By Ruth E. Cassidy, PharmD, FACHE, and Joshy Joseph, RPh.
Transitioning from a manual method of IV preparation to an automated IV workflow system dramatically increases safety, standardizes processes, and reduces waste. In fact, IV workflow systems are increasing in popularity; per Pharmacy Purchasing & Products’ 2019 State of Pharmacy Automation survey, 63 percent of facilities with more than 200 beds plan implementations in the near future. This is not surprising, as this technology engenders strong satisfaction ratings; 90 percent of pharmacists surveyed are satisfied with their IV workflow systems and 72 percent rate their systems good or excellent.
SBH Health System made the decision to implement an IV workflow management system. Prompting this implementation was a near-miss event that would have been immediately identified had the organization been utilizing IV workflow automation. A pharmacist noticed a discrepancy in the weight of the IV medication solutions; therefore, the batch was immediately sequestered. A root cause analysis revealed that the IV pharmacist had been interrupted during the preparation of the IV medication solutions, which led to the inaccuracy in production. In an effort to improve their internal processes, SBH began the search for a gravimetric IV workflow management system as a corrective action plan.
Report Near Misses
At SBH, Patient Safety Friday occurs weekly, a multidisciplinary, facility-wide event where one department presents a patient safety issue and a solution. When pharmacy was selected to present, the topic of medication safety was chosen, focusing on preventing medication errors with an emphasis on the strategic goal of reporting near misses.
To reinforce the potential for serious consequences that can result from medication errors, pharmacy engaged a nationally-known speaker and advocate for medication safety who had lost his young daughter due to a preventable medication error. Physicians, nurses, pharmacists and administrators attended the presentation. Response to the presentation was overwhelming, as professionals heard a personal account of how a medical error can impact not only a patient and their family but also the healthcare professionals caring for the patient. The grand rounds presentation justified the pharmacy department’s determination to implement an IV workflow system that would serve multiple areas of the hospital.
Choosing an IV Workflow Software System
In coordination with the patient safety presentation, pharmacy invited IV workflow management vendors to provide hands-on demonstrations of their products to the nurses, physicians and administrators that attended the presentation. The workflow systems were set up in a conference room to allow staff members to handle and manipulate the workflow products in a show-and-tell experience to see how a medication product would be prepared and checked using the system. Hospital executives were also invited to interact with the technology so they too could fully understand the system’s error prevention capabilities.
SBH was already utilizing IV robotics to prepare a large number of IV medication solutions; therefore implementing IV workflow software was the next obvious safety step. Often hospitals acquire IV workflow technology after a tragic event has occurred. The focus at SBH was to improve internal processes before a patient was harmed and to enhance our IV preparation automation by implementing a workflow system that would further ensure patients’ safety. The hands-on experience proved valuable for both staff and the executives in advocating the acquisition of the IV workflow software system.
Ultimately, SBH chose and purchased an IV workflow system that fulfilled all desired requirements, which included the following features:
• Gravimetric verification
• Bar code scanning for each process step, from compounding through
administration at the patient’s bedside
• Photo documentation of the entire compounding process, including the
• Dual verification
Once the drug is compounded by a pharmacist using the IV workflow system, a second pharmacist checks the preparation to validate that it is correct. SBH purchased six IV workflow software system workstations to serve multiple areas of the hospital. The workstations were placed in the following locations:
• Non-hazardous oral preparation rooms (two: one for solids and one for liquids)
• IV preparation room
• Chemotherapy infusion center
• Hazardous (non-chemotherapy) system
The Implementation Process
Implementation of the IV workflow systems required a significant time investment to build the drug library. Although the process was labor intensive, ensuring all medication products in the library were accurate was critical to ensuring medication safety. Our strategy included breaking down the compounding process piece by piece in order to build each step into the IV workflow system correctly. As we were one of the first health systems to adopt this particular IV workflow management solution, we had to build the entire drug library from scratch.
The library build began with about 25 drugs, which were primarily fast movers, and then we went live with the system for those drugs so pharmacists could familiarize themselves with using the system. Thereafter, we gradually introduced additional drugs.
The process was slow at first, and it became necessary to gain pharmacists’ buy-in to using the technology, as some initially believed they could prepare the product faster using a manual process. However, pharmacy leadership made it clear that the IV workflow systems would ensure accuracy and ultimately patient safety. Even though the new process required slightly more time than a manual system, it soon became evident that the system needed to catch compounding errors was unparalleled. Once those skeptical pharmacists understood our stance and saw it for themselves, they supported use of the system.
Until the library was completely built, pharmacists could use the system for drugs that were in the library, but had to rely on a manual process for drugs not yet in the system. Managing the compounding process at this point was challenging, as pharmacists had to switch back and forth between using the IV workflow system and manual compounding. However, we have now built approximately 90 percent of the formulations into the drug library. Each area’s library is customized to suit the needs of that area and to restrict drugs that are not used in that environment. For example, a pharmacist working in the Infusion Center does not have access to the drugs used in the non-hazardous inpatient workflow library.
Note that with USP <800> certification on the horizon, it is important to review safe handling processes for all hazardous drugs, not just chemotherapy. For example, oxytocin is on the NIOSH list of hazardous drugs. At SBH, these medications are prepared in a designated HD cleanroom, separate from the chemotherapy HD cleanroom, using the IV workflow system. As more non-chemotherapy drugs are likely to be classified as hazardous, implementing IV workflow technology will be increasingly advantageous.
IV Workflow Training
IV workflow training for all staff who would use the system was provided by the vendor, presented as 12 modules that cover the entirety of the IV workflow process with each module taking about 2 to 2.5 hours to complete. In addition, the vendor provided hands-on training to all staff. We designated some staff members as superusers, who have an enhanced understanding of the system and can field questions from other staff members. To ensure staff members are utilizing the IV workflow system as intended, the facility utilizes Lean Daily Management processes and gemba walk-throughs where the Pharmacy IV workflow system utilization is measured daily. As of January 2020, 90% of compounded preparations are prepared utilizing the IV workflow software system.
It is not uncommon for each health care worker to compound IV medications in slightly different ways. A significant benefit of implementing the IV workflow system is that the device standardizes how IV medications are prepared, so we have the assurance that every pharmacist is preparing medications identically. Utilizing a standardized process also protects against practice drift, which can occur when pharmacists compound manually and infrequently.
Looking to the future, we would like to have bidirectional communication between the IV workflow system and our IV robot. We discussed the possibility with both vendors and are currently working with them on attaining a bidirectional interface.
In addition, we would like to further standardize the drug library. Hospitals typically have between 2000 and 4000 formulations in their formularies; each of these entries may have multiple line items, so it is not unheard of for a formulary to become as large as 20,000 items. Ensuring the accuracy and size of the drug library is an ongoing effort.
Utilizing a manual IV compounding process creates an opportune environment for medication errors to occur. IV workflow management systems, which automate the processes of preparing and verifying compounded sterile preparations, are an important tool to enhance safe sterile compounding. Not only do these systems help prevent medication errors, but implementing IV workflow software provides pharmacy with peace of mind that patients’ IV medications are accurate and compounded safely.