Quality Improvement Project

Improving Inpatient Medication Dispensing

with an Automated System
Afaf Almalki,1 Aseel Jambi,1 Basem Elbehiry,1 Hala Albuti1
1
Department of Pharmacy, King Fahad Armed Forces Hospital, Ministry of Defense, Jeddah, Saudi Arabia

Address correspondence to Aseel Jambi ([email protected]).

Source of Support: None. Conflict of Interest: None.

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Submitted: May 15, 2023; First Revision Received: Jul 27, 2023; Accepted: Aug 14, 2023
Almalki A, Jambi A, Elbehiry B, Albuti H. Improving inpatient medication dispensing with an automated system. 2023; 6:117–125.
DOI: 10.36401/JQSH-23-15.
This work is published under a CC-BY-NC-ND 4.0 International License.

ABSTRACT
Introduction: Medication inventory management and error prevention are complex issues. Single interventions are
insufficient to make improvement across the spectrum. A uniform system for dispensing and distributing medications can
help reduce the risk of medication errors, improve efficiency, and minimize waste. This quality improvement project aims
to: 1) decrease – the time from ordering medication to administration, including delay incidents, by . 70%; and 2) decrease
the inpatient monthly total medication consumption by . 20% and ward medication stock items by . 70%, including
decreasing returned items and loss from in-house expired medications by . 70%. Methods: A Six-Sigma approach was
applied to eliminate deficiencies throughout the medication management process. Failure mode effect analysis and staff
surveys were used to evaluate implementation of automated dispensing cabinet (ADCs) and reengineered workflows for
expensive, misused, and restricted medications. Results: After the new processes were implemented, the turnaround time
from ordering medication to administration was reduced by 83%, with zero delay incidents reported. Most nurses (64%) and
pharmacists (67%) stated that implementation of ADCs increased their productivity by more than 40%. Monthly medication
consumption was reduced by 24%, with an estimated annual saving of $4,100,000 USD. The number of returned items per
month was reduced by 72%, and the estimated annual savings from loss of in-house expired medications was $750,000 USD.
Conclusions: This quality improvement project positively impacted stock control while reducing costs and turnaround time
for inpatient medication dispensing. Medication delay incidents were reduced, and staff satisfaction levels were positive.
Next steps are to reengineer narcotic, anesthesia, and refrigerated products’ management.

Keywords: Waste, inventory, medication error, Six-Sigma, FMEA, automation-satisfaction, safety, automated dispensing
cabinets

INTRODUCTION integration of prescribing, electronic medication admin-

istration records, and dispensing hardware and software
Delays in medication availability to the patient have must be planned to maintain patient safety [6] and to
been identified as a substantial component of medication optimize the workflow down to administration and
error overall with the United States National Coordinating replenishment. [5,7–10]
Council for Medication Error Reporting and Prevention, In the literature, nursing responses to automation of
relating such events to procedures and systems, including medication management have been generally positive,
prescribing, order communication, dispensing, and distri- with one study showing statements such as “I now spend
bution.[1] Many studies have attempted to evaluate initia- less time waiting for medications that come from the pharmacy
tives that include improving direct clinician-to-clinician than before the automated dispensing cabinet (ADC) was
communication for stat doses,[2[ electronic prescribing,[3] implemented” scoring well in surveys.[10] In a Qatar hospi-
and clinical dashboards with visual indicators for over- tal study[11], similar positive responses were found, with
due doses.[4] 87% of nurses agreeing that they were able to administer
Automation of the medication management process medication more efficiently with the ADC and a 91%
with more centralized control over the dispensing and overall satisfaction rate for ADC use.
distribution process has been suggested as having a posi- Waste minimization can help with maintaining sup-
tive impact on overall time required for medication ply.[12] According to West et al[13], “medication wastage
delivery and management,[5] with the caveat that robust refers to any medication which expires or remains unused

Global Journal on Quality and Safety in Healthcare 2023 | Volume 6 | Issue 4 | 117
jqsh.org
118 Almalki et al: Improving an inpatient medication dispensing system

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Figure 1. Overview of pre-automation workflow.

throughout the whole medicines supply chain (and) also times for inpatient medication dispensing (i.e., approxi-
refers to the unnecessary or inappropriate consumption of mately 170 minutes [range: 140–210 mins]). These inci-
medications by patients, or the unjustified non-adherence dents included delayed dose administration versus facility
to treatment guidelines by healthcare professionals.” targets for stat and routine orders of 30 minutes and less
In terms of the cost of transitioning to an automated than 1 hour, respectively; medication unavailability requir-
medication management process, Berdot et al[14] reported ing phone calls to the pharmacy; and workaround over-
that initial costs have to be built into budget impact stocking of nursing units, leading to medication wastage
plans, and there is a fairly immediate return on invest- through use of expired, inappropriate, and uncounted
ment from “gains in preparation time and fewer medica- medications.
tion process errors. Detectability of medication errors A study of nursing unit waiting times for medications
is extremely difficult, and a baseline rate for error in was undertaken with a Pareto 80/20 analysis to identify
traditional systems is hard to estimate. Reduction of where the project might best be applied during the pilot
medication error following implementation of ADCs has stage. This gave eight units to be targeted: pediatrics,
been reported to as 19% in the absence of effective inte- neonatal intensive care (NICU), two medical wards, gen-
gration with electronic prescribing systems and 50% or eral intensive care (ICU), emergency department (ED),
higher otherwise.[15–18] pediatric intensive care, and the transplant unit. The final
selection of the General ICU for pilot testing was based on
METHODS patient acuity, time criticality for medication delivery, the
requirement for constant bedside nursing presence and
No formal consent was required from the ethics commit- the Pareto analysis.
tee of the hospital. The project was approved by the hospi-
tal director. All patient data are automatically scrubbed Pre-Automation Workflow
from the metrics available in the Knowledge Portal. The pre-automation workflow is described in Figure 1.
This workflow relies heavily on manual distribution sys-
Baseline Assessment tems, including traditional floor stock and medication
A failure mode effect analysis (FMEA) was performed carts (patient-specific medications in individual patient
for the existing medication management system in cassettes). The floor stock system is flexible, but the phar-
December 2019 and was extended into the period of macy has little control over inventory. A 24-hour unit-dose
introducing ADCs to allow for mitigation of identified cart exchange system allows tighter inventory control
risks that were carried forward into the new system and than relying on whole-container floor stock, but there are
to allow for identification of new possible failure-modes limitations based on capacity for the central pharmacy
related to the introduction of automation. This approach to create and pick unit doses.20 Stat and new orders also
help identify where future improvement measures would require a nurse to visit the pharmacy, adding further
need to be established, and risk priority numbers (RPNs) potential delays for these medications. A major concern
were calculated for the medication chain from central with this workflow included unregulated “borrowing” of
pharmacy through to the patient’s bedside. RPNs greater patient-specific medications for other patients’ use.
than 100 were considered for immediate remediation.19 The Ishikawa diagram shows how the environment and
Flow charts, Ishikawa fishbone diagrams, and root-cause information technology (IT) infrastructure made it diffi-
analyses were used to explore issues of long turnaround cult to ensure that medications were consistently
 Quality Improvement Project 119

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Figure 2. Ishikawa fishbone diagram of the inpatient dispensing process pre automation. TAT: turnaround time.

dispensed with proper verification (Fig. 2). Floor stock the risk of incorrect dosing (i.e., the units dispensed are
medications were dispensed without being linked to a either the correct total dose or an uncomplicated multiple
particular patient profile, making it extremely difficult to of the prescribed dose).
track use and misuse of medications (including allergy The Ishikawa exercise made it clear that no single
supervision and detection of errors and near misses). A intervention would overcome all the problems in our
lack of medication tracking through the organization led medication chain. It was also clear that coordination
to understocking and overstocking, missing or inaccurate with nursing, logistics, transport, IT, and medical staff
medication charges, and complicated manual documen- was required for implementation of the planned interven-
tation procedures. Substantial amounts of unit-dose medi- tions. The Lean Six-Sigma approach of Define-Measure-
cations were returned to the pharmacy from nursing units Analyze-Improve-Control (DMAIC) method was used
because medications were discontinued or patients were because it focuses on eliminating defects (time, motion,
transferred and discharged. In nursing units, limited space and cost) throughout a process such as medication man-
within medication trolleys caused workarounds including agement. Processes introduced into the manufacturing
dispensed medications to be stored on top of trolleys, industry in the 1980s have been adapted by healthcare to
with potential for mixing with other patients’ medica- emphasize preventive error reduction, which aligns with
tions. The trolleys were not secure, and “whole package” FMEA and root-cause analysis of near-misses and actual
quantities of medications (i.e., greater than that required incidents.[21] The fundamentals of DMAIC and FEMA for
for the prescribed medication regimen) were dispensed. healthcare projects are well documented.[22–25]
This contributed to unused high-value medications being
destroyed when returned to the pharmacy due to the lack
of an efficient process for restocking them. Specific Aims
Beginning in January 2020, the planned interventions
Intervention included:
We recognized that a uniform system for dispensing • Installation of ADCs;
and distributing medications would help reduce the risk • Change in management of expensive and frequently
of medication administration errors. The hospital’s exist-
misused medications; and
ing process is to dispense medications in the “most ready- • Implementation of a secondary approval process for
to-administer form possible” to minimize opportunities for
restricted medications.
error during distribution and administration. This becomes
crucial during emergent situations and may also decrease Primary aims by end of 2021 include:
120 Almalki et al: Improving an inpatient medication dispensing system

• Decrease turnaround time from ordering to administra- restricted to two senior pharmacists. Second approval for
tion of regular and stat medications by more than 70% restricted medications was introduced via the CPOE and
(later, these would be patient-specific regular orders and approved by the Pharmacy and Therapeutics Committee;
stat orders, neither would be ADC stock items); restrictions were based on physician specialty, clinical indi-
• Decrease inpatient monthly medication consumption cation, and medication cost.
by more than 20%; Access to ADCs for both refilling and for administra-
• Decrease number of ward stock items by more than 70%; tion was based on the completion of training delivered
• Decrease number of returned items by more than 70%; exclusively by authorized Pharmacy Informatics and
• Decrease loss due to expired medications in both the cen- Automation service trainers as per American Society of
tral pharmacy and warehouse by more than 70%; and Hospital Pharmacists guidelines.26 Training covered (1)
• Decrease number of delayed stat and regular prescrip-

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how to create orders, dispense, and return medications;
tion medication incidents to zero. and (2) how to enter expiry dates, assign and load medi-
Secondary aims by end of 2021 include: cations, and create a picklist and delivery report. An
ADC Support Team of trained pharmacy staff was cre-
• Improve percentage of effectively answered medica- ated to resolve day-to-day problems and queries. Soft-
tion-related calls from nursing units handled by the ware, hardware, and interface issues were escalated to
pharmacy by more than 70%; the Pharmacy Informatics and Automation Team.
• Monitor nursing and pharmacy staff satisfaction with As the project expanded across the selected nursing
the new medication management processes; and units there were issues of day-case and ED patients not
• Support acceptance and assurance with the solution appearing in the system; the ADC vendor had to be con-
through training and acting promptly on feedback. tacted to expand the integration of the ADCs with the
Admission Discharge and Transfer system.
Introduction of Automated Dispensing Another systemic issue was encountered during the
Cabinets (ADCs) later integration of the dialysis unit. As patients were
ADCs can provide secure medication storage on patient being effectively discharged after each dialysis session,
care units,10 enhance the efficiency of medication distri- all “inpatient” medications were being removed from
bution, provide immediate access to medications, and the ADC, and physicians were required to order discharge
reduce medication-dispensing errors.15 They also allow medications as a separate action. This was resolved by
for more complete control of total in-facility medication modification of the system, with an option for these reg-
stock by the pharmacy department.14 ularly returning patients of “discharge with medications,”
BD Pyxis MedStation ES ADCs were integrated to the which automatically extends inpatient medications to
facility’s Computerized Provider Order Entry (CPOE) sys- outpatient status.
tem. The ADC installation plan used biometric-secured
access (end-user fingerprint) with scheduled refills by the Data Analysis
pharmacy department, with all dispensing and adminis- Data were collected over a protracted period because
tration being linked to patient profiles. Knowledge Portal the performance of medical devices and automation
reports were used for monitoring the effectiveness of commonly lags in performance as the human agents
selected par levels of medications, via nursing over- learn to work with automation and the system is opti-
rides of profiles to obtain medications when facing mized to meet the organization’s demands.27 We
stock-out situations, and to help identify potential anticipated an upturn in delayed medications fol-
medication diversion. lowed by a downward trend as pharmacists and nurses
ADC single-access drawers and cubies allowed tighter “learned the system.”28 For this reason, most data
control of medication withdrawal, the separation of Look- were interpreted in time-sequence graphs to examine
alike Soundalike (LASA) medications from each other, and variation at an aggregate level and to allow for an overlay
the isolation of high-alert medications. ADC inventory of linear trends.
management was devolved from pharmacists to phar- RPN scores and staff surveys were used to evaluate the
macy technicians. Pharmacists reviewed and checked new processes at 3 months and during the project’s roll
each patient’s medication profile for appropriateness, out. Turnaround time for non-ADC stat and routine
potential medication interactions, allergies, and against medication orders were taken from ADC and non-ADC
patient laboratory results. Medications were sent to the nursing units and amalgamated monthly.
nursing unit in their most ready-to-administer form, such The most complex aspect of data discovery was
as unit-dose packages, and oral syringes for liquid medica- ascertaining the bound stock and waste per annum pre
tions, both for dose control and to reduce waste of bulky ADC, as manual inventory was time-consuming and
items that could not be stored in the ADC. possibly inaccurate. The process of converting each
Expensive and commonly misused medications were nursing unit one by one helped in this process, as an
identified during planning, and during implementation audit could be undertaken in each area as medications
these medications were secured via dispensing access being were transferred from floor stock in cupboards to the
 Quality Improvement Project 121

ADCs, and expired medications were removed. In this DISCUSSION

way an ongoing tally could be kept that more accu-
rately assessed total bound stock pre-automation. Change is not always successful and sometimes diffi-
Consumption of expensive and commonly misused cult to measure. We feel that we have managed, in a
medications was also calculated. unique way, to triangulate the question of the project’s
Telephone calls to all inpatient pharmacy lines received success or failure with definitive cost and product savings,
and answered or not answered were monitored by the IT safety measures including RPN, and with a comprehen-
department, before and during the project. Although we sive satisfaction survey across the two key disciplines in
knew this would not directly reflect medication supply medication management: pharmacy and nursing. To our
issues per se, as there are other telephone queries, we felt knowledge, this theoretical framework for monitoring the
effectiveness of a change process for inpatient medication

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that as the bulk of calls to the department were supply
related, and that any reduction in the volume of such management, and the degree of triangulation of the cen-
calls would increase the likelihood of positively answered tral issues of waste, safety, and efficiency that it creates,
calls overall, this was an acceptable measure for the has not been previously applied.
The growing body of evidence on ADCs that are inte-
impact of ADC introduction, as we hoped to increase
grated into pharmacy stock management systems largely
medication lines available in the nursing units and
mirrors our experience. At the outset of the project, we
monitor stock successfully.
selected metrics to indicate successful change (i.e., reduced
turnaround time or cost savings targets) rather than estab-
RESULTS lished metrics (e.g., reducing RPN by half through each
cycle of change29 and establishing a downward trend for
The top five RPN scores from the pre-intervention FEMA stock-outs and overrides30). Setting 70% reduction in turn-
are shown in Table 1. All primary aims were met and went around time as a target was derived from pre-automation
beyond the original targets. Medication turnaround time data, where we found a mean average time of 170 minutes
from order to administration was reduced by 83% with (range, 140–210). The initial target of 50 minutes or less for
zero delay incidents reported. (See Fig. 3). each transaction, with a stretch target of 30 minutes or less,
In terms of our primary aims: was set as an achievable goal to put us en route to our final
• Monthly medication consumption was reduced by 24%. target of 30 minutes or less. As the results show, we achieved
• Overall, medication held as ward stock was reduced an 83% reduction, with almost all transactions taking 30
by 81%. minutes or less within 14 months of introducing the ADCs.
• The number of returned items per month was reduced The decision on what to set for achievable cost reduc-
tion was also set, in retrospect, somewhat conservatively.
by 72%.
•
We suggest that the question of bound stock within an
The estimated annual cost saving from total expired
organization—and therefore vulnerable to expiry loss,
medications (floor, inpatient pharmacy, and ware-
overordering, and apparent loss—is highly variable
house stock) was approximately $750,000 USD, a 57%
between facilities and is related to issues of transparency
reduction. This gave a substantial estimated annual
of stock, inventory constraints, and infrastructure. Con-
saving of
$4,100,000 USD.
versations with peers at other facilities indicated that the
• Reported medication delay incidents for both routine
wastage from stock totally from incorrect use, expiry, and
and stat orders fell from 7 to 0 by August 2020.
other losses could be as high as 80%. Although this infor-
For our secondary aims we found that: mation was anecdotal, it was drawn from experienced
pharmacists. An expectation of 70% reduction was there-
• The number of successfully processed telephone calls fore applied to the number of ward stock items, returned
to the pharmacy improved by 160% by mid-2021. items, and for loss due to expired medications in both the
This was primarily due to a substantial reduction in central pharmacy and warehouse.
“missing medication” calls. There was anticipation that savings in medication
• 64% of nurses and 67% of pharmacists stated that and costs would be achieved, but the team and the orga-
ADC introduction increased their productivity by nization were surprised by the volume of medications
. 40%. (See Fig. 4). expiring in the pre-change system. As discussed earlier,
• Workflow efficiency was the highest scoring item of ascertaining the bound stock and waste per annum pre
the benefits of automation for pharmacy staff. Nurs- ADC was time-consuming, and possibly inaccurate. The
ing staff scored medication safety as the most impor- process of auditing each nursing unit one by one had
tant benefit (see Fig. 5). not been done before, so a lot of discovery occurred
• The nursing and pharmacist surveys showed good during this stringent process. As discussed above, we
internal consistency, and reliability for the applied had set out our targets for cost-savings based on the
scale (Cronbach alpha for all items, 0.9709; range, organization’s wider goals of budget control across the
0.9625–0.9744). facility and through conversations with our peers from
Table 1. Top five RPN scoring activities in the inpatient pharmacy before introducing ADCs, with pre- and post-intervention scores
122

Integrate pharmacy Out of stock in nursing

formulary– Order verification units for individual
Activity monitoring system and approval Emergency situation medications LASA medication error
Potential failures
Failure of integration Physicians create Delay in unit receiving Medication administration Incorrect selection of medication by
incomplete order medication in acute delay administrating nurse
situation
Potential effects
No control of process Process of approval Failure to treat Failure of therapy Incorrect medication may reach the
delayed emergent patient patient
event correctly
Potential causes
Unable to integrate Physician Nurses have to wait for Inventory miscount, Wrong medication stocked or selected
unavailable to pharmacy approvals pharmacy miss refill
correct order and delivery of cycle
medications Medication placed in
wrong location
Current controls
None None None Manual reporting LASA medications separated in
pharmacy and inpatient units
Pre-Intervention
Scoresa
Severity 8 9 10 7 10
Occurrence 10 10 5 5 10
Detection 5 8 10 10 9
RPN 1 score 400 720 500 350 900
Corrective actions
Almalki et al: Improving an inpatient medication dispensing system

undertaken
Integrate ADCs with CPOE alert screen for ADC override function Scheduling refills with Avoid placing LASA medications in
pharmacy formulary– physician to allows staff to remove internal pharmacy matrix drawers in the ADC
monitoring system complete entry certain medications timetabling Use ADC modular “cubies” to isolate
from the ADC prior Barcode scanning of all medications within the ADC.
to approvals of medications for unit vs. Barcode scanning of medications
pharmacy pharmacy dynamic upon withdrawal for administration
inventory as confirmatory step
Clinical advisory for user for LASA
medications on ADC
Action owner
Pharmacy and ICT Pharmacy and ICT Pharmacy and ICT Pharmacy Pharmacy and nursing units
Team Team Team
Post-Intervention
Scoresa
Severity 8 9 10 7 5
Occurrence 3 1 1 2 1
Detection 5 5 1 10 1
RPN 2 score 120 45 10 140 5
a
RPN score can range from 0-1000. It is calculated as a product of likely severity (scale of 0-10, where 0 is unlikely and 10 is likely to cause death or severe harm), likely occurrence (scale of
0-10, where 0 is almost never and 10 is extremely frequent), and difficulty of detection (scale of 0-10, where 0 is fully and immediately detectable and 10 is undetectable at point of care).
ADC: automated dispensing cabinet; CPOE: Computerized Provider Order Entry; ICT: Information and Communication Technology; LASA: Lookalike Soundalike; RPN: risk priority
number.

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 Quality Improvement Project 123

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Figure 3. Average TAT from ordering to administration for non-ADC items: stat and patient-specific regular orders, with corresponding non-
ADC items dispensed within 30 minutes. ADC: automated dispensing cabinet; TAT: turnaround time.

other facilities who commonly gave us anecdotal but well- limited, and the savings in medication costs and the abil-
informed estimates of medication loss from expiry. Our ity for our plan to be modular (with hardware being firm-
cost savings of 57% per annum from total expired medica- ware-updatable and capable of further integration) means
tions was substantial. One study published after our pro- we are in a reasonable position for further expansion.
ject was completed of central pharmacy automation in an The project was undertaken partly during the 2019
outpatient department in Saudi Arabia reported an even coronavirus disease (COVID-19) pandemic, which was
more substantial reduction in waste, though this was lim- disruptive to the organization and may have slowed the
ited to a subset of medications rather than a full inventory improvements in turnaround time (the slope in turn-
assessment.31 We showed a monthly medication con- around time reduction does not follow the linear trend
sumption reduction of 24%, and a reduction of bound established between January and March 2020). The aver-
wards stock of 81%. The societal costs of unused, or inap- age patient census of the hospital remained largely
propriately dispensed or used, medications include harm unchanged, but several units received higher acuity
to social healthcare budgets and have an environmental nonroutine patients and changed their role.
opportunity cost in the raw materials and resources used Although it can be difficult to validate surveys, we
in the production of pharmaceuticals.
were able to structure the tool’s responses in such a way
that its internal consistency could be tested. The sample
Limitations
size was representative.
Narcotics and fridge items were excluded from the
study owing to local regulations and lack of integration
with refrigerators. The operating room (OR) was excluded CONCLUSIONS
owing to differing medication management needs, and
the NICU was excluded as it was undergoing renovation. Addressing harm related to patient safety caused by
We believe the findings of the study are broadly applicable medication delay is one of the key factors likely to
to the NICU, but the OR will require more specialist medi- improve medication distribution and improve patient
cation dispensing units. Local regulations for narcotic experiences. The fact that medication costs are rising at a
management are changing quickly. fast rate means that projects such as ours should be sup-
A more extensive overhaul of the system could have ported by organizations for tertiary healthcare delivery to
been undertaken, but our budget horizons are necessarily be sustainable.
124 Almalki et al: Improving an inpatient medication dispensing system

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Figure 4. Estimates of productivity increase post ADC implementation by discipline. ADC, automated dispensing cabinet.

Figure 5. Key benefits experienced from using ADCs by discipline: “All that Apply” selected. ADC: automated dispensing cabinet.

The potential for automation to improve safety and waste trends in healthcare systems. Any projects look-
efficiency in the outpatient setting, by adapting the les- ing at system change in medication management
sons of inpatient change processes such as our Six-Sigma need to evidence change through accurate quantitative
project, has been seen in some other recent regional data. Traditional inventory systems cannot achieve this.
studies.31,32 A systematic approach to medication cost The particular strengths of the project are that the
containment necessitates specific and extensive data on transparency and dynamic inventory achieved through
medication procurement, actual medication usage, and automation8 allowed for calculation of return on
 Quality Improvement Project 125

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