Current situation and analyses of drug placement before transformation
Before the transformation, the working mode was as follows. The drugs in each ward were summarized into a dispensing list and printed out on A4 paper (1-3 pieces of A4 paper were consumed according to the number of drugs in each ward, and printed out at least twice a day). The pharmacist placed the drugs according to the drug location code on the dispensing list and put the target drugs into the medicine basket. The pharmacist in charge of checking the medicine checked the medicine out of the medicine basket according to the paper list, and marked the correct medication on the list with a pen after ensuring that it was accurate. Finally, all of the drugs were handed to the logistics personnel in charge of receiving drugs in the ward.
There were problems in the working mode before the transformation. First, in order to ensure the printing speed, the pendulum list was printed on A4 paper. At least one A4 paper was used for each printing. Even if one drug was temporarily used in the ward, one A4 paper was consumed, resulting in a great waste of resources. In addition, the limited area of A4 paper limited the drug information that could be provided. When dispensing the paper drug list, it was inevitable that there would be "similar drug" errors, and indeed, there were many errors, and hidden dangers of drug safety. Second, the dispensed drugs were placed into the medicine basket in a disorderly manner. Although it is convenient for pharmacists to arrange drugs, it is inconvenient for the checking pharmacists. For example, checking pharmacists spend a lot of time looking for drugs in order to find all of drugs to check in the basket. The more the variety and quantity of drugs on the list, the more time it takes to find them. Taking too long to check, leads to ward patients failing to use drugs in a timely manner. Therefore, the ward nurses were dissatisfied with the efficiency of the inpatient pharmacy. Third, Due to historical and scale reasons, there are 70 wards in our hospital, which are distributed in eight inpatient buildings at different distances from the inpatient pharmacy. The farthest ward takes at least fifteen minutes to and from the inpatient pharmacy. Because the treatment area is scattered, the drug recipients in the ward often cannot return the drugs to the ward on time, and the ward nurses usually think that the work progress of the pharmacy pharmacist is too slow. In addition, the work progress of the pharmacy is not clear to the ward, and drug delivery cannot be reasonably arranged. Information communication is not smooth, resulting in many unnecessary misunderstandings between the ward and pharmacy. Lastly, the inpatient pharmacy drug logistics are not monitored. Once the drug leaves the pharmacy, the pharmacist loses the ability to monitor the drug logistics, which is a great potential safety hazard.
Taking advantage of "carbon neutrality" and HIMSS rating, it is imperative to reform the working mode of inpatient pharmacy and realize green, low-carbon and whole-process closed-loop management of inpatient pharmacy drugs.
Drug closed-loop management reform practice based on the HIMSS standard
The main practices of the inpatient pharmacy in our hospital are comprehensive dispensing and single-dose oral dispensing. After the transformation based on the HIMSS standard, the drug information is associated with the medical orders information in all wards of the hospital to form a traceable closed-loop management mode in all links, such as doctors issuing medical orders, pharmacists pre reviewing doctor's orders, summarizing and placing drugs according to medical orders, checking drug varieties and quantities, packaging and sealing drugs, centralizing and unifying distribution of drugs; and nurses confirming drug receipt (see Fig. 1). After each link is completed, personnel and time information will be recorded in the system to make the entire process from inpatient pharmacy to ward traceable.
In addition, several high-definition surveillance cameras were installed where there might be medical and protective disputes, to carry out all-round monitoring of checking and packing, and have real-time video streaming back within the department. If nurses have doubts about whether the quantity of drugs is sufficient whether the drugs are damaged, and other drug quality issues in the process of dispensing nuclear drugs, the staff of the pharmacy can immediately retrieve the monitoring video of the drug packing for verification and proof. The real-time call of monitoring video reduces the tendency to shift responsibility when drug quality problems occur due to dispensing drug errors, packaging process damage, and other links, greatly reducing the contradiction between pharmacists and nurses and masking the communication more harmonious.
Paperless comprehensive drug laying transformation
After analyzing the congestion points and combining the hardware advantages of our hospital's informatization, which has completed the full coverage of the hospital's wireless network, we completely abandoned the traditional paper-based drug dispensing mode and tablet computers are used as information media, and trolleys as drug carriers (Figure 1(a)). The specific working steps are as follows. First, the drugs in the ward are input to the tablet computer, which generates a list of drug orders. The drug dispensing sequence is automatically generated according to the pre-maintained dispensing route, and the drug dispensing pharmacists place the drugs in an orderly fashion on the drug-carrying trolley one by one according to the information on the tablet computer (including but not limited to cargo location information, picture information, and voice print information.) (Figure 1(b)). In the process of "not going back", the drugs on the list are dispensed at one time, and then, the drug-carrying trolley is pushed to a fixed position for checking under monitoring by high-definition cameras. Then, the pharmacist places the medicine into the logistics box for packing and sealing. Finally, a sealing label is generated and pasted on the outside of the box as a logo. The label contains information such as the name of department, the time of checking, the two-dimensional code of the drug list number and other information (Figure 1(c)).
Figure 1 Situation after transformation. (a) Take a trolley as the work carrier. (b) The tablet computer can provide all kinds of drug information, including location, package picture, voiceprint of name. (c) After the verification is completed, the pharmacist is undergoing logistics registration.
Single-dose tablet packing
Oral medical orders are subcontracted by the automatic tablet dispenser for single doses. Details including patient information, drug name, specification, quantity, usage and dosage, medication frequency, and medication time, are printed on each medicine bag. The medical orders and medicine bags have two-dimensional containing the above information, which are used for the pharmacist dispensing review. After the drug is delivered to the ward, the nurse scans the code to receive it, records the delivery time and the information of the drug giver and the recipient, and simultaneously connects the data with the mobile nursing system. Before drug delivery, the nurse needs to scan the two-dimensional of the patient’s wrist band to confirm his identity, and scan the barcode of the drug bag to check the medical order information. If the information matches, the operation can be carried out. At the same time, the mobile nursing system will send all data back to the closed-loop drug management system, to realize the traceability of the closed-loop management information of inpatient drug use, in order to prevent the occurrence of drug dispensing and drug administration errors.
Transformation of drug distribution logistics
The original mode of sending people from the ward to receive medicines was transformed into medicines being delivered to the ward, changing from "receiving here" to "delivering to ". Moreover, the open distribution basket was changed into a closed drug distribution box, supplemented by a cold chain incubator for the transportation of refrigerated drugs at low temperature . The process after logistics transformation is as follows: After drug packaging is completed, logistics personnel scan personal information and the two-dimensional code affixed to the sealing box and confirm the distribution order number information on the computer. In order to improve the efficiency of the scattered wards of our hospital, the logistics personnel divide the areas according to the distribution of wards to deliver medicines. After the logistics box arrives in the ward, the nurse scans the two-dimensional code on the logistics box to confirm and receive the medicine. The nurse does not need to open the box and check it in person. If there is any doubt about the drug quality later, the pharmacy can query the surveillance video for proof.
Reform of pre-prescription review of medical orders
A pre-prescription review team was formed for the inpatient pharmacy. It had a full-time pre-prescription pharmacist, and accomplished the pre-prescription medical orders through a rational drug use decision support system combined with manual review mode. Pre-prescription review is an important part of closed-loop drug management mode based on the HIMSS standard. After the doctor issues a medical order, the system automatically audits; the audit can generate a normal medical order. If the order does not pass the examination, the doctor will take the initiative to modify the problematic medical advice according to the system prompts. If the doctor refuses to modify the problematic medical advice, the system will automatically send the medical advice to the online auditing pharmacist, who will manually audit the medical advice, and the auditing and modification suggestions will be sent to the prescribing doctor through the system. The whole real-time review process of medical advice is completed within 40 seconds. Doctors can adopt the advice of pharmacists to modify medication problems, or they can sign for confirmation again and enforce it. Pre-review helps doctors correct medication problems when issuing medical advice (Figure 2).
Figure 2 Closed-loop management mode of outpatient medication
The records of drug dispensing time from November 2020 to March 2021 in five wards of our hospital and the error information from wards to inpatient pharmacy were selected as the research data by using the Excel table random formula.
SPSS 22.0 was used for the statistical analyses. The t- test was used to compare the data of the two groups before and after transformation, and P < 0.05 was considered statistically significant.