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HUGHUGPharmacy & Sterilisation

Prof. Pascal BONNABRYM. Hervé NEYM. Hervé NEY

Berner Fachhochschule

Geneva, September 13, 2013

Agenda

13h45 HUG presentation

0014h00 Theoretical introduction, processes at the:- Pharmacy- Sterilisation

15h00 Visit in 2 groups (1 hour per visit)- Pharmacy- Sterilisation- Sterilisation

17h00 Debriefing and use cases

18h00 End

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Geneva university hospitals(HUG)

Geneva university hospitals(HUG)

1 out of 5 swissuniversity hospitalsuniversity hospitals

Consortium of public hospitals in the Geneva county

1 central pharmacy1 central pharmacy1 central sterilisation

Annual report 2011

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Medical activity

Annual report 2011

Finances

• Expenditure • Income

Budget ≈ CHF 1,7 billion

Drugs≈ CHF 60 millions

Annual report 2011

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Human resources

• The larger employer in the Geneva county

Annual report 2011

Men at work…

Facts and figures of HUG, 2012

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IT to improve the safetyof the medication process

at the hospital

Prof. Pascal BONNABRY

Berner Fachhochschule

Geneva, September 13, 2013

Pharmacy strategic priorities

• Optimize the safety the efficiency• Optimize the safety, the efficiencyand the traceability of the physicalcircuit of drugs

• Optimize the information flow duringprescription, dispensing, preparationprescription, dispensing, preparationand administration of drugs

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Medication process organisation

• Existing models– Global distribution

The pharmacy delivers boxes of drugs and nurses dispense individualtreatments from the ward stock

– Nominal or individual distribution Drug dispensing is performedat the pharmacy, for each patient,based on the prescription

Global or individual ?

• Individual distribution is more convenient in some conditions– Few prescription modifications (chronic care)

– Pharmacy close to the wards

• At the HUG, the global model was selected– Acute care in majority– Long distance between the pharmacy and some

wards (multi-sites hospital)

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The medication processIndustry stock

Prescription

CytosTPN

Pharmacy stock Ward stock Dispensation Production

EPR

MP

Production stock

Raw-materialsanalysisProductionEnd-product

analysisAdministration

to patients

Safety problems ?

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The addition of two errors

Commission error AND Control failure

SelectionCalculationCounting

CheckDouble-check

Check-listElectronic

• Error rate= 1 %

Distribution errors(real life)

24%

20%

56%

Gschwind L, Carrez L, François O, HUG, 2006-11

20%

Counting Omission Selection

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Dispensing errors(experimental)

• Error rate= 3 %

74%

20%6%

Selection error

Repartition error

Counting errorGarnerin P, Eur J Clin Pharmacol 2007;63:769

Administration errors

• Error rate= 19 %

Observation study in 36 institutionsBarker KN, Arch Intern Med 2002;162:1897

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Limited performance of controls

• Introduction of errors during unit dose dispensingdispensing

• Detection ability during human-performedcontrol:

• Pharmacists: 87.7%• Nurses: 82.1%

Facchinetti NJ, Med Care 1999;37:39-43

Efficiency ≈ 85%(known value in the industry)

Do not be too confident with the double-checks!

Implementation of IT in the medication process

Diogène 1 - 1978

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Potential interests of IT

• To improve– The safety

by reducing the rate of errors and improving the reliability of controls

– The traceabilityby facilitating the registration of logs

– The efficiencyby increasing the working performance

– The communicationby connecting the different steps of the processes

Many questions before to start

• Positive impacts ?• New risks ?• New risks ?• Return on investment ?• System selection ?• Commercial or homemade ?• Interoperability ?• User’s training strategy ?• User s training strategy ?• Acceptability ?

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Electronic systemsto catch errors

Industry stock

Prescription

CytosTPNDelivery

Pharmacy stock Ward stock Dispensation Production

EPR

TPNMP

( )

Delivery

Production stock

Raw-materialsanalysisProductionEnd-product

analysisAdministration

to patients

Electronic systemsto avoid errors

Industry stock

Prescription

CytosTPN

CPOE / CDSS

Pharmacy stock Ward stock Dispensation Production

EPR

TPNMP

EDI

CDSS

Production stock

Raw-materialsanalysisProductionEnd-product

analysisAdministration

to patients

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Robotisation of drug distributionSafety

François O et al, HUG, 2013

Selection 0%Conveyor 0.27%Manual finalisation 0%

≈ 4500 avoided errors/yr

Robotisation of drug distributionEfficiency

François O et al, HUG, 2013

- 2 FTEROI 4.5 years

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• Experimental

Automation of drug dispensingSafety

3

0

0.5

1

1.5

2

2.5

3

Erro

r rat

e [%

]

without

with

Du Pasquier C, Riberdy L, HUG, 2003

Automation of drug dispensingEfficiency

• Real life (digestive surgery ward)600

Min

utes

/wee

k

- 8h +4h +1h

200

300

400

500

600sans armoireau débuten routine

without

beginning

routine

M

François O et al, HUG, 2011

0

100

200

3AL Assistante PharmacienNurse Technician Pharmacist

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Administration to patientsBedside scanning

• Cytostatics DrugNurse

Physician

Database

Patient

Administration to patientsSafety

• Benefit of bedside scanning

• Wrong drug - 75%

• Wrong dose - 62%

• Wrong patient - 93%

• Wrong administration time - 87%

Gl b ll 80%Globally - 80%

Johnson, J Healthcare Inf Manag 2002;16:1

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Automated dispensing systemRobotized

distribution

The medication processFinal perspective

Clinicalinformation

system

EDI

Pharmacystock

Manufacturerstock

Wardstock

CPOE

Logisticinformation

systemBedside scanning Distribution

with scanning

Computer-assisted production management

• ObjectivesT t t f ti b IT – To support any type of preparation by IT

• Batches• Cytostatics• TPN• Other individualized prescriptions

– To implement in-process electronic controls duringthe most critical stepsthe most critical steps

– To link individualized preparation to theirprescription and their administration

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Production managementAutomation

Nutrition (Baxa)

Cytostatics(CytoCare)

CIVAS (Smartfiller)

PharmaHelp (Medical Dispensing Systems), Riva, …

Production managementGravimetry

• Cytostatics(Cato Cypro )

• Batch production(Cato, Cypro )

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Production management Efficiency

• Production – Parenteral nutrition (10/day)

- 60%

Manual2 x 3h = 6 h

Automated (BAXA)1 x 2.5h = 2.5 h

Prerequisite to successfulIT implementation

• Electronic management of processesElectronic management of processes(CPOE, stocks, …)

• Technical infrastructure (hard-, soft-)

• Actors identification (caregivers, patients, drugs)

• Acceptability (patients, caregivers)

• Adaptation to processes• Adaptation to processes• Project leadership• Financing

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Actors identificationThe patient

The caregiver The drug

Drug identification

Reconditionedby the pharmacy

Identified

?Identified

by the industry

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Drug identification

Unit dose• Hierarchy

Unit dose

Secondary package

Hospital package

Box

Pallet

= international standard

GS1 codification of pharmaceuticals at HUG

• Product ID (cytostatics)y

01 07613167000009 7003 1103161400 21 cyt-11198499GTIN - cytos EXP (date and time) Serial

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GS1 codification of pharmaceuticals at HUG

• Product ID (batch production)p

01 17613167001249 17 120831 10 PDS-11289663GTIN BatchEXP date

How to progress?

• Determine an institutional strategy and an implementation schedule taking into accountimplementation schedule, taking into account– the local organisation– the local culture– the expected return on investment

• Involve the different partners• Re-think the process organisation

(re-engineering)• Manage each projet independently, without

loosing the global vision

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Conclusion

• The medication process at the hospital iscomplex and involves many differentcomplex and involves many differentprofessionals

• A clever organisation contributes to improvethe safety, the efficiency, the communication and the traceability

• IT take more and more importance in the i h h iprocess improvement approaches: their

implementation is necessary but is a challenge• Each hospital must determine a strategy, based

on the local context

Questions ?

• On the presentation ?O h ?• On the use case ?