaking the change The use of automation to support medication distribution is fundamental to the design specification of the new RAH. There are no drug rooms on the patient floors and space and storage within the pharmacies has been allocated with an automated solution in mind.

Order Medication

Validate Order

Dispense &

Deliver

Medication

Administer

Medication

Monitor Patient


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6. Feedback This proposal provides more detail in relation to the APDS. There are still details that need to be determined and your feedback, suggestions and questions will assist in implementing the APDS.

Feedback can be provided via https://www.surveymonkey.com/r/newRAHAPDS or in writing to Workforce Workstream, new RAH Program, Level 8, Emergency Block, Royal Adelaide Hospital, Adelaide, SA 5000. Feedback is due by 13 April 2016. In particular we are seeking responses to the following questions:

1. Do you think there are benefits of the APDS that have not been identified in

the consultation paper? If so what are they? 2. What is your feedback in relation to the implementation of the APDS? 3. What else would you like to know about the APDS?

7. Attachments Attachment 1: New RAH Guiding Principles for the use of Automated Dispensing Cabinets in Clinical Areas.

8. Glossary ADC Automated Dispensing Cabinet

AADC Anaesthetic Automated Dispensing Cabinet

AGV Automated Guided Vehicle

APDS Automated Pharmacy Distribution System

CLMM Closed Loop Medication Management

Day One Day One refers to the first day at the new RAH, when the hospital opens. This term is used to differentiate future changes that are to be implemented in the days, weeks or months after hospital opening.

EPAS Electronic Patient Administration System – Enterprise solution to provide an electronic medical record.

ICT Information and Communication Technology

Par Par is the minimum level of stock as determined by a consultative process currently underway between pharmacy and the inpatient and out-patient services.

Technical suites Technical suites at the new RAH include operating theatres, interventional rooms and procedural rooms.

Wing Inpatient area consisting of 16 beds and a central staff hub (known as wards in the current hospital)

New RAH Guiding Principles for the use of Automated Dispensing Cabinets (ADCs) in Clinical Areas

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New RAH Guiding Principles

for the use of Automated

Dispensing Cabinets (ADCs)

in Clinical Areas

November 2015

Attachment 1: Endorsed New RAH Guiding Principles for the use of Automated Dispensing Cabinets (ADCs) in Clinical Areas


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Background These principles are based on the Institute for Safe Medication Practices (ISMP)’s Guidance on the Interdisciplinary Safe Use of Automated Dispensing Cabinets and have been endorsed by the Automated Pharmacy Distribution System Steering Group and the Central Adelaide Local Health Network Medication Safety Committee. Principles

1. Provide ideal environmental conditions for the u se of ADCs

• Physical placement of the ADC can impact medication error rates; busy, noisy and chaotic environments lend themselves to distraction and increased errors. Within the new RAH, the situation of the ADCs has been determined as part of the building design and planning, and will be located within pod clean utility rooms.

• Provision of access to patient medication charts will be required within close proximity to the ADC. Recommended to install a designated computer monitor screen to review electronic medication administration records (MARs) in the setting of EPAS or sufficient space to place a paper MAR so that these can be referenced during ADC transaction.

2. Ensure ADC system security

• Security procedures must be in place to ensure control of medications stored outside the pharmacy and minimise diversion of medications from the ADC.

o Password assignment: passwords linked with HAD logon to validate staff identity; prohibit password sharing or reuse; use biometric ID or ensure regular and frequent password changing.

o Assign user profiles and privileges based on the need to limit access to specific medications for particular practitioners or patient care areas.

o Maintain the system database to ensure that inactive or expired passwords are deactivated.

o Provide remote smart locking mechanism for refrigerated medicines.

• Procedures must be developed for handling schedule 8 medicines (DDAs) and restricted schedule 4 medicines (RS4s) to ensure security that complies with State legislative requirements.

• Fixture of ADCs to solid structures of the building (walls or floors) via bolting.

• Requirement for two signatures for the supply, administration or destruction of DDAs / RS4s.



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• Proactively monitor drug usage patterns and destruction.

• Promptly address discrepancies with medication counts at the time of discovery.

3. Prefer use of ADCs in profile mode

• Ideally ADCs would operate in profile mode, providing real-time patient medication lists on the ADCs and allowing pharmacist verification of new medication orders. Profiled ADCs display only the selected patient’s medication orders and allow nursing staff access to only those medications, significantly minimising the risk of selection error. Profile mode is a key safety enhancement of ADCs and should be the default operating mode wherever possible. Note that profile mode requires a functional interface between the ADCs and an electronic prescr ibing module (EPAS) .

• In the absence of “profile mode”, a business decision is required on the range and extent of medicines to be stored within ADCs. Limiting the variety and quantity of medications in non-profiled ADCs is the safest option to mitigate the inherent risk of selection error in non-profiled ADCs. In the case of the new RAH however, pharmacy distribution services have been designed around 90% first-dose availability in the ADCs; limiting the variety and quantity of medications is not a viable solution in this context.

• Stocking the ADCs with extensive inventory will require the development of policies and procedures that dictate the safe and judicious use of the ADCs, thereby minimising risk of selection errors.

4. Identify information to be displayed on the ADC screen

• Having sufficient patient and drug information when administering medications is critical to the safety of the medication use process. Due to limited space available on the ADC screens, it is important to focus on presenting the information that is of greatest value to practitioners, allowing for the clear identification of specific patients, their current medications and supporting information.

• A collaborative approach will be used to determine the information displayed on the ADC, with input from end-users (particularly nursing and pharmacy staff) and final ratification by the CALHN Drug and Therapeutics Committee (or delegate).

5. Select and maintain appropriate ADC inventory

• The ADC inventory should be determined based on the needs of those patients in the relevant clinical area, and replenished on a regular basis. Medications should be routinely reviewed and adjusted, based on medication prescribing practices and drug utilisation.



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• The CALHN Drug and Therapeutics Committee (DTC) should be given oversight to approve individual ADC inventory lists, or delegate this responsibility to an appropriate pharmacy representative.

• Criteria should be established around the inclusion or exclusion of particular categories of medicines, including cytotoxic, DDAs/ RS4s and bulky liquid dose forms.

6. Select appropriate ADC configuration

• Restricting access to medications limits the potential for inadvertently selecting the wrong medication. Medications stocked in ADCs may be high-risk, high-cost or controlled, and it is important to ensure that only the right drug is selected. For these reasons, it is important that each drug has its own unique and discrete location within the ADC, so that only the specific drug needed is selected.

• High-risk, high-cost and controlled drugs will be configured in Cubie pockets, to restrict access. These are individual lidded ADC compartments that open only when the specific medication is selected.

• Where possible, standardise the configuration of high turnover medicines across the hospital.

• Based on aiming to achieve 90% of first-dose availability and the corresponding need to stock extensive inventory, look-alike and sound-alike medications will need to be stored in locations remote from one another.

• Arrange the layout of open matrix drawers to minimise the risk of look-alike and sound-alike medicines being stored together.

7. Establish safe ADC restocking processes

• The restocking process, which involves pharmacy staff and some technical suites nursing staff, must contain safeguards to ensure that the correct medication is placed in the correct location within the ADC. These processes must be well defined and organised to ensure that staff involved can only follow the correct pathway and the potential for process variation is limited.

• Par levels should be based on the clinical needs of the area served, and should reflect real-time notification of low inventory.

• Original packs should be barcode scanned in the loading process to inform of the stock location.

• Users are required to enter the count of the medication in the pocket on loading a DDA or RS4 medication. This is referred to as a ‘blind count’.



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8. Develop procedures to ensure correct selection o f medications from the ADC

• Processes must be developed that reduce the risk of administering the wrong medication due to retrieval errors of medications from the ADC. The contents and configuration of the ADC play a large role in the practitioner’s ability to safely select and remove medications from the ADC.

• Prefer ADCs in profile-mode as the principle means of mitigating selection error risk.

• Nurses must be required to remove medications from the ADC one patient at a time, and validate that each drug has been selected correctly.

• Nursing staff will create a culture that optimises safety and quality for patients, and develop internal processes to avoid batching of medications and minimise queueing at the ADCs.

9. Standardise processes for transporting medicatio ns from the ADC to patient bedside

• A standard procedure must be developed that reduces the risk of medications being administered to the wrong patient at the wrong time during the transportation of medicines from the ADC to the patient. If interruption or distraction occurs en route to the patient, and there is the risk of administering the wrong medication to the wrong patient, staff must discard the medication and start the process of selection and retrieval again.

• In the vast majority of clinical areas, medications must not be withdrawn from the ADC for more than one patient at a time (see Principle 8) or for more than one scheduled administration time. (Exceptions to this rule include ICU, Technical Suites and Perioperative Bays, where clinical practice will dictate the need for a unique approach to medication administration.)

• To ensure secure transport, carry a single patient’s medication for one administration time directly to the patient’s bedside and avoid transport in clothing pockets, or within medical records or drug charts. Ensure medications transported from the ADC are in ready-to-use form for administration and that the MAR is available at the bedside to support safe administration.

10. Establish processes for returning medications t o the ADCs

• One source of incorrectly stored medications is via practitioners returning medications directly to the ADC bin or pocket, when the medication is inadvertently returned to the incorrect ADC location.

• Instead, all returned or wasted medications should be deposited in a bin that is maintained by pharmacy.



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11. Non-ADC storage of medications within clinical areas

• Bedside lockers will be available in general all-purpose inpatient pods. Areas such as Mental Health and the Emergency Department will not be equipped with bedside lockers.

• Bedside lockers, where available, may be used to store a limited range of medications supplied for use during an inpatient admission. These items include selected creams, eye drops, inhalers and insulins that have been issued and labelled for the patient.

• Medications issued to the patient (via individual patient supply), that are not stored in the ADCs will not be stored in the bedside locker. These medicines will be kept in a dedicated storage area within the clean utility rooms.

• With the exception of DDs and RS4s, patients own medicines may be stored, in a sealed bag, in the bedside lockers, to be reviewed and returned as appropriate on discharge.

12. Provide staff education and skills validation

• All users of ADCs (pharmacists, technicians, nurses and others) must be educated and regularly assessed for skills in the safe use of ADCs, in order to ensure safe use. The majority of this education and training should occur during orientation but updates may be required in order to ensure ongoing appropriate use.

160310 automated pharmacy distribution system new rah

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