Today I was cleaning out my hard drive and ran across a draft document that never seemed to have gone anywhere entitled "Rethinking Medication Distribution in the Acute Care Setting". It is probably a couple of years old now, but I think it raises some questions that we need to answer as a profession. My interest was piqued by the article by Flynn et al entitled "The Autonomous Pharmacy"1, which did an excellent job of describing a 50,000 foot view of the problem but lacked details, as a vision statement should.
It also reminded me of a classic video of a lecture by Russ Ackoff (that I recommend to your viewing) wherein he describes the process by which Bell Labs moved telephony from the rotary dial telephone to most of what we enjoy (and rely on!) in modern communications. A key point in this tale involves their realizing that they had been incrementally improving on the same technology (the rotary dial telephone) for 50 years! It was time to throw it all away and start over.
I have had the privilege of knowing and working with a number of folk who were involved with our current acute care medication distribution technologies and realized that the oldest of those relationships goes back about 30 years. In those 30 years, we have been incrementally improving (maybe) those technologies but have introduced very little in the way of substantive or disruptive improvement.
This, in turn, caused me to look back on my over 50 years of practice experience and to assess how acute care medication distribution has changed. I experienced complete floor stock distribution, individual inpatient prescription (3-day supply labeled for the patient), unit-dose drug distribution (exchange carts) and, finally, automated dispensing cabinets (ADC).
Each of those steps reduced the supply of medications on the floor, presumably improved the safety of the medication administration process, and increased the nursing staff's dependency on pharmacy operations.
Each was expected to reduce the time pharmacy spent running medications to the patient care areas; a benefit that was not realized. It turned out that managing all those disparate inventories required (and still requires) a lot of human effort.
So, in the last 30 years, we have operated on a hybrid system in which some medications are delivered by ADC and some are not and have made few, if any, substantive changes in the way we deliver medications to patients.
Maybe it's time to take a page out of the Bell Labs playbook, and think about what an ideal distribution system might look like given the technologies that we have or are likely to have in the twenty-first century. If we were to start that process the way Ackoff describes, we would first start by enumerating problems in the current system we have to solve, and then set about solving them.
- Nursing workflow is hectic2,3,4,5,6. When our distribution systems interrupt medication administration to source needed medications, it becomes even more so. When a nurse has to run back and forth to an ADC, their risk of being interrupted escalates.
- Research I have done using ADC transactional data indicates has led to the development of an analytical model that identifies trips from the pharmacy to the patient care areas.7 It is by no means perfect, but irrespective of how it is configured or the relative size of the institution, the model shows that the most frequent trips involve few medications at few ADCs. This means that pharmacy is spending a lot of time running small amounts of medication up to the patient care areas.
One way we could solve both of these issues is to have a distribution system that delivers scheduled (and, perhaps PRN) medications just-in-time. The cost to do this with humans would be prohibitive, but, with advances that are occurring within the robotic space a number of things might be practical. Imagine a nurse being able to walk into a patient room, assess the patient condition, acquire the medications without having to leave the room (and ger interrupted many times) , administer and document the administration of those medications, assess the impact of the medications, and move to the next patient. I agree that there is a lot of magical thinking included in that description, but imagine how much more effective medication administration could be.
What do you think?
Dennis A. Tribble, PharmD, FASHP
Retired
Ormond Beach, FL
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1 Flynn A et al The Autonomous Pharmacy Amer J Health-Syst Pharm 78(7):636-645 April 1, 2021
2 Keohane, C et al Quantifying Nursing Workflow in Medication Administration JONA 38(1);19-26 January 2008
3 Garrett, S and Craig J Medication Administration and the Complexity of Nursing Workflow Clemson University(2009)
4 Cain C, Haque S Chapter 31 organizational Workflow and Its Impact on Work Quality Patient Safety and Quality: An Evidence-Based Handbook for Nurses Hughes, RG editor published by AHRQ, April 2008
5 Cornell P et al Transforming Nursing Workflow, Part 1: The Chaotic Nature of Nurse Activities JONA 40(9):366-373 September 2010
6 Cornell P et al Transforming Nursing Workflow, Part2: The Impact of Technology on Nurse Activities JONA 40(10):432-439 October 2010
7 Tribble, D Trips Model, patent pending - Application number WO2022271384 A1