Development of a system-wide pharmacy operational weighted workload model at a large academic health system.

PURPOSE: The purpose of this study is to develop a standard operational and distributional weighted workload model that is applicable across an integrated, diverse healthcare system. This model aims to not only demonstrate the operational intensity of pharmacy practice but also to inform opportunities to decrease waste, increase efficiency, facilitate growth, and demonstrate value across operational and distributional pharmacy services. SUMMARY: Time studies were conducted at 8 hospitals within the UNC Health system to objectively measure time spent within each operational process in order to create a system-wide weighted workload model. Time study results informed the development of a system-wide weighted workload model. Data from December 29, 2019, through December 26, 2020, was then applied to this weighted workload model. With this model, acute care hospital and infusion center operational areas were compared in thousands of combinations within single operational areas and across any and all operational areas by dispense code, weighted work, and ratio of weighted work to total sum of dispenses at each site. CONCLUSION: The model successfully achieved the objective to develop a standard operational weighted workload model that is applicable across the integrated, diverse care system. This model provides a foundation for UNC Health to further productivity measurement and fills a gap in the literature by offering a novel method of developing a system-level operational workload model that can be used to evaluate and compare operational workloads across health-system sites.

Identifying health-system pharmacy operational process categories and corresponding tasks across a diverse health system using a modified Delphi process.

PURPOSE: The purpose of this study was to identify and build consensus on operational tasks that occur within a health-system pharmacy. METHODS: An expert panel of 8 individuals was invited to participate in a 3-round modified Delphi process. In the first round, the expert panel independently reviewed an initial list and provided feedback. All feedback was incorporated into the second round and then reviewed and discussed as a group. The expert panel reviewed an updated list based on feedback from the second round and reached consensus on a final list of operational processes and corresponding tasks. RESULTS: All 8 participants agreed to serve on the Delphi expert panel and reviewed an initial list of 9 process categories (hazardous intravenous [IV] medications, nonhazardous IV medications, hazardous oral medications, nonhazardous oral medications, controlled substances, total parenteral nutrition [TPN]/fluid preparations, distribution and delivery, clinical tasks, and miscellaneous operational tasks) and 44 corresponding tasks. Through the Delphi process, 72 new tasks were identified in the first round, while 34 new tasks were identified in the second round. In the third and final round, the expert panel reviewed the updated list of 9 process categories and 150 corresponding tasks, made additional edits, and reached consensus on a final list of 9 processes and 138 corresponding tasks that represented operational work within a health-system pharmacy. CONCLUSION: The modified Delphi process effectively identified operational processes and corresponding tasks occurring within hospital pharmacies in a diverse health system. This process facilitated consensus building, and the findings may inform development of an operational workload model.

Practice-enhancing publications about the medication-use process in 2020.

PURPOSE: This article identifies, prioritizes, and summarizes published literature on the medication-use process (MUP) from calendar year 2020 that can impact health-system pharmacy daily practice. SUMMARY: The MUP is the foundational system that provides the framework for safe medication utilization within the healthcare environment. The MUP is defined in this article as having the following components: prescribing/transcribing, dispensing, administration, and monitoring. Articles evaluating at least one step of the MUP were assessed for their usefulness in practice improvement. A PubMed search for articles published in calendar year 2020 was conducted in January 2021 using targeted Medical Subject Headings (MeSH) keywords, and the table of contents of selected pharmacy journals was searched, providing a total of 9,433 articles. A thorough review identified 49 potentially practice-enhancing articles: 15 for prescribing/transcribing, 10 for dispensing, 6 for administration, and 18 for monitoring. Ranking of the articles for importance by peers led to the selection of key articles from each category. The highest-ranked articles are briefly summarized, with a mention of why they are important within health-system pharmacy. The other articles are listed for further review and evaluation. CONCLUSION: It is important to routinely review the published literature and to incorporate significant findings into daily practice. This article assists in identifying and summarizing the most impactful recently published literature. Health-system pharmacists have an active role in improving the MUP in their institution, and awareness of the moist significant published studies can assist in changing practice at the institutional level.

Practice-enhancing publications about the medication-use process in 2019.

PURPOSE: This article identifies, prioritizes, and summarizes published literature on the medication-use process (MUP) from calendar year 2019 that can impact health-system pharmacy daily practice. The MUP is the foundational system that provides the framework for safe medication utilization within the healthcare environment. The MUP is defined in this article as having the following components: prescribing/transcribing, dispensing, administration, and monitoring. Articles that evaluated one of the steps were gauged for their usefulness in promoting daily practice change. SUMMARY: A PubMed search was conducted in January 2020 for calendar year 2019 using targeted Medical Subject Headings keywords; in addition, searches of the table of contents of selected pharmacy journals were conducted. A total of 4,317 articles were identified. A thorough review identified 66 potentially practice-enhancing articles: 17 for prescribing/transcribing, 17 for dispensing, 7 for administration, and 25 for monitoring. Ranking of the articles for importance by peers led to the selection of key articles from each category. The highest-ranked articles are briefly summarized, with a mention of why each article is important within health-system pharmacy. The other articles are listed for further review and evaluation. CONCLUSION: It is important to routinely review the published literature and to incorporate significant findings into daily practice; this article assists in identifying and summarizing the most impactful recently published literature in this area. Health-system pharmacists have an active role in improving the MUP in their institution, and awareness of the significant published studies can assist in changing practice at the institutional level.

Screening for expired medications in automated dispensing cabinets.

PURPOSE: Results of a study to quantify rates of identification of expired medications in automated dispensing cabinets (ADCs) are reported. METHODS: A pre-post analysis was conducted to determine the effect of various types of ADC audits on rates of finding expired medications in ADCs. For the experimental phase of the study, 4 ADCs at the main campus of an academic medical center were randomly assigned to receive one of 4 interventions: (1) monthly audits of all ADC pockets, (2) monthly audits of matrix (open pocket) drawers only, (3) monthly audits of unassigned pockets only, and (4) no additional intervention. RESULTS: At baseline, rates of finding expired medication doses in the 4 ADCs ranged from 0.4% to 0.7%. During the 3-month experimental period, rates of finding expired medication doses ranged from 0.1% to 0.3%. During a final audit 1 month later, the ADC targeted for monthly audits of all pockets was found to contain no expired doses, with an overall improvement in expired-dose rates for all audited ADCs observed over the course of the 4-month study. The average time to perform a full audit for an ADC with about 340 pockets was 1 hour, or 15 seconds per pocket. The average time to perform matrix drawer-only audits averaged around 45 minutes, or 11 seconds per pocket. The average time to perform audits of unassigned matrix drawers averaged 30 minutes, or 10 seconds per pocket. CONCLUSION: Auditing of all ADC pockets on a monthly basis appears to be an effective method of reducing the rate of identification of expired medications in ADC pockets.

Practice-enhancing publications about the medication-use process in 2018.

PURPOSE: This article identifies, prioritizes, and summarizes published literature on the medication-use process (MUP) from calendar year 2018 that can impact health-system pharmacy daily practice. The MUP is the foundational system that provides the framework for safe medication utilization within the healthcare environment. The MUP is defined in this article as having the following steps: prescribing/transcribing, dispensing, administration, and monitoring. Articles that evaluated one of the steps were gauged for their usefulness toward daily practice change. SUMMARY: A PubMed search was conducted in February 2019 for articles published in calendar year 2018 using targeted Medical Subject Headings (MeSH) keywords, targeted non-MeSH keywords, and the table of contents of selected pharmacy journals, providing a total of 43,977 articles. A thorough review identified 62 potentially significant articles: 9 for prescribing/transcribing, 12 for dispensing, 13 for administration, and 28 for monitoring. Ranking of the articles for importance by peers led to the selection of key articles from each category. The highest-ranked articles are briefly summarized, with a mention of why they are important within health-system pharmacy. The other articles are listed for further review and evaluation. CONCLUSION: It is important to routinely review the published literature and to incorporate significant findings into daily practice. This article assists in identifying and summarizing recent impactful contributions to the MUP literature. Health-system pharmacists have an active role in improving the MUP in their institution, and awareness of significant published studies can assist in changing practice at the institutional level.

Evaluation of telepharmacy and the use of a gravimetric technology-assisted workflow system for remote sterile product pharmacist checks.

PURPOSE: To evaluate the impact of remote sterile product pharmacist checks when used with a gravimetric-based technology-assisted workflow (TAWF) system on product checking accuracy, pharmacist review time, workload sharing, cost savings, and staff perceptions. METHODS: A double-arm, prospective study was conducted at 4 pharmacy locations for a 90-day period. Each compounded sterile product (CSP) checked by a remote pharmacist was also checked by a local pharmacist at the site of CSP preparation. An anonymous, online survey was emailed to staff before and after implementation to evaluate perceptions of the accuracy, timeliness, safety, potential impact, and value of the remote process. RESULTS: There was no statistically significant difference in the numbers of errors detected through the remote process and through the current, nonremote process (P = 0.177). The median pharmacist review time in the local process was significantly lower (P < 0.001). Remote pharmacists in the study workflow verified 30.4% of the total number of CSPs verified in the 90-day period. Annualized cost savings were calculated to be $23,770.08. Percent agreement increased from the preimplementation to the postimplementation period for survey questions about the safety of the remote process, opportunity for workload sharing, and optimization of current workflow. Percent agreement decreased for questions about the accuracy, timeliness, and value of the remote process and its impact on job security. CONCLUSION: The study demonstrated that with use of a gravimetric-based TAWF system, there was no difference in the accuracy and safety of sterile product pharmacist checks performed remotely and those performed at the product preparation site. In addition, the remote process allows for opportunities for workload sharing and cost savings.

Practice-enhancing publications about the medication use process in 2017.

PURPOSE: This article identifies, prioritizes, and summarizes published literature on the medication use process (MUP) from calendar year 2017 that can impact health-system pharmacists' daily practice. The MUP is the foundational system that provides the framework for safe medication use within the health care environment. The MUP is defined in this article as having the following components: prescribing/transcribing, dispensing, administration, and monitoring. Articles that evaluated one of the steps were gauged for their usefulness toward daily practice change. METHODS: A PubMed search was conducted in March 2018 for calendar year 2017 using targeted Medical Subject Headings (MeSH) keywords, providing a total of 2,288 articles. RESULTS: A thorough review identified 45 potentially significant articles: 19 for prescribing/transcribing, 5 for dispensing, 4 for administration, and 17 for monitoring. Peer review ranking for importance led to the selection of key articles from each category. The highest ranked articles are briefly summarized, with a mention of why this article is important within health-system pharmacy. The other articles are listed for further review and evaluation. CONCLUSION: It is important to routinely review the published literature and to incorporate significant findings into daily practice. This article assists in identifying and summarizing those that are most impactful. Health-system pharmacists have an active role in improving the MUP in their institution and awareness of the significant published studies can assist in changing practice at the institutional level.

Harmonization of technology across an integrated delivery network.

PURPOSE: A standardized blueprint for use when harmonizing or standardizing pharmacy automation and technology resources across individual institutions or an integrated delivery network (IDN) of institutions is described. SUMMARY: Whether to strive for standardization (use of the same vendors and equipment) versus harmonization (use of various technologies to meet patient-specific needs and organizational stability requirements) and how to coordinate activities across IDNs consisting of 3-30 or more hospitals are common questions due to consolidations in the healthcare industry. For most IDNs with legacy systems, harmonization may be the better option. Large-scale harmonization initiatives require significant planning and coordination involving all affected parties. Detailed project plans should include the compiling of all associated harmonization costs that involve human resources, information on ongoing services and equipment, and program schedules for multiple concurrent projects in order to provide a framework for planning and coordination. Part of the planning process for harmonization efforts should include an extensive current-state analysis that includes review of contracts and vendors. Final harmonization decisions should be based on a mix of vendor recommendations, best practices, and accommodation of current practices that result in the lowest complexity of system redesign with regard to existing systems. When harmonizing existing technologies, planning must also consider the impact of the change to both the organization and individual users. CONCLUSION: Harmonization is an evaluative process whereby process variation due to automation and technology variability can be reduced and organizational interoperability to meet patient-specific needs can be promoted.

Dihydroergotamine-induced vasospastic angina in a patient taking a calcium channel blocker.

OBJECTIVE: To report a probable case of vasospastic angina after administration of dihydroergotamine mesylate in a patient without coronary artery disease. CASE SUMMARY: A 49-year-old woman with relapsing/remitting multiple sclerosis was admitted for severe headache and pain crisis. She received a single dose of intravenous dihydroergotamine and, within 30 minutes, experienced chest pain, nausea, and vomiting. No changes on electrocardiogram were noted, but cardiac enzyme levels were elevated. Brief episodes of chest pain persisted for several days and resolved spontaneously before the woman's discharge. She had several cardiac risk factors, including cigarette smoking, hypertension, and a family history of coronary artery disease, but cardiac catheterization on hospital day 5 revealed no underlying coronary artery disease. DISCUSSION: Although cardiovascular adverse reactions have been reported with ergotamine tartrate, dihydroergotamine has rarely been linked with such reactions, including coronary vasospasm and myocardial infarction. Prescribing information for dihydroergotamine cautions against its use in patients with coronary artery disease or risk factors for underlying coronary artery disease without a cardiac workup before initiation of therapy. This patient had several cardiac risk factors, but cardiac catheterization revealed no underlying coronary artery disease. Concomitant verapamil therapy for hypertension did not prevent the vasospastic effects of dihydroergotamine. The Naranjo probability scale revealed a probable adverse reaction of vasospastic angina associated with dihydroergotamine. CONCLUSIONS: Health-care professionals should be aware of the possibility for vasospastic angina in patients receiving dihydroergotamine who have no underlying coronary artery disease. Prescribing information should be closely followed.