1.Stored on unit in machine by drug, JIT from machine, machine fill is assembled and batched based on volume, new or changed order to dispensing time = 1 hour

Patient specific meds are delivered for a 24 hr period in the med room in a patient specific drawer

Typical Dispensing Machine Scenario

Discontinued meds

Narcotics diversion

Non-standard doses

New Drug/First Dose

Fill Errors

Nurse Workarounds

Refrigerated and IV meds

Multi-dose medications

10

5

3

6

3

7

3

4

Incorrect medications or incorrect dose can be given to patient

Clinical staff may be practicing in a impaired state

Patient receives either too little or too much medication

Patient may receive incorrect medication, dose or route

Patient may receive medication not prescribed for him

Chance of patient receiving wrong med, dose or route increases

Patient receives an incorrect medication, dose or route as visual scan the only safety check

Patient receives an incorrect medication, dose or route as there is no double check and discontinued meds may be available

Could be left in refrigerator if not part of the dispensing machine; multi-dose vials would be left in a drawer

Possible through observing nurse code

Nurse must assemble dose at time of administration

First dose can be taken from Pyxis bypassing pharmacist check

Medications can be placed in the wrong storage bin inside the dispensing machine and into the wrong patient drawer

Likelihood depends on proximity of machine to patient room

Meds are stored in a central refrigerator; IVs kept in separate location; safety check for the medication is a visual scan

Requires additional storage in patient-designated drawer or refrigerator; if in Pyxis refrigerator, nurse has to draw up pt. dose from a large non-patient specific bottle

5

10

4

1

5

8

5

7

Clinical pharmacist on floor who can enter and check new orders JIT

Bar-coding and scanning are crucial error trap

Non standard dosing is assembled in pharmacy

Nurse-specific swipe card or thumb print for narcotics

Refrigerator on dispensing medications and discontinued refrigerated medications are picked up on a twice daily schedule

2. Stored on unit in dispensing machine by drug, JIT from machine, fill is assembled and batched based on volume, order to dispensing time = 1 hour; all medications not stored in dispensing machine are delivered to floor within 3 hours of administration by pharm. techs, discontinued meds picked up every 3 hours,

# 2= 1 + Continuous Flow for Patient-Specific Meds Scenario

Discontinued meds

Narcotics diversion

Non-standard doses:

New Drug/First Dose:

Fill Errors

Nurse Workarounds

Refrigerated and IV meds

Multi-dose medications

7

6

1

4

3

7

3

Incorrect medications or incorrect dose can be given to patient

Clinical staff may be practicing in a impaired state

Patient receives either too little or too much medication

Patient may receive incorrect medication, dose or route

Patient may receive medication not prescribed for him

Chance of patient receiving wrong med, dose or route increases

Patient receives an incorrect medication, dose or route as visual scan the only safety check

Patient receives an incorrect medication, dose or route as there is no double check and discontinued meds may be available

Could be left in refrigerator if not part of the dispensing machine and multi-dose vials would be left in a drawer for up to 3 hours with an every 3-hour delivery/pick-up

Possible through observing other nurses' codes

Delivered every 3 hours- not stored on unit or assembled by nurse

3 hour delivery service (First ordered dose could be put on 3hr schedule)

Medications can be placed in the wrong storage bin inside the dispensing machine

Likelihood depends on proximity of machine to patient room

meds stored in a centrally located refrigerator; IVs kept in separate location

Delivered every 3 hours so requires no storage in patient-designated drawer

5

10

1

1

4

8

5

2

Clinical Pharmacist on floor to approve new meds would speed up administration

Bar coding and scanning meds and patient

Nurse-specific swipe card for narcotics

Use of dispensing machine screen to get all medication information re: current meds, discontinued med. information

3. All medications dispensed from pharmacy to patient room on unit and discontinued meds picked up every 3 hours by pharm tech.

Narcotics centrally available through Pyxis

Made to Order and Delivered to Room Scenario

Discontinued meds

Narcotics diversion

Non-standard doses

New Drug/First Dose

Fill Errors

Nurse Workarounds

Refrigerated and IV meds

Multi-dose medications

2

6

1

1

3

1

2

incorrect medications or incorrect dose can be given to patient

Clinical staff may be practicing in a impaired state

Patient receives either too little or too much medication

Patient may receive incorrect medication, dose or route

Patient may receive medication not prescribed for him

Chance of patient receiving wrong med, dose or route increases

Patient receives an incorrect medication, dose or route as visual scan the only safety check

Patient receives an incorrect medication, dose or route as there is no double check and discontinued meds may be available

In patient specific storage bin until pick up

possible through observing nurse code;

Non-standard doses assembled and delivered to room

Received in 1 hour from pharmacy or as part of the 3 hour delivery service

Individual dispensing machine fill errors are possible

Almost Eliminated

Most medications are stable in a syringe for 24 hours; IVs kept in separate location

Kept in patient-specific medication storage bin or central refrigerator

2

10

1

1

5

1

4

3

Bar coding and scanning meds and patient

4. Patient specific meds (UNIT DOSED) in a patient specific drawer are delivered for a 24 hr period in the med cart that is batched and filled in pharm

floor stock

IVs separate

Refrigerator separate

Discontinued meds

Narcotics diversion

Non-standard doses:

New Drug,

First Dose:

Fill Errors

Nurse Workarounds:

Refrigerated and IV meds

Multi-dose medications

10

5

3

8

5

10

3

2

5

5

3

9

7

9

5

4. Scenario 1 or 2 plus patient-specific meds loaded in a temporary drug location (cubie) in dispensing machine every 24 hours;

Pure Decentralization- one Scenario

Discontinued meds

Narcotics diversion

Non-standard doses:

New Drug/First Dose:

Fill Errors

Nurse Workarounds:

Refrigerated and IV meds

Multi-dose medications

10

6

3

6

3

7

3

4

incorrect medications or incorrect dose can be given to patient

Clinical staff may be practicing in a impaired state

Patient receives either too little or too much medication

Patient may receive incorrect medication, dose or route

Patient may receive medication not prescribed for him

Chance of patient receiving wrong med, dose or route increases

Patient receives an incorrect medication, dose or route as visual scan the only safety check

Patient receives an incorrect medication, dose or route as there is no double check and discontinued meds may be available

In pt-specific drawer until administration or pick up

Possible through observing nurse code;

Non standard doses delivered every 24 hours

Checked by pharmacist in pharmacy and received in 1 hour from pharmacy

Medications can be placed in the wrong storage bin inside the dispensing machine and into the wrong patient cubie

Likelihood depends on proximity of machine to patient room

Meds are stored in a central refrigerator; IVs kept in separate location

Requires additional storage in patient cubie or refrigerator; if in dispensing machine refrigerator, nurse has to draw up pt. dose from a large non-patient specific bottle

5

10

4

1

5

8

5

Clinical Pharmacist on floor to approve new meds

Non standard dosing is assembled in pharmacy

Discontinued medications are picked up on a twice daily schedule

Bar coding and scanning meds and patient

Refrigerator on dispensing machine and discontinued refrigerated medications are picked up on a twice daily schedule

Nurse-specific swipe card for narcotics

Use of dispensing machine screen to get all medication information re: current meds, discontinued med. information