TRI Pharmacy Pre implementation workflow

Allergy Documentation

Nurse/Pharmacy

Completes initial patient interview

Asks patient about drug, food, latex and other allergies

Fills out patient allergy and assessment form

Original copy in chart and copy goes to Pharmacy

Note: Allergy documentation is an interdisciplinary workflow and is recorded on multiple patient documentations Ex. Physician orders, allergy sheet, MAR etc

Technicians

Copy of allergy sheet is sent to technicians or written on med rec. form Tech enters allergy information into SoftRx

Second tech verifies entry

Information will then be seen on MAR and patient profile

TRI Pharmacy Pre implementation workflow

Auto Med Machine - Stocking

Technicians

Receive Medication from courriers Canister empty? NO

Add medication to shelf inventory using FIFO process Continue with secondary task

Collect all medications for run in laundry bins

YES

Wait for machine to prompt for empty canister

Reload canister, scan product, double check

Enter loaded meds to computer system: Barcode, lot # and quantity

TRI Pharmacy Pre implementation workflow

Auto Med Machine Tray Fills

Tray Fills

Technicians

AutoMed generates report

Split one type of pill manually using pill splitter Clean pill splitter and trays

Fill tray to designated Automed tray where custom lights provide a prompt or other manual tray Call designated inspector to verify in trays

Re-start Auto-Med machine

Changing Packaging unit

Remove lower (multi dose or unit dose) unit from machine when prompted Pull unit to clear a path for replacement unit

Pull replacement unit into alignment with Auto Med machine, place into machine, close doors

Re-start Auto Med machine

Process for tray fills before run?

TRI Pharmacy Pre implementation workflow

Auto Stop Orders

Physician (MD)

MD writes an order with an auto-stop drug

Date specified?

NO

YES Drug stay discontinued

Rx will attempt to clarify if no date is given

Drug will automatically discontinue after 7 days if no clarification

Drug will fall off the MAR and moves to the drug history in Soft Rx system

Pharmacy (Rx)/System

Drug discontinue after written number of days or number of doses

Note: o o

TRI Pharmacy Pre implementation workflow

Auto Sub Orders

Physician (MD)

MD orders a nonformulary medication No

MD will write an alternate formulary drug order

RPh available on unit?

YES

Rx will suggest a formulary alternative Yes Source non-form item

NO

Pharmacy (Rx)

RPh will go and visit the unit at a later time

Auto Sub drug

RPh will re-write order as per auto subs policy

The med will continue as a regular order

Drug must be entered into system

Tech can put comment in patient SoftRx file saying auto-substituted Not Auto Sub drug

Technicians

Follow filling process

Note:

- If patient is going home then can put reference order of what the patient was originally on this order is not active and wont go on the MAR just in patient profile as a reference when patient is discharged - Currently no automatic auto subs in SoftRx (all manual process)

TRI Pharmacy Pre implementation workflow

Blister Pack Refill/ Dossette

Tech 1

Clinical Team/ RPh

Clinical team/RPh makes request for patient blister pack

Pharmacy completes SMP form in policy

Tech updates SCC to identify patient as SMP

SCC fill report for unit to identify SMP patients per unit

Pharmacy tech modifies existing prescriptions that can be part of SMP program Pharmacy tech fills blister pack per schedule, leaving packs open

Labeled by tech and checked by RPh

Pharmacy tech delivers meds to patient

Pharmacist

RPh inspects blister pack

RPh closes blister pack

Build MED Card

Make up template of patients meds Turn on glue gun

Find expired meds from inventory, or use current inventory

Glue meds to worksheet

Deliver MED Card to patient

TRI Pharmacy Pre implementation workflow

Cart Fill
List of PRNs/nonauto med drugs also scheduled to print

AutoMed

SCC sends AutoMed the run file

AutoMed run scheduled medications from machine for unit

Tech 1

Tech refers to specific cart fill schedule Meds put in bin for patient

Tech verifies each unit dose package for duplicates, crushed pills etc PRN and non-auto med drugs are checked

Tech will continue to Cassette Exchange workflow

Tech 2

Separate medication by patient name Clip medications into roll/strips

Picks PRN and non-auto med drugs

Confirm if these are set or do they manually do this?

TRI Pharmacy Pre implementation workflow

Cassette Exchange Prepare/Deliver

Load orders into cassette. Follow cart fill process Left over meds? No Reorganize trays as necessary.

Walk with cart to elevator, then to units medication area Swap bins from existing cassette with new bins.

Tech will move all non-auto multidose items (drops, creams) into new bin at time of exchange Yes

Move to other cassettes on the unit and repeat process.

Tech 1

Meds are dumped out Yes No

Multi dose pack?

Returned to shelf for re-use

Return cart to pharmacy with empty cassette.

Charge ward stock to unit through SCC

Complete ward stock fill list (delivered on next unit run)

Move to ward stock area and update ward stock.

TRI Pharmacy Pre implementation workflow

Interim Doses

MD/RN

MD writes an order for a changed order

Nurse pulls order for pharmacy and puts in pharmacy bin

Tech 1

Order brought down or tech picks up order from pharmacy bin on unit Discontinued label prints out and is attached to prescription Enter new order in system Label prints out Picks meds

If old order in system discontinue old order in system

Meds delivered to unit

Not Approved

Tech 2

Tech verifies order is correct

Checks meds

Approved

Pharmacist

Change order is screened

TRI Pharmacy Pre implementation workflow

Cassette exchange left over meds

Prior to cassette exchange tech will check for left over meds Yes Meds are dumped out

Multi dose pack?

Tech

No

Tech will move all non-auto multidose items (drops, creams) into new bin at time of exchange

Returned to shelf for re-use

What about unit dose packaged meds?

TRI Pharmacy Pre implementation workflow

Refill Doses (including PRNs)

Tech will pick up all forms in pharmacy bin on unit Shortage of drug in Pharmacy? Keep label on want list book Print an extra label Yes after entering into system Try and source drug from sites if no Fill whatever amount of drug they have present Place purchase order for drug needed

Refill drug in system by tech

Once arrives can top up left over meds

Tech

Label prints

Fill Med

Tech 2 reviews med order

Drug delivered to unit

No

RN

RN will call pharmacy or fill out nursing communication form

Pharmacist

Pharmacist will review only MAR discrepancy

TRI Pharmacy Pre implementation workflow

Narcotics Ward Stock System

RN

RN fills narcotic requisition form (sometime will call or fill MAR req form)

RN signs Narcotic Admin sheet that correct narcotic was received

Tech 1

Tech enters information from form into system Narcotic report is printed by unit/cart Narcotic is bagged and takes to unit

Creates an interdepartmental transfer of stock and charged to unit/cart

Tech picks narcotic to be filled, signed and maintaining perpetual count

Tech delivers wanted amount of narcotic & RN verifies amount received

Tech signs narcotic admin sheet

Tech 2

Tech checks & signs narcotic meds that have been filled

TRI Pharmacy Pre implementation workflow

Narcotic Returns

RN

RN will subtract amount taken from Narcotic Admin Sheet RN will sign the Narcotic Admin Sheet

Tech

Tech and nurse will identify narcotics to be removed from cart based on usage Tech witnesses signature Narcotics are taken down to Pharmacy Return entered into SCC by unit/ cart Returned to stock if expiry allows and added to perpetual count

Tech 2 checks and signs the logs count

TRI Pharmacy Pre implementation workflow

Narcotic Med Select

Tech

Report will print in pharmacy from the med select which narcotics to fill Narcotic drawer will open

Tech will fill & charge narcotics in unit dose packs to the app. Med Select Both techs will take the unit dose narcotics to med select machine Tech 1 will enter drugs into Med select and scan barcode

Tech 2

Tech 2 checks the narcotics that are picked by Tech 1

Tech 2 will load Med Select coils with correct narc and close. Logs off Med Select

Do tech 1 and 2 double check each other?

If RN has to give a narcotic the process will work the same as getting a medication from the Night Cupboard

TRI Pharmacy Pre implementation workflow

Change Orders

MD

MD initiates a change using Physician order form

Original is filed in chart

Pharmacy tech collects order from designated basket during rounds

Copy is pulled and sent to pharmacy Pharmacist approves

Pharmacist reviews (screens) changes on order

Rx

Nurse hand-delivers an order Pharmacist proposes changes Physician contacted for verification or physician changes

Tech 1

Order is delivered to unit

1st pharmacy tech fills order

1st pharmacy tech reviews order and inputs to computer system

Tech 1

2nd pharmacy tech verifies filled order

2nd pharmacy tech verifies paper entry on separate computer login for authentication and label prints

TRI Pharmacy Pre implementation workflow

Discontinued Medications Pharmacy Task

Physician (MD)

MD writes med to be discontinued on physician order sheet Copy of physician order sheet goes in Rx bin on unit

Nurse pulls d/c med is pulled and put in pharmacy bin on unit for pick up

Tech 1

Tech will pick up all items in Rx bin when on unit Discontinued label will print out Tech will affix label on order

Tech will enter discontinued med order into Soft Rx system

If on cart exchange day med removed before going to unit

Discontinued med order is filed

Tech 2

Tech 2 will verify that tech 1 properly discontinued order and sign

Pharmacist

Pharmacist will screen the discontinued meds order for error

TRI Pharmacy Pre Implementation Workflow

Discontinued Meds RN Tasks

RN will put unit dose med in Rx bin on unit along with d/c physician order sheet Unit dose

Med being discontinued is unit or multi dose Will circle the med being discontinued and put a line through it Med will be pulled out of the package and discarded at time of administration Discontinued physician order sheet will go in Rx bin on unit

Nurse (RN/RPN)

Multi dose

RN will look for med in multi dose package

Tech

Proceed with Discontinued meds process pharmacy task

Unit dose medication can be reused (no patient info)

Tech will pick up all contents of Rx bin

TRI Pharmacy Pre implementation workflow

Discharge Medications

Other

Pharmacy

Nurse (RN/ RPN)

Physician (MD)

TRI Pharmacy Pre implementation workflow

Discharge Prescription

Physician (MD)

MD will review the discharge med rec with the pharmacist and drug profile Order pulled MD signs

MD/RPh checks discontinues & discharged and modifies drug order according on physician order sheet

Pharmacist

Pharmacist will go through the patient drug profile

Pharmacist will initiate a discharge med reconciliation form Med rec form finalized by pharmacist Signed form becomes the list of new orders

Pharmacist reviews list of orders with patient and family

RPh generates discharge prescription

Tech

Patient/Family

Patient uses list of order as a prescription at local drug store

IS THIS FLOW RIGHT?? Doesnt make sense according to corrections made by team

Order processed by tech in SCC

TRI Pharmacy Pre implementation workflow

Drivers Schedule
8:30 am UC LC

Bickle

11:30 am

UC

HC

Toronto Rehab Driver

1:30 am

UC

Mon, Tue, Thurs and Friday

9:15 am

HC

Private Courier

Bickle

2:00 pm

LC (Thursday only)