Pyxis Usergroup Meeting September 23-25, 2008 THE HSC EXPERIENCE Jan Beales, Pharmacy Linda Carroll,...

Pyxis Usergroup Meeting

September 23-25, 2008

THE HSC EXPERIENCE Jan Beales, Pharmacy

Linda Carroll, PharmacyRoberta Lowry, Nursing Monique Yakiwchuk, Pharmacy

NARCOTIC DIVERSION



OVERVIEW

Who are we?What were our challenges?What were our solutions?What are the current barriers?What are our future plans?What is our wish list?



Who are we?

• 850 bed tertiary bed teaching hospital

• Catchment area- Province of MB and northwestern Ontario

• Hospital footprint 32 acres

• HSC Staff – Total 7,000– 3,800 nursing staff– 150 pharmacy staff– 90 anesthesiologists



Who are we?

• Unit Dose Distribution- includes both cart fill and Pyxis/CIVA

• Pyxis Operations – Pharmacy/Nursing Operations Committee

• Pyxis Equipment (46 wards)– 62 Pyxis Medstations– 41 Pyxis Auxiliary cabinets– 1 tower– CII Safe



OVERVIEW

Who are we?What were our challenges?



NARCOTIC DIVERSION



What were our challenges?

• 2001 completely manual narcotic system

• 2002 Pyxis on 20 Adult patient care wards – many areas still a manual narcotic system & a manual narcotic

vault

• High volumes of narcotics– 167,000 T3 tablets/year– 103,000 morphine 10mg/ml amps/year– 20,000 fentanyl 100mcg/2mL/year

• Security –over 4,000 staff in database– difficult to maintain

• Reporting tool deficiencies

• Limited resources for proactive surveillance



OVERVIEW

Who are we?What were our challenges?What were our solutions?



What were our solutions ?

• Proactive Audit



Roberta Lowry , Nursing

THE PROACTIVE AUDIT



THE PROACTIVE AUDIT

Mandate: (March 2005)

Develop a business plan for a Proactive Narcotic Diversion Monitoring Program

Plan to include software, P&P, education & staff



THE PROACTIVE AUDIT

Deficiencies of Existing System: Pyxis: insufficient data reporting (1 mo.)

Pandora: reports don’t combine mirrored MS

No dedicated EFT positions

No data to project workload requirements



THE PROACTIVE AUDIT

Starting point:Anomalous Use Report: Hospital–Wide All

Stations Report (for 9 mo)

Findings:• 547 potential “highly likely” diversions• 819 potential “highly suspect” diversions



Where do we start???????

THE PROACTIVE AUDIT



THE PROACTIVE AUDIT

Narrowing the choices……..

Select a drug likely to be used in many areas

Select an area with a single MS

……..and the winner is



THE PROACTIVE AUDIT

Diazepam 10 mg tablets



THE PROACTIVE AUDIT

Next step……• Pandora Anomalous Use Report for selected MS

nursepatienttime frame

Findings…..• Mean removals for all MS = 77• Selected MS: Max = 660 (2nd = 431)

Next step….• Audit 1 health record with diazepam+++ use



THE PROACTIVE AUDIT

Findings:

All diazepam accounted for on MAR, but

Dose not always indicated (ROD order) Initials missing from MAR & Signature Record Initials & signature of nurse who removed from

MS nowhere in the health record Nurse who signed MAR had no MS activity



THE PROACTIVE AUDIT

Now what ???

1. Meet with Manager Mystery nurse identified

2. Select other nurses with same EFT, similar rotations and run activity reports (Pyxis OPS)

3. Health record audits (Manager)



THE PROACTIVE AUDIT

Findings:1. Nurse removes: approx = amt month/month amt similar to cohort for the specialty area

(5 mo; 325 vs 301 tab)

2. Doses removed from MS signed for on MAR but >4 instances drug admin documented on MAR or PN with no corresponding removal from MS

3. No personality or behaviour changes



THE PROACTIVE AUDIT

Conclusion

We could not find evidence of diversion



THE PROACTIVE AUDIT

Some Measurable Costs of the Audit

Report generation & analysis 8h

Report review (MOPC/DOPC) 2h

Chart/MAR review 5h

Meetings 5h

20 hours!



THE PROACTIVE AUDIT

Or,

> $800.00!!



THE PROACTIVE AUDIT - Summary

Did our solution work?Pro Some data on how long an audit would

take

Consx Lots of resources requiredx Not always productive use of resourcesx Software reporting tools not adequate



What were our solutions ?

• Proactive Audit

• CII Safe



CII SAFE

Jan Beales, Senior Pharmacist



CII SAFE

Automated Checks & Balances

Purchasing/Receiving Inventory Compounding Restocking/Returns Expire, Waste, Recall Outpatient Rx/Resale Non- Pyxis Restocking Returns



CII SAFE

Purchasing/Receiving Meds Suggested PO prints weekly

Purchasing done by Purchasing Tech

Med received and scanned into C2 Safe by Narcotic Tech

Invoice reconciled with Acquisition Record by Manager/Pharmacist



CII SAFE

Inventory/NarcVault Access

CII Safe controls both accessible and remote stock

All accessible inventory is counted once a week by two narcotic technicians

All remote inventory is counted once a month

All CII Safe Events report prints daily and is reviewed for unusual activity



CII SAFE

Compounding

CII Safe automatically reduces bulk inventory and increases unit dose quantity for compounded item

If item not returned to CII Safe a variance is created on the Pyxis vs. CII Safe Report



CII SAFE

Medstation Restocking/ReturnsRestocking Communication link between MedStn & CII safe Meds removed from CII safe must be loaded into

MedStn or a variance is createdReturns Removals from a MedStn must be returned to the CII

Safe or a variance is createdOverall Open Discrepancy & Pyxis vs CII Safe reports are

printed daily. Pyxis vs CII Safe report picks up loads, returns, loads

to wrong machines, return bin variances, unload variances

Variances resolved daily by narcotic tech



CII SAFE

Expire, Waste, Recall Med’s returned first, then expired, wasted, or

recalled

Meds pending destruction report reconciled with return bin contents

Requires witness to empty return bin



CII SAFE

Fill a RX /Sell to Another Pharmacy

The All CII Safe Events report shows “fill a prescription & rx sales”. These are reconciled with signature delivery sheets and RX or sales report

Only Pharmacists & Narc Techs have access to Sell to Another Pharmacy



CII SAFE

Non- Pyxis Restocking/Returns Narcotic Control Record (NCR) generated for non-

Pyxis areas Barcoded for tracking of outstanding forms

Restocking Locked Drawer Signature delivery sheets returned to pharmacy

Returns NCR scanned upon return to pharmacy Labels & Returns on NCR’s reconciled with signature

delivery sheets & return reports 10% of NCR’s audited for complete information



CII SAFE - Summary

Was it a solution? Pros Automated areas increased tracking and

reconciliation of narcotic transactions to 100% Gained efficiencies in staffing Expanded services and track more medications (all

control drugs) ConsX Generates lots of paperX Only 10% monitoring in non-pyxis areasX Still too many non- pyxis high use narcotic areas



What were our solutions ?• Proactive Audit• CII Safe

• Expansion of Pyxis – Psychiatric Hospital– Cart fill wards (ICU,

Peds) added Pyxis for narcotics only

– Anesthesia use in OR



PYXIS FOR ANESTHESIA

Working with the Physicians

Monique Yakiwchuk, Pharmacy



DEVICE SET UP

No OR Admitting feed

Set up as Non-Rx, Dr’s as patients

Pharmacy sets user templates



CLINICAL DATA

Add to clinical data category “ENTER NCDUR #”

Narcotic Control Drug Utilization Record (NCDUR) – manual record for the shift.

Pharmacy reconciles removals, returns and wastes associated to that NCDUR Dr’s activity compared to the Pyxis All Station Events Report



RETURN BIN

A double sized drawer reserved for an internal return bin

Accommodates a large quantity of returns

Unloaded daily & reconciled with manual NCDUR / All Station Events Reports



PENDING MEDS

Single dose pockets – no beginning count is required

12 pocket mini drawers

Anaesthesia Med Station set on “OVERRIDE”



USER SET UP

USER ACCESS

Approval for access from Head of Anaesthesia

Pharmacy Create user ID – ANES + licence number

Create Users as Patients – will enable Dr’s to remove under their own name



EDUCATION & TRAINING

Pharmacy Education & Support – key to success of TEAM

culture

Highlights Removals Setting up Kits NCDUR’s Returns Waste Demanding Recounts Document Discrepancies



INVENTORY MANAGEMENT

Maintaining accurate Inventory according to usage reports

Pharmacy manages all Attention Notices

Loads / Refills and Unloads are accurate



DISCREPANCY MANAGEMENT

Monitor / Reconcile Discrepancies for ALL End Users

Reports Currently Being Used by Pharmacy:DAILY

Manual NCDUR’s compared to Pyxis All Station Events Report – done every morning to reconcile anything not matching

Pyxis vs. CII Safe Compare - reviewed daily; detects pocket refills, unloads, loading errors and potential diversion

All CII Safe Events – reviewed daily; provides an account for all activities



OUTSTANDING DISCREPANCIES

Narc Tech to follow up with the end user

Pull patient MAR for review /compare to NCDUR’s & OR record

Un-resolvable occurrence report completed & documentation given to Senior Pharmacist

Follow-up with Head of Anesthesia



PYXIS ANESTHESIA - SummaryWas it a solution? Pros Anesthesia took ownership of their narcotic usage (no more nursing

involvement)

Anesthesia workflow has changed with 24 hour access

Ability to track electronically, an area with high narcotic volumes

Significant decreases in outstanding discrepancies

Anesthesia & Pharmacy work as team

ConsX Return of manual NCDUR still not 100%



What were our solutions ?• Proactive Audit• CII Safe• Expansion of Pyxis

– Psychiatric Hospital– cart fill wards added Pyxis for narcotics only– anesthesia use in OR

• Security: Centre- Wide Process



SECURITY

• Centre- Wide Process

Standard Employee Application Form for all computer access

Pyxis User Database – maintained by Nursing & Pharmacy

BIOid registration handled by Nurse Educators or Pharmacy

Monthly HR Turnover Report used to process terminations & transfers to non-Pyxis areas

Annual purge of users inactive for > 1 yr

Expiry dates for students are grad dates



OVERVIEW

Who are we? What were our challenges? What were our solutions?What are the current barriers?



What are the current

barriers?

o Still have non-pyxis areas ( 10%)

o Proactive Diversion Surveillance– Staff resource– Reporting Tools– Formalized process



OVERVIEW

Who are we? What were our challenges? What were our solutions? What are the current barriers?What are our future plans?



What are our future plans?

Pandora SQL Software Narcotic Diversion Education & Support

for Managers Quarterly Diversion Reports for

Managers to review and monitor potential problems

Formal Investigation Template– Intervention– Checklist

Formal Intervention TeamHospital Pharmacy 2007 Vol.42 No.3 pp244-248



OVERVIEW

Who are we? What were our challenges? What were our solutions? What are the current barriers? What are our future plans?What is our wish list?



What is on our wish list? Extra staff resources

Pyxis Reporting capabilities- more dynamic Medstation, console, and CII Safe reports (eg >1 month at Medstation, large capacity for large data)

Fix Anesthesia set-up – discrepancy causes drawer failure

Interface Pyxis with electronic staffing program & medical records to reconcile staffing, patients & removal times



Questions?

NARCOTIC DIVERSION



NARCOTIC DIVERSION

BREAK OUT SESSION

What has worked well in your institution?

What are your barriers?

What is your wish list?

Pyxis Usergroup Meeting September 23-25, 2008 THE HSC EXPERIENCE Jan Beales, Pharmacy Linda Carroll,...

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