1. Minton, Tamra MBA, MSN, RN

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What if you were given the chance to design your dream hospital? To develop the processes, hire the staff, and hand-select the technology that would make it all happen? Many hospitals remodel or build a new structure, transferring the core group of staff and workflow processes to a new building. The opening of University of Pittsburgh Medical Center (UPMC) East, a 156-bed community hospital in Monroeville, Pa., presented the unique opportunity to build a brand-new facility, grounded in a safety-based culture.


Top priorities

From its inception, UPMC's mission has been to provide exceptional care in a safe environment. This was the driving principle as we chose the technology, developed workflows, and hired staff. Our initial core expanded to over 23 teams, consisting of pharmacists, pharmacy techs, front-line nurses, physicians, and administrators, who brought their expertise from our sister hospitals to help create medication processes. We studied evidence-based practice to determine how to incorporate technology into every point of care.


Safety was a factor in every decision we made. For example, we went with private rooms because they've been shown to improve clinical outcomes by reducing hospital-acquired infections, adverse drug effects, and falls. Research also showed that the closer you keep the medication to the patient, the safer the medication process becomes. As such, we designed the hospital to get the medications as close to the patient rooms as possible. To ensure the safest medication process and eliminate the potential for human error, we implemented a barcode infrastructure from the pharmacy with point-of-care scanning.


Optimizing care

In conjunction with the bar code-based medication infrastructure, we use robotic pharmacy technology to prevent picking errors, manage inventory, and increase accuracy. We researched and simulated the dispensing function to determine the safest method to get the medications closest to the patient. We considered carts, but each one has multiple patient bins, so a component of safety would be lost. The hospital was designed with "nurse servers" outside every patient room, which provide a cabinet, as well as a locking drawer.


Ultimately, we decided the best solution was a hybrid approach: locked nurse servers outside of every patient's door to store a 24-hour supply of medications and automated dispensing cabinets on the floors for nonpatient-specific medications. Bedside administration was a given, and hand-held bar code scanners offered the ability to prevent errors at the point of care. Portable workstations enable charting to be done at the bedside so the nurse can focus on the patient instead of paperwork. We simulated every step of the medication process to find automated solutions that provided greater control, accuracy, and efficiency. We utilized a medication storage and retrieval system in the pharmacy, combined with controlled substance tracking software and a secure storage system on the floor. The OR received anesthesia carts that store, dispense, and label all relevant medications so that anesthesiology providers never have to leave the room.


In selecting the technology, integration of solutions was key to our success. UPMC East is a paperless system with a comprehensive electronic medical record. We also have a full menu of point-of-care testing (POCT) that's performed on each nursing unit. We use the same bar code scanner for medications, lab collection, and POCT. We ensured that every one of these components worked together to keep the patient safe. We chose a single formulary and database to quickly produce and access data to continuously improve our processes. And in addition to integration, ergonomics was a factor. Considering the aging nursing workforce, what makes more sense: pushing a heavy cart down the hallway or opening up a drawer and pulling out meds?


Streamlined workflow

After the technology and infrastructure were determined, it was up to our team to put the workflows in place. The entire medication process is driven through a single pipeline, so order filling is quite efficient. All med requests come through the bar code scanner and immediately appear on the pharmacist's screen for review. After the pharmacist approves the order, the robot pulls the medications and dispenses them into an envelope, which is labeled and bar coded with the patient's name. The envelopes are delivered to the nurse servers outside of every patient room, including the ICU.


Cabinet inventory is based on the specific needs of each floor and generally includes first doses, opioids, controlled substances, and medications that need to get to patients without delay. After an order is verified, the nurse can quickly take the medication out of the cabinet and give it to the patient. Locking drawers ensure nurses don't pull the wrong drug, and built-in alerts prevent look-alike, sound-alike errors.


Medication is administered safely by scanning the patient's ID band, the medication, and the nurse's badge. Because we're scanning at the bedside, we aren't seeing near misses. Double doses are prevented with real-time, electronic charting.


Empowering employees

UPMC East opened on July 2, 2012, and nursing feedback has been very positive. When you look at turnaround times, every second makes a difference for the patient. Nurses love the fact that the medications are right outside the room so they can address a patient's needs faster. Not having to pull and change the cart drawers each shift saves time and is much safer because the envelopes are patient-specific. Access to the cabinets is faster with biometric finger swipes, saving the time required to enter a password.


Automation has totally changed the traditional workflow of our pharmacy. Pharmacists can quickly review orders and consult physicians if there are questions about the dosage or allergies. Instead of spending time stocking med carts, techs are on the floor interacting with nurses and patients, which makes them feel more like part of the healthcare team.


From a management standpoint, we have a real-time, enterprise-wide picture of medications stored, dispensed, credited, and administered through the system. Everything is bar coded, making reporting much more accurate for compliance and quality purposes. We can track where medications are going and trend by associate to see if we have a possible issue with diversion. We can look for missing doses if an opioid has been signed out but not administered, and we can waste medications with a witness who also signs electronically. Data supports our processes, and we're very proud of this and of how technology supports our systems.


In the end, though, it's all about patient care. I believe that you can build a beautiful facility with all private rooms and the best technology in place, but that isn't what makes the patient experience positive. It's the people. We've worked tirelessly to hire the right people and build the culture that we want at UPMC East. My proudest moments are watching our associates take care of our patients while using the technology and processes that we've put into place. Our teams have embraced this technology because they support that it's in the best interest of the patient.