ASHP national survey of pharmacy practice in acute care settings

REPORTS ASHP national survey

REPORTS

ASHP national survey of pharmacy practice in acute care settings: Dispensing and administration—1999 DEBRA JONES RINGOLD, JOHN P. SANTELL, AND PHILIP J. SCHNEIDER

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his article discusses the objectives, methodology, and results of a national survey of pharmacy directors of general and children’s medical–surgical hospitals and health systems in the United States. This survey was conducted during September, October, November, and December 1999 and is the second in a series of three national surveys designed to refine and extend previous ASHP studies of hospital-based pharmaceutical services. The first survey was concerned with current prescribing and transcribing practices.1 This second survey focuses on pharmacists’ traditional role in the preparation and distribution of medications, as well as on their role in improving the safety of drug administration. Pharmacists’ activities related to patient monitoring and education and wellness programs will be the subjects of the third survey. Together, these three surveys will provide a complete view of the role pharmacists play in

Abstract: Results of the 1999 ASHP national survey of pharmacy practice in acute care settings that pertain to drug dispensing and administration practices are presented. Pharmacy directors at 1050 general and children’s medical–surgical hospitals in the United States were surveyed by mail. The response rate was 51%. About threefourths of respondents described their inpatient pharmacy’s distribution system as centralized. Of those with centralized distribution, 77.4% indicated that their system was not automated. Decentralized pharmacists were used in 29.4% of the hospitals surveyed; an average of 58.9% of their time was spent on clinical, as opposed to distributive, activities. About 67% of directors reported pharmacy computer access to hospital laboratory data, 38% reported access to automated medication-dispensing-unit data, and 19% reported computer access to hospital outpatient affiliates. Only 13% of hospitals had an electronic medication order-entry system; another 27% reported they were in the process of developing such a system. Decentralized medication storage and distribution devices were used in 49.2% of hospitals, while 7.3% used bedside information systems for medication man-

DEBRA JONES RINGOLD, PH.D., is Professor of Marketing, Atkinson Graduate School of Management, Willamette University, Salem, OR. JOHN P. SANTELL, M.S., is Director, Center on Pharmacy Practice Management, American Society of Health-System Pharmacists, Bethesda, MD. PHILIP J. SCHNEIDER, M.S., FASHP, is Clinical Professor and Director, Latiolais Leadership Program, College of Pharmacy, The Ohio State University, Columbus. Address reprint requests to [email protected]. The assistance of the members of the 1998–99 ASHP Council on Administrative Affairs, the ASHP Pharmacy Practice Management Advisory Group, the staff of ASHP, and the pharmacy directors who participated in the survey is acknowledged.

agement. Machine-readable coding was used for inpatient pharmacy dispensing by 8.2% of hospitals. Ninety percent reported a formal, systemwide committee responsible for data collection, review, and evaluation of medication errors. Virtually all respondents (98.7%) reported that their staff initiated manual reports. Only two thirds tracked these reports and reported trends to the staff. Fewer than 15% reported that staff were penalized for making or contributing to an error. Pharmacists are making a significant contribution to the safety of medication distribution and administration. The increased use of technology to improve efficiency and reduce costs will require that pharmacists continue to focus on the impact of changes on the safety of the medication-use system. Index terms: Administration; American Society of Health-System Pharmacists; Automation; Clinical pharmacy; Computers; Data collection; Dispensing; Drug distribution systems; Drug information; Errors, medication; Medication orders; Organizations; Pharmaceutical services; Pharmacists, hospital; Pharmacy, institutional, hospital; Storage Am J Health-Syst Pharm. 2000; 57:1759-75

Supported by Eli Lilly and Company. Copyright © 2000, American Society of Health-System Pharmacists, Inc. All rights reserved. 1079-2082/00/1001-1759$06.00.

This Report was a project of the ASHP CENTER

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Pharmacy Practice ManagementSM

Am J Health-Syst Pharm—Vol 57 Oct 1, 2000

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managing and improving the six steps of the medication-use process: prescribing, transcribing, dispensing, administration, monitoring, and patient education and wellness. Specifically, the present study sought to describe the methods by which the integrity of medications is ensured, to characterize drug preparation and dispensing activities, to describe the use of technology in drug preparation and dispensing, to characterize drug administration activities, to report on the design and implementation of quality improvement programs, and to characterize activities associated with identifying and reporting medication errors. Methods From a methodological perspective, the survey objective of documenting current dispensing and administration practices in acute care settings required attention to three factors. First, it was important to develop a methodology that would maximize the number of completed interviews. Relatively high response rates make significant bias in the results due to nonresponse less likely. Second, any survey runs the risk of producing biased results if the questions fail to communicate simply and unambiguously. For this reason, it was important to design clear questions and answers, present them in a simple format, and have them follow a logical sequence. Third, both response rate and response accuracy improve as questionnaire length declines. Thus, it was necessary to limit the amount of time and effort needed to complete the survey. Questionnaire development. One form of the questionnaire was developed and pretested by using procedures suggested by Dillman.2 During spring and summer 1999, several drafts were pretested on pharmacy administrators who serve on ASHP councils and advisory groups, as well as on ASHP staff members. Iterative revisions and deletions were made. To reduce the number of questions, 1760

we decided to use data on hospital characteristics (i.e., number of licensed beds, number of occupied beds, U.S. Bureau of the Census region, ownership, U.S. Bureau of the Census metropolitan statistical area [MSA] status,3 and medical school affiliation) available in the SMG Marketing Group, Inc., hospital database for 1999.4 Survey sample. ASHP purchased the SMG hospital database in January 1999. To build this database, SMG surveys all state health departments, state health planning agencies, and health insurance commissions responsible for monitoring health care delivery and planning. SMG also obtains data submitted to the Health Care Financing Administration. In many cases, individual hospitals are contacted directly through SMG’s mail and telephone surveys. In addition, multihospital organizations and group purchasing organizations provide information on their market segments, including profiles of health systems and lists of individual members. Data for the calendar year are then collected from all hospitals in the United States. SMG compares this information with historical data to assess accuracy. From the database of 7054 hospitals, a sampling frame of 5323 general and children’s medical−surgical hospitals with pharmacies was constructed. A simple random sample of 1067 was drawn from the sampling frame, and each hospital was telephoned to verify the name and address of the pharmacy director. Eleven addresses were incorrect, two hospitals were closed, two hospitals had consultant pharmacists only, one hospital failed to meet the eligibility criteria, and one hospital returned the survey unanswered. Therefore, the adjusted sample consisted of 1050 hospitals. Data collection. Pharmacy directors in the sample were contacted a total of six times during the survey period. An announcement letter was sent to the entire sample during the


first week of September 1999. This was followed, one week later, by the first survey mailing. One week after this first mailing, reminder post cards were sent. During the second week of October 1999, the surveys were mailed a second time to the 794 pharmacy directors who had not responded. A third mailing was sent by Federal Express or Priority Mail to the remaining 679 nonrespondents during the first week of November 1999. Between November 8 and 10, a final contact with nonrespondents was attempted by a telephone service (Reliance Teleservice, Arnold, MD). Members of the sample were offered a $50 ASHP certificate for membership services or publications. Data analysis. During data processing, each respondent’s record was matched to the selected hospital characteristics previously described by using a unique identification number generated by the SMG database. Descriptive statistics were used extensively. Chi-square analysis and analysis of variance were used to examine how responses differed as a function of hospital characteristics. The a priori level of significance was set at 0.05. Results and discussion During the response period, which lasted 12 weeks, 539 surveys were returned. One respondent’s SMG identification number was obliterated, but all other data were intact. The response rate of 51% was substantially higher than for most mail questionnaires. (The rate was especially high in light of the complex information requested by the survey, which took up to an hour to complete.5) Hospital and pharmacy characteristics. Table 1 shows the size, location, ownership, and affiliation of the respondents’ hospitals, the nonrespondents’ hospitals, and the 5323 general and medical−surgical hospitals with pharmacies in the SMG database. The distribution of hospital size (i.e., number of occupied beds), region, ownership status, and medi-


Table 1.

Size, Location, Ownership, and Affiliation of Responding Hospitals and Systems Respondents

Nonrespondents n %

Characteristic

n

%

All hospitals and health systems Licensed beds 5, d.f. = 1, p < 0.017. d 2 χ > 11, d.f. = 1, p < 0.004. a 2 b

tomated medication dispensing unit data; about 35%, to electronic medical records; and about 19%, to outpatient affiliates. Larger hospitals and systems, those within an MSA, and those affiliated with a medical school were more likely than others to have linkage between the pharmacy computer and the hospital computer. Only 13% of the hospitals and systems had an electronic order-entry system (a computerized system that allows physicians and other authorized staff members to directly enter medication orders as part of the patient’s electronic medical record). Another 27% reported that they were developing an electronic order-entry system. Thirty-four percent of the institutions with 400 or more occupied beds reported having an electronic order-entry system, compared with 6.6% of those with fewer than 50 occupied beds. Similarly, 37.5% of the institutions with 400 or more occupied beds were developing this kind of system, versus 23.6% of those with less than 50 occupied beds (χ2 = 44.66, d.f. = 10, p < 0.0001). Pharmacists entered 75% or more 1766

of all medication orders in 92.9% of the hospitals and systems with electronic order entry. Physicians entered 25–49% of all medication orders in 47.1% of hospitals and systems with electronic order entry. Pharmacy technicians, nurses, unit or ward clerks, and medical students all entered 1–24% of medication orders with an electronic system. When the electronic order-entry system identified a potential problem, 93.0% of the respondents reported that a pharmacist was alerted; 57.7%, that the prescriber was alerted; and 42.3%, that a nurse was alerted. When asked about the types of automation used to support inpatient drug preparation and distribution services, 42.5% of the pharmacy directors reported that no automated drug preparation system was in use and 40.6% reported that no automated drug distribution system was in use. Larger institutions were more likely than smaller ones to have automated drug preparation and distribution systems. About 91% of the hospitals and systems with 400 or more occupied beds used an auto-


mated drug preparation system, in contrast to 31% of those with fewer than 50 occupied beds (χ2 = 105.22, d.f. = 5, p < 0.0001); the results were almost identical for automated drug distribution systems. Decentralized medication storage and distribution devices were used in 49.2% of the hospitals and systems, automated transportation systems in 29.4%, i.v. production and manufacturing systems in 27.5%, centralized unit dose dispensing systems in 9.4%, and bedside information systems for medication management in 7.3% (Table 8). All five types of automation were more common in larger hospitals and systems, those within an MSA, and those affiliated with a medical school. In two thirds of the hospitals and systems with automated storage and distribution devices, pharmacy technicians were primarily responsible for checking the accuracy and integrity of medications contained in automated devices. In another 30%, pharmacists were primarily responsible. Machine-readable coding was used for the inpatient pharmacy dis-


Table 8.

Percentage of Hospitals and Systems with Automation Supporting Inpatient Drug Preparation and Distribution Services

Characteristic Occupied beds All hospitals 16, d.f. = 5, p < 0.006. MSA = metropolitan statistical area. c 2 χ > 5, d.f. = 1, p < 0.024. d 2 χ > 7, d.f. = 1, p < 0.026. a 2 b

pensing process in 8.2% of the institutions. Fifty-five percent of these respondents used machine-readable coding for drug processing and dispensing, 43.2% for inventory ordering and tracking, and 18.2% for i.v. admixture labeling, recycling, and verification. About 18% used machine-readable coding for outpatient pharmacy prescription processing, about 14% for medication verification at the bedside, and about 11% for documentation in the medication administration record (MAR). Drug administration. In 88.7% of the responding hospitals and systems, pharmacists were formally required to review medication orders in inpatient areas before drugs could be administered. Pharmacists were required to follow such a policy less frequently in outpatient clinics (21.3%), surgical and procedure areas (15.6%), and the emergency department (11.5%). The pharmacy directors were asked to indicate the degree to which certain conditions circumvent pharmacists’ ability to review medication orders before drug administration. Automated storage and

distribution devices were cited as occasionally or often circumventing this activity in 36.2% of the institutions, traditional floor stock rooms in 44.9%, borrowing from other patient medication drawers in 63.5%, and hidden storage of medications in patient care areas in 49.8%. The hospitals and health systems used a number of quality assurance methods to improve the safety of drug administration. Medications in unit dose packaging were removed from their packages only immediately before administration in 77.0% of the hospitals and systems. The patient’s name was always verified through oral questioning of the patient or checking of the patient’s identification tag in 74.9%. Standardized, preprinted order forms were regularly used in 65.3%. New medication orders were reviewed by the pharmacy prior to transcription into the MAR in 50.2%. Any new medication order entered into the MAR automatically triggered prompt review of the entire MAR in 23.2%. In 2.7% of the hospitals and systems, patients were provided with a copy of

their MAR or a similar medication record. In 1.1%, bar coding of the drug product was used in conjunction with bar coding on the patient’s identification tag. Table 9 gives the frequency, at the responding institutions, of a number of tasks that affect the accuracy of drug administration and the frequency with which a pharmacist always carries out each task. The entering of monitoring guidelines, special instructions, or cautions on the MAR was routine in 75.9% of the hospitals and systems, and this task was always carried out by a pharmacist in 31.0%. Manual generation of MARs was routine in 36.4% of the hospitals and systems; 4.2% reported that this was always done by a pharmacist. Table 10 shows the frequency with which several personnel groups were authorized to administer medications and how often they actually did so. Nurses were authorized to administer medications in almost all hospitals and systems (98.7%). When asked how often nurses actually did so, 81.2% of these respondents indicated that nurses always administer


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Table 9.

Tasks Affecting Accuracy of Drug Administration and Extent of Involvement by a Pharmacist

a

Task

n

% Hospitals and Systems in Which Task Is Routine

% Reporting Task Is Always Carried Out by a Pharmacist

Computer generation of MARa Manual generation of MAR Checking MAR against original order New orders entered on MAR Monitoring guidelines, special instructions, or cautions entered on MAR Discontinued orders deleted from MAR Administration times verified by using MAR

529 522 529 530

53.9 36.4 72.6 64.9

41.2 4.2 25.9 36.8

527 528 528

75.9 70.1 70.3

31.0 36.5 24.6

MAR = medication administration record.

Table 10.

Personnel Groups Authorized To Administer Medications and Frequency with Which Task Is Undertaken Personnel Group

n

% Respondents Where Group Has Authority To Administer Medications

Frequency of Task

% Respondents Indicating Frequency

Pharmacists Pharmacy technicians Nurses Medication aides Physicians

526 524 532 510 530

23.4 1.7 98.7 16.3 95.1

Occasionally Occasionally Always Occasionally Occasionally

62.9 63.6 81.2 42.1 85.1

medications. In contrast, only 1.7% of the hospitals and systems authorized pharmacy technicians to administer medications, and in 63.6% of those institutions technicians actually did so only occasionally. Larger institutions required personnel to take special training for administering high-risk drug therapies more frequently than smaller ones (χ2 = 29.46, d.f. = 5, p < 0.0001). Ninetyfour percent of the hospitals and systems with 400 or more occupied beds required special training for high-risk drug therapies, versus 71.0% of those with fewer than 50 occupied beds. Eighty-three percent of the respondents required all personnel who administer high-risk drug therapies to undergo special training on proper administration and precautions. Just under half of these respondents reported that pharmacists were involved as instructors in the associated training programs. This finding highlights an important opportunity for pharmacists. Quality improvement programs. Quality improvement programs were common for both drug preparation and dispensing operations and drug 1768

administration operations. Table 11 reports the frequency with which the hospitals and systems had formal quality improvement processes for preparation and dispensing operations and the pharmacy directors’ perceptions about whether the operations actually led to quality improvement. For all but 3 of the 14 operations (i.e., end-product testing of total parenteral nutrient solutions, cardioplegia solutions, compounded admixtures, etc.; determining the accuracy of stocking of automated storage and distribution devices; and auditing of doses returned in patient medication drawers), a majority of the hospitals and systems had formal quality improvement processes in place. In every instance, a majority of the pharmacy directors believed that the quality improvement programs had resulted in actual improvements. Table 12 gives the percentage of hospitals and systems reporting formal quality improvement processes for medication administration operations. For four of the nine operations, a majority of hospitals and systems had formal quality control programs in place: review of MARs for


accuracy and completeness, patient identity verification, appropriate timing of medication administration, and personnel education and training. Medication errors. More than three fourths of the hospitals and systems (76.9%) reported having a formal committee for addressing the prevention, identification, and evaluation of medication errors. Ninety percent reported having a formal, institutionwide committee responsible for data collection on and review and evaluation of medication errors. Virtually all of the respondents (98.7%) reported that medication errors were identified through manual reports initiated by staff. A little over 15% reported error detection through random observation, 10% reported that free-text entries describing errors were made in the computer by staff, about 10% reported that they downloaded error data from the hospital information system and medical records, and 8% reported that medication errors were detected automatically by their information system. Nearly all responding hospitals and systems (98.9%) monitored


Table 11.

Percentage of Hospitals and Systems with Formal Quality Improvement Processes for Medication Preparation and Dispensing Operations Medication Preparation or Dispensing Operation

n

%

% Reporting Actual Improvements

Sterility of i.v. admixtures Accuracy of i.v. admixture preparation and dispensing Accuracy and safety of antineoplastic drug preparation End-product testing of total parenteral nutrient solutions, cardioplegia solutions, compounded admixtures, etc. Accuracy of oral drug preparation and dispensing Accuracy of pharmacy’s patient medication record Completeness of pharmacy’s patient medication record Dispensing turnaround time Medication-dispensing errors Evaluation of checking of cart filling by technicians Accounting for missing doses Accuracy of stocking automated storage and distribution devices Personnel education and training Audit of doses returned in patient medication drawers

529 528 502

66.2 66.3 62.7

63.5 71.0 77.6

517 527 530 527 526 533 515 527

26.7 74.0 60.8 52.0 52.9 92.7 67.8 54.3

70.8 78.8 78.2 77.8 80.0 74.3 81.3 66.1

462 528 516

33.1 83.3 29.5

75.5 70.7 70.7

Table 12.

Percentage of Hospitals and Systems with Formal Quality Improvement Processes for Medication Administration Operations Medication Administration Operation

n

%

Administration of i.v. push medications Administration equipment Review of medication administration records for accuracy and completeness Pre-medication-administration checks Patient identity verification Appropriate timing of medication administration Physical and cognitive assessment Self-administration of medications by patients Personnel education and training

528 530

29.7 39.2

526 528 528 526 527 523 532

60.5 46.8 58.1 58.6 47.4 36.1 77.3

medication errors that were caused by pharmacy personnel and detected after dispensing. In over 90%, medication errors caused by pharmacy personnel and detected after dispensing were discussed with the employee by a pharmacy supervisor. In about two thirds of the institutions, errors were documented and analyzed for trends, and the information was provided to staff. Two thirds of the respondents said errors were discussed in departmental meetings, and 70% indicated that ideas for preventing errors were solicited from pharmacy personnel. Medication errors were included in performance reviews of pharmacists and technicians at 38.8% of the hospitals and

systems, and about the same percentage reported that medication errors were handled the same as any other type of error by health care professionals. Two thirds of the pharmacy directors reported that the medical staff received copies or summaries of medication error incident reports; 56.5% indicated that administrators received this information. About 90% reported that pharmacists received the information; about 85%, risk managers; 83%, quality assurance and quality improvement managers; and about 80%, nurses. Less than 15% of the respondents indicated that staff members were penalized when they committed or con-

tributed to a medication error. In most hospitals and systems (73.1%), staff knew what to do if an error occurred because procedures for handling errors that result in patient harm had been established. In about half of the hospitals and systems, formal methods were used to support and counsel staff who made mistakes that harmed patients; in less than 15%, staff were rewarded for reporting medication errors and adverse drug events. These data suggest that more could be done to create an environment where staff are encouraged to identify and report medication errors. Hospital and pharmacy activity levels. Several measures of annual hospital and pharmacy activity are presented in Tables 13 through 18. Hospitals and systems that were larger, located in the Northeast, located in an MSA, and affiliated with a medical school tended to have more outpatient visits (Table 13). Institutions that were larger, Northeastern, nonprofit, within an MSA, and affiliated with a medical school tended to have higher total operating expenses (Table 14). The same relationships were noted with respect to total operating expenses for the inpatient pharmacy and with respect to total acquisition


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Table 13.

Outpatient Visits in Preceding Fiscal Yeara REPORTS ASHP national survey

Characteristic Occupied beds All hospitals