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Rose Lynas, BSc, MPSNI, was a clinical
pharmacist, Agnes Hunter, BTEC, is a
clinical technician, Dianne Gill, MSc, MPSNI,
is principal pharmacist, Surgical and Woman and Child Health Directorates,
Michael Scott,
PhD, FPSNI, is chief
pharmacist, and Bernadette Irvine, RGN, is ward manager, United
Hospitals HSS Trust
James McElnay, PhD, FPSNI, is professor of pharmacy practice at
Queen’s University Belfast
Correspondence to
Michael Scott, Chief Pharmacist, Antrim Area
Hospital, 45 Bush Road, Antrim BT41 2RL
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In Northern Ireland an integrated medicines management (IMM) project,
funded under the Executive Programme Funds scheme, was commenced in the
United Hospitals HSS Trust.1 The purpose
was to provide a comprehensive medicines management service to a selected
group of high-risk patients.
It is recognised that if patients bring their medicines into hospital,
and if all their medicines are available beside them and labelled from
admission to discharge, this helps to ensure an accurate medication history
from admission. It also produces a safer, faster and more efficient system
for the storage, management and administration of medicines on the ward
and at discharge.2
Therefore, as part of the second phase of the IMM project, it was decided
to introduce a one-stop dispensing system into a 28-bed acute surgical
ward in Antrim Area Hospital (a 426-bed district general teaching hospital).
Protocols were designed to produce the following desired outcomes:
· Accurate and rational drug history from admission
· Reduced medication errors
· Faster drug administration rounds
· Decreased time to discharge
· Elimination of unnecessary patients’ own drugs and broken stock
wastage
· Reduced process costs
· Cost savings to the combined health economy
· Extension of the role of the ward technician and pharmacist
The service will eventually be developed to include self-administration
of medicines.
Installation of lockers was recognised as crucial to achieve a number
of the desired improvements. For example, a study carried out by Wirral
Hospitals NHS Trust showed that “giving medicines from patient
lockers reduced errors; a baseline error rate of 10 per cent dropped
to 2.5 per cent when drugs were administered from the patients’ own
medicines lockers”.3
However, in terms of the actual choice of locker type, a number of issues
arose and although it constituted only a small part of the process, it
took some time to achieve a suitable product that met all the concerns
of the staff involved.
Locker design
A project group was established consisting of pharmacists, pharmacy
technicians, nursing managers and sisters, infection control nurses,
the domestic
supervisor, IT personnel and staff from Queen’s University Belfast.
At the preliminary meeting, concerns were expressed by nurse managers
regarding the management of multiple keys when the scheme would eventually
evolve to include self-administration of medicines. It was agreed unanimously
at this stage that the traditional lock and key mechanism was unacceptable.
Initial market inquiries provided minimal information on alternatives
and all medication lockers that were in production incorporated the
simple lock and key option. A more detailed search was started and
companies beyond the usual locker manufacturers were approached to
ascertain possibilities. Two alternative locking options were sourced.
The first was a digital lock, which proved to be impractical because
it is impossible to programme a suite of such locks to obey a master
command. This is an essential requirement for ward and pharmacy staff
who require easy access to all lockers without the added difficulty of
memorising 28 codes. Security was also a point of concern since with
regular use the panel can become imprinted which would enable the code
to be ascertained relatively easily. Space is also limited on the ward
and beds are close together allowing patients to see what their neighbour
or staff member is typing.
The second option, which proved appropriate, uses transponder technology
and is known as Dialock, manufactured by Hafele. The transponders necessary
to activate the lock are available in several guises such as key bars,
wristbands and swipe cards. These alternatives allow staff and patients
the option of different formats ensuring both groups have the most appropriate
for their needs. In appearance the visible portion of the lock resembles
a button, which, when pressed in using a “key”, kick starts
the battery which in turn activates the transponder to make the necessary
connection.
The key bars can be individually programmed to suit each user |
Key bars were selected for ward and pharmacy staff because
they can be easily attached to their existing key chain. The key bars
are individually
programmed using a corresponding software package. It is possible to
limit their access to specific times, days and duration of employment
and extend its capabilities to activate all locks as well as log into
the system and make changes.
For the duration of the pilot four key bars were available on the ward
and one each for the pharmacist and technician. Each has master function
capabilities and is named according to the profession responsible for
that particular “key”. Eventually each staff member will
have his or her own, programmed specifically for them, to match the extent
of their grade and responsibilities. As an additional security feature
it is possible to interrogate the system using a hand-held programming
device. Information from each lock can be downloaded, including details
of the previous 150 transactions. Incidents can therefore be investigated
thoroughly as “names” of the individual “keys” that
have opened the lock, including corresponding dates and times, are available.
For self-administration, patients will be given a fob which will be placed
on their identity band. The available Velcro wristbands were deemed inappropriate
by the infection control department due to their potential to potentiate
cross infection. The fobs themselves can be effectively disinfected using
existing fluids, such as the routinely used liquid detergent, and can
be immersed in the same between patients without adversely affecting
the mechanism. These fobs are not locker specific and so do not require
programming. It is therefore not necessary to match up a particular fob
to a particular lock. Any fob can be selected for a patient on admission
but as soon as it has been used to close their medicines cabinet it becomes “locked” into
that lock. It will not open another until, at the point of discharge
or transfer, it can be “released” when the cabinet is left
open for the next patient. This facilitates the movement of patients
around the ward, which would be difficult to manage with a system which
operates a specific key for a specific lock. Cabinet design
The design and procurement of the cabinet itself was as important as
the selection of the locking mechanism. Due to the size of the chosen
lock special consideration had to be given to the dimensions which
would allow for sufficient storage space within the cabinet. No commercially
available lockers were suitable, which prompted the design of a bespoke
cabinet to include in its specification all desirable characteristics.
These included:
· Specific dimensions
· Thickness and standard of steel used
· Coatings and colours
· Split shelf to allow for the option of a full or half shelf
· Integral dispensing tray on top to facilitate administration
· No sharp edges
· Specified weight capacity both on the hinged door and in the cabinet
· Suitable for disinfection using specified cleaning products
· All areas easily accessible
· Option of attachment to the existing bedside cabinets
· Delivery and installation instructions
Several companies were approached and one selected which could deliver
what was requested. Prototypes of the lockers were produced and further
alterations made until all requirements were satisfied. Twenty-eight
examples of the finalised version were produced and installed on the
ward in May 2003 as a joint effort between the manufacturer and the hospital’s
estates personnel. Due to insufficient space on the wall around the beds
the cabinets were fitted to the front of the existing bedside cabinets.
The ideal would be to have the locker as an integral part of the bedside
cabinet and this is currently being investigated.
Outcome
The keyless locker system has proved extremely successful with all
staff using the lockers. A satisfaction questionnaire showed that 100
per
cent of nursing staff, 92 per cent of patients and 92 per cent of GPs
were “happy with the new way of dealing with medicines in hospital”.
The response from the ward manager was “great job, medicines
round faster and good for ‘when required’ medications”.
The product is now available on the new national contract.
Acknowledgements We acknowledge the support of Santha Magrath, infection
control sister, Sean Armstrong, information technology, Ted Hepworth
and Simon Montgomery of Bristol Maid, and David Edwards of Hafele UK
Ltd.
References
1. Fleming GF, Hogg A, Woods A, Scott MG and McElnay JC. A hospital-based
integrated medicines management model. The Pharmaceutical Journal 2003;271:214–5
(PDF 75K)
2. Hospital Pharmacists Group. One stop dispensing, use of patients’ own
drugs and self-administration schemes. Hospital Pharmacist 2002;9:81–6
(PDF 85K)
3. Giving medicines from patient lockers reduces errors. The Pharmaceutical
Journal 2002;268:274. |
The
Pharmaceutical Journal