riverside hospital's pharmacy services_che program_pcu
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Ivey Case studyTRANSCRIPT
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9B11D014 RIVERSIDE HOSPITAL’S PHARMACY SERVICES
Dr. Anne Snowdon and Hannah Standing Rasmussen wrote this case solely to provide material for class discussion. The authors do not intend to illustrate either effective or ineffective handling of a managerial situation. The authors may have disguised certain names and other identifying information to protect confidentiality. Richard Ivey School of Business Foundation prohibits any form of reproduction, storage or transmission without its written permission. Reproduction of this material is not covered under authorization by any reproduction rights organization. To order copies or request permission to reproduce materials, contact Ivey Publishing, Richard Ivey School of Business Foundation, The University of Western Ontario, London, Ontario, Canada, N6A 3K7; phone (519) 661-3208; fax (519) 661-3882; e-mail [email protected]. Copyright © 2011, Richard Ivey School of Business Foundation Version: 2012-11-02
As she drove to work on a Monday morning in the spring of 2009, Barbara Jordan, vice-president of patient services and chief nursing executive at Riverside District Memorial Hospital (RDMH), thought about the upcoming board meeting about pharmacy services at the rural hospital. RDMH was unable to afford a full-time pharmacist, and since it was only a 62-bed hospital, there wasn’t enough work to justify a full-time pharmacy position. RDMH had been “making do” with short-term arrangements with a variety of pharmacists in the region. Five different pharmacists would come to RDMH from other hospitals once a week to supply their services. More recently, Jordan had uncovered some evidence that the quality and safety of pharmacy services might be becoming compromised. There had been an increasing number of medication errors resulting in adverse drug events (ADEs — events where there were injuries to patients resulting from the use of medication1). Jordan knew there was a need to examine the quality of service delivery in the pharmacy department. Three weeks earlier, an elderly patient at RDMH, Mrs. Farell, died from a reaction between her anti-cholesterol medicine (Lipitor) and one of the antibiotics she had been prescribed by a hospital physician following a hip replacement operation at RDMH. The patient had been on the anti-cholesterol drug since 2008 due to cardiac problems. The surgery, performed in late January 2009, went well but while in hospital recovering she developed a secondary bleed and an infection in her wound. In early February 2009, the physician ordered antibiotics to treat the infection. Farell’s antibiotics were changed during her treatment throughout February and included teicoplanin and fusidic acid, flucloxacillin with fusidic acid, and doxycycline. In late February 2009, the physician took her off the drug Lipitor as a precaution because of the drug’s risk of reaction with antibiotics.2 However, by this time it was too late. Farell died in early March. The pathologist’s report found that the cause of death was rhabdomyolysis and renal failure due to probable drug reaction between Lipitor and an antibiotic. The pathologist added that it was not possible to say which antibiotic had the adverse reaction with Lipitor.
1 J. Lazarou, B. H. Pomeranz, and P. N. Corey, “Incidence of Adverse Drug Reactions in Hospitalized Patients,” The Journal of the American Medical Association, 279:15, 1998, p. 1200. 2 “Lipitor,” Drugs.com, www.drugs.com/lipitor.html, accessed June 21, 2011.
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This death was not the first death at RDMH that had been brought to the attention of the board. In 2008, there were several deaths reported due to errors in the volume of morphine given to patients. All patents had been prescribed morphine 1 to 2 mg subcutaneously but a different form of morphine product was available in the hospital. Several times the patients received correct volumes of morphine. However, on the day of the death of each patient, a different amount was administered in error. A different nurse administered the morphine at each death. Each cause of death was determined to be heart failure caused by the administering of the wrong dose of morphine. A final issue that concerned the board was not a death but was still a substantial problem. A patient had been prescribed a painkiller in pill form. When he complained that he was still in pain after several doses, the head nurse investigated. While the pills looked correct on first inspection, she noticed when she looked closer that many of the pills in the bottle were not for pain, but were instead antibiotics that looked almost identical to the pain medication. The nurse contacted the hospital pharmacy and the correct medication was sent to the floor and given to the patient. Jordan’s role in the organization was the hospital risk manager, which was over and above her role as chief nursing executive. It was her responsibility to manage risk, investigate all adverse events (including pharmacy-related events), and recommend solutions or changes in practice to improve the quality of care and prevent future adverse events. Any recommendations to improve risk were made with consideration of existing budget limitations. Jordan had been involved in a recent survey of RDMH regarding hospital safety. This survey had revealed widespread fear of blame related to reporting events of patient risk, and a lack of awareness of risk management strategies. Surprised by this result, RDMH had introduced a series of initiatives to improve patient safety. The hospital began to encourage staff to report any concerns or problems in the hospital. Many of the staff reported problems, and potential problems, with medication management in the hospital. For example, staff reported that:
i. There were errors in the timing, dosage and type of medication being given to patients. ii. Pharmacy technicians were performing duties that would normally be the job of the pharmacist.
iii. Medications were being contaminated (unused doses of medications that had been dispensed to the patient floor to fill prescriptions were being returned to the pharmacy and placed back in the stock supply).
Jordan knew these issues had to be resolved before there was another serious adverse event for a patient. These issues raised by the staff had to be resolved, and quickly. The hospital board wanted a solution. She needed to make a recommendation at tonight’s meeting. There were several different options for RDMH. The question was — what should she recommend at the board meeting tonight? HOSPITAL BACKGROUND Riverside, Ontario Riverside, Ontario, was a rural municipality in Southwestern Ontario. Its population was roughly 25,000 people. RDMH served Riverside, as well as the farms and villages that surrounded the municipality. The majority of people in Riverside spoke English. However, there was a growing population of seasonal laborers that came from Mexico and Jamaica. Additionally, Mexican Mennonite settlers had also begun to settle outside Riverside.
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According to the census, the average age of people living in Riverside was 72 years. The economy of Riverside was based on farms and greenhouses. In 2009, Riverside had the largest number of commercial greenhouses in North America. Historically, tobacco was an important crop in the Riverside economy. However, this was now in fast decline. Recently, Riverside was becoming a retirement community. Riverside had many golf clubs and beautiful waterfront parks, and had a very warm climate compared to most of Canada. The Riverside District Memorial Hospital (RDMH) was opened in 1948. It was a rural community hospital with both inpatient beds and a large outpatient population. RDMH considered outpatient treatment and the medical management of geriatric patients to be its specialty, which was a strong fit with the needs of the population it served. Outpatient surgeries were the most common type of procedure offered by RDMH. A fully staffed emergency department managed the urgent care needs of the town, and more complex cases were referred to one of two nearby community hospitals in a medium-sized urban centre. RDMH had been increasingly working with the two nearby hospitals to reduce costs and improve efficiency by streamlining infrastructure and services including information technologies, referrals to specialists, and obstetrical services. RDMH Outpatient Population In 2004, RDMH had 100 inpatient beds. However, due to ongoing budget cuts, by 2009 there were only 62 inpatient beds remaining. The majority of these were acute care beds since wherever possible, healthy patients were served as outpatients. One of RDMH’s main strengths was its outpatient surgical program, which included procedures such as cholecystectomy (removal of gallbladder, endoscopy, bladder surgery and lumpectomy). With these surgeries, a patient was allowed to return home on the same day that a surgical procedure was performed.3 Outpatient services were considered by many experts as the most economical and patient-focused way to provide health care to individuals.4 For example, outpatient surgery often reduced the amount of medication prescribed, and used a doctor’s time more efficiently. It was also preferred by most patients as they could return to the comfort of their own homes to recover.5 More than 60 per cent of elective surgery procedures in the United States were performed as outpatient surgeries in 2005.6 Health experts expected that this percentage would increase to nearly 75 per cent over the next decade.7 Although not all types of surgeries and/or patients were suitable for outpatient surgery at RDMH, 90 per cent of all surgical cases, regardless of suitability, were performed on an outpatient basis. Geriatric Patients RDMH considered the medical management of geriatric patients to be its other specialty. On any given day in 2009, the average age of an inpatient at RDMH was 86. Most of these inpatients were admitted for acute illnesses. For example, they were admitted for acute exacerbations of one or more chronic illnesses,
3 “Definition of Outpatient,” MedicineNet.com, April 27, 2011, www.medterms.com/script/main/art.asp?articlekey=4700, accessed May 12, 2011. 4 L. Peng and E. J. Norris, “Outpatient Surgery,” emedicinehealth, January 11, 2006, www.emedicinehealth.com/outpatient_surgery/article_em.htm, accessed June 21, 2011. 5 Ibid. 6 Ibid. 7 Ibid.
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such as chronic obstructive pulmonary disease (COPD), diabetes, infections (e.g., pneumonia) or injury (falls). Geriatric patients could be challenging to treat since they most often suffered multiple co-morbidities, that is, two or more coexisting medical conditions. As people aged, they were increasingly likely to suffer from a compromised nutritional state, have balance and gait problems, suffer from sight and hearing loss, have out-of-date immunizations, and have cognition problems or dementia, and were more likely to suffer from depression.8 As a result of experiencing one or more of these illnesses, many geriatric patients were prescribed many different medications, resulting in a challenge referred to as “polypharmacy.” Polypharmacy referred to the interactions of multiple medications, which, when taken together, interacted to cause adverse effects such as fatigue, dizziness, nausea and loss of coordination.9 The adverse effects of polypharmacy could make it very difficult for a physician to diagnose a geriatric patient quickly and correctly.10 Additionally, numerous medications also caused side effects that could be very dangerous, if not deadly, to patients.11 For example, many geriatric patients were on the blood thinner Coumadin. Coumadin interacted negatively with many medications, including simple aspirin (both drugs prevented platelets from clotting), which, when ingested at the same time, caused excessive bleeding that was difficult to control.12 Local Health Integration Network RDMH was a part of the South East Local Health Integration Network (SELHIN). This network was one of 14 networks that were established in 2006 in Ontario. These networks were intended to coordinate health care across the province and to provide effective and efficient management of the health system at the local level. The goal of local health integration networks (LHINs) was to plan and allocate resources more efficiently to ensure better access to health care now and in the future. One of their secondary goals was to work with local health service providers to identify ways to reduce duplication in the health system and to improve health services in Ontario.13 The SELHIN serviced three rural regions in Ontario that made up more than 649,000 people. It had an annual budget of more than $900 million. Jordan knew, from her years of working in the region, that the population had some specific health issues that needed to be considered whenever health services were reviewed for RDMH. Specifically, the population of the region was older, more likely to be either overweight or obese, more likely to practice poor lifestyle habits, and more likely to have chronic health conditions (such as diabetes, chronic heart failure, and asthma). As a result, the population of the SELHIN had higher rates of hospitalization than the rest of Ontario.
8 J. W. Yates, “Comorbidity Considerations in Geriatric Oncology Research,” CA: A Cancer Journal for Clinicians, 51:6, 2001, pp. 329-336. 9 S. N. Hilmer and D. Gnjidic, “The Effects of Polypharmacy in Older Adults,” Clinical Pharmacology & Therapeutics, 85:1, 2009, pp. 86-88. 10 Ibid. 11 K. E. Miller, R. G. Zylstra, and J. B. Standridge, “The Geriatric Patient: A Systematic Approach to Maintaining Health,” American Family Physician, February 15, 2000, www.aafp.org/afp/20000215/1089.html, accessed June 21, 2011. 12 C. Bartecchi and R. W. Schrier, “The Bad (Polypharmacy) and the Ugly (cocaine, methamphetamines, marijuana, and anabolic steroids),” Online Guide to Living Healthier and Longer, www.healthierlongerlife.org/?page_id=72, accessed June 21, 2011. 13 “About LHINs,” Ontario’s Local Health Integration Networks, www.lhins.on.ca/aboutlhin.aspx?ekmensel=e2f22c9a_72_184_btnlink, accessed June 21, 2011.
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Across the province, at least 50 per cent of hospitals (75 hospitals) were in deficit in 2008 and almost 70 per cent (104 hospitals) were projected to be in deficit in 2009. In 2008, there was a major round of hospital restructurings and cuts across the province of Ontario. The LHINs were told to review services in all hospitals to either avoid a deficit or reverse a projected deficit. With the increasing costs of hospital services across the province, there had been some discussion at the provincial level of either amalgamating services across the regions or amalgamating hospitals, as a way to reduce health system costs.14 The Riverside community had always feared it would be forced to amalgamate with one of the larger community hospitals in the region, a 40-minute drive away from Riverside. The LHINs were required to make cuts to eliminate any waste. The LHINs’ cuts included the closure of emergency departments, cuts to hospital departments and beds, closure of small and rural hospitals, privatization of support services, lay-offs and attrition, increased fees for patients and their visitors, and other measures. The South East Local Health Integration Network had hired consultants to review the role of the emergency rooms in three small rural hospitals, including RDMH. Additionally, service reviews to identify cuts were underway in other hospitals within the LHIN. Another challenge for small rural hospitals like RDMH was the availability and retention of health professionals. Due to the small number of beds, there were always challenges ensuring that specialist care was available when needed. For example, there was only one obstetrician in the community, pharmacists were in short supply across the province, and diagnostic imaging technicians were difficult to retain. Adding to this challenge was the relatively small volume of patients at RDMH, which was not large enough to sustain full-time health professionals in practice. This was particularly an issue in the pharmacy, which, on occasion, had no pharmacist coverage for parts or all of busy weekends. In 2008, both the federal and provincial governments created funding for special infrastructure projects for Ontario hospitals. LHINs could make appeals for funding for both minor capital projects and projects for hospitals within LHINs that would result in systems that enabled authorized health care providers to access, manage, share and safeguard patients’ medication histories. These grants had been used in other hospitals for upgrades to heating, ventilation and air-conditioning systems, fire alarms, and master medical gas equipment, as well as drug information systems, laboratory information systems, and telehealth.15 RDMH Hospital Operations RDMH had a long history of fiscal prudence and accountability, finishing each of the previous decades with a balanced budget. No other hospital in its region had been able to achieve a balanced budget the previous five years. The culture of the organization was one filled with pride about this accomplishment. The senior team promoted this message and most of the staff saw themselves as intimately involved in producing the balanced budget (see Exhibit 1). Being a small community hospital, the hospital staff was composed of people who had lived and worked in this community hospital for decades. Ninety-five per cent of the staff members lived in, or around, Riverside. Many of the hospital staff had never worked in another hospital. They were very loyal to the
14 “Cross-Province Hospital Cuts Cause Major Lay Offs, Privatization; Threaten Local Emergency Rooms, Birthing, Hospital Beds,” Canada’s Newswire, December 2, 2008, www.newswire.ca/en/releases/archive/December2008/02/c6197.html, accessed June 21, 2011. 15 B. Lauckner, “Ontario Health-Based Allocation Model (HBAM) Overview,” Waterloo Wellington LHIN, March 26, 2009, www.waterloowellingtonlhin.on.ca/uploadedFiles/HBAMOverview.pdf, accessed June 21, 2011.
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hospital and were seriously concerned with the possibility that RDMH would be closed if the government thought it wasn’t fiscally responsible. Many members of the hospital staff took part in activities throughout the hospital to ensure that money was not wasted. RDMH had developed a procedure for recommendations from staff to cut waste. Once a recommendation was submitted, it needed to be approved before staff could implement it. For example, a nurse submitted a recommendation to organize a recycling program for juice containers. She pointed out that RDMH distributed three juice containers a day to every inpatient and on average two to every outpatient. These containers were thrown out. However, a friend had told her that they could be returned to the local recycling company for cash. This recommendation was approved and the juice containers were now collected every day and redeemed once a month. This money, roughly $5,000 a year, was placed into the general budget. There were several approved of initiatives like this that the staff members participated in to ensure that RDMH did not waste money. However, Jordan suspected that the RDMH staff members were participating in other activities not officially approved of by the hospital as well. PATIENT SAFETY Patient safety was a major concern for all hospitals in Canada. According to the Ontario government, “Patient safety is about managing and reducing risk to ensure that the care patients receive is as safe as possible.”16 This involved the prevention of adverse events (AEs). These were accidental injuries or complications caused by one or more members of a patient’s healthcare team that resulted in death, disability or prolonged hospital stay. An AE could be an adverse drug event, a hospital-acquired infection, a hospital-incurred patient injury, an unplanned removal, injury or repair of organ during surgery, and many others.17 In 2004, Baker and Norton examined the rates of AEs in Canadian hospitals. Their published results were considered to be a wake-up call throughout the country. In their study they found that 187,500 out of 2.5 million patients admitted annually to acute care hospitals experienced an AE. Thirty-seven per cent of all AEs were “highly” preventable. The three most common areas for AEs in a hospital were surgery, medication and infection.18 AEs as ADEs While reviewing this study for information on medication-related adverse events, Jordan noted that the authors found that one out of nine adults would potentially be given the wrong medication or wrong medication dosage and that 24 per cent of preventable adverse events were related to medication error. Medication errors often resulted in adverse drug events (ADEs).19 The authors noted that many of the hospital medication systems were prone to error because they were manual systems that relied heavily on individuals, who could make mistakes.
16 “Patient Safety,” Ontario Ministry of Health and Long-Term Care, October 26, 2009, www.health.gov.on.ca/patient_safety, accessed June 21, 2011. 17 Baker et al., “The Canadian Adverse Events Study: The incidence of adverse events among hospital patients in Canada,” Canadian Medical Association Journal, 170:11, 2004, pp. 1678-1685. 18 Ibid. 19 “The Canadian Adverse Events Study and Medication Safety,” Institute for Safe Medication Practices Canada, July 2004, www.ismp-canada.org/download/hnews/HNews0407.pdf, accessed June 21, 2011.
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AEs and RDMH Many healthcare workers, after reading this study, called for an investment in new systems that would decrease medication error by taking it out of the hands of fallible humans.20 For example, hospitals investigated purchasing computerized physician order entry to eliminate both medication errors caused by poor handwriting and medication errors caused by the use of confusing abbreviations used by physicians.21 The RDMH board of directors endorsed a patient safety action plan designed to raise awareness about patient safety and to improve the safety of patients at RDMH. This action plan was made up of six initiatives aimed to increase patient safety. Initiative #1 - Education and Awareness Increase the education and awareness about the issues of patient safety with staff and physicians. Increase the awareness of how medication errors affect RDMH’s patients. Increase the awareness of patient safety concerns with visitors. Initiative #2 - Medication Management Introduce new safe medication management practices and processes. Control the practices surrounding the use of high-risk medications. Initiative #3 - Incident Management Implement an information systems risk management system to track and monitor patient safety
incidents. Initiative #4 - Patient Identifier Program Introduce a patient identifier program, which ensures that all patients are properly identified before a
test or procedure is performed, or before medications are administered. Initiative #5 - Infection Avoidance in Critical Care Introduce new standards and practices to avoid hospital-acquired infections. Initiative #6 - Hand Hygiene Campaign Participate in a major hand-washing campaign in participation with the Ontario Hospital Association’s
“Just Wash Your Hands.”
20 Ibid. 21 Ibid.
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MEDICATION MANAGEMENT INITIATIVE Jordan initially focused her attention on the safety issues in the pharmacy. Specifically, she addressed safe medication management and planned to recommend strategies to the board to support and ensure safe medication management practices and processes. To begin, Jordan investigated all adverse events involving medication administration at RDMH. Specifically, she needed to identify the prevalence and severity of drug errors at RDMH. In professional practice, the “Five Rights” needed to be followed with every medication administered to ensure safe practice. The Five Rights There were five important steps to follow when administering medication to a patient. Anyone giving medication in a hospital needed to ensure that “Five Rights” were practiced every time a patient received a medication.22 1. The Right Patient: In this step, the person administering the medication needed to identify the patient.
It was not enough just to ask the person what their name was. Sometimes the patient was confused, or their level of consciousness was altered due to medication or a procedure, or they were non-verbal. The person administering the medication needed to check the patient’s arm band and verify it with the patient’s name on the chart and the doctor’s order on the chart.
2. The Right Medication: In this step, the person administering the medication needed to double check
the medication to be administered. This was very important since some medications with similar names might look the same.
3. Right Dose: In this step, the person administering the medication needed to ensure that the right dose
of the medication was administered. Many hospitals used generic drugs and the person administering the medication might need to measure liquid or split tablets to ensure that the dose was correct. The dose in the original prescription needed to be checked to be sure that the dose was accurate and to ensure that the pharmacy dispensed the correct dose and medication.
4. Right Route: In this step, the person administering the medication needed to ensure that it was being
given using the right method. For example, if the medication was ordered as an intravenous infusion it might hurt the patient if it was given orally. Additionally, if the medication was ordered as a deep intramuscular injection, the person administering the medication needed to ensure that a needle of the correct length and gauge was used, and that the medication was injected safely in the correct site.
5. Right Time: In this step, the person administering the medication needed to ensure that each
medication was given at the right time. There were several reasons for this. Some medications might interact with one another or with food so they needed to be given at the right time to avoid these interactions. Additionally, levels of certain medications in a patient’s bloodstream needed to be maintained to make sure the patient got the most benefit possible from the treatment.
22 F. Federico, “The Five Rights of Medication Administration,” Institute for Healthcare Improvement, November 7, 2007, www.ihi.org/IHI/Topics/PatientSafety/MedicationSystems/ImprovementStories/FiveRightsofMedicationAdministration.htm, accessed June, 21, 2011.
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From January 2008 to December 2008, there were 195 reported errors at RDMH. These errors included the wrong dose being given, a dose of medication being missed, an extra dose being given or the wrong drug being given. Of these, 16 errors were found after harm was caused. Five of these errors might have contributed to a patient’s death. When Jordan looked at a further breakdown of the errors, she noted that 108 of the errors occurred during the administration of the doses compared to only one that occurred during physician ordering, 61 during transcription, and 26 during dispensing and delivery. However, when Jordan raised this issue with the nurses involved in the administration of the doses, she was reminded that it was possible that some of the errors in administration really occurred at other times but were only found when the medication reached the nursing unit. The incident of the wrong medication being given to the patient because the pharmacy had made a mistake was given as an example, since this error was recorded as an administration error and not a dispensing error. In addition to these reported errors, Jordan knew that many errors went unreported because medication errors were reported voluntarily by the staff members who found the errors. Historically, the reaction to an error, throughout healthcare, had been to either hide the problem or assign blame to an individual and then punish the individual.23 For example, at RDMH five years earlier, a nurse accidently gave the wrong medication to a patient. Despite evidence that the label was difficult to read, that the nurse had more patients than the College of Nurses of Ontario deemed safe as a workload, and that the nurse had worked a double shift (two eight-hour shifts), the only outcome was the termination of the nurse. Researchers had found that the use of blaming and punishment, or hiding the problem, had no positive impact on patient safety. This was because it did not identify the root causes of problems.24 Often the cause of an ADE was not the actions of one individual, but a combination of many poor practices. This was referred to as the “Swiss cheese” model of error causation in the patient safety literature. In this understanding of ADE, many poor practices existed and one day, they would all align so that a hole was created that allowed the safeguards to be bypassed and the ADE to occur.25 In the example of the nurse who got fired, the practice of working long shifts back-to-back, too many patients, and the poor quality of the label on the medication all combined together to result in an ADE. Clearly, there were many processes involved in safe medication dispensing and administration in the hospital setting. Jordan needed to identify and fix the different medication dispensing practices that might cause adverse events for patients at RDMH. In order to do this, Jordan investigated the medication management process at RDMH. DRUG DISPENSING PROCESS AT RDMH “In-house” Pharmacy An “in-house” pharmacy referred to a pharmacy that operated within the hospital. It supplied all the medication for use in the hospital.26 Hospital pharmacists in general were responsible for the purchase, manufacture, dispensing, quality testing and supply of all the medicines used in the hospital. Pharmacists
23 M. Grissinger, “The Five Rights: A Destination Without a Map,” Pharmacy & Therapeutics Journal, 35:10, October 2010, p. 542, www.ncbi.nlm.nih.gov/pmc/articles/PMC2957754/pdf/ptj35_10p542.pdf, accessed June, 21, 2011. 24 Ibid. 25 Ibid. 26 “Glossary of Pharmacy-Related Terms,” U.S. Department of Health and Human Services, www.hrsa.gov/opa/glossary.htm, accessed June, 21, 2011.
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often consulted with physicians and nurses on the inpatient issues. “Clinical pharmacy” was a term which referred to the pharmacist being involved in the clinical areas so that they could be directly involved in patient care with the health team. They would advise on a patient’s type of medication, dose and method of delivery — such as tablet, injection, ointment and inhaler, taking into account factors including their existing medication, their medical history, their lifestyle and their ability to understand and adhere to a medication treatment plan.27 These pharmacists were able to provide information to the medical staff about potential side effects and ensure that new treatments were compatible with existing medication. For example, they were expected to provide expert advice on medications for patients with conditions such as heart failure, and kidney or liver disease, and for pregnant or breast-feeding women for whom certain medications were contraindicated. In addition, they monitored the effects of treatment to ensure that medication was safe and effective. One of their main roles in the dispensary was to “professionally check” all prescriptions to ensure that the dispensed medicines were appropriate and safe for individual patients.28 RDMH “In-house” Pharmacy In 2004, RDMH had an “in-house” pharmacy staffed by one full-time pharmacist and one part-time pharmacist. The director of the pharmacy provided pharmacist services to the hospital Monday through Friday from 8:30 a.m. to 4:30 p.m., while the part-time pharmacist provided pharmacist services Saturday and Sunday from 8:30 a.m. to 4:30 p.m. For pharmacist services after hours, the full-time pharmacist was on call. In addition to the pharmacists, the pharmacy had six pharmacy technicians. The technicians worked full-time to staff the pharmacy from 8 a.m. until 9 p.m., seven days a week. In 2008, the South East LHIN investigated the use of pharmacists in all hospitals. It found that the number of patients in RDMH did not justify this level of pharmacy coverage. As a result, the part-time pharmacist position was cut. The full-time pharmacist’s on-call duties were extended to cover the weekend as well. In situations in which the pharmacist was on holiday or sick, a pharmacist from another hospital was contracted to be on call. Six months later, the director of the pharmacy announced that she had accepted a position in Toronto. During her exit interview, she told the hospital human resource manager that she was unhappy with the constant on-call duties of the RDMH position. Since the departure of the full-time pharmacist, the hospital had been unable to fill the position. As an alternative, two part-time pharmacists were hired to cover pharmacy services Monday through Friday from 9:30 a.m. to 3:30 p.m., and were on call on the weekends and in the evenings. Jordan noted that it was only for unusual or critical issues that a pharmacist was now called in. When Jordan asked about this, she was told that the pharmacy technicians tried not to call the pharmacist unless absolutely necessary because of the on-call bonus that the hospital had to pay each time the pharmacist was called in. Collection System RDMH used what was known as the collection system for delivering medication to the patients. This was an old system that was still widely used in hospital pharmacies. Jordan followed the path of a prescription
27 “The definition of clinical pharmacy,” National Electronic Library for Medicines, January 29, 2010, www.nelm.nhs.uk/en/NeLM-Area/Evidence/Medicines-Management/References/2010---January/29/The-definition-of-clinical-pharmacy, accessed June, 21, 2011. 28 “Hospital Standards of Practice and Guidelines on Practice in Hospital Pharmacy,” The Manitoba Pharmaceutical Association, July 2002, www.mpha.mb.ca/pdf/Standards-of-Practice-Hospital-09.pdf, accessed June, 21, 2011.
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from the time the physician ordered it until the patient received it, in order to see if there were any areas of concern causing ADEs. Following the Medication Path On a Tuesday morning at 8 a.m., an admitted patient was seen by one of the hospital’s physicians. The patient was in great pain due to chronic cancer pain. The physician wrote an order for a narcotic analgesic, Dilaudid, in the patient’s chart. Dilaudid was a trade name for Hydromorphone, a derivative of morphine. This drug was three to four times stronger than morphine. It acted quickly and had a lower risk of dependency for long-term use. It had become a very popular drug in the treatment of moderate to severe pain.29 This order contained the name of the drug, the dosage and the frequency: “Dilaudid 3 mg p.o., every 4-6 hours prn.”30 The physician then put a red tag on the patient’s chart to alert the ward clerk that there was a medication ordered. The ward clerk transcribed the order onto the patient’s medication record and took the patient’s chart to the registered nurse to check that it had been transcribed correctly. The registered nurse then initialed the order and checked the patient’s medication record for other medications ordered. The ward clerk sent a clerk down to the pharmacy with the order. The drug order was placed in a queue. When the pharmacist got the order, she counted out enough Dilaudid pills to last for five days, put the pills in a medication bottle, labeled it with the patient’s name, and hospital number, and placed it in the bin to be picked up by the clerk and delivered to the patient’s floor. The bottle was then taken up to the floor by a clerk who gave it to the registered nurse to put it safely into the medication room on the floor. Since Dilaudid was a narcotic (a controlled drug), it was placed in the locked narcotic drug cupboard in the medication room. The head nurse designated one registered nurse who carried the keys to the narcotics cupboard. After the registered nurse reviewed her patient care plans and medication for her six other patients and gave the morning medications and care, she checked the medication room and found that her patient’s pain medication had been delivered and placed in the locked drug cupboard. The registered nurse found the nurse with the narcotic keys to unlock the cupboard. The two nurses reviewed the patient’s medication orders, checked the medication and patient name on the bottle to make sure it was the correct medication and dose, and was for the correct patient, and then recorded that the narcotic had been removed from the locked narcotic cupboard. The medication was then given to the patient. The nurse recorded that the Dilaudid was administered, as well as the time and dose, on the patient’s medication chart. The second registered nurse with the narcotic keys then signed to confirm that the right drug and dose had been given to the right patient. According to the chart, the patient received his first dose of Dilaudid at 2 p.m., six hours after admission to the hospital. From experience, Jordan knew that there were several problems that could arise with dispensing medication from the pharmacy and administering a drug to a patient. First, this system relied on handwritten medication orders. She had personally experienced trying to decipher between a physician writing “10 mg” versus “1.0 mg” in a patient’s chart. Additionally, this process was very time consuming. In the above example, the patient waited six hours, experiencing severe pain, before receiving his pain medication. Because nurses did not want their patients to remain in pain or to otherwise go untreated, nurses would sometimes “borrow” medication from one patient to give to another patient if they felt the order was taking too long. The nurse then had to remember to replace the borrowed medication. On this floor there were 60 to 70 drugs being administered in the morning. The nurses were very busy and would
29 “Hydromorphone,” The Titi Tudorancea Bulletin, October 10, 2010, www.tititudorancea.com/z/hydromorphone.htm. 30 p.o. = orally; prn = as needed.
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often forget to replace the borrowed medication. Finally, this system was very labor intensive.31 It was estimated that nurses spent about 20-30 per cent of their time administering medications.32 Other Practices After Jordan performed this review, she noticed other procedures regarding medication management that she felt raised patient safety concerns. First, if a patient was discharged and still had medication left in the floor medication room, the nurses returned it to the pharmacy. Instead of discarding or destroying these medications, the pharmacy poured medications back into the stock bottles to be reused. Second, Jordan realized that a pharmacist was not available at all times when their expertise was required. The best-practice standard was for the pharmacist to check all medication prescriptions as they were delivered by the clerks to ensure that there would be no medication errors. The pharmacy technicians would then dispense and double check the prescriptions before they were picked up. However, even when the pharmacist was on duty, many medications left the pharmacy without the prescriptions being checked by the pharmacist. This was not technically wrong, since dispensing and double checking prescriptions without the pharmacist was within the scope of practice of the College of Pharmacists.33 However, in RDMH the official policy was the same as most hospital pharmacies. In this policy, pharmacy technicians were not allowed to perform as many tasks as their College allowed them to do within their scope of practice. This included the dispensing and double checking of prescriptions. At RDMH, this practice had developed without a change of official policy since inadequate pharmacist coverage was the norm and often there was no pharmacist on duty. OPTIONS Jordan had identified several different options that RDMH could adopt to satisfy the medication management concerns of the hospital. These were an integrated pharmacy, a bar-code medication administration system (BCMAS), a unit dose system, and an automated pharmacy. Unit Dose System The unit dose system was a medication-dispensing system. In this system, the medication doses were individually prepared, and packaged in bubble packs for each individual patient by a machine off site. Each individual dose was then labeled with the name of the drug, the name of the patient, and the dose and time the medication was to be given. Instead of the pharmacy sending up a bottle with the five days’ worth of medication, the pharmacy sent up the five days’ worth of medication in the individual bubble packs.34 In this system, many medications arrived at the pharmacy in unit dose packages. However, there were many medications that the pharmacy would still receive in bulk. The pharmacy staff n e e d e d t o then
31 Shack & Tulloch, “Integrated Pharmacy Automation Systems Lead to Increases in Patient Safety and Significant Reductions in Medication Inventory Costs,” McKesson, 2008, www.mckesson.com/static_files/McKesson.com/MPT/Documents/MAIFiles/CaseStudy_Shore_Memorial_Hospital.pdf, accessed June 21, 2011. 32 “Productive Ward Project,” Poole Hospital NHS Foundation Trust, www.poole.nhs.uk/about_us/productive_ward.asp, accessed June 21, 2011. 33 Z. Austin and M. H. H. Ensom, “Education of Pharmacists in Canada,” The American Journal of Pharmaceutical Education, 72:6, December 15, 2008, pp. 1-10, www.ajpe.org/aj7206/aj7206128/aj7206128.pdf. accessed June, 21, 2011. 34 “Lesson 2: Unit Dose System,” Parts Hangar, May 5, 2008, www.tpub.com/content/armymedical/MD0811/MD08110020.htm, accessed June 21, 2011.
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break the medications into unit doses and package them in the bubble packs. Medications available in unit dose packages usually cost slightly more per dose t h a n t h e same medications in bulk packaging. The pre-packaged drugs would cost $0.02 per dose. Additionally, there would be an initial cost of $200,000 and an annual cost of $30,000 for the packaging equipment to dispense the drugs in unit doses for patients using the bulk drugs supplied to the hospital. These systems had been in place in some Canadian hospitals since the 1970s. Jordan knew that many hospitals in the LHIN had already converted to the unit dose system. The pharmacists and nurses all spoke of the advantages of the system, saying that they felt it reduced medication errors, medication waste, nursing time involved in dispensing medications to patients, and inventory holding costs. In general, they felt it increased the amount of time both pharmacists and nurses were able to spend in direct patient care.35 Additionally, Jordan knew that the Canadian Society of Hospital Pharmacists endorsed the unit dose system as a best practice. All rural hospitals in Saskatoon used this system for distributing medication to patients.36 However, Jordan was also told that the unit dose system was more labor intensive for pharmacies. Pharmacies often had to increase their staffing to handle individual doses instead of sending a medication in bulk to a ward.37 Bar-Code Medication Administration System (BCMAS) Another option Jordan investigated was adopting a BCMAS. In a BCMAS, each drug was labeled with a unique bar code. The nurse and the patient also had bar codes. BCMAS Medication Path Jordan followed the path of a prescription from the time the physician ordered it until the patient received it, in order to see how the BCMAS worked. After the physician wrote a prescription, it was hand delivered to the hospital’s pharmacy in the same way as at RDMH. The pharmacist then entered the prescription into the pharmacy computer system. The pharmacist then dispensed a unit dose of the drug. A bar code was then attached to the unit dose. This unit dose, five days’ worth in individual bubble packs, was then taken back to the ward, in a similar method as at RDMH. The nurse then received the unit dose medication on the floor. She used a handheld device to scan the bar codes on her identification badge, the patient’s wristband, and the drug. If the system could not match the drug to be given with the order in the system, it would alert the nurse of a possible error. At that point, the nurse would either stop the process or override the warning. The details of the administration, including the drug, patient, time, any warnings and the nurse’s name, would be recorded in the hospital’s electronic
35 “Rosthern Hospital moves to unit-dose system,” The Region Reporter, June 25, 2010, http://regionreporter.wordpress.com/2010/06/25/rosthern-hospital-moves-to-unit-dose-system, accessed June 21, 2011. 36 Ibid. 37 “Disadvantages,” Parts Hangar, May 5, 2008, www.tpub.com/content/armymedical/MD0811/MD08110021.htm.
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medication administration record for the tracking of possible errors in the system.38 Jordan knew that none of the hospitals in the LHIN used this system but that many were interested in how it could help hospitals save money and reduce ADEs. In a study in 2008, 31 types of problems were identified with the system. For example, unreadable medication bar codes, malfunctioning scanners, unreadable or missing patient identification wristbands, and non-bar-coded medications resulted in nurses having to “work around” the system. These workarounds sometimes resulted in mistakes in the administration of medications.39 Jordan was concerned by these mistakes, plus the issue of cost. The system required the use of the unit dose system. In addition, the bar-coding technology and supplies would have an initial cost of $500,000 plus a 20 per cent annual cost.40 Automated Pharmacy As Jordan researched more options, one that many different hospital pharmacists mentioned to her was an automated pharmacy. This was a system that automated the unit dose packaging, storage, and dispensing of medication into one workstation. With this system, a physician would enter his or her prescription onto any hospital-approved digital device. This order would be received by the workstation. The system would then automatically dispense the unit doses package. A digital order would go to the floor, notifying the floor that a prescription was ready to be picked up.41 Again, Jordan knew that none of the hospitals in the LHIN used this system but that many were interested in how it could help hospitals save money and reduce ADEs. Many hospitals in the United Kingdom had implemented automated pharmacies. National Health Service research found that these systems reduced the dispensing errors from 16 per cent to 50 per cent, depending on the hospital.42 Additionally, the system increased the efficiency of the pharmacy. Before the system was introduced, the pharmacies handled 10-12 prescriptions per technician per hour.43 With the system in place, this increased to 15 prescriptions per technician per hour. Costs for the LHIN would exceed $2,500,000 and the annual costs would be 15-25 per cent of initial costs.44 The LHIN would be required to sign a five-year contract with any company that they chose to use. Additionally, the system would require the use of a BCMAS. The results were not all positive. For example, Jordan noted that not all medications could be stored in the system. For example, some systems could not store medication that needed refrigeration. Finally, the system sometimes “crashed,” in which case the pharmacy could not dispense medications with the machine, and staff would have to fill prescription orders “by hand.”45
38 N. C. Hodges, “QA Practices for Bar Coded Unit Dose Packaging Operations,” Pharmacy Purchasing & Products Magazine, September 2006, www.pppmag.com/article_print.php?articleid=20, accessed June 21, 2011. 39 J. Sakowski, T. Leonard, S. Colburn, B. Michaelsen, T. Schiro, J. Schneider, and J. M. Newman, “Using a Bar-Coded Medication Administration System to Prevent Medication Errors,” American Journal of Health-System Pharmacy, 62:24, 2005, pp. 2619-2625. 40 Ibid. 41 “Pillpick® Pharmacy Automation System,” Swisslog, 2009, www.swisslog.com/hcs-pharmacyautomation.pdf, accessed June 21, 2011. 42 S. Goundrey-Smith, “Pharmacy robots in UK hospitals: the benefits and implementation issues,” The Pharmaceutical Journal, 280, 2008, pp. 599-602, www.pharmj.com/pdf/articles/pj_20080517_pharmacyrobots.pdf, accessed June, 21, 2011. 43 Ibid. 44 This did not include the extra costs associated with the unit dose. 45 Ibid.
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INTEGRATED PHARMACY The final possibility explored by Jordan was an integrated pharmacy with London General Hospital (LGH). LGH LGH was a tertiary acute care hospital in the South East Local Health Integration Network. It provided advanced care in the areas of complex trauma, renal dialysis, acute mental health, cardiac care, stroke, and neurosurgical, as well as the broad foundation of medical and surgical services required to support these areas of specialization. It operated 505 patient beds, cared for 14,644 inpatients a year and employed 1,985 staff. When Jordan visited LGH, she noted that it seemed to share a similar work culture and set of values with RDMH. The pharmacies each had a similar IT system. Additionally, she knew from the different meetings arising out of the LHIN that there was now a high level of trust between the administrative leaders of both hospitals. Integrated Pharmacy An integrated pharmacy would mean that RDMH and LGH would share their pool of pharmacists. The part-time pharmacists at RDMH would have to become employees of LGH. The pharmacy at RDMH would be under the leadership of the director of the pharmacy at LGH. In this situation, RDMH would have access to LGH’s pharmacists. These pharmacists together would provide services to RDMH Monday through Friday from 8:30 a.m. to 4:30 p.m. In addition, the RDMH pharmacy would still have six pharmacy technicians. Patient prescriptions would be reviewed remotely by computer by a pharmacist at LGH, when there was no coverage at RDMH. RDMH would be required to cover the cost of one and a half full-time equivalent pharmacists in its budget. It would also be required to invest in any technology required to allow the prescriptions to be reviewed remotely. This could include a basic scanner and dedicated workstation, or it could require handheld digital devices for physicians to digitally record their prescriptions. All medication at RDMH would be packaged in unit doses by the pharmacy at LGH. Usually, one hospital pharmacy was not allowed by law to dispense for another hospital pharmacy. However, if the pharmacies were integrated by formal contractual agreements by the hospital boards, the legal issues would be resolved and a special outpatient license would not be needed. When Jordan spoke to the director of the pharmacy at LGH, Jordan pointed out that there were many processes that would have to be harmonized between RDMH and LGH. Specifically, she asked the director to introduce the best clinical practice standards used at LGH to RDMH’s pharmacy. This would require RDMH’s pharmacy staff to cease both its practice of returning unused patient medications to stock bottles and the practice of filled scripts leaving the pharmacy without pharmacist review. CONCLUSION As she drove into the parking lot at Riverside District Memorial Hospital, Jordan thought about what she would recommend at the board meeting. What option or options would work best for RDMH’s board, staff and patients?
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Exhibit 1
RDMH STATEMENT OF REVENUE AND EXPENSES 2007 AND 2008 (IN MILLIONS AND $CDN)
Revenue 2008 2007 Inpatients - Ministry of Health and Long-Term Care and LHIN
309.217 300.000
Inpatients - other 8.692 9.287 Outpatients 11.681 11.533 Educational programs 31.758 20.236 Marketed services 5.626 6.648 Recoveries 17.896 14.314 Amortization 6.710 6.388 Investment income .074 .018 Total revenue 391.654 368.424 Expenses Salaries and benefits 263.220 259.799 Patient care supplies and services 66.162 63.423 Utilities 5.214 5.083 General 40.715 38.020 Amortization of major equipment 13.215 12.015 Total expenses 388.526 378.340 Surplus (deficiency) of revenue over expenses
3.128 (9.916)
PHARMACY STATEMENT OF REVENUE AND EXPENSES 2007 AND 2008
(IN MILLIONS AND $CDN)
Revenue 2008 2007 Recoveries 5.500 4.676 Other 1.000 .780 Total revenue 6.500 5.456 Expenses Purchased services 30.000 25.000 Salaries and benefits 512.098 516.000 Supplies - printed forms .405 .395 Supplies - stationery 4.100 3.980 Supplies - photocopying .600 .495 Med. surg. supplies - general .395 .370 Med. surg. supplies - syringes .685 .642 Med. surg. supplies - gloves .125 .117 Med. surg. supplies - IV 1.000 .968 Drugs - IV 2.395 2.100 Drugs - other 76.000 70.000 Gases - oxygen 10.000 9.212 Gases - oxygen service charges 10.500 12.000 Other medical gases 9.272 8.800 General supplies 5.600 5.000 Equipment maintenance 2.631 2.500 Total expenses 665.806 657.579
Source: Created by author.