• Team shared our data and rationale for norm optimization. We also intended to perform on-going reviews of the norms and range with inputs from nursing to ensure patients’ needs are met.

Nursing managers were initially uncomfortable with the idea of removing and/or reducing the medication norms as they were concerned that it will affect the timeliness of the medication administration.

• As above

Ward pharmacists’ concerns that nursing managers & staff nurses may not be receptive of the changes and valuable time will be spent trying to negotiate and rationalize the changes.

• We reached a consensus that frequent top-ups was preferred over bulk topping at a go, as it takes a longer time for our machines to churn out larger quantities of unit dose packages. The higher the volume, the longer it will take for PTs to reach the wards as they have to wait for the machines to be ready.

PTs’ concerns that changing the medication norms will increase the top-up frequency increase the workload and time spent preparing for and doing top-ups

Generate unloading report for AMCs to determine optimal norm

Using information from the report

1) Formula was devised by calculating the daily usage of each medication in each AMC

2) Determine the number of days each medication can last in every AMC (Turnaround time) before it reaches zero:

Turnaround time =

Max quantity of medication in AMC ÷ (Total quantity topped up)/ (Total no. of days)

3) Identify medications that had zero top-up (slow moving medications that can potentially be removed from the AMC)

Obtain verification data to identify usage patterns

Medication orders made by doctors have to be verified by pharmacists. Linking the verification data with the unloading report allowed us to identify high and low medication usage patterns.

An information database was created to provide a standard recommendation which serves a s guide on setting new optimal norms for every medication in the AMC.

4 pairs of team members then reviewed all the recommendations (1 pair for each block at SGH). [ Average of 200 medication line items/AMC; Average of 3000 medication line items/block]

Collaborate with PTs to identify short expiry medications

Block reviewers and PTs discussed details of all recommendations to ensure consistency of review and feasibility of recommendations across all blocks.

Reviewers briefed all ward pharmacists in charge of blocks on how the review was conducted and ensured that they are agreeable with the recommendations made. They will then get the buy-in from their respective nurse managers to make the recommended changes.

Reduce Wastages due to Expired Medications in the Automated Medication Cabinets (AMCs) Yeang Shu Hui, Lee Jun-Yin, Song Jielin, Mastura Yusof, Edmund See, Soong Jie Lin, Sia Wan Jin, Deepika Mallya, Ooi Seok Khoon Inpatient Pharmacy, Department of Pharmacy, Singapore General Hospital

Singapore General Hospital (SGH) is the largest hospital in Singapore with a total of 1800 beds. Inpatient pharmacy (IP) distributes and supplies medications to warded patients. IP is supported by 70 pharmacists and 89 pharmacy technicians (PTs), and has 1650 medications in its formulary. Since April 2013, the use of automated medication cabinets (AMCs) was rolled out in SGH wards.

An AMC is a computerized medication storage cabinet that electronically dispenses medications in a controlled manner and tracks medication use. It allows medications to be stored and dispensed near the point of care. A wide range of commonly used/ emergency medications are kept in the 99 AMCs.

Each medication has a pre-determined maximum and minimum norm level. When the quantity of a medication in a AMC falls below the minimum level, a report will be generated for IP PTs to replenish it to the maximum level. There had been an increase in medication wastages due to expired medications in the AMCs arising from under-utilization. Baseline data collected from Jan to Aug 2015

84 medications expired from the AMC $6798/annum

INTRODUCTION TO PROJECT SELECTION

- To increase the proportion of medications that have a turnaround time of 30 days by 30% • A longer inventory turnover is an indicator of excess and unnecessary stock holding in the AMC thus increasing the probability of expiring medications.

- To achieve lean stocks inventory holding in the AMC

- Reduce manpower hours required to handle and manage expiring medications in AMCs

PRIMARY OBJECTIVE

- To reduce medication wastage by 30% and optimise the medication range of the 99 AMCs in 1 year SECONDARY OBJECTIVES

PROJECT ANALYSIS

SOLUTIONS IMPLEMENTATION

PROJECT ACHIEVEMENTS

The total cost of expired medications written-off was collected from January to August 2016. It was compared with our data from January to August 2015. Our improvement initiatives resulted in a reduction in cost incurred due to drugs expiring in the AMCs

We also increased the proportion of medications that have a turnaround time of 30 days by 30%.

We also achieved an absolute monetary reduction of $7060.75 in the overall AMC stocks inventory holding from March 2015 to March 2016.

SUSTAINABILITY

A standard work process has been put into place. The review of the medications norm level and range will be conducted on an annual basis. To ensure continuity of review, at least 5 pharmacists from the review in the previous year will participate in the review process the following year. An electronic database has also been created to allow staff to track unexpected increase in the quantity of medications expired due to recent medication use practices changes with the advancement in clinical practice guidelines. This would allow prompt review of medication norm.

SAFETY

Improve patient safety by ensuring medications

with good expiry dates are kept in the AMCs

COST

Reduce cost due to unnecessary wastage of

medications

EFFICIENCY

Improve process efficiency to ensure that medication top ups

into the AMCs are efficient

Project selected based on the following criteria:

Stakeholders and Potential Impact

Medication Turnaround Time

Log in to AMC

Close storage location

All unit doses with

same expiry date?

Yes

No

Key in the earliest expiry date

Affix “Use First” sticker on unit doses with earliest expiry date

Select Load and Refill function

Scan the barcode of the drug to be topped

up

Count the current quantity in the storage

location

Key in the quantity counted

Key in the quantity to be topped up

Checked expiry date for all unit doses

Key in the expiry date

Log in to AMC

Close storage location

All unit doses with

same expiry date?

Yes

No

Key in the earliest expiry date

Affix “Use First” sticker on unit doses with earliest expiry date

Select Outdate

Select the drug that is expiring

Count the current quantity in the storage

location

Key in the quantity counted

Key in the quantity of expiring soon drugs to

be removed

Checked expiry date for all remaining unit doses

Key in the expiry date

Process of AMC topping up Process of removing expired medications from the AMC

Overestimation of medication usage during norm setting

• Norm was estimated to usage prior to implementation of unit dose packaging

Medications with short expiry were kept in AMC

• Based on records of medications which were written off

Infrequently used medications were kept in AMC

• Based on consumption records for AMCs in each ward

ROOT CAUSES IDENTIFIED

SOLUTIONS DEVELOPMENT

All 3 solutions were implemented in one PDSA cycle by optimizing all available. PDSA cycle was carried out between Aug – Oct 2015.

DIFFICULTIES ENCOUNTERED

$6798.27/annum 2015:

$3548.12/annum 2016:

To optimize the medication range in the AMCs, we had to balance between ensuring sufficient supply of medications in the AMCs while minimizing surplus that may expire Comparing medians (see left)

Reduction in the amount of and cost incurred from expired medications being written-off was achieved

Reduced ad-hoc requests from PTs and nurses to review ward norms indicated improved optimization of medication range and norms.

Overall, the cost-savings achieved for this project is $10, 265.91 per annum

Nurses

AMCs accommodate wider range of medications with lower

individual norms

Less delay and overall improved turnaround time for timely drug

administration

Pharmacists

Lesser negative feedback from nurses regarding medication

turnaround time

Pharmacy Technicians

Decrease in necessity to highlight to ward pharmacists to review the norms of items kept

in AMCs

Improve staff satisfaction

Our improvement initiatives resulted in a 47% reduction in cost incurred due to expired medications in the AMCs with cost savings amounting to $10,265.91 per annum. Process efficiency is improved through process standardization and implementation of good practice at Inpatient Pharmacy.

CONCLUSION