First Dose Administration TimeThe time from initial order of antibiotic (IV piperacillin and tazobactam for injection) to first dose administration was significantly reduced post ADC installation in all units. There was a 40.00% reduction in time between scheduled time and administration time

INSIDE

Medication administration, a key component of patient care, has emerged as the most common source of medical errors impacting 1.5 million patients annually. Of the utmost importance for optimal patient outcomes and achieving excellence in nursing practice is: attaining the expected therapeutic aim, minimizing the time from order to administration of first dose, promoting timely administration of scheduled medications, and preventing medication errors. There is a paucity of data in peer-reviewed journals on the impact of integrated technology on demonstrat-ing efficiency, medication errors, patient safety and nursing satisfaction. The Centers for Medicare and Medicaid Services (CMS) requires dispensing and administration of time critical medications within 30 minutes.

Introduction & Background

The goal of this two-part retrospective-prospective study was to evaluate the impact of a new ADC System compared to a prior ADC system on the medication administration processes and nurse satisfaction in select high-volume units.

Objectives and Endpoints

Primary Objective:

• To assess the efficiency of medication administration process for a time critical IV antibioticpre and post install of the new regulated ADC system.

Primary Endpoints:

• Demonstrate a 10% reduction in time from scheduled dosing times to first dose for the• IV piperacillin and tazobactam for injection, USP post install of the new regulated ADC• System compared to pre-installation in the medical-surgical, orthopedic, and oncology

units. Demonstrate a 10% reduction in the difference from scheduled time to documentedadministration time for all doses of all IV antibiotics in the medical-surgical, orthopedic, and oncology units.

Secondary Objectives:

• Evaluate medication error rates for two time-sensitive medications pre-install and post-installof the new regulated ADC system.

• Evaluate the new regulated ADC system’s impact on patient safety pre and post install.• To evaluate how nursing staff felt about the impact of the new regulated ADCs on the safe

administration of medication and patient safety.

Secondary Endpoints:

• Medication error rates for heparin and insulin pre-install of the new regulated ADC systemcompared to post installation.

• Evaluate the following pre-installation and compare to post-installation of the newregulated ADC System

1. Number of in basket messages related to missing medications2. Accuracy of medication labeling pre and post installation of new ADC system.

Design: The study was designed in two parts:

• Retrospective, single-center data collection study to evaluate medication administration processes preand post installation of the new ADC system (replaced a prior system)

• Prospective, single center study to evaluate nurses’ satisfaction, based on the Medication Adminis-tration System—Nurses Assessment of Satisfaction (MAS-NAS) Scale.[6] The MAS-NAS was giventwo times, 6 months apart, post ADC installation

Statistical Analysis:

• One sided Wilcoxon rank sum test was used to compare the difference in times. • Comparison of medication error rates, in basket messages and medication labeling was performed

using Poisson regression analysis using the PROC GENMOD in Statistical Analysis Software (SASv9.4).

• Ordinal logistic regression with Generalized estimating equations (GEE) were used to evaluate thenurses’ satisfaction post ADC installation.

New ADC System installed at HackensackUMC:

• Omnicell® Medication Dispensing System• Integrated Medication Label Printer• Touch and Go™ Biometric ID System

Methodology

Results

Scheduled Dosing TimeThe duration of time from the scheduled dosing time to actual administration for all IV antibiotics was significantly reduced post ADC installation in all units. There was a 13.34% reduction in time between scheduled time and administration time.

Purpose

IMPACT OF A REGULATED AUTOMATED DISPENSING CABINET (ADC) SYSTEM ON MEDICATION DISTRIBUTION AND ADMINISTRATION VARIABLES – THE IMPROVE STUDY

Nilesh Desai, MBA, BS, RPh.; Claudia Douglas, DNP, RN, CNN, APN.C; Mohammed Quadri, MD, MBA, SSBB; Dianne A.M. Aroh, MS, RN, NEA-BC; Themba Nyirenda, Ph.D.; Rose Williams, BSMT, MSCRA, CCRP; Frank Aroh II

Unit (#Pre-New-ADC/#Post-New ADC)

Pre-New ADC (n=8,869) Post-New ADC(n= 8, 386) Change (% Change)

*P-value

All (8,869/8,386)

Median (25th . 75th percentile) 14.0 (-3.0 . 49.0) 9.0 (-18.0 . 44.0) 5.0 (35.7) <0.0001

Minimum . Maximum -120.0 . 3,858.0 -115.0 . 324.0

Medical Surgical (6,948/6,021)

Median (25th . 75th percentile) 14.0 (-1.0 . 48.0) 11.0 (-16.0 . 47.0) 3.0 (21.4) <0.0001

Minimum . Maximum -120.0 . 3,858.0 -75.0 . 324.0

Oncology (1,298/1,642)

Median (25th . 75th percentile) 23.0 (-21.0 . 59.0) 2.0 (-22.0 . 35.0) 21.0 (91.3) <0.0001

Minimum . Maximum -83.0 . 312.0 -60.0 . 284.0

Orthopedic (361/385)

Median (25th . 75th percentile) 30.0 (0 . 52.0) 3.0 (-23.0 . 39.0) 27.0 (90.0) <0.0001

Minimum . Maximum -60.0 . 450.0 -115.0 . 277.0

Difference in minutes = administration time - scheduled time of IV PIPERACILLIN - TAZOBACTAM dose. A comparison of administration time - scheduled time difference between the Pre-New-ADC and Post-New ADC installation period was evaluated using a one-sided Wilcoxon rank sum test.

TABLE 1. Summary of the difference in Scheduled Administration time of IV PIPERACILLIN - TAZOBACTAM in the Pre-New ADC (Prior) and Post-New ADC installation period.

TABLE 2. Summary of the difference in Scheduled Administration time of all IV Antibiotics in Pre-New ADC (Prior) and Post-New ADC installation periods.

Unit (#Pre-New-ADC/#Post-New ADC)

Pre-New ADC (n=46,122) P-valuea

Post-New ADC(n=46,294) Change (% Change)

*P-value

All (46,122/46294)

Median (25th . 75th percentile) 15.0 (-8.0 . 53.0) 13.0 (-13.0 . 50.0) 2.0 (13.3) <0.0001

Minimum . Maximum -165.0 . 3,858.0 -270.0 . 399.0

Medical Surgical (32,228/32,544)

Median (25th . 75th percentile) 18.0 (-8.0 . 53.0) 16.0 (-10.0 . 55.0) 2.0 (11.1) <0.2778

Minimum . Maximum -150.0 . 3,858.0 -241.0 . 399.0

Oncology (8,780/7,773)

Median (25th . 75th percentile) 8.0 (-9.0 . 55.0) 5.0 (-21.0 . 39.0) 3.0 (37.5) <0.0001

Minimum . Maximum -165.0 . 476.0 -270.0 . 357.0

Orthopedic (5,114/5,977)

Median (25th . 75th percentile) 11.0 (-4.0 . 45.0) 3.0 (-13.0 . 33.0) 8.0 (72.7) <0.0001

Minimum . Maximum -6120.0 . 2,090.0 -180.0 . 383.0

Difference in minutes = Administration time - Scheduled time of Antibiotic dose. A comparison of administration time - scheduled time difference between the Pre-New-ADC and Post-New ADC installation period was evaluated using a one-sided Wilcoxon rank sum test.

• Evaluate process improvement post new regulated ADC installation by administration ofMAS-NAS questionnaire two times, six months apart.

1. Medical Surgical Units2. Orthopedic Units3. Oncology Units

FIG 1. Comparison boxplots of the difference in time (administration time - scheduled time) for Pre-New-ADC installation and Post-New ADC installation for IV Piperacillin-Tazobactam in the medical surgical, oncology and orthopedic department. Boxplot: The lower end of the box represents the 25th percentile; the upper end represents the 75th percentile: the horizontal line in the middle of the box is the median value the difference in time - scheduled time. Whiskers: The upper vertical line extends from the top of the box to the value 75th percentile +.1.5 x (75th=25th percentile). The lower vertical line extends from the bottom of the box to the value 25th percentile - 1.5 x (75th-25th percentile). The circle or cross inside the box represents the mean difference in time.

FIG 2. Comparison boxplots of the difference in time (administration time - scheduled time) for Pre-New-ADC installation and Post-New ADC installation for IV antibiotics in the medical surgical, oncology and orthopedic department.

( Medication Error Rates continued on next page )

200 -

100 -

0 -

-100 -

-200 -

-300 -

Diffe

renc

e in T

ime (

Minu

tes)

ADC Period: Prior ADC Post New ADC Installation

oo +o ++

MEDICAL SURGICAL ONCOLOGY ORTHOPEDIC

Administered-Scheduled Time Difference for All IV Antibiotics

60 min

Target

- 60 min

200 -

100 -

0 -

-100 -

Diffe

renc

e in T

ime (

Minu

tes)

ADC Period: Prior ADC Post New ADC Installation

oo +o

++

MEDICAL SURGICAL ONCOLOGY ORTHOPEDIC

30 min

Target

- 30 min

Medication Error Rates

The medication error rates for insulin post new ADC installation was not signifi cantly different than pre new ADC installation rates, with an incidence rate ratio (IRR) of 0.34 and 95% confi -dence intervals (CI) of 0.04-2.79 (p = 0.3136).

In-Basket Messages (Missing Medications)

Analysis of in-basket messages, which are indicative of missing medications, showed a signifi -cant reduction in post new ADC in-basket messages compared with pre new ADC installation (IRR = 0.82, CI = 0.80 – 0.83, p< 0.0001).

Medication Labeling Errors

The rate of medication labeling errors post new ADC installation was not signifi cantly different than the pre new ADC installation rate, (IRR = 1.22, CI = 0.80 – 1.85, p = 0.3592).

Summary

• The effi ciency of medication administration process for a time critical IV antibiotic pre and post install of the new regulated Automated Dispensing Cabinet (ADC) system improved due to the increased availability of IV antibiotics. There was a statistically signifi cant reduction in fi rst dose administration times for time critical IV antibiotics from scheduled dosing times.

• This study did not show a signifi cant reduction in medication errors related to two-time sensitive medications (heparin and insulin) with the new ADC as compared with the old ADC.

• Installation of a new ADC and associated medication label printer was associated with statistically signifi cant improvements in the medication administration process and nursing satisfaction. The anal-ysis showed statistical signifi cance in nurse satisfaction in the following areas: effi ciency of medica-tion administration, effectiveness in reducing and preventing medication errors, ease to check active medication orders before administering medication, drug alert feature, availability of medications, and availability of information on side effects and adverse events.

• The timely administration of medications signifi cantly improved post install of the new ADC system, which may be due to increasing the accessibility of medication in patient care units.

1. ASHP Guidelines on preventing medication errors in hospitals. Medication Misadventures–Guide-lines https://www.ashp.org/DocLibrary/BestPractices/MedMisGdlHosp.aspx

2. CMS Manual System – Department of Health and Human Services (DHHS) Center for Medicare and Medicaid Services (CMS).  Pub 100-07 State Operations Provider Certifi cation.  Revised Appendix A Interpretative Guidelines for Hospitals. December 22, 2011.

3. CMS Manual System – Department of Health and Human Services (DHHS) Center for Medicare and Medicaid Services (CMS).  Pub 100-07 State Operations Provider Certifi cation.  Revised Appendix A Interpretative Guidelines for Hospitals. December 22, 2011. https://www.cms.gov/Regula-tions-and-Guidance/Guidance/Transmittals/downloads/R77SOMA.pdf

4. Elganzouri ES, Standish CA, and Androwich I.  Medication Administration Time Study (MATS) - Nursing Staff Performance of Medication Administration.  JONA 2009; Vol 39(5), 204-210.

5. Gooder V.J. Nurses’ Perceptions of a (BCMA) Bar-coded Medication Administration System – A Case Control Study.  Online Journal of Nursing Informatics 2011

6. Hurley AC, Lancaster D, Hayes J, Wilson-Chase C, Bane A, Griffi n M, Warden V, Duffy ME, Poon EG, Gandhi TK. The Medication Administration System—Nurses Assessment of Satisfaction (MAS-NAS) Scale. Journal of Nursing Scholarship, 2006; 38:3, 298-300.  Vol 15(2).

7. To Err is Human: Building a safer health system. Institute of Medicine. Shaping the future of health. http://www.iom.edu/~/media/Files/Report%20Files/1999/To-Err-is-Human/To%20Err%20is%20Human%201999%20%20report%20brief.pdf

References

Acknowledgments

• Nurses who have participated in the survey• Nurse Managers for their support• Special Projects/Patient & Family Engagement Specialist

Sponsored by Hackensack University Medical Center, Hackensack, NJWe wish to acknowledge support provided by Omnicell, Inc.

*Disclaimer: No confl ict of interest reported by study investigators with the new ADC company.

Results of Medication Administration System-Nurses Assessment of Satisfaction:

• In the prospective phase of the study, an adaptation of the Medication Administration System–Nurses Assessment of Satisfaction questionnaire was administered using a 6-point Likert scale (strongly agree, agree, somewhat agree, somewhat disagree, disagree, and strongly disagree).

• The questionnaire was completed by 120 nurses’ pre and post new ADC installation 6 months apart.

• The analysis showed statistically signifi cant improvement in nurse satisfaction post new ADC as compared with pre ADC installation with regard to effi ciency of medication adminis-tration, preventing medication errors, ease of checking medication orders, drug alert feature, availability of information on actions and possible side effects (and how to treat adverse reactions), and increased availability of medications.

Impact of a Regulated Automated Dispensing Cabinet (ADC) System on Medication,

Distribution, and Administration Variables

– THE IMPROVE STUDYNilesh Desai, MBA, BS, RPh.; Claudia Douglas, DNP, RN, CNN, APN.C;

Mohammed Quadri, MD, MBA, SSBB; Dianne A.M. Aroh, MS, RN, NEA-BC; Themba Nyirenda, Ph.D.; Rose Williams, BSMT, MSCRA, CCRP; Frank Aroh II

As presented at the NEW JERSEY SOCIETY OF HEALTH SYSTEMS PHARMACISTS

APRIL 24, 2015

Funded and supported by Omnicell, Inc.

• Study completed in three high volume patient care areas:

- Medical Surgical Unit - Oncology Unit - Orthopedic Unit

• Study showed:

- Signifi cant reduction in time from order to 1st dose for time critical antibiotic.

- Increase in nurse satisfaction related to the medication administration process compared to the prior ADC System.

- Improvement in timely administration of scheduled medications.

As presented at the

Domain OR 95% CI P-value

Effi ciency of medication administration

1.96 1.34, 2.87 p=0.0005

Effectiveness in reducing and preventing medication errors

1.58 1.07, 2.33 P=0.0225

Ease of checking active medication orders before administering

medications1.55 1.04, 2.30 p=0.0298

Drug alert feature 1.53 1.04, 2.26 p=0.0295

Availability of information on drug actions and possible

side effects1.53 1.04, 2.26 p=0.0314

Need for stashes of medications 0.69* 0.48, 0.99 p=0.0426

OR = odds ratio (likelihood of responding “strongly agree”), CI = confi dence interval *For this item, OR<1 shows improvement (decreased need to stash medication.

Note: *Need to keep stashes of medications post installation of new ADC system was reduced.

TABLE 3. Analysis of Medication Administration System-Nurses Assessment of Satisfaction

( Continued from Graphs )