PHARMACY AUTOMATION

Research by Lona Hong, Pharmacy Extern
University of New Mexico, College of Pharmacy
2000

    Pharmacy is a growing market and will not slow down anytime soon. With todays population growing older and better, newer medications are out in the markets, more medications are needed by the patients. What does it mean to the pharmacy? The pharmacy will be busy. Most of the time, the pharmacists are tied up retrieving the medications, pouring and counting, checking and dispensing. They have very little time to counsel patients about their medications or check the patient profile for a potential drug-drug interaction. This old routine of the pharmacist practice is not very efficient in today booming pharmacy. There has to be a better solution!

    Today technology is changing the world, and pharmacists can greatly benefit from the new technology. Pharmacists no longer need to be in their old traditional role, product-focused dispensing. Automation can take over many of their duties. Automation can outperform them in tasks that require tedious repetition, tiresome movement, intense concentration, immense memory retention, and tedious record keeping, and it will replace many labor-intensive tasks, thus saving time for them to practice pharmaceutical care.

    Automated pharmacy systems are already in use throughout the pharmacy practice. Their primary use is for counting, packaging and labeling dosage forms for pharmacists and other health professionals to dispense and/or administer to patients while electronically documenting the process.¹ Pharmacy automation equipment may be centralized, pharmacy-based devices, decentralized devices on nursing units, in long-term care facilities and other health facilities.    

    For decentralized pharmacy (exp. Omnicell), automated pharmacy systems can store and dispense drugs and supplies in a location outside the pharmacy and link with a central pharmacy computer to keep track of the drug storage and distribution process. Certain devices can be used to dispense multiple-dose packages, while others dispense unit-doses. Some systems package the doses, while others systems are used only to dispense prepackaged medications.

    Community pharmacies have used automated pharmacy systems to facilitate the drug distribution process since the 1970's. The first machine simply counted the tablets. Today, automated pharmacy systems are available to automate the entire dispensing process. ScriptPro, for example, used in Rite Aide pharmacy has been successful. There are other automated devices to serve for various functions in the community pharmacies, depending on the prescription volume.

    The operations of automated pharmacy systems begin with an order entered into the pharmacy computer system and sent to the automated pharmacy system computer. The automated pharmacy system initiates the printing of barcoded labels and receipts, selecting the prescription bottle, labeling of the container, filing and capping. A video image of the medication is captured inside the bottle before capping. When the bottle-specific bar code is scanned by the pharmacist, the video image of the medication is displayed on the monitor to allow the pharmacist to compare with the reference image for a final check. This technology will allow pricing of the prescription, adjusting the inventory and documenting the transaction. ¹

    Today mail service pharmacies are increasingly busy, due to easy internet prescriptions, more older patients and chronic disease states. Patients are turning to mail service pharmacies to deliver their medications at home. Mail service pharmacies are turning to automation systems to assist with high prescription volume. Mail service pharmacies use "assembly line" automated drug distribution systems to dispense prescriptions, which are checked by the pharmacist and mailed with patient information directly to the patient.²

    Hospitals and institutional long-term care pharmacies use various centralized automated pharmacy systems, which are integrated with the pharmacy information system, for repackaging and labeling of solid oral medications.³ These automation systems can count, package and label medications according to patient, date, time of specific unit-dose and multidose and patient packaging(all medications for a particular administration time are packaged together).

    Robotic systems that can read overwrapped barcoded unit-dose packages are used to fill patient medication cassettes and return unused medications to the stock. These systems can handle oral liquid unit-dose and solid dosage form, injectables and suppositories.

    Pharmacy automation can be used in a nursing home, pretty much a unit-based, decentralized systems feature "ATM-like" dispensing cabinets, which offer secure, computer-controlled  access to medications and related supplies.¹ When linked with the central pharmacy system, as soon as the pharmacist finishes entering the order, the nurses may request the dose from the automated systems to give to the patient.

    Automated pharmacy systems are used in all setting of pharmacy. Each company designed their systems slightly different. See automated. doc in the F drive server, under Lona's folder for a brief list of their descriptions.

    There are no national standards for automated pharmacy systems. However, some state boards of pharmacy are in the process of writing regulations for the use of automated pharmacy systems. The problems with each state board of pharmacy regulating the automated systems are the lack of resources and expertise to evaluate the automated systems. Because of these, each state board of pharmacy may be slow to write laws regulating automated pharmacy systems. The process can speed up if there is national pharmacy automation developed. Working with the automation industry to develop a standard automated system and National pharmacy associations to develop guidelines for selection, evaluation and appropriate use of automated system, maybe each state boards of pharmacy can regulate the automated systems a lot quicker.

    Pharmacy automation is here to stay. They are very efficient machines to save pharmacist's time. Retail and hospital pharmacies may greatly benefits from the use of these machines. It's about containing costs, reducing medication errors, increasing efficiency, system integration, productivity and more time for clinical care.

What about the accuracy and safety of these machine?

    A controlled hospital study was done in 1984 to examine the use of a bedside automated dispensing unit that sounded an alert to notify the nurse that the medication is ready for administration. The device only allows access to the medications that are ready to administer at that time. The devices were randomly assigned to patients on one medical-surgical nursing unit, with a crossover during the two weeks study period. Medication errors declined from 15.9% to 10.6%, a result of a reduction in wrong time and omission errors.²

    Kratz and Thygesen did a study in 1992. They looked at patient medication profiles of a computer-driven automated pharmacy system and found a 99.98% filling accuracy. The errors found included an extra tablet, half tablet or missing tablet.³

    In 1993, Maliekal published an evaluation of an automated dispensing systems in an ambulatory setting. 270 prescriptions filled by machine during a normal operation were pulled off line. They counted the number of tablets in the machine dispensing vial to the computer labeled amount and found 38 discrepancies , 22 were overfills, 14 were underfills and two cannot be classified.⁴

    Klein, Santora and Pascale compared automation to technician cart filling and found filling errors were fewer than 1% of the doses; 0.84% for the traditional filling system and 0.65% for the automated system. ⁵

    In 1995, a study report of medication administration errors, evaluated by Barker and Allan, which involved a hospital nursing unit-based automated device used for narcotic and selected first-dose medications. The automated systems configuration allowed nurses to obtain any medications stored in the device for any patient. This system was not integrated with the patients' computerized medication profiles. The error rate for all doses retrieved from the automated device was 16.3%(20 errors per 123 opportunities), 11% of the errors were administration of twice the dose ordered and seven doses have no chart ordered. The errors rate for doses retrieved from a non-automated system was 5.4%.(43 errors per 796 opportunities). The observers noted that the nurses retrieved doses from an automated system did not check the medications, whereas those taken from the patient's medication drawer were typically checked.⁶

    Ray and his associates tried to compare the technician filling error rates before and after the installation of an automated system in a 26-bed adult medicine unit. Six weeks before and six weeks after conversion to the automated station, the medication cassettes that were filled by the technicians were checked by the pharmacists and compared to the automation filled. There was a significantly lower error rate in filling the automated medication system (0.61%) than in filling the traditional unit-dose cassettes (0.89%), a relative difference of 28.7%. ⁷   

    Although the studies are in the favor of automation, stating automation can do a better job by decreasing the administration errors, filling errors, but most of these studies are limited, mainly based on observation techniques. The findings of these studies should not be accepted without evaluating other primary literatures.

      What are the possible drawbacks of using automation?

-Order entry errors are troublesome. Automated systems can only be as accurate as the data entered. When order entry errors occurred, repeated errors can go without detection, meaning "garbage in, garbage out."

-Automation can have downtime and system failure, these need to be accounted for.

-Machine errors-automated pharmacy systems are capable of producing new source of errors, mainly due to hardware defect or software failure.

-The systems are expensive, so most retail and hospital pharmacies cannot afford the high cost of automated pharmacy systems.

-Bar code can be problematic. There is not a uniform bar code required on all products, making automated pharmacy systems using bar code scanning difficult.

Even if the products have the bar code, automated pharmacy systems might have difficulty scanning the products if the bar code is torn or removed from the package bottles, plastic containers, vials and IV bags, making the products useless. Using the bar code from a different container of the same product to scan is not acceptable because the lot number and expiration date is different.

      These are some drawbacks using automated pharmacy systems, but if the pharmacists are properly trained to use the automated systems, tedious tasks perform by the traditional pharmacist are avoided, thus saving times for the pharmacist to provide pharmaceutical care.

    In conclusion, automation is not a bad technology. They have great potential for improving medication distribution efficiencies, accelerating the pharmacists to change from the traditional, product-focused dispensing role to one of patient-focus provider. Although medication distribution will be increasingly control by automation in the future, the responsibility for the control and oversight of the automation must rest with the pharmacist, who should be well trained. Automation provides many benefits. They can reduce medication errors, improve documentation, increase authorized access to both medication and information and enhanced the security. However, automation can be indirectly contributed to human errors, because pharmacist may rely too much on automation. Automation is evolving to a sophisticated machine. Pharmacist needs to continue the education and training in order to effectively monitor these automated systems.

Reference:

1.      Http://www.ascp.com/public/pubs/tcp/1998/mar/feature2.shtml

2.      Barker KN, Pearson RE, Hepler CD et al. Effect of an automated bedside dispensing machine on medication errors. Am J Hosp Pharm 1984;41:1352-8.

3.      Kratz K, Thygesen C. A comparison of the accuracy of unit-dose cart fill with the Baxter ATC-212 computerized system and manual filling. Hosp Pharm 1992;27:19-22.

4.      Maliekal JJ. Evaluation of the Drug-O-Matic automated dispensing system. J Pharm Technol 1993;9:47-8.

5.      Klein EG, Santora JA, and Pascale PM. Medication cart-filling time, accuracy, and cost with an automated dispensing system. Am J Hosp Pharm 1994;51:1193-6.

6.      Barker KN, Allan EL. Research on drug-use system errors. Am J Health-Syst Pharm 1995;52:400-3.

7.      Ray M, Aldridge L, and Lew P. Experience with an automated point-of-use unit-dose drug distribution system. Hosp Pharm 1995;30:18-30.