It was 1997 and I was starting a new job. My previous hospital (where I worked eighteen years) was closing. My boss (Director of Pharmacy) had made the transition to another hospital’s pharmacy department. Working with her vice-president, she proposed a unique concept that would comprise her pharmacy management team. It would consist of:
- An Administrative Team Leader. This person would be in-charge of the day-to-day operation of the pharmacy.
- A Clinical Team Leader. This person would be in-charge of the clinical aspects of the pharmacy.
- An IV Team Leader. This person would be in-charge of the IV room.
She wanted me to be her Administrative Team Leader. Frankly, I would have taken the job even if my hospital weren’t closing. But since it was closing— taking this position was a no-brainer. I welcomed the opportunity to work with my boss again in this new role.
Pharmacy was a lot different in 1997. We did have computers, but that was about it for technology. And even the computerized pharmacy program was very basic. If a pharmacist was viewing a patient’s medications and wanted to know more about a specific drug, the pharmacist looked the information up in a reference book. There were no programs that would provide the drug information on the computer.
And forget data from other areas. The pharmacy computer system was not integrated with other departments. Nor were other departments integrated with pharmacy. Thus, the pharmacy couldn’t view laboratory blood work, x-rays, physician and nursing notes, and other test results.
In addition, everything was done with paper. Doctors would write their orders at the nursing unit on three-part paper forms. The white page would remain on the patient’s chart. The yellow page (with the medication order) was sent to the pharmacy. The pink page contained orders that were sent to other departments (lab, x-ray, radiology, dietary, etc.).
The yellow page medication orders arrived in the pharmacy in one of three ways:
- The hospital had a group of messengers who made regular rounds and delivered the yellow page medication orders to the pharmacy.
- Nurses directly brought the yellow page medication orders to the pharmacy. (However, this did not happen that often, because nurses did not want to leave their nursing unit.)
- Some hospitals had a pneumatic tube system which would transport the yellow page medication orders to the pharmacy (we didn’t have one at the time, though).
I don’t remember faxing or scanning medication orders at that time. I thought the rule was that it had to be the original (white) page or pharmacy (yellow) page— not a “copy” that was produced by faxing or scanning.
Once the pharmacists received the yellow page medication orders, they entered the information into the computer. The computer program maintained a profile for all the medications administered to each patient. The computer program also searched for problems with drug overdose, under dose, allergies, drug interactions and duplicate drugs.
A computerized label was generated and applied to the finished product. The final preparation was checked by a pharmacist (another requirement). It was sent to the nursing unit where the nurses would give it to the patient.
The processed yellow page medication orders were collected on a daily basis and stored by the pharmacy. The pharmacy had to keep five years worth of yellow pages (Imagine that!).
Making Pharmacists Available
I began working at this particular hospital in 1997. Prior to my start, this hospital pharmacy had won an award. I didn’t know if it was from a national society, a state society or some other group. But it was a major award.
The pharmacy staff submitted the idea of having the pharmacists work directly on the nursing units. There they could enter orders, speak with patients, and interact with doctors and nurses.
In addition, the pharmacists were teamed up with pharmacist technicians. The pharmacy techs would serve as runners. They would prepare the orders and deliver the medications to the nursing unit. Then the pharmacists would check the medications prior to them being administered to the patient.
Again this was 1997. Having pharmacists on the nursing units was a radical concept at that time.
Publicizing The Project
Having pharmacists on the nursing units started out as a major public relations activity for the hospital as well as for the pharmacy. The hospital was featured in several prominent magazines and trade journals. Upper management was quoted in local and national newspapers. The CEO was even interviewed with the Director of Pharmacy on a local, Sunday morning, TV program.
The hospital and the pharmacy were surely enjoying the attention. However, it was short lived.
A few months passed. The pharmacists were still going to the nursing units. But the hospital had moved on to other projects. The program continued, but the hospital’s focus just wasn’t what it was. This was apparent when several things began to happen.
Denying Computer Upgrades
The pharmacy had several laptop computers. They were big and bulky. They did not run on Windows. I believe they used a DOS program. As previously stated, the computers did not have the capability to interact with other departments. Thus, they could not provide information about a patient’s x-rays, test results, or other non-pharmacy information.
The computers did not have any cables to permit charging or improve battery life. And the internet did not exist at the time.
What they did have was a large battery (about the size of today’s average smartphone). This battery had to be removed multiple times throughout the day and charged in a device kept in the pharmacy department. Thus during these times, the computer generally was out of commission.
Once fully charged, the battery would provide approximately two hours of battery life to the computer.
Many times, I requested new upgraded laptop computers. I was always turned down. My pharmacy was expected to make due with our existing devices.
Utilizing Massive Med Carts
Back in 1997, the pharmacy filled medication for each patient on the nursing unit. The medications were placed in bins and delivered to the floors. The bins held a 24-hour supply of medications for each patient.
Once these bins were delivered to the nursing unit, they were swapped with bins already on the units. These “swapped” bins were presumably empty since they held medications that were administered from the past 24 hours.
The “swapped” or empty bins were brought back to the pharmacy, while the delivered bins were stored in these massive med carts on the nursing units. It was recommended that these massive med carts should be stored as close to the nursing station as possible. However, in actuality, they were kept locked in the hallways near the patient’s rooms. This made it very convenient for nurses to administer medications.
These massive med carts served as workstations for the pharmacists who were up on the nursing units. The pharmacists would utilize the top of the med carts for their computer, reference books, medication orders, and any other materials needed for their job.
One might wonder why the pharmacists had to use the top of a med cart as a workstation? Why couldn’t they just sit at the nurses’ station and use that area as their workstation?
I had asked that question several times. And I received an official answer. Yet, I was very skeptical. I did not think that the answer that I received was the actual answer.
I was told that it would be too crowded to have the pharmacists be in the nursing station. In other words, nurses and ward clerks were already experiencing crowdedness while being jammed into the nursing station. Surely by having the pharmacists use this space would result in greater space limitations. Thus for comfort reasons, the pharmacists simply could not work there.
However, I felt that this was not the actual reason.
As I stated in one of my previous articles, the nursing and pharmacy departments always clashed. They were both there to help the patient. But unless they were forced to do so, they were never willing to help each other. Each department was very possessive of their belongings and would not share their resources with one another.
Generally, having pharmacists directly on the nursing unit benefitted the patients. It also helped nursing. However, this was viewed as a pharmacy project. Therefore, it was the pharmacy's responsibility to work out the logistics. And thus, there was no way that nursing would allow the pharmacists to use their nursing station for a pharmacy project.
Lacking Nursing Support
Previously I discussed that this was a pharmacy project and not a nursing project. This was further evident by another aspect involving the nursing station.
As I mentioned, the pharmacists’ laptop computers had an extremely short battery life. It was approximately two hours. In addition, the battery had to be charged in a device kept in the pharmacy department. Thus, quite often throughout the day, the pharmacists were without their computers. During these times, the pharmacists wrote everything out on paper and eventually entered everything into their computers when they were later available. This was a monumental task!
The nurses had several computer work areas in their nursing station. These desktop computers were reserved for residents, dietitians, lab personnel, and physicians. Most of the time, these computers were unused since the aforementioned personnel were only there for short periods of time throughout the day.
Was the pharmacist allowed to use these computers which sat idle throughout the day?
Of course not! The reason that I was told was that they were “the residents’” or “the dietitians’” computers. And what would happen if these people needed to use their computers?
My response was that if these other people wanted to use their computers, then the pharmacists would finish what they were doing. And then the pharmacists would then relinquish the computers.
But I was told “no” and my pharmacists were not allowed to use the computers. I felt this was another example of the lost interest in the pharmacy project.
Ignoring Pharmacy’s Needs
My hospital was revamping one of the nursing units. It had not been used for about six months. The hospital decided to convert it into a step-down critical care unit. This was for patients who had been recently discharged from ICU/CCU. But they still required the extra care that a medical surgery unit could not provide.
The new unit would be completely refurbished. It would have new fixtures and lighting, new furniture, and even a new floor layout. The nursing station would be in the center with individual patient rooms around in a circle. These patient rooms would also be redone. They would have new wallpaper, draperies, beds, and state of the art equipment.
I advocated for a pharmacy work area adjacent to the nursing station. That way, the pharmacists could have easy access to the patient charts containing the medication orders.
I knew I’d never get a desktop computer on a workstation, but a designated work area and chair would be nice. It would surely be better than the massive med carts which the pharmacists were currently using for their work area.
The pharmacy did receive a designated work area on the new unit. It wasn’t the one that I hoped for, though. There was a 6 foot by 3 foot shelf that was built into the wall. Half of the shelf contained several cardboard file boxes. These boxes contained charts of recently discharged patients. The other half of the shelf was the new pharmacy work area.
This new pharmacy work area was not to my liking. First of all, the work area was smaller than the top of the med cart which the pharmacist currently used. There was simply no room for the pharmacist to work. It did not have sufficient space to accommodate their computer, the medication orders, and any reference books.
I asked if my pharmacists could switch back and use the top of the med carts. I was told “no”. The med carts were going to be stored in the clean utility room. This would reduce clutter in the halls, which was frowned upon by JCAHO and other regulatory groups. Using the med carts as work stations was no longer an option.
The other reason that I found this new pharmacy work area to be unsatisfactory was its location. The shelf was adjacent to the patient rooms. So technically it was outside the nursing station.
And the main problem with that was that nursing had implemented a rule stating that patient charts could not be removed from the nursing station. Thus if the pharmacist wanted a medication order (or any patient chart information for that matter), they would have to make photocopies of the information.
This was a huge time factor issue— as well as a major inconvenience for the pharmacist.
Revisiting The Projects Rebirth
Shortly after the year 2000, three things happened at my hospital that ended the pharmacist on the nursing units project. They were
- Medication error reporting became the trend. Many hospitals implemented no fault environments to encourage medication error reporting. My hospital held meetings, published newsletters, and hired speakers to discuss medication errors in hopes that our employees would learn from another hospital’s mistakes.
- To increase efficiency and minimize medication errors, my hospital implemented a single company’s technological system throughout the facility. This system allowed integration amongst the departments and streamlined the medication administration process.
- Computerized Physician Order Entry (CPOE) became the standard. CPOE allowed physicians to directly enter medication orders directly into the computer. Thus, many common problems including transcription errors, illegible handwriting, overdose and underdose issues, and duplicate meds were virtually eliminated. This, in turn, reduced medication errors. In addition, a physician could enter orders from any computer simply by logging in with their ID information and password.
Of course, the pharmacists still had to review the physicians’ medication orders. However, the pharmacists were no longer on the nursing unit. It seemed that this company’s technology required the pharmacists to be tethered to two computer screens in the pharmacy department. There, the pharmacists would receive medication orders on one screen and process them on the other screen.
The pharmacists were finally off the nursing unit. And I don’t think anybody really missed them.
Several years later, the role of the clinical pharmacist evolved and the pharmacists were once again on the nursing units. Now they were welcomed for their knowledge and all the assistance they provided. Their presence was finally viewed as a benefit.
Daniel Shifrin, R.P., M.S. is a recently retired pharmacist who enjoys sharing his insights about hospital pharmacy. He is proud to own one of the largest collections of Pharmacy Stamp First Day Covers.