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Foglia E, Asperti F, Antonacci G, Jani YH, Garagiola E, Bellavia D, Ferrario L. Automated Drugs Dispensing Systems in Hospitals: a Health Technology Assessment (HTA) Study Across Six European Countries. CLINICOECONOMICS AND OUTCOMES RESEARCH 2024; 16:679-696. [PMID: 39319287 PMCID: PMC11421443 DOI: 10.2147/ceor.s468417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2024] [Accepted: 08/16/2024] [Indexed: 09/26/2024] Open
Abstract
Background Automated Drug Dispensing (ADD) systems are considered to be strategic hospital assets used to reduce errors and enhance economic and organizational sustainability. With regards to efficacy and safety, the literature evidence demonstrates the incremental benefits of centralised or decentralised systems compared to manual dispensing. Analyses about organisational and economic sustainability are still lacking and the present study aims to perform a Health Technology Assessment (HTA), producing multidimensional evidence on the use of ADD systems within hospitals. Methods In 2023, a comprehensive HTA draws insights from healthcare professionals across six European nations: Italy, France, Germany, the Netherlands, the United Kingdom, and Belgium. This appraisal juxtaposed four drug dispensing scenarios: manual methods, centralized ADD systems, decentralized ADD systems, and integrated solutions employing cutting-edge technologies in both central pharmacies and wards. The study deployed an Activity-Based Costing approach that was combined with a cost-effectiveness and Budget Impact Analysis to evaluate economic impacts. Qualitative questionnaires were implemented to assess ethical, legal, organizational, safety, and efficacy aspects. Results From a multidimensional perspective, healthcare professionals acknowledged ADD manifold advantages of ADD systems. From an organizational perspective and within a 12-month timeframe, transitioning to automation may face initial challenges that are attributed to potential resistance from professionals and significant investments. However, 36 months past its adoption, automation's superiority over manual methods was recognized. Economically, savings burgeoned from +17.9% in UK to +26.6% in Belgian hospitals that adopted integrated systems in comparison to traditional manual approaches. Conclusion Compared to traditional methods, implementing ADD systems could improve the logistic management of drug in the hospital setting, thereby enhancing safety and efficacy, streamlining the healthcare professionals' workflow, and bolstering financial stability.
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Affiliation(s)
- Emanuela Foglia
- LIUC - University Cattaneo, Healthcare Datascience LAB, Castellanza, Varese, 21053, Italy
| | - Federica Asperti
- LIUC - University Cattaneo, Healthcare Datascience LAB, Castellanza, Varese, 21053, Italy
| | - Grazia Antonacci
- Department of Primary Care and Public Health, Imperial College London, National Institute of Health Research (NIHR) Applied Research Collaboration (ARC) Northwest London, London, UK
- Business School, Centre for Health Economics and Policy Innovation (CHEPI), Imperial College London, London, UK
| | - Yogini H Jani
- Centre for Medicines Optimisation Research and Education, University College London Hospitals NHS Foundation Trust, London, UK
| | - Elisabetta Garagiola
- LIUC - University Cattaneo, Healthcare Datascience LAB, Castellanza, Varese, 21053, Italy
| | - Daniele Bellavia
- LIUC - University Cattaneo, Healthcare Datascience LAB, Castellanza, Varese, 21053, Italy
| | - Lucrezia Ferrario
- LIUC - University Cattaneo, Healthcare Datascience LAB, Castellanza, Varese, 21053, Italy
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Jermini M, Fonzo-Christe C, Blondon K, Milaire C, Stirnemann J, Bonnabry P, Guignard B. Financial impact of medication reviews by clinical pharmacists to reduce in-hospital adverse drug events: a return-on-investment analysis. Int J Clin Pharm 2024; 46:496-505. [PMID: 38315303 PMCID: PMC10960916 DOI: 10.1007/s11096-023-01683-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Accepted: 11/30/2023] [Indexed: 02/07/2024]
Abstract
BACKGROUND Adverse drug events contribute to rising health care costs. Clinical pharmacists can reduce their risks by identifying and solving drug-related problems (DRPs) through medication review. AIM To develop an economic model to determine whether medication reviews performed by clinical pharmacists could lead to a reduction in health care costs associated with the prevention of potential adverse drug events. METHOD Two pharmacists performed medication reviews during ward rounds in an internal medicine setting over one year. Avoided costs were estimated by monetizing five categories of DRPs (improper drug selection, drug interactions, untreated indications, inadequate dosages, and drug use without an indication). An expert panel assessed potential adverse drug events and their probabilities of occurrence for 20 randomly selected DRPs in each category. The costs of adverse drug events were extracted from internal hospital financial data. A partial economic study from a hospital perspective then estimated the annual costs avoided by resolving DRPs identified by 3 part-time clinical pharmacists (0.9 full-time equivalent) from 2019 to 2020. The return on investment (ROI) of medication review was calculated. RESULTS The estimated annual avoided costs associated with the potential adverse drug events induced by 676 DRPs detected was € 304,170. The cost of a 0.9 full-time equivalent clinical pharmacist was € 112,408. Extrapolated to 1 full-time equivalent, the annual net savings was € 213,069 or an ROI of 1-1.71. Sensitivity analyses showed that the economic model was robust. CONCLUSION This economic model revealed the positive financial impact and favorable return on investment of a medication review intervention performed by clinical pharmacists. These findings should encourage the future deployment of a pharmacist-led adverse drug events prevention program.
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Affiliation(s)
- Mégane Jermini
- Pharmacy, Geneva University Hospitals, Rue Gabrielle Perret Gentil 4, 1205, Geneva, Switzerland.
- Institute of Pharmaceutical Sciences of Western Switzerland, School of Pharmaceutical Sciences, University of Geneva, Geneva, Switzerland.
| | - Caroline Fonzo-Christe
- Pharmacy, Geneva University Hospitals, Rue Gabrielle Perret Gentil 4, 1205, Geneva, Switzerland
| | - Katherine Blondon
- Medical and Quality Directorate, Geneva University Hospitals, Geneva, Switzerland
| | | | - Jérôme Stirnemann
- Division of General Internal Medicine, Department of Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Pascal Bonnabry
- Pharmacy, Geneva University Hospitals, Rue Gabrielle Perret Gentil 4, 1205, Geneva, Switzerland
- Institute of Pharmaceutical Sciences of Western Switzerland, School of Pharmaceutical Sciences, University of Geneva, Geneva, Switzerland
| | - Bertrand Guignard
- Pharmacy, Geneva University Hospitals, Rue Gabrielle Perret Gentil 4, 1205, Geneva, Switzerland
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Hänninen K, Ahtiainen HK, Suvikas-Peltonen EM, Tötterman AM. Automated unit dose dispensing systems producing individually packaged and labelled drugs for inpatients: a systematic review. Eur J Hosp Pharm 2023; 30:127-135. [PMID: 34795001 PMCID: PMC10176995 DOI: 10.1136/ejhpharm-2021-003002] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 11/01/2021] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES Pharmacy automation is increasing in hospitals. The aim of this systematic review was to identify and evaluate the literature on automated unit dose dispensing systems (UDDS) producing individually packaged and labelled drugs for inpatients. METHODS The search was conducted on eight electronic databases, including Scopus, Medline Ovid, and Cinahl, and limited to peer reviewed articles with English abstracts published 2000-2020. Studies were included in the review if drug dispensing was performed by an automated UDDS where individually packaged and labelled unit doses were subsequently assembled patient specifically for inpatients. All outcomes related to UDDS functionality were included with specific interest in medication safety, cost-efficiency and stock management. Outcomes were categorised and results synthesised qualitatively. RESULTS 664 publications were screened, one article identified manually, resulting in eight included articles. Outcomes of the studies were categorised as medication administration errors (MAEs), dispensing errors, costs and cost-effectiveness. Studies showed that automated UDDS reduced significantly MAEs of inpatients compared with traditional ward stock system (WSS), especially when UDs were dispensed patient specifically by unit dose dispensing robot. Patient specific drug dispensing with automated UDDS was very accurate. Of three different automated medication systems (AMSs), patient specific AMS (psAMS) was the most cost-effective and complex AMS (cAMS) the most expensive system across all error types due to the higher additional investments and operation costs of automated dispensing cabinets (ADCs). None of the studies investigated the impact on the medication management process such as efficiency, costs and stock management as primary outcome. CONCLUSIONS UDDS improved patient safety. However, automation is a costly investment and the implementation process is complex and time consuming. Further controlled studies are needed on the clinical and economical outcomes of automated UDDS to produce reliable knowledge for hospital decision makers on the cost-benefit of the investment and to support decision making.
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Affiliation(s)
- Kaisa Hänninen
- Hospital Pharmacy, Central Finland Hospital Nova, Jyvaskyla, Finland
- Faculty of Pharmacy, University of Helsinki, Helsinki, Finland
| | - Hanne Katriina Ahtiainen
- Faculty of Pharmacy, University of Helsinki, Helsinki, Finland
- HUS Pharmacy, Helsinki University Hospital, Helsinki, Finland
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Alanazi MF, Shahein MI, Alsharif HM, Alotaibi SM, Alanazi AO, Alanazi AO, Alharbe UA, Almfalh HSS, Amirthalingam P, Hamdan AM, Veeramani VP, Mohamed SHP, Ali MAS. Impact of automated drug dispensing system on patient safety. Pharm Pract (Granada) 2022; 20:2744. [PMID: 36793902 PMCID: PMC9891784 DOI: 10.18549/pharmpract.2022.4.2744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Accepted: 10/06/2022] [Indexed: 12/13/2022] Open
Abstract
Objectives Automated drug dispensing system (ADDs) is an emerging technology positively impacts drug dispensing efficiency by minimizing medication errors. However, the pharmacist perception of the impact of ADDs on patient safety is not well-established. This cross-sectional observational study aimed to evaluate the dispensing practice and pharmacist perception of ADDs towards patient safety through a validated questionnaire. Methods A self-designed questionnaire was validated and the pharmacist perception of dispensing practice was compared between two hospitals adopting ADDs and traditional drug dispensing system (TDDs). Results The developed questionnaire had an excellent internal consistency (both Cronbach's α and McDonald's ω coefficients were >0.9). Factor analysis retained three significant factors (subscales) that explained pharmacist perception of dispensing system, dispensing practice, and patient counseling (p<0.001 for each factor). The average number of prescriptions dispensed per day, drugs contained in each prescription, average time for labeling each prescription and inventory management were significantly varied between ADDs and TDDs (p=0.027, 0.013 0.044 and 0.004, respectively). The perception of pharmacists using ADDs on three domains were higher than the TDDs. The pharmacists in ADDs agreed that they had enough time to review the medications before dispensing than TDDs and this difference was found to be statistically significant (p=0.028). Conclusions ADDs was highly effective in improving dispensing practice and medication review; however, the pharmacists need to emphasize the importance of ADDs to translate the pharmacists' freed-time towards patient care.
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Affiliation(s)
- Majed Falah Alanazi
- Pharm.D student, Faculty of Pharmacy, University of Tabuk, Tabuk, Saudi Arabia.
| | | | | | | | | | | | - Umar Abdolah Alharbe
- Director of Pharmaceutical Care Department, King Fahd Multispecialty Hospital, Tabuk, Saudi Arabia.
| | - Hanad S S Almfalh
- Clinical Pharmacist, King Khalid Civil Hospital, Tabuk, Saudi Arabia.
| | | | - Ahmed Mohsen Hamdan
- Department of Pharmacy Practice, Faculty of Pharmacy, University of Tabuk, Tabuk, Saudi Arabia.
| | - Vinoth Prabhu Veeramani
- Department of Pharmacy Practice, Faculty of Pharmacy, University of Tabuk, Tabuk, Saudi Arabia.
| | | | - Mostafa A Sayed Ali
- Department of Pharmacy Practice, Faculty of Pharmacy, University of Tabuk, Tabuk, Saudi Arabia and Department of Clinical Pharmacy, Faculty of Pharmacy, Assuit University, Egypt.
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Abdul Nasir HH, Goh HP, Wee DVT, Goh KW, Lee KS, Hermansyah A, Al-Worafi YM, Ming LC. Economic Analysis of Patient's Own Medication, Unit-Use and Ward Stock Utilization: Results of the First Pilot Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:11350. [PMID: 36141623 PMCID: PMC9517008 DOI: 10.3390/ijerph191811350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 08/17/2022] [Accepted: 08/18/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND Medication wastage is causing a cost burden to the healthcare system that is worth millions of dollars. An economic and ecological friendly intervention such as using a patient's own medications (POM) has proven to reduce wastage and save the cost spent by the hospital. The potential benefits of using POM in inpatient settings have yet to be explored in a country with universal health coverage. This study aimed to pilot test the POM intervention in an adult ward setting and to perform the economic analysis of using POM and ward stock during hospitalization. METHODS A prospective cross-sectional observational study was conducted among the patients admitted to the medical and surgical wards in a public hospital located in Brunei Darussalam between February 2022 and April 2022. Hospitalized adults above 18 years old with regular medications with a minimum length of stay of 48 h and a maximum length of stay of 21 days were included in the study. These eligible patients were divided into a POM group and a non-POM group. The economic analysis of using POM was performed by calculating the direct cost per unit of medication used during admission (from unit-use, ward stock and POM) and comparing the cost spent for both groups. Expired ward stock deemed as medication wastage was determined. Medical research ethics were approved, and all participating patients had given their written informed consent before enrolling in this study. RESULTS A total of 112 patients aged 63.2 ± 15.8 years participated in this study. The average cost of medication supplied by the inpatient pharmacy for the non-POM group was USD 21.60 ± 34.20 per patient, whereas, for the POM group, it was approximately USD 13.00 ± 18.30 per patient, with a mean difference of USD 8.60 ± 5.17 per patient (95% CI: -3.95, 27.47, p ≥ 0.05). The use of POM minimized 54.03% (USD 625.04) of the total cost spent by the hospital for the POM group within the period of the study. CONCLUSION The pilot study showed that the supplied medication cost per patient was not significantly different between the POM and non-POM groups. Nevertheless, the utilization of POM during hospitalization is capable of reducing at least 50% of the total cost spent on inpatient medications by the hospital. The use of POM during hospitalization also helped in reducing the total time spent on the medication process per patient.
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Affiliation(s)
| | - Hui Poh Goh
- PAPRSB Institute of Health Sciences, Universiti Brunei Darussalam, Gadong BE1410, Brunei
| | - Daniel Vui Teck Wee
- Pharmacy Department, Suri Seri Begawan Hospital, Ministry of Health, Belait, Kuala Belait KA1131, Brunei
| | - Khang Wen Goh
- Faculty of Data Sciences and Information Technology, INTI International University, Nilai 78100, Malaysia
| | - Kah Seng Lee
- Faculty of Pharmacy, University of Cyberjaya, Cyberjaya 63000, Malaysia
| | - Andi Hermansyah
- Department of Pharmacy Practice, Faculty of Pharmacy, Universitas Airlangga, Surabaya 60115, Indonesia
| | - Yaser Mohammed Al-Worafi
- College of Medical Sciences, Azal University for Human Development, Amran P.O. Box 447, Yemen
- College of Pharmacy, University of Science and Technology of Fujairah, Fujairah P.O. Box 2202, United Arab Emirates
| | - Long Chiau Ming
- PAPRSB Institute of Health Sciences, Universiti Brunei Darussalam, Gadong BE1410, Brunei
- Department of Pharmacy Practice, Faculty of Pharmacy, Universitas Airlangga, Surabaya 60115, Indonesia
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Jessurun JG, Hunfeld NGM, van Dijk M, van den Bemt PMLA, Polinder S. Cost-effectiveness of central automated unit dose dispensing with barcode-assisted medication administration in a hospital setting. Res Social Adm Pharm 2022; 18:3980-3987. [PMID: 35853809 DOI: 10.1016/j.sapharm.2022.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 05/14/2022] [Accepted: 07/10/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND Central automated unit dose dispensing (cADD) with barcode-assisted medication administration (BCMA) has been shown to reduce medication administration errors (MAEs). Little is known about the cost-effectiveness of this intervention. OBJECTIVE To estimate the cost-effectiveness of cADD with BCMA compared to usual care. METHODS An economic evaluation was conducted alongside a prospective before-and-after effectiveness study in a Dutch university hospital. The primary effect measure was the difference between the rate of MAEs before and after implementation of cADD with BCMA, obtained by disguised observation in six clinical wards and subsequent extrapolation to the entire hospital. The cost-analysis was conducted from a hospital perspective with a 12-month incremental costing approach. The total costs covered the pharmaceutical service, nurse medication handling, wastage, and materials related to cADD. The primary outcome was the cost-effectiveness ratio expressed as costs per avoided MAE, obtained by dividing the annual incremental costs by the number of avoided MAEs. The secondary outcome was the cost-effectiveness ratio expressed as costs per avoided potentially harmful MAE (i.e. MAEs with the potential to cause harm). RESULTS The intervention was associated with an absolute MAE reduction of 4.5% and a reduction of 2.7% for potentially harmful MAEs. Based on 2,260,870 administered medications in the entire hospital annually, a total of 102,210 MAEs and 59,830 potentially harmful MAEs were estimated to be avoided. The intervention was associated with an increased incremental cost of €1,808,600 annually. The cost-effectiveness ratio was €17.69 per avoided MAE and €30.23 per avoided potentially harmful MAE. CONCLUSIONS The implementation of cADD with BCMA was associated with a reduced rate of medication errors, including harmful ones, at higher overall costs. The costs per avoided error are relatively low, and therefore, this intervention could be an important strategy to improve patient safety in hospitals.
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Affiliation(s)
- Janique Gabriëlle Jessurun
- Department of Hospital Pharmacy, Erasmus MC, University Medical Center Rotterdam, Rotterdam, P.O. Box 2040, 3000 CA, the Netherlands.
| | - Nicole Geertruida Maria Hunfeld
- Department of Hospital Pharmacy, Erasmus MC, University Medical Center Rotterdam, Rotterdam, P.O. Box 2040, 3000 CA, the Netherlands; Department of Intensive Care, Erasmus MC, University Medical Center Rotterdam, Rotterdam, P.O. Box 2040, 3000 CA, the Netherlands.
| | - Monique van Dijk
- Department of Internal Medicine, Section of Nursing Science, Erasmus MC, University Medical Center Rotterdam, Rotterdam, P.O. Box 2040, 3000 CA, the Netherlands.
| | - Patricia Maria Lucia Adriana van den Bemt
- Department of Hospital Pharmacy, Erasmus MC, University Medical Center Rotterdam, Rotterdam, P.O. Box 2040, 3000 CA, the Netherlands; Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, Groningen, P.O. Box 30.001, 9700 RB, the Netherlands.
| | - Suzanne Polinder
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, P.O. Box 2040, 3000 CA, the Netherlands.
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Yusuff KB, Mustafa M, Al-Qahtani NH. Prevalence, types and severity of medication errors associated with the use of automated medication use systems in ambulatory and institutionalized care settings: A systematic review protocol. PLoS One 2021; 16:e0260992. [PMID: 34860852 PMCID: PMC8641865 DOI: 10.1371/journal.pone.0260992] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Accepted: 10/05/2021] [Indexed: 11/19/2022] Open
Abstract
The use of automated systems within the medication use process has significantly reduce the occurrence of medication errors and the associated clinical and financial burden. However, automated systems lull into a false sense of security and increase the risk of medication errors that are often associated with socio-technical interactions, automation bias, workarounds and overrides. The objective of the systematic review is to determine the prevalence, types and severity of medication errors that are associated the use of automated systems in ambulatory and institutionalized care settings. The search strategy will be guided by PRISMA framework. Selected databases and relevant gray literature were searched and screening was done independently by two researchers between 01 April and 29 June 2021. These covered all relevant articles published from the inception of the use of automation in the medication use process (2000) until 2020. De-duplication and screening of all studies were done independently by two researchers with a clear inclusion / exclusion criteria. Data extraction and synthesis are currently on going (started on 06 July 2021) and being conducted independently but the validity and completeness of the processes will be confirmed by the third researcher. The Cochrane Risk of Bias tool and the Hoy et al's quality assessment checklist will be used for the assessment of methodological bias while the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system will be used for the quality of evidence assessment. Detailed qualitative synthesis of key findings will be done with thematic and descriptive analyses. If the number and types of included studies permit, fixed or random effect model meta-analysis will be conducted based on the degree of homogeneity in the sampling frame used in the included studies. Heterogeneity will be assessed with I2 statistics and I2 > 50% will be considered a high statistical heterogeneity. The systematic review may provide new perspective especially from developing settings about the prevalence, types and severity of medication errors associated with the use of automated systems at all the stages of medication use process, and in all categories of patients. This may add to global knowledge in the research area. Systematic review registration: The systematic review was registered and published by PROSPERO (CRD42020212900).
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Affiliation(s)
- Kazeem Babatunde Yusuff
- Department of Clinical Pharmacy and Practice, College of Pharmacy, QU Health, Qatar University, Doha, Qatar
| | - Mariam Mustafa
- Department of Clinical Pharmacy and Practice, College of Pharmacy, QU Health, Qatar University, Doha, Qatar
| | - Najla Hezam Al-Qahtani
- Department of Clinical Pharmacy and Practice, College of Pharmacy, QU Health, Qatar University, Doha, Qatar
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Mulac A, Mathiesen L, Taxis K, Gerd Granås A. Barcode medication administration technology use in hospital practice: a mixed-methods observational study of policy deviations. BMJ Qual Saf 2021; 30:1021-1030. [PMID: 34285114 PMCID: PMC8606443 DOI: 10.1136/bmjqs-2021-013223] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Accepted: 07/05/2021] [Indexed: 11/30/2022]
Abstract
Introduction Barcode medication administration (BCMA) can, if poorly implemented, cause disrupted workflow, increased workload and cause medication errors. Further exploration is needed of the causes of BCMA policy deviations. Objective To gain an insight into nurses’ use of barcode technology during medication dispensing and administration; to record the number and type of BCMA policy deviations, and to investigate their causes. Methods We conducted a prospective, mixed-methods study. Medication administration rounds on two hospital wards were observed using a digital tool and field notes. The SEIPS (Systems Engineering Initiative for Patient Safety) model was used to analyse the data. Results We observed 44 nurses administering 884 medications to 213 patients. We identified BCMA policy deviations for more than half of the observations; these related to the level of tasks, organisation, technology, environment and nurses. Task-related policy deviations occurred with 140 patients (66%) during dispensing and 152 patients (71%) during administration. Organisational deviations included failure to scan 29% of medications and 20% of patient’s wristbands. Policy deviations also arose due to technological factors (eg, low laptop battery, system freezing), as well as environmental factors (eg, medication room location, patient drawer size). Most deviations were caused by policies that interfere with proper and safe BCMA use and suboptimal technology design. Conclusion Our findings indicate that adaptations of the work system are needed, particularly in relation to policies and technology, to optimise the use of BCMA by nurses during medication dispensing and administration. These adaptations should lead to enhanced patient safety, as the absolute goal with BCMA implementation.
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Affiliation(s)
- Alma Mulac
- Department of Pharmacy, Faculty of Mathematics and Natural Sciences, University of Oslo, Oslo, Norway
| | - Liv Mathiesen
- Department of Pharmacy, Faculty of Mathematics and Natural Sciences, University of Oslo, Oslo, Norway
| | - Katja Taxis
- Pharmacotherapy and Pharmaceutical Care, University of Groningen, Groningen, The Netherlands
| | - Anne Gerd Granås
- Department of Pharmacy, Faculty of Mathematics and Natural Sciences, University of Oslo, Oslo, Norway
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Baraka SE, Ouedraogo JM, Sessouma A, Arbai S, Belahcen MJ, Rahali Y. Economic impact of implementation of an automated drug supplying and management system in a Central Chemotherapy Preparation Unit in a Moroccan hospital. J Oncol Pharm Pract 2021:10781552211013393. [PMID: 33940986 DOI: 10.1177/10781552211013393] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Automated Drug Supplying and management System (ADS) are effective devices that secure drug's circuit and reduce hospital's expenses. The purposes of this study are to estimate the earnings made from ADS through a cost-benefit medical economic study, to highlight its impact on Central Chemotherapy Preparation Unit's (CCPU) global organization, its ergonomy and staff's satisfaction. METHOD Measurement of cytotoxic drug's consumption, expiration losses, pharmacy staff's working time, drugs stock-out before and after the implementation of ADS on the one hand, and assess its ergonomy and acceptability by users on the other hand. RESULTS After the implementation of ADS, cytotoxic drug's consumption decreased by 9 (%), expiration losses by 98.3 (%), and we could see a gain in working time among CCPU'S technicians of 1.32 (h/day) and pharmacist of 0.67 (h/day), in contrast to the stock manager who increased his working time by 0.95 (h/day). Stock-out have decreased by 41.1 (%). The cost-benefit analysis has shown a net benefit of 67,437 between the two six-month phases, which corresponds to an economy of 134,874 (USD) over one year. The ADS was generally appreciated by the CCPU and pharmaceutical staff and 93(%) don't want to return to the old system. CONCLUSION ADS implementation within CCPU led to financial savings in the hospital, an optimization of expenses and better pharmaceutical management.
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Affiliation(s)
- Soumaya El Baraka
- Faculty of Medicine and Pharmacy, Mohammed V University in Rabat, Rabat, Morocco.,Ibn Sina University Hospital Center, Rabat, Morocco
| | - Jean-Marie Ouedraogo
- Faculty of Medicine and Pharmacy, Mohammed V University in Rabat, Rabat, Morocco.,Ibn Sina University Hospital Center, Rabat, Morocco
| | - Abou Sessouma
- Faculty of Medicine and Pharmacy, Mohammed V University in Rabat, Rabat, Morocco.,Ibn Sina University Hospital Center, Rabat, Morocco
| | - Soumaya Arbai
- National Institute of Oncology, Ibn Sina University Hospital, Rabat, Morocco
| | | | - Younes Rahali
- Faculty of Medicine and Pharmacy, Mohammed V University in Rabat, Rabat, Morocco.,National Institute of Oncology, Ibn Sina University Hospital, Rabat, Morocco.,Team of Formulation and Quality Control of Health Products, Faculty of Medicine and Pharmacy, Mohammed V University in Rabat, Rabat, Morocco
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Batson S, Herranz A, Rohrbach N, Canobbio M, Mitchell SA, Bonnabry P. Automation of in-hospital pharmacy dispensing: a systematic review. Eur J Hosp Pharm 2021; 28:58-64. [PMID: 32434785 PMCID: PMC7907692 DOI: 10.1136/ejhpharm-2019-002081] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Revised: 03/20/2020] [Accepted: 03/31/2020] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES The current systematic review (SR) was undertaken to identify and summarise the published literature reporting on the clinical and economic value of automated in-hospital pharmacy services with a primary focus on systems supporting the dispensing of medicines. METHODS Literature searches were conducted in MEDLINE, Embase and the Cochrane Library on 17 December 2017 to identify English-language publications investigating any automated dispensing systems (ADSs) in the inpatient setting to include central pharmacy and ward-based systems. RESULTS 4320 publications were screened by title and abstract and 45 of 175 full publications screened were included. Grey literature searching identified an additional three publications. Therefore, 48 publications relating to ADSs were eligible for inclusion. Although a relatively large evidence base was identified as part of the current SR, the eligible studies were inconsistent in terms of their design and the format of reporting of outcomes. The studies demonstrate that both pharmacy and ward-based ADSs offer benefits over traditional manual dispensing methods in terms of clinical and economic outcomes. The primary benefits following implementation of an ADS include reductions in medication errors, medication administration time and costs. Studies examining optimisation/inventory management strategies/refill programmes for these systems suggest that optimal implementation of the ADS is required to ensure that clinical success and economic benefits are maximised. CONCLUSIONS The published evidence suggests positive impacts of ADS and should encourage hospitals to invest in automation, with a global strategy to improve the reliability and the efficiency of the medication process. However, one of the key findings of the current SR is the need for further data from adequately powered studies reporting clinically relevant outcomes which would allow for robust, evidence-based recommendations on the return on investment of the technologies. These studies would probably contribute to a larger adoption of these technologies by European hospitals.
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Affiliation(s)
| | - Ana Herranz
- Hospital Pharmacy department, Hospital General Universitario Gregorio Maranon, Madrid, Spain
| | | | | | | | - Pascal Bonnabry
- Pharmacy, Geneva University Hospitals (HUG), Geneva, Switzerland
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Teo MEH, Chia BY, Lee YC, Tay PLY, Wong JA, Lee SB, Lim MM, Cheen MHH. Cost-effectiveness of two technology-assisted manual medication picking systems versus traditional manual picking in a hospital outpatient pharmacy. Eur J Hosp Pharm 2021; 28:100-105. [PMID: 33608438 PMCID: PMC7907698 DOI: 10.1136/ejhpharm-2019-001997] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2019] [Revised: 10/27/2019] [Accepted: 10/29/2019] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE To evaluate the cost-effectiveness of two technology assisted manual medication picking systems vs traditional manual picking. METHODS This was a retrospective observational study comparing three outpatient pharmacies of a tertiary referral hospital in Singapore, where a light-emitting diode (LED-guided) manual picking system, an LED-guided manual picking plus lockable drawer (LED-LD) system, and traditional manual picking were implemented, respectively. The primary outcome measure was the incidence of medication near-misses over the observation period. The incremental cost-effectiveness ratio (ICER) per near-miss avoided was also determined. Data on medications picked and near-misses reported between September 2017 and June 2018 were retrieved from electronic databases. The incidence of medication near-misses from the LED-guided and LED-LD systems, relative to traditional picking, was compared using logistic regression. We compared annual operating costs between manual medication picking systems, and reported ICERs per near-miss avoided, to evaluate the cost-effectiveness of each picking system. RESULTS A total of 358 144, 397 343 and 254 162 medications were picked by traditional manual picking, LED-guided and LED-LD systems, respectively. The corresponding near-miss rates were 8.32, 4.08 and 0.69 per 10 000 medications picked, respectively. Medication near-miss rates were significantly lower for the LED-guided (OR 0.49, 95% CI 0.40 to 0.59, p<0.001) and LED-LD systems (OR 0.08, 95% CI 0.05 to 0.13, p<0.001) compared with traditional picking. The annual operating costs of traditional picking, LED-guided and LED-LD systems were S$60 912, S$129 832 and S$152 894, respectively. The LED-guided and LED-LD systems yielded ICERs of S$189 and S$140 per near-miss avoided, respectively, compared with traditional manual picking. CONCLUSION The LED-LD system is more cost-effective than both the LED-guided and manual medication picking systems in reducing medication picking near-misses.
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Affiliation(s)
| | - Bih Yee Chia
- Pharmacy, Singapore General Hospital Department of Pharmacy, Singapore
| | - Yeng Ching Lee
- Pharmacy, Singapore General Hospital Department of Pharmacy, Singapore
| | | | - Jane Ai Wong
- Pharmacy, Singapore General Hospital Department of Pharmacy, Singapore
| | - Soo Boon Lee
- Pharmacy, Singapore General Hospital Department of Pharmacy, Singapore
| | - Mun Moon Lim
- Pharmacy, Singapore General Hospital Department of Pharmacy, Singapore
| | - McVin Hua Heng Cheen
- Pharmacy, Singapore General Hospital Department of Pharmacy, Singapore
- Medicine Academic Clinical Programme, Duke-NUS Medical School, Singapore
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Batista A, Polidori P, Kohl S. Position paper on patient safety. Eur J Hosp Pharm 2020; 28:ejhpharm-2019-001924. [PMID: 33355293 PMCID: PMC8077631 DOI: 10.1136/ejhpharm-2019-001924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Affiliation(s)
- Aida Batista
- Pharmacy, Centro Hospitalar Vila Nova de Gaia/Espinho, EPE, Vila Nova de Gaia, Portugal
| | | | - Stephanie Kohl
- Policy & Advocacy, European Association of Hospital Pharmacists, Brussels, Belgium
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Sørensen CA, de Thurah A, Lisby M, Olesen C, Sørensen SB, Enemark U. Cost-consequence analysis of self-administration of medication during hospitalization: a pragmatic randomized controlled trial in a Danish hospital setting. Ther Adv Drug Saf 2020; 11:2042098620929921. [PMID: 32922722 PMCID: PMC7457413 DOI: 10.1177/2042098620929921] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVES The objective of this study was to evaluate the costs and consequences of introducing "self-administration of medication" (SAM) during hospitalization as compared with nurse-led dispensing and administration of medication. METHODS This pragmatic randomized controlled trial was performed in a Danish Cardiology Unit. Patients ⩾18 years old capable of self-administering medication were eligible. In the intervention group, patients self-administered their medication. In the control group, medication was dispensed and administered by nurses. The implementation of SAM was used to evaluate the cost-consequences. The micro-costing analysis used the hospital perspective and a short-term incremental costing approach. The costs for medication, materials, and nursing time were included. Consequences included the dispensing error proportion, patients' perceptions regarding medication, satisfaction, and deviations in the medication list at follow-up. In addition, the number of readmissions and general practitioner (GP) contacts within 30 days after discharge was included. RESULTS The total cost (TC) per patient in the intervention group was 49.9€ (95% CI: 46.6-53.2) compared with 52.6€ (95% CI: 46.6-58.6) in the control group. The difference between the groups was not statistically significant (p = 0.09). Sensitivity analysis consistently showed TCs favoring the intervention. The dispensing error proportion was 9.7% (95% CI: 7.9-11.6) in the intervention group compared with 12.8% (95% CI: 10.9-15.6) in the control group. The difference was statistically significant (p = 0.02). The analysis also found changes in the perceptions regarding medication (indicating higher medication adherence), increased satisfaction, and fewer patients with deviations in the medication list at follow-up. No statistically significant differences between the groups in relation to readmissions and GP contacts within 30 days were observed. CONCLUSIONS SAM seems to cost less although the cost difference was small and not statistically significant. As SAM had positive effects on patient outcomes, the results indicate that SAM may be cost-effective. PLAIN LANGUAGE SUMMARY Self-administration of medication: a research study of the costs and consequences Objectives To evaluate the costs and consequences of introducing "self-administration of medication" (SAM) during hospitalization compared to medication dispensed by nurses. Methods This research study included patients ≥18 years capable of self-administering medication and was performed in a Danish cardiology unit. Patients self-administered their own medication during hospitalization in the intervention group, whereas nurses dispensed and administered the medication in the control group. Patients were allocated between groups by randomization. The costs of SAM were analyzed from a hospital perspective and included costs for medication, materials, and nursing time. The consequences included the proportion of dispensing errors, patients' perceptions regarding medication, patient satisfaction, deviations in the medication list at follow-up, the number of readmissions and general practitioner (GP) contacts within 30 days after discharge. Results The total cost per patient was 49.9€ in the intervention group compared to 52.6€ in the control group (p = 0.09). The cost difference between groups was not significant. The proportion of dispensing errors was significantly lower in the intervention group compared to the control group. In addition the research study found changes in the perceptions regarding medication, increased satisfaction, and fewer patients with deviations in the medication list at follow-up. For readmissions and GP contacts within 30 days no significant differences between groups were found. Conclusion SAM cost less or equal to medication dispensing and administration by nurse. SAM had positive impacts on patient outcomes. Therefore, SAM may be cost-effective.
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Affiliation(s)
- Charlotte Arp Sørensen
- Randers Regional Hospital, Dronningborg Boulevard 16D, Randers NØ, 8930, Denmark
- Hospital Pharmacy, Central Denmark Region, Medical Department, Department of Clinical Medicine, Aarhus University, Denmark
| | - Annette de Thurah
- Department of Clinical Medicine, Aarhus University, Health, Denmark
- Department of Rheumatology, Aarhus University Hospital, Denmark
| | - Marianne Lisby
- Department of Clinical Medicine, Aarhus University, Health, Denmark
- Research Center for Emergency Medicine, Aarhus University Hospital, Denmark
| | - Charlotte Olesen
- Hospital Pharmacy Central Denmark Region, Clinical Pharmacy, Aarhus University Hospital, Denmark
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Mathy C, Pascal C, Fizesan M, Boin C, Délèze N, Aujoulat O. Automated hospital pharmacy supply chain and the evaluation of organisational impacts and costs. SUPPLY CHAIN FORUM 2020. [DOI: 10.1080/16258312.2020.1784687] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- Caryn Mathy
- School of Management and Engineering Vaud, HES-SO // University of Applied Sciences and Arts Western, Switzerland
| | - C. Pascal
- Univ Lyon, Jean Moulin, IFROSS, GRAPHOS, F-69007, Lyon, France
| | - M. Fizesan
- Hospital Central Pharmacy, Mulhouse and South Alsace Region Hospital Group (GHRMSA), Mulhouse, France
| | - C. Boin
- Hospital Central Pharmacy, Mulhouse and South Alsace Region Hospital Group (GHRMSA), Mulhouse, France
| | - N. Délèze
- School of Management and Engineering Vaud, HES-SO // University of Applied Sciences and Arts Western, Switzerland
| | - O. Aujoulat
- Hospital Central Pharmacy, Mulhouse and South Alsace Region Hospital Group (GHRMSA), Mulhouse, France
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Agarwal P, Poeran J, Meyer J, Rogers L, Reich DL, Mazumdar M. Bedside medication delivery programs: suggestions for systematic evaluation and reporting. Int J Qual Health Care 2020; 31:G53-G59. [PMID: 31053860 DOI: 10.1093/intqhc/mzz014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Revised: 12/04/2018] [Accepted: 02/12/2019] [Indexed: 11/12/2022] Open
Abstract
PURPOSE Several factors lead to medication non-adherence after hospital discharge. Hospitals and pharmacies have implemented bedside medication delivery (BMD) programs for patients, in an attempt to reduce barriers and improve medication adherence. Here, we provide a critical review of the literature on these programs. DATA SOURCES We conducted a literature search on BMD programs in PubMed, Google Scholar, Scopus and a general Google search using these keywords: 'medication delivery bedside', 'discharge medication delivery', 'meds to bedside' and 'meds to beds'. STUDY SELECTION We identified 10 reports and include data from all reports. DATA EXTRACTION Data on study characteristics and settings were extracted along with four outcomes: medication error, patient satisfaction, 30-day hospital readmission and visits to the emergency department. RESULTS OF DATA SYNTHESIS Of the 10 reports, only 4 were peer-reviewed publications; others were reported in the lay press. Outcomes were reported in both qualitative and quantitative terms. Less than half of reports provided quantitative data on 30-day readmission and patient satisfaction. Others suggested qualitative improvement in these outcomes but did not provide data or specific details. None reported outcomes of their programs beyond 30 days. CONCLUSION We highlight the need for increased use of optimal program design and more rigorous evaluations of the impact of BMD programs. We also provide guidelines on the types of evaluations that are likely needed and encourage improved reporting.
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Affiliation(s)
- Parul Agarwal
- Department of Population Health Science and Policy, Institute for Health Care Delivery Science, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1077, New York NY 10029, USA
| | - Jashvant Poeran
- Department of Population Health Science and Policy, Institute for Health Care Delivery Science, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1077, New York NY 10029, USA
| | - Joanne Meyer
- Department of Pharmacy, The Mount Sinai Hospital, Annenberg B2-12, One Gustave L. Levy Place, Box 1211, New York NY 10029, USA
| | - Linda Rogers
- Mount Sinai-National Jewish Respiratory Institute, The Mount Sinai Hospital, 10 East 102nd Street, 5th Floor, New York NY 10029, USA
| | - David L Reich
- Anesthesiology and Perioperative Pain Medicine, The Mount Sinai Hospital, 10 East 102nd Street, 5th Floor, New York NY 10029, USA
| | - Madhu Mazumdar
- Department of Population Health Science and Policy, Institute for Health Care Delivery Science, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1077, New York NY 10029, USA
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Mauskopf J. Multivariable and Structural Uncertainty Analyses for Cost-Effectiveness Estimates: Back to the Future. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2019; 22:570-574. [PMID: 31104736 DOI: 10.1016/j.jval.2018.11.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/01/2018] [Revised: 11/01/2018] [Accepted: 11/09/2018] [Indexed: 06/09/2023]
Abstract
BACKGROUND In this commentary, celebrating the 20th anniversary of the journal Value in Health, I present a brief overview and illustration of the evolution over the past 20 years of the methodological literature providing guidelines for multivariable and structural uncertainty analysis for cost-effectiveness estimates. METHODS To illustrate the impact of the guidelines for uncertainty analyses, I show how the inclusion of multivariable and structural uncertainty analyses in cost-effectiveness analyses published in Value in Health changed over the past 20 years using publications from 1999/2000, 2007 and 2017. RESULTS The commentary is organized in three sections: past, focusing on the development and use of methods for multivariable uncertainty analysis; present, focusing on the growing awareness of the need for structural uncertainty analysis, suggested frameworks for structural uncertainty analysis and how it is currently implemented; and future, considering different methods for combining multivariable and structural uncertainty analyses over the next decades. CONCLUSIONS I conclude by suggesting how the continued evolution of uncertainty analyses in published studies and health technology assessment submissions can best take into account an important goal of cost-effectiveness analyses: to provide useful information to decision makers.
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Risør BW, Lisby M, Sørensen J. Complex automated medication systems reduce medication administration errors in a Danish acute medical unit. Int J Qual Health Care 2018; 30:457-465. [DOI: 10.1093/intqhc/mzy042] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Accepted: 03/07/2018] [Indexed: 11/12/2022] Open
Affiliation(s)
- Bettina Wulff Risør
- Department of Public Health, Centre for Health Economics Research (COHERE), University of Southern Denmark, J.B. Winsløwsvej 9B, Odense C, Denmark
- Hospital Pharmacy, Central Denmark Region, Noerrebrogade 44, Aarhus C, Denmark
| | - Marianne Lisby
- Research Centre of Emergency Medicine, Aarhus University Hospital, Building 1B, Noerrebrogade 44, Aarhus C, Denmark
| | - Jan Sørensen
- Department of Public Health, Centre for Health Economics Research (COHERE), University of Southern Denmark, J.B. Winsløwsvej 9B, Odense C, Denmark
- Healthcare Outcome Research Centre, Royal College of Surgeons in Ireland, Beaux Lane House, Dublin 2, Ireland
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Risør BW, Lisby M, Sørensen J. Comparative Cost-Effectiveness Analysis of Three Different Automated Medication Systems Implemented in a Danish Hospital Setting. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2018; 16:91-106. [PMID: 29119475 DOI: 10.1007/s40258-017-0360-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
INTRODUCTION Automated medication systems have been found to reduce errors in the medication process, but little is known about the cost-effectiveness of such systems. The objective of this study was to perform a model-based indirect cost-effectiveness comparison of three different, real-world automated medication systems compared with current standard practice. METHODS The considered automated medication systems were a patient-specific automated medication system (psAMS), a non-patient-specific automated medication system (npsAMS), and a complex automated medication system (cAMS). The economic evaluation used original effect and cost data from prospective, controlled, before-and-after studies of medication systems implemented at a Danish hematological ward and an acute medical unit. Effectiveness was described as the proportion of clinical and procedural error opportunities that were associated with one or more errors. An error was defined as a deviation from the electronic prescription, from standard hospital policy, or from written procedures. The cost assessment was based on 6-month standardization of observed cost data. The model-based comparative cost-effectiveness analyses were conducted with system-specific assumptions of the effect size and costs in scenarios with consumptions of 15,000, 30,000, and 45,000 doses per 6-month period. RESULTS With 30,000 doses the cost-effectiveness model showed that the cost-effectiveness ratio expressed as the cost per avoided clinical error was €24 for the psAMS, €26 for the npsAMS, and €386 for the cAMS. Comparison of the cost-effectiveness of the three systems in relation to different valuations of an avoided error showed that the psAMS was the most cost-effective system regardless of error type or valuation. CONCLUSION The model-based indirect comparison against the conventional practice showed that psAMS and npsAMS were more cost-effective than the cAMS alternative, and that psAMS was more cost-effective than npsAMS.
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Affiliation(s)
- Bettina Wulff Risør
- Department of Public Health, Centre for Health Economic Research (COHERE), University of Southern Denmark, J.B. Winsløwsvej 9B, 5000, Odense C, Denmark.
- Hospital Pharmacy, Central Denmark Region, Nørrebrogade 44, 8000, Aarhus C, Denmark.
| | - Marianne Lisby
- Research Center of Emergency Medicine, Aarhus University Hospital, Building 1B, Nørrebrogade 44, 8000, Aarhus C, Denmark
| | - Jan Sørensen
- Department of Public Health, Centre for Health Economic Research (COHERE), University of Southern Denmark, J.B. Winsløwsvej 9B, 5000, Odense C, Denmark
- Healthcare Outcome Research Centre, Royal College of Surgeons in Ireland, Beaux Lane House, Dublin 2, Ireland
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