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The effect of a ward-based pharmacy technician service

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The Pharmaceutical Journal Vol 264 No 7102p961-963
June 24, 2000 Original Papers

The effect of a ward-based pharmacy technician service

By Jean M. Langham, HNC, and Kathryn S. Boggs, DipClinPharm, MRPharmS

AIM - To examine the effect of a ward-based pharmacy technician (WPT) on nursing time, pharmacy workload and risk management.
DESIGN - Comparison of data collected before and after initiation of the service, and a user-satisfaction survey.
SUBJECTS AND SETTING - 3 medical directorate wards (approximately 160 beds) at Walsgrave Hospitals NHS trust, Coventry.
OUTCOME MEASURES - Nursing time spent on drug supply, doses missed due to drug unavailability, pharmacy workload.
RESULTS - Nurse involvement in drug requisition was eliminated. Number of missed drug doses was reduced. Non-stock items ordered from pharmacy was reduced by 15% on weekdays; pharmacy items ordered at weekends reduced by approximately 50%. 90 minutes of pharmacy staff time was saved each week.
CONCLUSION - A ward-based pharmacy technician service confronts demands on nursing time, reduces medication errors and, through effective medicines management, controls pharmacy workload. It also aids staff communication, a team approach to patient care and risk management.


Traditionally, nursing staff have performed the requisition of drugs for patients at Walsgrave general hospital. Pharmacy services highlighted two main problems with this system. First, we were aware of the increased demands on nursing time and resources and it was felt that we could reduce nursing time spent in drug supply. Second, we needed to improve medicines management at ward level to address increased pharmacy workload. Duplication in ordering of non-stock drugs could be avoided if a designated individual completed requisitions. By removing responsibility for ordering drugs from nursing staff, repeated interruption of the drug administration process to complete an order form would be unnecessary. This would have positive implications for risk management. By improving both stock and non-stock drug levels on the ward, we believed we could reduce the number of drug omissions.
A pilot project was proposed to senior nursing staff within the medical directorate. This involved basing a pharmacy technician at ward level to provide a ward pharmacy service. The role of ward pharmacy technicians (WPTs) in medication management has previously been investigated at the Northern general hospital, Sheffield.1,2
Objectives were to:

  • Reduce nursing time spent on drug supply
  • Reduce the number of doses missed due to drug unavailability and hence improve patient care
  • Reduce pharmacy workload
  • Examine communication within the pharmacy and between pharmacy and the wards
  • Provide a team approach to patient care
  • Assess risk management of medicines at ward level

Funding was made available to second a pharmacy technician (MTO2) to work with clinical pharmacists and nursing staff for a six-month period. Three high-throughput medical wards (A4, B4 and C4) were chosen as project success would allow us to assume success in other areas should the service be extended. The ward-based pharmacy technician was available between 8am and 4.30pm, Monday to Friday, and the service commenced in September, 1998.

Method

In order to demonstrate the benefits of the system, a number of comparisons needed to be recorded. The WPT co-ordinated collection of these data.
The WPT kept a diary of her activities, once fully established, in order to identify ward contact time and her expanded role.
The number of orders received by pharmacy for non-stock drugs before and during the project months was compared. Orders from the three pilot wards were identified for a period prior to the project to provide baseline figures. The orders placed by the WPT were similarly analysed during October and November, 1998.
The time taken for the WPT to organise and rationalise drug items in the drug trolley was recorded. This activity could not be directly compared with nursing staff.
The time taken to unpack ward stock orders by the WPT was compared with the time taken by nursing staff. Nursing staff were asked on repeat occasions to unpack the ward order so that an average time could be obtained.
The number of "drug not available" entries on the drug chart was compared for a ward without a WPT and wards with a WPT. The ward pharmacist collected the comparative data from a medical ward over seven weeks.
The time taken by the WPT to order ward stock drugs was compared with that taken by the assistant technical officers (ATOs) assigned to pharmacy stores who previously undertook this activity. The stores team leader provided an average time per "top-up" and the WPT recorded an average time required to complete this service for each ward.
The number, type and origin of queries dealt with by the WPT were recorded from September to December, 1998. The WPT was issued with a bleep and maintained a log of inquiries received. This obviously will not reflect queries received in person at ward level or in pharmacy.
The number and type of patient counselling episodes performed by the WPT were recorded. This activity was introduced for November, December and January following appropriate training to enable accurate and safe counselling performance.
A questionnaire was designed and distributed to nursing staff in January, 1999. The opinions of nursing staff on the WPT service were analysed using this survey.

Results

The month of September was used by the WPT to establish her role on the wards. Data collection was initiated in October, 1998, and continued to January, 1999.
The pharmacy technician provided a ward pharmacy service to approximately 160 beds.
The diary maintained by the WPT indicated that approximately 75 per cent of her day was spent at ward level.
The average time taken for the WPT to organise and rationalise drug items in the drug trolley varied between 17 and 36 minutes. Ten drug trolleys were in use on the pilot wards and thus the number of times this activity was undertaken per week depended on ward type, the number of non-stock items in use and perceived need by the WPT. Time taken varied depending on whether drug charts were at bed-ends or in a central folder.
Table 1 shows the average time taken to unpack ward stock orders. These results are statistically significant (chi-squared, P<0.05). The WPT service saved over three hours of nursing time each week.
Table 2 shows the number of missed doses over a seven-week period on wards with and without a WPT. The results show that drug omissions can be reduced by between 52 and 82 per cent utilising a WPT service. Analysis of "drug not available" on one of the pilot wards (admissions and short-stay) was not included for this comparison, as the different nature of this ward would have skewed the results. Table 3 shows reasons for missed doses of medication on wards with a WPT.
Table 4 shows the average number of non-stock items ordered by the pilot wards on weekdays and at the weekend. The WPT reduced the number of non-stock items ordered by the pilot wards on weekdays by 15.3 per cent and workload over a weekend by 51.1 per cent.
Stock drugs were ordered for each of the three pilot wards twice a week. The average time per "top-up" by the ATO was 40 minutes and by the WPT 24 minutes. This amounts to a saving of approximately 90 minutes per week of pharmacy staff time .
Table 5 shows that nursing and pharmacy staffs communicated with the WPT.
Fifty-eight user satisfaction survey questionnaires were issued and 27 (47 per cent) were returned completed. Table 6 shows questions posed to nursing staff and the responses. Further questions addressed the impact of the WPT on discharge medication and overall opinion of the service. Eighty-one per cent of respondents felt that the WPT service had an impact on discharge medication. Reasons given were that the service appeared more efficient (61 per cent), that the WPT could be contacted readily for information on discharge prescriptions (TTOs) (19 per cent), that nursing staff received fewer inquiries regarding TTOs (8 per cent) and that errors in the discharge prescription were less frequent as the WPT was checking the TTO against the drug chart for transcription errors (12 per cent).
Positive points noted on the questionnaires included the reliability and personality of the WPT, the efficiency of the service, a notable improvement in ward stock and non-stock management, a notable reduction in nurse involvement with drug supply and encouragement for the counselling activities. Negative points were few: however, an issue of overstocking prior to weekends and bank holidays was raised.
The WPT counselled eight patients commencing warfarin therapy and assessed the inhaler technique of six patients over three months. This excluded discharge counselling performed within a patient's own drugs (PODs) procedure. Counselling was performed under supervision of or in conjunction with a clinical pharmacist.

Table 1: Average time taken to unpack stock orders
WardTime (min) taken by
 WPTNursing staff
A41066
B42256
C42260
Total54182
Table 2: Number of missed doses over seven weeks
WardMissed doses
Ward with no WPT62
A411
C430
Table 4: Average number of non-stock items ordered
 Items ordered
 Pre-WPTWPT
Weekdays183155
Weekends4522
Table 5: Number of bleeps received from different staff members
Bleep from:Number
Pharmacy73
A446
B443
C426
Doctor2

Table 3: Reasons for missed doses of medication
ReasonPercentage
The drug prescribed was a non-stock item and needed to be ordered64
Stock was available but was either not found or not looked for22
The patient was transferred from another ward and non-stock items already dispensed to this ward were not transferred with the patient9
Prescribing was inaccurate or illegible3
Drug was a stock item but the stock level was zero1
The drug was available on the ward; it was either in the incorrect drug trolley or in the correct trolley but unable to be found by the nurse1

Table 6: Result of questionnaire to assess nurses' opinion
QuestionPercentage answering "yes"
Do you feel the WPT service has reduced the number of missed drug doses?96
Do you feel the WPT is easy to contact?100
Once contacted, do you feel you can rely on the WPT to carry out your requests?100
Do you feel that by having a WPT nurse time spent drug ordering and unpacking ward boxes is less?96
Do you feel that ward stock management has improved?93
Do you find that you have more of the drugs necessary to complete drug rounds?93
Do you feel that the WPT and ward pharmacist work effectively as a team?100
Would you like the WPT service to continue?100

Discussion

Results of this pilot project show that all the objectives were met and provide further evidence of the benefits of a ward-based pharmacy technician service.

Nursing time spent on drug supply Nursing time spent on drug supply has been reduced. This concurs with the audit performed on orthopaedic and spinal injuries wards at the Northern general hospital,2 where it was concluded that ward staff spent less time ordering drugs with a ward pharmacy technician service. The service implemented was different from that at Walsgrave hospital, where the technician was ward based.
An evaluation of nursing time spent ordering non-stock drugs prior to the WPT service was not feasible. Completion of drug requisition forms by nursing staff traditionally occurred during the drug round. It would have been difficult to separate time taken for this process from that for drug administration. Since implementation of the WPT service, nurses have no longer been required to order non-stock drugs. The ward-based technician service to the medical admissions unit at Northern general hospital1 shows a similar percentage reduction in inpatient items supplied (13.5 per cent compared with 15.3 per cent at Walsgrave hospital). The WPT was familiar with the ward stock list and ordered non-stock items appropriately.
The role of the WPT in organising and rationalising drug trolleys does not remove a duty for nursing staff working daytime shifts. The questionnaire results, however, indicate that nurses perceive drug rounds to be completed more effectively.
Nursing time was saved each week by the WPT unpacking the ward stock orders (Table 1). The WPT had placed these orders and was familiar with the layout of the stock cupboards.

Drug doses missed due to drug unavailability The presence of a WPT reduced the incidence of drug unavailability (Tables 2 and 3). This contributes to effective patient care, and reduces medication errors.3 The most common reason for missed doses was the drug not being available as ward stock. The limiting factor was usually storage space. An unlimited and irrational number of stock drugs could, however, have a negative impact on risk management.
There were factors outside the influence of the WPT which affected drug omissions, such as new nursing and locum consultant staff. These, however, were temporary and resolved once staff became more familiar with the trust formulary.

Pharmacy workload Pharmacy workload is reduced by a WPT service (Table 4). Data collected prior to the project was during summer months, when activity was lower than during the project itself. The reduction may have been greater if these data had been collected at a time of year similar to that when the project data were collected.
Other benefits included a saving of ATO time. Although this may appear to be inappropriate skill-mix, the advantage of the WPT having personal control of ward medicines management outweighs this issue. The WPT completed appropriate drug order forms with information required for supply, thus eliminating clarification that is often sought from other wards. With responsibility for pharmacy orders resting with an individual, duplication was avoided.

Communication within pharmacy and between pharmacy and the wards The results show that ward and pharmacy staffs are communicating through the WPT (Table 5). Inquiries included whether items were on order, where to find items in cupboards or trolleys, clarification of prescribing and whether items were ready for collection. Nursing staff favoured the individualised pharmacy service and the WPT has been welcomed into the multidisciplinary ward team.

Team approach to patient care The questionnaire results (Table 6) indicated that the ward pharmacist and WPT were seen as a team. This was important as we wished to avoid confusion to nursing staff as to the differing roles. The role of the WPT developed throughout the pilot period. The main activities performed are shown in the Panel.
Although drug ordering was previously undertaken by nursing staff, clinical pharmacists usually endorsed these orders during the ward visit. This routinely allowed less time for patient contact and the practice of clinical pharmacy. With a WPT, the clinical pharmacist has more time to develop pharmaceutical care.
With the WPT undertaking patient counselling, information could be provided to a larger number of patients. A team approach is evident here as the ward pharmacist identified patients and provided the WPT with any necessary background information needed for counselling.

Risk management of medicines at ward level The implementation of a WPT ser- vice has had positive implications for risk management.

Disruption of the drug administration process As nurses are no longer required to order drugs, interruption of the drug administration process has been reduced. With the WPT organising and rationalising drug trolleys, nurses do not have to distract themselves from the drug round to obtain necessary drugs from stock cupboards. The potential for error is thus reduced.4?6

Transcription errors Errors in the discharge prescription are less frequent as the WPT is checking the TTO against the drug chart and confirming any discrepancies.

Communication pathways Nursing and pharmacy staffs are encouraged to communicate through the WPT to reduce the potential for error. Errors can be caused by, for example, disturbing nursing staff completing drug rounds or by pharmacy staff relying on nurses unfamiliar with patients to answer questions on discharge prescriptions.
Prior to the WPT service, nursing staff may not have had a contact for the information described earlier. This could result in duplication of ordering, omission or delay in drug administration and drug errors.

The role of the ward-based pharmacy technician

  • Visits each ward twice a day, morning and late afternoon (to check for new admissions); reviews all patients' charts and orders any non-stock items required; endorses charts in an agreed way to identify to nursing staff which items are stock or non-stock, specially controlled or Controlled Drugs
  • Organises and rationalises drug items in the ward drug trolleys; empties the drug trolley and replaces with items currently required
  • Unpacks non-stock orders into trolleys and returns stock items not in use to stock cupboards
  • Orders stock drugs for each ward twice a week and unpacks these orders; keeps stock cupboards tidy and returns unwanted items to the pharmacy
  • Updates ward stock lists in liaison with clinical pharmacists and ward managers
  • Checks the discharge prescription (TTO) against the drug chart for transcription errors and delivers the TTO to the pharmacy
  • Facilitates the use of patients' own drugs (PODs) in discharge prescriptions according to procedure
  • Organises and rationalises the TTO and PODs cupboards on each ward; returns TTOs not required to the pharmacy
  • Dispenses or provides the professional check for non-stock orders from the pilot wards
  • Counsels patients, including providing information for patients starting warfarin therapy, assessing inhaler technique and discussing discharge medication
  • Records high-cost drugs in use on each ward for the attention of the medical directorate pharmacist
  • Encourages the transfer of dispensed non-stock items and PODs with patients who are required to move wards
  • Contacts ward pharmacists with drug information inquiries and when clarification with medical staff required

Conclusion

A pharmacy technician has been successfully integrated at ward level. The need for nursing staff to order non-stock drugs has been eliminated and nurses no longer have to set aside time to unpack stock orders. The service markedly reduces drug unavailability at ward level and helps to control pharmacy workload.
Relationships between pharmacy and the pilot wards have improved due to the pharmacy team approach and effective communication through the WPT.
Risk management issues relating to drug administration, transcription errors and communication have been addressed.
Following the end of the study period, funding was agreed for the WPT service to continue to the pilot wards. Due to the success of the project, we are now providing this service to three further medical wards. The service will eventually be extended throughout the medical directorate and offered to the other directorates.

Mrs Langham is a ward-based pharmacy technician and Miss Boggs is medical directorate pharmacist at Walsgrave Hospital, Clifford Bridge Road, Walsgrave, Coventry CV2 2DX. Correspondence to Miss Boggs (e-mail kathryn.boggs@wh-tr.wmids.nhs.uk)

References

1.Rogers A. Effect of a ward based technician service. Hosp Pharm 1998;5:222-3.
2.Reeves J, Hamshaw-Thomas S. Give technicians a ward role. Pharmacy in Practice 1998;8:324-6.
3.ASHP standard definition of a medication error. Am J Hosp Pharm 1982;39:321.
4.Williams A. How to avoid mistakes in medicine administration. Nursing Times 1996;92:40-1.
5.Gladstone J. Drug administration errors: a study into the factors underlying the occurrence and reporting of drug errors in a district general hospital. J Adv Nurs 1995; 22:628-37.
6.Pepper GA. Errors in drug administration by nurses. Am J Health-Syst Pharm 1995;52:390-5.

Citation: The Pharmaceutical Journal URI: 20001982

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