Running Head: Unit 4

Unit 4

ED 672

Overcoming Barriers to the Implementation

of a Pharmacy System for Medication

Dispensing: A Case Study

Robert A. Hess

18 June 2013

Unit 4

Abstract

The use of modern technology can vastly improve the services and reduce medication

errors that are produced at Bayne Jones Army Community Hospital Pharmacy. This case study

will report barriers to, and facilitators of, the implementation of a pharmacy dispensing system

that will reduce medication dispensing errors at a medium sized military hospital pharmacy.

During this case study I will interview staff, pharmacists, nurses, and doctors about their

experiences during the implementation of the Pyxis medication dispensing system. I will review

notes during the interviews to look for common information. There were some major barriers to

the implementation of the Pyxis system were: process (training requirements, process flow

issues), facilities (ability to successfully complete work orders in a timely manner or in the

correct fashion), technology (hardware, software, and compatibility/upgrade issues), and

resistance (communication issues, roles, and negative feelings towards anything new being

introduced). During the implementation the team I belonged to helped to overcome these

barriers by providing training, improving on existing situations, and adapting as problems arose.

The implementation team from Pyxis keep all parties involved, informed, accepted limitations,

and found ways to overcome barriers. Staff resistance to change was overcome by clearly

defining actions and objectives, identifying those who took well to the new equipment and

empowering them to help others, emphasizing how the new system could be implemented in

their work environment, and collaborating with other teams throughout the process.

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Introduction

Patient safety has always been a topic of intensive research and design of

program, technology, and processes. Patient injuries are most commonly due to adverse drug

reactions (ADEs), which occur at a rate of 6.5% or approximately 1,900 ADEs per hospital per

year. (Bates, 1995). Many of these ADEs are caused by medication errors that could have been

prevented. These errors occur during different stages of the medication process which includes

ordering, transcribing, dispensing, administering, and monitoring. Some solutions we currently

use are computerized physician order entry (Essentris and CHCS). These hope to avoid errors

that occur during the ordering stage. Dispensing errors occur at a rate of nearly 4%, of which

only 80% are intercepted. In a larger hospital, these error rates can translate to more than 45,000

undetected dispensing errors annually. (Bates, 1995).

The Pyxis medication dispensing system offers a new way to address medication errors in

an inpatient setting. It seeks to ensure that the correct medication is dispensed to the correct

patient at the correct dose, correct time, etc. The Pyxis medication system ensures that nurses

verify medication before it ever reaches the patient for administration. By using this technology

we have reduced medication errors by over 90%. In addition, the use of this technology has sped

up nurse’s workflow by making medication availability easier. The difficulty in the use of the

Pyxis system is attempting to define how much money it has saved. As the military pharmacy

and hospital does not directly bill any patient it is hard to justify, or quantify, these numbers.

The results of the implementation of Pyxis have been wonderful. Since the

implementation errors have decreased, workflow has been made better, and accountability has

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improved. The problems during its implementation included staff who did not want to use the

system, facilities not having equipment ready to be installed, and limited time to train the staff on

how to use the system. During the Pyxis implementation leadership helped to ensure the project

was a success. They made sure that resources and personnel were available to get the technology

installed, they worked closely with the vendor and implementation team to ensure it was

installed according to regulations and specifications, and they addressed any issues/concerns as

they arose.

Case Description

The Bayne Jones Army Community Hospital Inpatient department services the

Progressive Care Unit with capability of 15 beds, the Labor and Delivery / C-Section department

with capability of 15 beds, the Operating room with capability of 4 simultaneous surgeries, the

Recovery room with capability of 10 beds and expandable to 20, and an Emergency room with

the capability of 10 beds. The Inpatient pharmacy employs 1 full time pharmacist and 4

pharmacy technicians. Prior to December 2012 the pharmacy used cart exchange to ensure that

each patient received medications in a timely manner. The problem with that system was that

exchanged were never 100% complete and often nurses would hoard or hide medications for use

later. The switch to the Pyxis system came about as a result of end of year budget spending. The

project was forced into existence without any prior planning or input from the pharmacy

department.

The initial implementation of the Pyxis medication dispensing system required me to

dedicate time to helping implement the program. As the machines arrived from the distributor

they were loaded in the Inpatient pharmacy. Each medication was added based on previous

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stocking used during the old cart exchange program. Each medication was loaded into its own

pocket and was verified by a pharmacist for correct dose, strength, and medication name. The

Pyxis stations once full were sent to the patient care areas and inventoried again by pharmacy

and nursing staff to further reduce the possibility for medication or administrative errors. The

implementation team went floor to floor installing the system, training the nurses, and answering

questions.

This technology has significantly reduced medication errors and produced a positive

return on the initial money invested into their purchase. The implementation team and I

encountered many challenges, which were overcome. To capture some of the lessons learned, I

interviewed leaders, pharmacists and pharmacy technicians during the implementation process. I

conducted an analysis of the barriers I encountered, those who helped facilitate overcoming those

barriers, and I took a look at the sources of resistance and how I overcame them.

Participants

To maximize potential responses I interviewed the pharmacy chief, outpatient pharmacy

officer in charge, pharmacists, technicians, and nurses who were part of the implementation and

use of the Pyxis system. I developed a set of interview questions that focused on staff

perceptions of barriers to, and facilitators of, the Pyxis medication system. Interviews took place

during a 6 month period following system implementation. Each interview lasted approximately

one-half hour and was conducted by myself. I ensured to record notes during each of the

interviews and compared these notes against each other. I interviewed pharmacy and nursing

personnel who were either using the Pyxis system or involved in its implementation. The initial

set of interviewees was selected by my deputy commander from a total of 50 potential

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interviewees. As the interviews progressed, I asked those interviewed to help identify other staff

members who were champions to the Pyxis project. I ensured that each interviewee remained

anonymous and could withdraw or stop answering questions at any time.

A total of 25 people were interviewed between December 2012 and May 2013. Two

interviewees were pharmacy leaders, two pharmacists were interviewed, four pharmacy

technicians were interviewed, and the remainder were nurses. Results of my findings were

presented to the two pharmacy leaders to verify my results.

Barriers

During the implementation and continued use of the system I discovered several barriers

to the system. Training was a major problem. Due to facilities issues the implementation

timeline continued to get pushed back. This allowed only one week to load, install, and train

personnel. Original configurations has this process taking three weeks. Due to the limited

available time most training was conducted on-the-job, without formal classes. Champions were

identified early on and relied upon to ensure that those within their department became familiar

with the Pyxis machine and has a local point of contact to refer to when questions arose. During

interviews training was one of the major concerns. Many of the interviewees thought they were

not adequately trained and identified this as an obstacle to system implementation. Although the

addition of formal training or training over a longer period of time may have helped, limited time

barriers made this challenging. Increased time and resources would have been required to ensure

that the training was appropriate for a range of skill sets and tailored to individual differences in

learning. Pharmacy leaders also identified the importance of training in future implementation

processes. One interviewee emphasized that people needed practice in order to gain perfection.

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As people gained more experience with the Pyxis medication system, their comfort level with the

system increased. Super-users were trained outside of the one week time frame and have served

as peers who have provided informal support to their coworkers. The super user assisted in

medication administration for nurses in the patient care areas and really helped the pharmacy

throughout the continued system usage. Although the pharmacy was unable to implement the

super user method during the first week of training, its implementation afterward has helped

those personnel who continue to have difficulties by providing them with one-on-one training

from a champion.

Another issue with the Pyxis system was how to change workflow to use the system to its

maximum potential. For example, during the initial system implementation, cart exchange

medications were being sent once a day at 1 p.m. This practice was originally intended to limit

the number of time the pharmacy had to go to each floor. However, the downfall of this system

is that patients were admitted to the hospital at all hours of the day and each admission meant

medications that were needed on a designed schedule which did not fit into a 1 p.m. delivery.

The technician was still having to go to the floor several times during the day to bring up

individual doses for patients. While medication carts were being exchanged all medications

were not returned that were unused. Nurses made a habit of hoarding or hiding away

medications they felt they might need for future use. This produced an excess of medications

that were hidden and often expired before discovery. As well, without medications being

reviewed by the pharmacist there were medication errors made as nurses thought they were

giving the correct medication when in fact they were not. The Pyxis medication system

improved this process by having stocks of readily accessible drugs in individual pockets

available for nurse use. The Pyxis medication system required nurses to verify the amount of

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medication in a drawer before medications are removed. This prevents and identifies medication

mismanagement and potential theft issues. Having standard stocked medications in individual

pockets ensures the medication is available regardless of the time the patient is admitted to the

floor and stops nurses from hoarding. An additional benefit of the Pyxis system is that it tracks

the amount of medication in the drawer, a reorder point can be established that informs pharmacy

to reload the machine, and expiration dates are electronically monitored. Pharmacy staff can run

a report at any time to check on any of these factors and is used during the end of the month to

ensure no medication in the machine is getting ready to expire or is already expired. Having the

Pyxis medication systems in secure areas on the floor where patients are seen also makes the

workflow (from a nursing prospective) easier.

With the implementation of the Pyxis medication system, several technical problems

affected system implementation. These included both hardware and software problems, and the

role of vendors. Hardware problems were largely related to the biometric scanners installed.

Common issues included the scanner not scanning and power interruptions which require the

system to be shut down and restarted (taking valuable time out of patient care and workflow). It

was identified that scanners were not functioning properly because they were not being cleaned

at regular intervals and smudges and residue from fingertips was being left on them. Power

interruptions were unforeseen as the generator has been having technical difficulties as of late,

including the backup generator. This behavior was unanticipated and therefore not anything that

could have been addressed during the limited training process. However, since the

implementation these behaviors have been addressed and cleaning schedules and UPS

(uninterrupted power supply) have been implemented to alleviate these problems. Another

continued problem is that medications are mapped or loaded into improper drawers. To address

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this issue, pharmacy has mapped out incorrect fills and retrains technicians on procedures one a

quarter (every three months). To address the issue, pharmacy leaders created a process whereby

one technician pulls the medications to be loaded into the Pyxis based on the pull/fill report and

another technician checks to ensure the pulled medications are correct. This alleviates wrong

drug pulls. Technicians can still load the wrong drug into the wrong cell and certain medications

have warning associated on the screen with the medication that reminds the technician to double

check the medication prior to loading it into the machine. To alleviate many of these issues, the

vendor was involved to overcome these issues. Several strategies from the Pyxis team were

suggested. The Pyxis team continues to provide 1-800 support 24 hours a day 7 days a week.

Training can be scheduled at any time for any issue with the Pyxis system. Online training was

provided free of charge on a website that Pyxis users can access. The Pyxis team reviewed the

workflow both before, during, and after and recommended improvement to the process and ways

to use Pyxis to maximize its potential.

Staff resistance was a barrier identified during the implementation and interview process.

Resistance to the Pyxis system was due to communication issues, staff being overwhelmed by

another new system, and negative perceptions about technology. People thought that the new

system would do the work for them and make things better without any effort from their part. As

people roles changed there was backlash. Someone who once was responsible for an action had

to forget that information and implement a new plan within a short time frame. The Pyxis

system eliminated the need for numerous trips to and from the wards which allowed the

technicians to focus on other issues and resolving any discrepancies that the system revealed.

Although the role changing caused some to feel alienated it brought out champions who took n

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leadership roles and encouraged others to overcome any hurdles that came their way. These

champions helped others to overcome frustrations and reminded them of the system’s benefits.

The technology itself was a problem. People were worried about the overdependence for

technology, the potential for harm that the technology could bring, and the worry about increased

performance monitoring with more advanced reports. People were worried that when the

machine went down we would be unable to function. One interviewee was worried that with a

shift from manual checks to electronic checks that the human factor would be removed. One

interviewee thought that the system was only being put into place as a way to track their

performance. These negative views were mitigated by its useful functionality. As people used

the Pyxis they came to realize that the system made things easier, make dosage and medication

checks more accurately, and was not being used as a performance monitoring or punitive system.

Relationships among the Three Major Barriers

Staff resistance and process and technology barriers are related and all lead to system

flaws such as workarounds, in which users have found ways to bypass the intended safety

features of the system. Due to the inadequate training, process flow issues, and technology

shortcomings the pharmacy and nursing staff felt overwhelmed and developed negative

perceptions about the technology. This, in turn, encouraged users to find ways to cheat the

system. Instead of only taking out one tablet the nurse would take out two. Instead of charging

out medications for each patient they would charge out all of the same medication type for one

patient (i.e. multiple patients on the floor getting Motrin 800mg they’d charge out 6 tablets for all

patients instead of 1 tablet for the dose for the 1 patient). The pharmacy leaders and nursing

leaders dealt with this by becoming aware of these behaviors, continually resolving any issues

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that arose in a timely fashion and ensuring ongoing communication between pharmacy

technicians, pharmacists, pharmacy leaders, and nursing staff.

Discussion

Using a qualitative approach, I identified three major barriers to implementing the Pyxis

medication system: Processes, Technology issues, and Staff resistance. Although these barriers

were significant, those interviewed, and myself, found ways to overcome them. My results have

shown that the more information someone has during the implementation of a program the easier

it is to make decisions, and that when a system fits with their workflow, they tend to use it. The

champions that arose and the positive attitudes of participants toward technology were essential

to the successful Pyxis implementation. My case suggests that these principles hold true not only

for nurses but also for pharmacists and pharmacy technicians with varying backgrounds,

responsibilities and levels of education. My results are consistent with others experienced by

Pyxis as implemented in other installations. My case suggests that many of the workarounds

created by staff, such as the removal of more medications than requested, are also created by

others during the system implementation process. Important safety issues addressed during the

implementation and continued use have been reported to Pyxis in other implementations and

installations. Many of the barriers that I identified in the implementation of this project are

similar to those that were occurring before the addition of this technology. Our solutions and

lessons learned from this implementation process have use outside of my environment.

Pharmacy Pyxis implementation presents several unique implementation issues. For example,

training requirements must be uniform, scheduled, and based on varied education and skill

levels. The reactions of pharmacists and pharmacy technicians varied greatly to those of the

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nursing staff. Pharmacy staff were appreciating of the capabilities and information now readily

available to them. While some were concerned that the technology would allow their own work

to be tracked, others welcomed the opportunity to be able to track a medication through the

process. The tracking capability was a double-edged sword. It either acted as a barrier or

facilitator during the implementation of Pyxis. Due to budget and time lines this project was

implemented in a short time frame. All people interviewed, myself included, would have done

better with an extended implementation and training program. Many of the issues, concerns, and

work a rounds, I feel, could have been avoided with more training and instruction. Many

opportunities exist for others to implement Pyxis. Others may want to consider the cost of

technology implementation, beyond software and hardware. The largest problems we had were

infrastructure and organizational resistance. Policy makers at other installations should actively

promote knowledge sharing as part of the implementation process itself.

In summary, Pyxis medication system implementation is a difficult process with several

barriers involving processes, technology and organizational resistance. Fortunately, those

interviewed and participants of the Pyxis medication systems have identified many strategies and

policies to overcome these barriers. I can only hope that one day the lessons I’ve learned from

the Pyxis implementation may benefit others during their Pyxis implementation.

References

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Bates DW, Cullen DJ, Laird N, et al. Incidence of adverse drug events and potential adverse drug

events. Implications for prevention. ADE Prevention Study Group. J Am Med Assoc

1995; 274:29-34.

Ritchey, T. (1991). Analysis and synthesis on scientific method. Retrieved from

http://www.swemorph.com/pdf/anaeng-r.pdf

Stuter, L. (1996, March). The Delphi technique - what is it? Retrieved from

http://www.learn-usa.com/transformation_process/acf001.htm

Whitehead, C. (1967, September). Use and limitation of systems analysis. Retrieved from

http://www.rand.org/content/dam/rand/pubs/papers/2008/P3683.pdf

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