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Hospital Pharmacy 55(4)

Figure 1. Anti-infectives with the highest number of wasted doses and highest waste in cost ($).

recent national shortage. These include cefepime, meropenem, metronidazole, and ceftriaxone.
Discharged patients and discontinued/changed orders
are the most feasible target for process improvement. First,
the implementation of an electronic queue for high-waste
and high-cost anti-infectives in the pharmacy would limit
waste when these orders are discontinued. Presently (as in
2016), the pharmacy at CHCO rarely confirms that medications in the hardcopy queue are still active prior to preparation; an electronic queue, displayed on a screen in the
pharmacy, will interface with the EMR and automatically
remove discontinued or changed medication orders.
Second, the standardization of anti-infective doses would
allow doses that are returned to the pharmacy to be repurposed for another patient provided they are kept in a sterile
location with an expiration date. At CHCO, all doses of
medication that are sent to the units are date and time
stamped in a sealed envelope. Assessing integrity and stability of the dose (eg, envelope not opened, dose within
drug stability time window) is an important process for
returned doses. Third, the standardization of dose administration times for once-daily anti-infectives to evenings will
mitigate waste from patients discharged during the day.
Fourth, the requirement of order end dates when the provider places an order in the EMR will prevent the preparation of unnecessary doses on the day an order is discontinued.
Fifth, the implementation of a night screening by the onservice pharmacist in the hematology/oncology unit-the
unit with the highest anti-infective use4-will limit the dispensation of unnecessary medications the next morning for

patients admitted for fever and neutropenia who are culture
negative and no longer febrile or neutropenic. The clinical
pharmacist on duty could place a hold in the medication
administration record for patients with a high likelihood of
discharge (resolved febrile neutropenia) so that anti-infective doses are not batched, but prepared only when the hold
is released if the patient is not discharged.
While the proposed process improvement measures will
be beneficial to CHCO in reducing waste, we recognize that
not all of these will be applicable to pharmacy workflow at
other hospitals. Of the above process improvement measures, standardizing doses, standardizing dosing times for
once-daily medications, and requiring order end dates are the
most exportable to other pediatric centers and already commonly practiced at adult centers.
These targets for process improvement will be considered for implementation at CHCO, but do have limitations.
First, anti-infective waste and hospital pharmacy operations
may not be similar at other institutions, so these plans for
process improvement may not be applicable to other hospitals. Second, drug shortages forced certain changes in preparation and dispensing practices that cannot be altered
within CHCO's improvement plan. Third, the $100 000 dollars in anti-infective drug cost waste discovered at CHCO is
an underestimate, as it does not account for pharmacy time,
materials, waste disposal, or the cost of redispensed doses.
Based on internal audits, CHCO pharmacy management
estimates the time to prepare a dose to be 2.2 minutes, correlating to approximately $12 913 dollars in wasted labor
costs for the year of our study. This neither includes time or

Hospital Pharmacy - August 2020

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