Implementation of a Technician Checking Program at an Academic Medical Center
by Sara J. McEnaney, PharmD, MBA
March 9, 2011
Implementation of a Technician Checking Program at an Academic Medical CenterAs published in KeePosted, Official Newsjournal of the Illinois Council of Health-System Pharmacists (Volume 37, Issue 02)
by Sara J. McEnaney, PharmD, MBA
Pharmacy Clinical Specialist, Regulatory Compliance, Internal Audit, Performance Improvement and Training
Rush University Medical Center
BackgroundTechnician
checking programs are gaining popularity in hospital pharmacies to
allow pharmacists to focus their time on more clinical functions
including answering drug information questions and providing
medication-dosing recommendations. Wisconsin law states a pharmacist is
responsible for the final check of medications. However, the Pharmacy
Examining Board (Board) in the state of Wisconsin has granted variances
to hospitals to allow pharmacy technicians to check unit dose cart fill.
The purpose of this study was to design and implement a technician
checking program and to assess the baseline checking accuracy of a
pharmacist compared to that of a trained and validated technician.
Froedtert
Hospital (FH) is a 500-bed academic medical center located in
Milwaukee, Wisconsin. FH pharmacy department is continually looking for
ways to optimize the medication distribution model. The goal for
medication distribution is to have a seamless system from receipt of
medication from the wholesaler to administration to the patient with
barcode verification at every step of the process. The unit dose drug
distribution model used at FH is documented in
Figure 1.
Figure 1 Unit dose drug distribution model used at Froedtert Hospital
Pharmacists
working in the central pharmacy are responsible for all clinical
monitoring for assigned patient care units. Pharmacists evaluate all
medication orders for appropriateness prior to verification in the
electronic medical record (EMR). Upon verification, any medication doses
needed prior to the next scheduled cart fill are dispensed from the
central pharmacy.
The twenty four hour cart fill is downloaded
through the EMR and sent to the medication carousel and high speed
repackaging machine for processing. The technician removes medications
from the carousel and puts them into patient specific medication
drawers. A pharmacist is responsible for performing the final check of
these medications, an important but time-consuming task that limits the
amount of time spent on clinical activities. Nurses are also responsible
for checking medications against the electronic medication
administration record and barcode scanning the patient’s armband and the
medication prior to administration to the patient.
A technician
checking program allows specialty trained technicians to perform the
final check on certain medications filled by another technician.
Pharmacy literature has demonstrated these programs are as safe and
effective as having a pharmacist perform the final check
1-2.
By using pharmacy technicians to take on more responsibility for
distributive tasks, this allows pharmacists to spend time on clinical
activities.
MethodsThis study was designed in a similar fashion to a previous study conducted by Ambrose et al
1.
The first phase of the study was to develop a technician training
program, present the program to the Board and validate technicians who
successfully complete all steps of the program. The second phase of the
study was to assess the baseline accuracy of pharmacists checking the
unit dose cart fill and ADC refills. The third phase was to evaluate
accuracy of technicians checking the unit dose cart fill and ADC
refills. The fourth and final phase is to develop quality assurance
audits for the technician checking program and to maintain data to
present to the Board.
Phase one involved the creation of a
technician checking program deemed acceptable by the Board. Minimum
requirements to participate were defined by the hospital. To participate
in the program a technician must be working full time with at least one
year of technician experience and be a Certified Pharmacy Technician
(CPhT) through the Pharmacy Technician Certification Board (PTCB). The
training program consisted of two parts: A self-learning packet and a
simulated checking environment. The self-learning packet contained
several sections including: Introduction to the technician checking
program, qualifications / validation / quality assurance (QA), elements
of packaging and product characteristics, medication errors and the
medication distribution process. A pharmacist reviewed the sections of
the self-learning packet with the technician explaining details and
requirements of the program. The technician was then given a week to
review the self-learning packet and answer the self-assessment
questions. Any incorrect answers would be discussed with the technician.
The technician was required to score 90% on the test questions to move
on to the next phase of training the simulated checking environment.
The
simulated checking environment was developed to mirror the unit dose
cart fill. Intentional errors were introduced throughout the simulated
environment prior to the technician checking. The technician checked the
entire simulated cart and documented any errors identified. Upon
completion, the technician discussed all errors identified with the
auditing pharmacist. The technician was required to score 90% prior to
entering the final phase of training the validation period.
During
the validation period the technician was required to maintain a 99.8%
accuracy rate in checking at least 3,500 consecutive doses, during at
least five separate audits. The audit process consisted of a registered
pharmacist checking the accuracy of unit dose cart fill drawers or ADC
refills after the technician checked them. Any errors resulting from
improper checking were documented and recorded on the validation log.
The pharmacist auditor discussed the errors with the technician as they
were encountered. During the validation process the technician filling
the carts intentionally introduced errors at a minimum rate of 0.2%
(seven doses per 3,500). The pharmacist auditor had a record of the
intentional errors to ensure they were removed prior to distribution of
medications to the patient care areas. Intentionally introduced errors
included an occurrence of a wrong drug, a wrong dose, a wrong dosage
form, an extra or insufficient quantity and an omitted medication. The
pharmacist auditor evaluated the technician checker using the Validation
Competency Assessment Checklist (see
Figure 2).
If a technician missed more than seven errors per 3,500 doses, they
failed the validation. If a technician did not achieve the required
99.8% accuracy level in checking 3,500 consecutive doses after two
months of training, the technician was no longer eligible to participate
in the technician checking program. Upon successful completion of the
validation (99.8% accuracy rate) the technician was recognized as a
Validated Technician Checker (VTC).
Figure 2 Validation Competency Assessment Checklist
The
technician checking program was presented at the Board Meeting in
December 2009 and a variance was granted until March 2011. FH is
required to submit technician specific QA data to the Board at six month
intervals for the duration of the variance.
Phase two began in
October 2009 upon completion of training and validation of selected
technicians. The goals of this phase were to audit 3,500 cart fill doses
and 2,000 ADC refill doses. All participants were aware that audits
were being conducted on checking accuracy. Third shift pharmacy
technicians filled the carts according to their normal workflow. The
technician filling the carts documented and introduced intentional
errors at a rate of seven errors per 3,500 doses to correspond to a
99.8% minimum accuracy rate required by the Board. The pharmacist
checking the cart fill or ADC refills documented and worked with the
filling technician to correct all errors that were detected. A
pharmacist auditor then rechecked all medications to verify the accuracy
of a pharmacist checking cart fill and ADC refills. Any errors
overlooked by the checking pharmacist were documented and corrected
before medications were delivered to the patient care units.
Phase
three began immediately upon the completion of phase two with the same
goals. Participants were again aware that audits were being conducted
for checking accuracy. Phase three followed the same procedures as phase
two, however, a technician was doing the initial check followed by a
pharmacist auditor.
Phase four, the QA program, is ongoing as
the technician checking program is being implemented. For the QA
program, a pharmacist is required to check ten percent of all doses
checked by a VTC. The results of this check are documented in the QA
database and maintained on site and submitted to the Board at six month
intervals. As part of the QA program, ongoing standards for technician
participation were implemented to maintain safety and accuracy for
medication distribution. If the accuracy of the VTC is less than 99.8%
over the lesser of a six month period or for the first 2,000 double
checked doses within a six month period, the VTC is required to be
re-trained and re-validated (3,500 doses, 99.8% accuracy). If the
accuracy of the VTC is less than 99.8% on more than four occasions in a
year, the VTC will be relieved from their VTC status for a six month
period. The technician checker may be re-trained and re-validated after
the six month period. If the re-validated technician checker has less
than 99.8% accuracy on any occasion during the three months following
their six-month leave, they will be permanently removed from their VTC
status and unable to participate in the technician checking program. If a
VTC does not check for more than two months, re-validation (99.8%
accurate, 3,500 doses) should be done with the first check upon return.
If the VTC does not check for four months, they must be re-trained and
re-validated.
ResultsFour
pharmacists participated in phase two of the study to assess the
baseline accuracy of a pharmacist checking the unit dose carts and ADC
refills. Three technicians successfully completed the training
requirements and were validated to participate in phase three of the
study.
Table 1 displays the
results from phase two and three of the study. The mean accuracy rate
for pharmacists checking the cart fill was 99.93% and 99.85% for
technicians (p=0.054). The mean accuracy rate for pharmacists checking
the ADC refills was 99.40% and 100% for technicians (p<0.001). The
difference in accuracy rates for pharmacists and technicians was not
significant for cart fill, but was significant for ADC refills. The mean
accuracy rate for technicians for unit dose cart fill and ADC refills
was higher than the 99.8% required by the Board. After three months of
the program, all VTC had maintained a minimum accuracy rate of 99.8%
during the required 10% percent audits and no technicians had been
required to complete any of the ongoing standards for failed QA audits.
Technician specific QA data will be presented to the Board at six-month
intervals (see
Table 2).
Table 1 Results from phases two and three of the study
Table 2 Technician specific QA data
DiscussionThe
results of this study support the hypothesis that well trained
technicians can accurately check unit dose cart fill medications filled
by another technician. This is similar to what has been published in the
literature
1-2. The study also demonstrated that technicians could maintain at least a 99.8% accuracy rate when checking ADC refills.
It
was determined that pharmacists spend approximately two hours on third
shift checking the unit dose cart fill. Throughout the day pharmacists
also spend approximately one to two hours checking the ADC refills. With
the implementation of the technician checking program, pharmacists are
required to check ten percent of these doses requiring approximately
thirty minutes total each day. The time saved by the pharmacists is now
spent on clinical activities within the central pharmacy for the
assigned patient care areas. The senior pharmacy technician for
operations is responsible for training and coordinating the validation
of technicians for continued expansion of the technician checking
program.
Some limitations to this study have been identified.
The pharmacists and technicians who participated in the study were not
randomized. The technicians were selected based on meeting baseline
requirements for participation in the program and availability during
the study period. The pharmacists volunteered to participate in the
study based on schedule availability. The pharmacists and technicians
were all aware that accuracy studies were being conducted. Also, the
intentional errors in the study were not randomly introduced. The
technicians filling the cart or ADC refill would introduce errors as
required by the study guidelines. However despite these limitations, the
QA program implemented has shown that technicians are able to maintain
the minimum accuracy rate required for continued participation in the
program. VTC have been given increased responsibilities in the central
pharmacy which has contributed to overall job satisfaction.
ConclusionThis
study demonstrated that technicians could accurately check ADC refills.
This study also reaffirmed previous literature stating pharmacy
technicians who have been adequately trained and validated through a
technician training program can accurately check unit dose cart fills
while maintaining patient safety in medication delivery. Â?"
References
1.
Ambrose PJ, Saya FG, Lovett LT, et al. Evaluating the accuracy of
technicians and pharmacists in checking unit dose medication cassettes.
Am J Health-Syst Pharm. 2002; 59:1183-8.
2. Woller TW, Stuart J,
Vrabel R, Senst B. Checking of unit dose cassettes by pharmacy
technicians at three Minnesota hospitals. Am J Hosp Pharm. 1991;
48:1952-6.
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