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Manual vs Auto – Driving Medication Safety
Ken Tam
Senior Pharmacist – Electronic Medicines Management
Pharmacy Department I Fiona Stanley Hospital
FSH Medication Management System
Pharmacy
Theatres & Procedural Areas
Wards
Consult Prescribe
Resupply
Administer &
Record
Refill
Fill
Assign
Administer &
Record
Request
Standard Shelving
Standard Shelving
Picking & refill errors Manual Expiry Checks Side-by-Side Strengths
Pharmacy Robots
• Automated storage and retrieval
• Barcode scan & product library validation
• First-in, First-out + exact expiration dates
• ~75% of packs stored
Inventory Robots – Errors
Issue RCA Response
Telmisartan 80mg
output instead of 40mg
User overrode input
barcode scan
Override disabled –
every item must be
scanned
Dispensing error
caused by stock
removed from robot
jam.
User cleared a robot jam
and assumed the stock
manually removed was for
them.
Jammed stock always re-
input before dispensing
again.
• Automation is only safe if users know how to use it
Ward Imprest Shelving
Selection & refill errors Manual Expiry Checks
• Groups of dosage forms e.g. tablets in one section, vs injections
• Manual paper registers for controlled drugs
• No point of removal guidance
• Challenging recall process
Side-by-Side Strengths
MedStations
Workflow
Login with BioID
Select patient
Select drug & quantity
Initiate removal
Drawers/Doors open
sequentially one at a time
Electronic
Drug Register
Drawer Options
Cubie Open Matrix / Tower
• Individual containers per drug
• One drug at a time
• Tamper evident
• APINCH & Controlled Drugs
• Open tray with dividers
• Screen directs user to a
numbered compartment
• All other drugs
Open Matrix Drawers
43 44 45 46 47 48
37 38 39 40 41 42
31 32 33 34 35 36
25 26 27 28 29 30
19 20 21 22 23 24
13 14 15 16 17 18
7 8 9 10 11 12
1 2 3 4 5 6
48 Drugs 48 Compartments per Drawer
What is the optimal configuration to minimise picking errors?
Open Matrix Guidance Algorithm
Paired Product Comparison
• Both on ACSQHS Sound Alike List?
• Same first letter?
• Same strength?
• Same unit of measure (UOM)?
Product ACSQHS 1st Letter Strength UOM Pair Risk
Ceftriaxone 1g Vial
Ceftazidime 1g Vial
Score 1 1 1 1 4
Product ACSQHS 1st Letter Strength UOM Pair Risk
Salbutamol 100mcg MDI
Ceftazidime 1g Vial
Score 0 0 0 0 0
Product Pair Risk Score
Open Matrix Guidance Algorithm
Bag Syringe Patch
Sachet Nebule MDI Cream
Automated Imprest & Critical Low Reorders
Clinical Area
Imprest
Order
Refill
Pharmacy
1595
453
0 500 1000 1500 2000
June 2015 (Pre-Auto)
June 2016 (Post-Auto)
Number of Order Lines Submitted
Number of Stock Lines Manually Ordered by Nursing
• Weekly Imprest
• Daily Critical Low
• 20% for most drugs
• 100% for certain drugs e.g.
antidotes
Point of Removal Guidance
• Too Close Warnings
• Configurable per drug
• Requires override reason
• 2hrs for most items
• Facility wide
Point of Removal Guidance
• Dose/Volume Calculations
• Configurable per drug
• Qty to administer
• Qty remaining
Point of Removal Guidance
• Pop-up Warnings
• Configurable per drug & machine
• Interactive options
Errors with MedStations
• Medication search selection error
• Automation does not prevent transcription/selection error.
• The 6 Rights are still essential
• Is there a better way?
Electronic Prescribing
Login with BioID
Select patient
Select time – Drugs auto-
populate
Initiate removal
Drawers/Doors open
sequentially one at a time
Take Away Messages
• Automation brings many advantages
• Modified risk profile
• Technology does not replace the clinician
• The 6 Rights
• Checking of dispensed items
• Outcomes dictated by the lowest common denominator (the user)
• Staff training is essential
• Platform for ongoing safety enhancements e.g. ePrescribing
Manual vs Auto – Driving Medication Safety
Ken Tam
Senior Pharmacist – Electronic Medicines Management
Pharmacy Department I Fiona Stanley Hospital
Questions?