Non-Controlled Medication Discrepancy Management - The Pyxis ...

Non-Controlled Medication
Discrepancy Management
Introduction
Pyxis MedStation ® system was introduced in 1990 to help hospitals safely and securely manage controlled
substances. As the benefits of increasing the percentage of medications managed via the Pyxis pathway has been
realized, increasing amounts of medications are now managed in Pyxis, including both controlled and NON-
CONTROLLED substances.
While hospitals have implemented tight controls as to monitoring and preventing diversion of controlled substances,
increasingly regulatory agencies are expecting that facilities establish a process by which NON-CONTROLLED
substance diversion is monitored and prevented.
In California, the California Department of Public Health (CDPH) established the Medication Error Reduction Plan
(MERP) Program to promote safe and effective medication use in General Acute Care Hospitals (GACH) through
reduction of preventable medication-related errors and adverse events 1.
Per the Health and safety code section 1339.63(e)(1); Each facility's plan shall: Evaluate, assess, and include a
method to address each of the procedures and systems listed under subdivision (d) to identify weaknesses or
deficiencies that could contribute to errors in the administration of medication (including, but not limited to,
prescribing, prescription order communications, product labeling, packaging and nomenclature, compounding,
dispensing, distribution, administration, education, monitoring, and use) 2 .
One area of focus includes non-controlled medication discrepancies.
The purpose of this document is to identify options that are available to assist in the management of NON-
CONTROLLED medication discrepancies.
Overview of Discrepancies
When a user is required to count a medication in a Pyxis MedStation system pocket, a discrepancy occurs if the
physical count is different than the inventory count tracked by the Pyxis MedStation system. A physical count of
the inventory is always required on medications when the pocket is refilled, loaded, unloaded or inventoried.
Additionally, medications can be configured for a physical count each time the medication is removed.
In Table 1 summarizes two types of physical counts and how they may be configured.

Table 1: Types of Physical Counts
Physical Counts Advantages Disadvantages
Blind Count
Requires the end user to
enter the quantity instead of
showing the expected
beginning count and asking
for confirmation or correction
Verify Count
Provides the end user with
the expected beginning count
and asks for confirmation or
correction
Accurate medication counts upon
access of pocket
If count IS performed, accurate
medication counts upon access of
pocket
Increased time required during
medication removal process
Difficult to drive compliance
IF COMPLIANT, requires same
amount of time as BLIND COUNT
Discrepancy Resolution
When a discrepancy is created, depending on the software configuration, resolution will either be manual or
automatic.
Resolution-required discrepancies: The user is notified immediately and is required to resolve the
discrepancy at the Pyxis MedStation. A discrepancy is documented as resolved when the reason or
explanation statement is entered at the device.
Auto-resolved discrepancies: The user is not notified of the discrepancy. A discrepancy is documented as
resolved and no resolution is required.
Common Reasons for Discrepancies
There are many causes of non-controlled medication discrepancies:
A user removed a quantity greater or less than the quantity requested
A user cancelled the removal, but removed the medication
A user did not remove the medication requested
A user made a typographical error (for example, 11 instead of 1)
A user accessed the wrong pocket during remove, return, refill or load
A user indicated incorrect quantity during refill or load
A user diverted or pilfered a medication.
Basic Elements for Non-Controlled Substance Management
An essential element to initially consider is the development of policies and procedures. Policies should be
developed to address the prevention, identification, and monitoring of non-controlled discrepancies. A second
essential element required is that of education. Multidisciplinary involvement is recommended to design an
educational curriculum for ongoing staff education for pharmacy, nursing, respiratory and other providers (i.e.
anesthesia department.) Lastly, a third area for consideration is that of accountability. Processes that drive
accountability and compliance should be evaluated. Table 2 summarizes basic elements.

Table 2: Basic Elements
Elements
Develop policies and procedures to prevent,
identify and monitor non-controlled substance
discrepancies
Develop ongoing, multi-disciplinary curriculum to
address safety and non-controlled medication
discrepancies
Evaluate options to drive compliance
Charging discrepancy amount back to the
respective departmental budgets
Implement disciplinary action against users
that do not comply with their policies and
procedures
Advantages
Provides guidelines and framework to assist in
prevention, identification, tracking, and trending of
non-controlled medication discrepancies
Increased awareness and compliance
Options to drive compliance
Departments aware of value of discrepancies;
managers can track and trend the dollar
amounts month by month
Staff held accountable to policies and
procedures
Determination of Non-Controlled Substances to Prioritize
Policies should address which non-controlled substances will be prioritized as to preventing, identifying and
monitoring non-controlled discrepancies. One option includes the prioritization of all non-controlled substances.
Alternatively, a subset of non-controlled substance may be prioritized due to decreased time commitment and
allow increased focus on selected subset Table 3.
Table 3: Non-Controlled Substances Subsets to Prioritize
Subset of Non-Controlled Medications
Prioritize high cost non-controlled substances
Prioritize high alert/high risk non-controlled substances
Prioritize high volume non-controlled substances
Prioritize non-controlled substances on back order/medication shortages
Prioritize non-controlled substances with highest amount of discrepancies
Prioritize non-controlled substances via department: i.e. respiratory therapy medications
Prioritize non-controlled substance via patient care area, i.e. areas with highest discrepancies
Prioritize a random selection of non-controlled substances
Options to Assist in Preventing Non-Controlled Discrepancies
One the determination of which non-controlled substances will be prioritized, options as to preventing
discrepancies should be evaluated. Table 4 displays options to assist in preventing discrepancies.

Table 4: Preventing Non-Controlled Discrepancies
Store non-controlled
medications in secure,
single drug access pockets
(CUBIE ® s, Mini-drawers,
Carousels)
Store non-controlled
medications in single dose
medication storage (minidrawers)
Activate notice: removal
amount does not match
ordered amount
notification
Do not allow return to
pocket
Advantages
• User has access to one
medication line item:
decrease error in removal,
refill, load or return.
• Decrease incidence of
discrepancies related to
pilferage
• User has access to one
medication DOSE
• Decrease incidence of
discrepancies related to
pilferage
• Notifies end user if
amount to remove
different than ordered
amount
• Reduces potential for the
user to place medication in
wrong location and return
a medication that is not
intact or has been altered
• Reduces potential for user
to use the return function
to access medications not
on a patient profile
Disadvantages
• Increase cost of CUBIEs and Mini-
Drawers versus matrix drawer or
carousel
• User may still remove more or less
than the quantity indicated at station
• Single dose storage requires larger
footprint to hold the same number of
medications (decreased capacity)
• Increased pharmacy workload to refill
• Increased cost versus matrix drawer
or carousel.
• Not offered on all versions of Pyxis
MedStation
• If an internal return bin is used,
challenges may occur with large items
Options to Assist in Identifying Non-Controlled Discrepancies
Secondly, options to assist in identifying non-controlled substances should be determined.
Table 5 displays options to assist in identifying discrepancies.
Table 5: Identifying Non-Controlled Discrepancies
Activate blind count and
disable auto resolve for
non-controlled medications
Activate verify count for
non-controlled medications
Implement daily/weekly
inventory of non-controlled
substances
Advantages
• Accurate medication
counts upon access of
pocket
• If count IS performed,
accurate medication
counts upon access of
pocket
• Accurate inventory counts
• Non-controlled medication
discrepancies are
identified by nursing daily
Disadvantages
• Increased time required for nursing
during medication removal process
(decreased efficiency)
• Potential to create lines at Pyxis
MedStation
• Potential delay in medication
administration
• Increased time to resolve
discrepancies
• Difficult to drive compliance
• If compliant, same disadvantages as
blind count
• Increased time/workload

Implement daily/weekly
ACCESSED inventory
(Inventory those noncontrolled
substances that
HAVE been accessed).
• Improved ownership of
discrepancies
• Accurate inventory for
medications located in
secure pockets
• Non-controlled medication
discrepancies are
identified by nursing daily
• Improved ownership of
discrepancies
• In matrix mode (matrix, mini drawers
in matrix mode, and towers), during
removal, nurses have access to all
medications (not just documented as
accessed)
• Increased nursing time/workload
Monitoring Non-Controlled Discrepancies
Lastly, consideration needs to include which non-controlled substance discrepancies will be monitored, the
frequency to monitor and which tools to access. One tool available for monitoring is the CareFusion Knowledge
Portal for Medication Dispensing and Data Insights.
Table 6 and Table 7 reflect advantages to use of Knowledge Portal and sample reports.
Table 6: Advantages of Knowledge Portal and Data Insights
Accessible via network by pharmacy, nursing leadership, quality
Data refreshed every 24 hours for Knowledge Portal every 3 hours for Data Insights
Ease in monitoring via the Executive Summary
Ability to down load data to tables, charts, power points, & a variety of user data files
Ability to drill down by clicking links for all activity details
Nursing leadership can independently monitor discrepancies pertaining to their nursing units/users
Table 7: Knowledge Portal Reports
Key performance indicator (KPI) Reports
Key Performance Indicator (KPI) Reports provide system-wide summary KPI data about Diversion and
Inventory Loss, Inventory Management, Safety and Compliance, and System Management. KPI Reports
comprise 4 report categories containing 30 reports.
Reports Access Comments
Average number of non-CS
discrepancies per station
Viewable from Executive
Summary
Equation:
High level view of Hospital/IDN status
Average number of non-CS discrepancies
per station=Discrepancy transaction
counts/total number of Pyxis MedStations
Drill down: Number of
non-controlled
discrepancies per station
then medication then
pocket
Click on KPI: Average number
of non-CS discrepancies:
select analysis path: per
station then medication then
pocket
View stations with highest number of noncontrolled
discrepancies

Drill down: Number of
non-controlled
discrepancies per
medication then station
Click on station to view
non-controlled
discrepancies in station
Click on KPI: Average number
of non-CS discrepancies:
select analysis path:
medication then station
Click on medication to
view medications with
discrepancies
View medications with highest number of
non-controlled discrepancies
Audit Reports
Audit Reports provide summary and detail level data about transactions, diversions, usage, compliance,
and inventory tracking.
Reports Access Comments
Discrepancy Audit
Summary report provides a
summary metrics data for
discrepant transactions
associated with a particular
Station, User, Medication,
and/or any combination of
these, for the specified date
range
Discrepancy Audit Detail
report provides detailed
metrics data for discrepant
inventory counts in all
Stations for the specified
date range.
Select: Run a report
Select Audit tab
Edit Criteria: Filter by med
class, exclude, controlled
substances
Select date range
Select: Run a report
Select Audit tab
Edit Criteria: Filter by med
class, exclude, controlled
substances
Select date range
Provides station, user name, user ID,
user type, med ID, medication
description, medication class, number
of exceptions
Ability to sort by each column
o
Click on column to see
discrepancy audit (as below)
Provides station, med ID, medication
description, medication class, expected
count, actual count, unit cost*, total
cost*, drawer/pocket, discovery user
name
Ability to sort by each column
*If cost information is uploaded
© 2012 CareFusion Corporation or one of its subsidiaries. All rights reserved. Pyxis, Pyxis MedStation system and CUBIE
are trademarks or registered trademarks of CareFusion Corporation or one of its subsidiaries. September 2012
CareFusion
San Diego, CA
carefusion.com