Using Technology to Address Medication Errors by John Chee,Using Technology to Address Medication Errors

1. 1
Using Technology to Address
Medication Errors
John Chee
Business Director
Dispensing, BD Asia
21 October 2016

2. 2
Prescription
Prepare/check
by pharmacist
Delivery to nursing unit
Administration
Ward Stock
Medication Distribution System

3. 3
Medication Safety
Source: Hong Kong Hospital Authority Medication Incident Statistics in Jul-Dec 2010
Top 3 Most Common Error Type
PRESCRIBING DISPENSING ADMINISTRATION
Position In-patient Out-patient In-patient Out-patient In-patient Out-patient
1 Wrong Drug
Wrong
Strength/
Dosage
(17%)
Wrong
Patient
(41%)
Wrong Drug
(40%)
Wrong
Drug
(29%)
Dose
Omission
(22%)
Dose
Omission
(22%)
2 Wrong
Drug/
Wrong
Patient
(13%)
Wrong
Strength/
Dosage
(14%)
Wrong
Strength/
Dosage
(15%)
Wrong
Strength/
Dosage
(24%)
Extra
Dose
(17%)
Extra Dose
(17%)
3 Wrong
Frequency
(9%)
Wrong
Frequency
(9%)
Wrong Patient/
Wrong Label
Information
(10%)
Wrong
Label
Information
(18%)
Wrong
Dose
(14%)
Wrong
Dose
(11%)

4. 4
Medication Management
Challenges
• Medication turnaround time
• Time spent on non-clinical
activities
Nurse
• Patient safety
• Medication management & control
• Medication diversion
Pharmacist
• Billing accuracy
• Patient care quality
• Hospital reputation
Administrator

5. 5
Best Practices
• Decentralized: Nurses dispense >80% inpatient
medication from Automated Dispensing Cabinet
(ADC)
• 2010 ASHP survey: 49% in 1999 to 89% in 2010
United States
• Parallel ADC growth seen in Canada
• 53%
Canada
Pedersen CA, Schneider PJ, Scheckelhoff DJ. ASHP national survey of pharmacy practice in hospital settings:
dispensing and
administration—2011. Am J Health Syst Pharm. 2012;69(9):768–85. doi:
10.2146/ajhp110735. [PubMed] [Cross Ref]

6. 6
Pyxis® ES MedStation ADC
Pyxis
ES

7. 7
Medication Safety Enhancement
Pyxis ES system devices
Patient dose-specific medication labeling
Configurable, secure single line-item storage
with smart CUBIE™ pockets
Duplicate patient name alerts
Easy to clean keyboard & work surface
Supporting JCI Standards

8. 8
Smart CUBIE™ Pockets
Enhanced security supports diversion prevention
Market-leading configurability
Quicker, more reliable access to medications
Improved serviceability
Forward compatible with smart CUBIE system
Secure single line-item access to all meds- small and large

9. 9
Enterprise-Wide Integration
Pyxis Enterprise Server
Integrate with PIS to standardize formulary
management
Integrate with Active Directory
to standardize user management
Centralize configurations across hospital
groups & provide site-specific flexibility
Leverage IT investments and manage
less with software-only or VMware-ready
Pyxis ES system
Facility 1 Facility 2 Facility 3

10. 10
Improved Safety and Control
Narcotics & Control Medications - VOC
“At KAMC the implementation
of the Pyxis MedStation and Pyxis
CIISafe systems has helped optimize
resources and reduced the need for
nursing-pharmacy phone calls and
possible miscommunication.
We are justifiably proud of our
practice, with streamlined paperless
workflow, and greater accuracy and
efficiency in managing N&C
medications and meeting regulatory
requirements—all the result of our
having implemented Pyxis systems.”
Pharmacist Mohammed Ali Al-Ghanmi,
Director of Pharmaceutical Care
Department,
King Abdullah Medical City, KSA
“The implementation of the Pyxis systems to
help optimize dispensing and inventory
control of N&C medication at KAMC is all
part of meeting our ultimate goal: patient
safety. We now have complete confidence
that the N&C medications we dispense every
day go to the right patient, right dose with
the right instructions at the right time in a
shorter period of time, and that every
transaction is automatically documented
electronically, helping to ensure accuracy
and prevent diversion. Automating N&C
medication management has freed our staff
from error-prone manual processes to
devote more of their time and attention to
clinical interventions and quality of care.”
Pharmacist Tariq Saad Tamim,
Supervisor of Pharmacy Automation &
Informatics Unit Pharmaceutical Care Department,
King Abdullah Medical City, KSA
source: White paper study King Abdullah Medical City,
June 2015

11. 11
Optimized Medication Mgt
Enterprise – wide - VOC
source: Case study
KFSH&RC Ryadh,
KSA, June 2015

12. 12
Pyxis Facts!
Over 7,500 customers with over 400,000 units installed across
the globe!
Pyxis® products have nearly 3x the customers of the nearest
competitor in USA!
Currently #1 in all 6
ADC categories!
#1 in Medication
Cabinet Nurse
performance!
Used in 14 out of 17
U.S. News Honor Roll
Hospitals!

13. 13
Improving Patient Care
in the Changing Healthcare
Environment