Medicines Management
Issue no 2, p15-17
March/April 2002
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Medicines Management |
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Features |
Automated dispensing could be the way forward for your department
The Royal London is part of Barts & The London NHS Trust. It was formed in the mid-1990s by the merger of four east London hospitals, including the major teaching hospitals, the Royal London and St Bartholomew's. Many of the acute services, including A&E, general medicine and general surgery have been centralised at The Royal London. The site now has about 650 beds and 35 wards. The in-patient dispensary was designed before the merger when workload was about 50 per cent of its current level of 14,000 items a month. Although it was situated near the wards it was a five-minute walk from back up stocks. It had been apparent for sometime that the dispensary was much too small for what we had to do. The problem became more acute over the past few years with the introduction of patient packs. As a result the pharmacy was allocated additional space bringing the total to100 square metres. However, even then, we did not have enough space for shelving, benching and staff to give an efficient, safe working environment with a traditional design. It was therefore decided to explore the possibility of automation. Our main aim in deciding to automate was to save space; but we were aware of other benefits that could be achieved namely: increased efficiency and accuracy and better stock control. At the time there was nothing in use that met our needs within the UK; but we were able to see a machine in action in Germany. Although the machine was installed in community pharmacies there, it was immediately apparent it had possibilities for use in a hospital. We established that the machine was quick enough to keep up with our current and potential workload. It had automated filling with good reliability reports and fitted well into the space available. Putting together a business case We were fortunate in that approval had already been given for the refurbishment of the dispensary. Our main task was to show that the new space allocated was not sufficient to meet the current and future needs of the service; and that a machine was a cost-effective way of overcoming this. We demonstrated that with the increased efficiency we could achieve, we could free staff to further develop our patient centred services away from the department. Improved stock control would reduce supply failures, 'missed doses' and discharge times. We received approval in the autumn of 2000 with work due to start at the beginning of the 2001/2 financial year. We used this time to put together a specification and to get the tender process underway with an Official Journal of the European Community advert. As soon as the money was released we were able to place the order. How the machine works The machine we purchased is a ROWA Speedcase. It is basically a big box: 8m long, 3m high and 1.3m wide. Down each of the long sides there are seven bays of approximately 50 shelves of varying heights. This provides almost 700m of usable shelving and holds approximately 11,000 packs. Our average stockholding is about 8,500 with a throughput of roughly12,000 packs per month. A robotic arm runs the length of the machine pulling boxes off the shelf and dropping them down chutes in the side of the machine to a tray immediately next to the labeller. To fit into the machine an item must be packaged in a cuboid box that has a readable barcode printed on it. Of the 1,900 lines in the dispensary we have been able to put in over 1,100. Items that will not go in are either too large, not in boxes, have no bar code, are Controlled Drugs or fridge items or are in boxes of the wrong shape. Items are entered into the machine by scanning the barcode and placing the box onto an input belt that runs the length of the machine. It takes about 10 minutes to fill the belt and a further 15 minutes for them to be taken from the belt and placed on the shelves. The machine selects the shelf, placing them in the smallest available space. This may take longer if the machine is dispensing at the same time, as dispensing takes priority. Items are removed from the machine using the labelling system of the pharmacy computer. The labeller produces a label in the normal way. If the label is for a whole pack of an item that is stored in the machine, a message is sent to the machine's computer. The item is removed from the shelf by the robotic arm and sent down the chute into a tray next to the labeller. It takes about 12 seconds for an item to reach the tray once it has been requested. Connecting to the pharmacy computer system An interface is needed to use the machine with a pharmacy computer system. We have our own pharmacy computer system so that we were able to have this written "in-house". It is important to allocate money and adequate time for this interfacing. Dispensary workflow Having a robot alone will not necessarily improve the efficiency of the dispensing process. It is how it is used in the context of the workflow of the whole department where most gains are achieved. In a traditional hospital dispensary much time is taken up by walking, whether it be going to and from the shelves to pick stock, finding space to dispense the prescription or taking the dispensed item to checking area. In designing our new dispensary we put considerable effort into planning the workflow. Our aim was to reduce the time and distances spent walking when dispensing. Three labelling computers were placed on a bench next to the output chutes. The dispensary layout was then put together in such a way that the dispensers work in roughly a circular direction as they label the items from the robot, dispense the non-robot items and place the finished prescription on the checking bench. This has reduced the amount of walking across and around the area and resulted in a much calmer working environment, less time wasted and reduced tiredness. Sufficient storage space needs to be allocated for part-packs of items that are normally kept in the robot. The new system has changed the dispensing process significantly. Before automation, the rate-limiting step was dispensing; it is now labelling and checking. If a labelling backlog is cleared, it will now move quickly to the checking bench. As a result we have increased our numbers of accredited checkers so that we can move staff quickly within the dispensary to clear any backlogs. In designing a dispensary it is important to allow enough room for the dispensed, unchecked prescriptions and for the checkers to check them. This space should be away from disturbances like telephones and visiting staff. Stock control When asked "what is the biggest benefit of automation?" our dispensary manager invariably replies "improved stock control". We have developed the interface so that the stock balance in the robot is checked each time a picking request is made. A report of all discrepancies is produced daily. Every evening a file of all items in the robot, with their stock balances, is sent from the robot's computer to a server. As part of the pharmacy system's housekeeping these balances are compared to those on the pharmacy system and a report produced. This is printed next morning and the discrepancies investigated and rectified. This means that we have nearly 100 per cent stock control on the 1,100 items and 8,500 packs in the machine. We have therefore been able to reduce stockholding at the same time as reducing delays and inefficiencies caused by incorrect stock levels. Now that things have settled down it will be possible to reduce stockholding even further. Dispensing error reduction In the four months that the machine has been operational we have seen a 70 per cent reduction in errors with items that now come out of the machine. It must be remembered that automation does not eliminate error. The machine picks what it is asked for; if the wrong item is requested, that is what will be picked. Also the potential is still there for the wrong label to be stuck on the wrong box. It is also important that dispensers do not become complacent and make errors in selection of non-robot items. Savings in staff time It must be remembered that the savings in staff time will be achieved around dispensing and stock maintenance. The time for clinical screening, labelling and checking largely remains unaltered. However, the issue is not solely about needing fewer staff but in altering the skill mix of the dispensary. We have found that our pharmacy assistants spend less time dealing with stock issues and hence can spend more time dispensing and so release more technician time. The dispensary now only works late when prescriptions are received late - all prescriptions that arrive before 4pm are dispensed by 5.30pm. This has had a positive effect on staff morale. Turn around times for dispensing have improved. Reliability So far we have not had any problems with the machine itself. There have been one or two problems with the interface, which are being resolved. The machine can work independently of the pharmacy system if necessary. As a last resort, packs can be picked manually from the machine. Is there a downside? We have had few problems with the introduction of this technology. A major factor in this is that we planned thoroughly. We spent a lot of time working on the dispensary layout and preparing and pre-filling the machine. We had a clear vision of how we wanted to operate the machine and planned with this in mind. Future developments Dual machines — when two machines are connected to one computer: This has the effect of doubling the speed, as there are two picking heads. Labelling: There is now a labelling option available that will stick labels directly onto the boxes. Refrigeration: A refrigerated unit is now being developed that would allow several hundred more items to be stored in the machine. Stock picking: It would not be possible to pick all stock items with the machine, but it could be used for certain items, with the balance still being picked manually. Remote siting: It is possible to use conveyers so that if necessary the machine can be situated in a different room or floor to the dispensary. Automation has definitely been the right development for our department. We have already got approval to have another robot installed in one of our satellite hospitals and are in the process of putting a proposal together to install one in our out-patient dispensary. Automation entails a large capital outlay; but we believe with careful planning and a clear vision of how to operate the machine, the benefits in staff efficiency, dispensing error reduction, improved stock control and faster turn round times make it a cost effective investment.
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©The Pharmaceutical Journal
The
Royal London Hospital has had a robotic dispensing machine in use since
November 2001 in the in-patient dispensary, and I hope the following account
will inspire others (despite the difficulties we faced) to consider the
benefits.