The system comprised the following three elements.
Electronic prescribing, scheduling and administration software
There were two prescribing terminals on the study ward, and one in the pharmacy department. There were also two hand‐held tablet computers on the study ward, which could be taken from patient to patient and used to view, prescribe and discontinue medication orders. These had to be synchronised with the ward‐based server via a docking station before and after use. The software was Windows based, and the patient medication screen was intended to resemble an inpatient drug chart (fig A1). When prescribing, a doctor could access pull‐down lists of all drug products stocked on the ward, all drug products in the trust's formulary and all products in the drug dictionary. Prescribing was by product (aspirin 75 mg soluble tablets) rather than by drug (aspirin). Default doses were suggested for most products. No other decision support was enabled. If the patient had any allergies entered, these were displayed on the prescribing screen. When patients were transferred from other wards, pharmacists were authorised to transcribe their existing medication orders onto the computer system.
Figure A1Prescribing screen showing active medication orders. The triangles show doses that have not been administered; regular medication is shown in dark text and medication given when required in light text.
Once drugs had been prescribed, a nurse (or, less often, a pharmacist or doctor) scheduled the doses to specific drug round times and indicated the drug round at which the first dose was to be given.
Pharmacists checked and “approved” medication orders from a separate pharmacy screen, which highlighted unapproved medication orders. Medication orders did not have to be approved before they could be administered by nursing staff. At the approval stage, pharmacists could enter additional instructions relating to administration; further instructions could not be entered after orders had been approved.
Figure A2Nurse selecting stock medication from drawer in automated cabinet. The patient‐specific drawers can be seen below the open drawer, and the screen to the right. Photo published with nurse's permission.
Ward‐based automated dispensing
The majority of medication was stored in large automated cabinets; the doses required were transferred by nursing staff to an electronic drug trolley at each drug round. The automated cabinets, containing computer‐controlled drawers and a touch‐sensitive computer screen, were situated in the ward's treatment room. Products that were ward stock were in product‐specific drawers containing only that drug, dose and formulation, in original packs. Non‐stock medication dispensed for individual patients was stored in patient‐specific drawers, which could contain several products dispensed for that patient. The patient's name was indicated on the drawer using a liquid crystal display. The computer screen indicated the patients for whom doses were due in the next 2 h. To prepare for a drug round, the nurse selected each patient using the touch‐sensitive screen and was then presented with a list of the doses due. On selecting each dose, the relevant drawer in the cabinet opened (fig A2) so that the nurse could take the number of dosage forms required and place these in the electronic drug trolley.
Figure A3One of the two electronic drug trolleys. One drawer is allocated to each patient for whom medication is due and their name shown on the liquid crystal display. The barcode scanner is on the top of the trolley.
To restock the cabinet, a pharmacy technician printed a list of products below the specified reorder level. Barcodes on each drug product were used to confirm the identity of the medication loaded into each drawer. Non‐stock medication was ordered by nursing staff via the ward pharmacist.
Electronic drug trolleys
There were two electronic drug trolleys (fig A3), one for each half of the ward. Each contained 20 drawers and could be docked with the automated cabinet. When medication was being prepared for a drug round, only one drawer in the drug trolley opened at a time, and the patient's name was indicated on the drawer's liquid crystal display. When all medication for a given patient had been prepared, the system instructed the nurse to close that patient's drawer in the drug trolley before medication for the next patient could be prepared. Once all medication had been prepared for a given drug round, the trolley could be disconnected and taken around the ward. The barcode on each patient's wristband was scanned, which triggered the system to open that patient's drawer in the trolley so that the medication could be administered. The nurse confirmed administration using a touch‐sensitive screen on the trolley, and entered the reasons for any doses not given.
On completion of the drug round, details of all doses administered and reasons for any omission were uploaded to the main server once the trolley was docked.
Medication prescribed “to be given when required” was generally given separately outside the main drug rounds.