PHCM9748 Assessment 1: Robotic Medication Dispensing Risk Analysis

This report presents a risk analysis of implementing a Robotic Medication Pack Dispensing System (RMPDS) at Dingo Creek Hospital (DCH). The introduction highlights the need for this initiative due to issues with the current manual drug dispensation system, including picking and packaging errors, increased costs, and delays in medication supply. The report then identifies and analyzes potential risks associated with RMPDS, including patient safety concerns (e.g., medication errors, privacy breaches), technological risks (e.g., software failures, maintenance issues), and operational needs (e.g., regulatory compliance, financial implications). Each risk is described, rated for severity and likelihood, and potential risk minimization strategies are proposed. The report also evaluates the relative importance of each risk in relation to the potential benefits of the RMPDS, such as improved efficiency, reduced human error, and enhanced patient safety. References to supporting literature are included, and a conclusion is not provided in the text.

PHCM9748 Assessment 1, 2019
Student ID:
Robotic Medication Pack Dispensing Risk Analysis
Introduction
[Provide a short introduction to the quality and safety issue that has led to this quality and safety initiative, with reference to how this addresses continuous quality
improvement (i.e. was the change stimulated by a need, a negative event, cost blow out, and so on)]
To,
The Hospital Executive Board,
Dingo Creek Hospital (DCH)
Re: Proposal to implement Robotic Medication Pack Dispensing System (RMPDS) in DCH
Dear Board Members,
I would like to draw your attention towards our manual drug dispensation system which is subject to risk such as picking and
packaging errors. In addition, there is an increased cost pressure due to an increased demand for additional staff and delays in supply of
medication as a result of excessive workload (Rodriguez‐Gonzalez, 2019). Introduction of robotic medication pack dispensers will improve
efficiency and effectiveness of drug dispensation, because the pharmacist will have more time to educate the patient on safe drug use (De
Luc, 2018).
RMPDS was first introduced in the 1990s with the aim of improving service delivery, inventory (Loy, 2016), minimizing cost
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PHCM9748 Assessment 1, 2019
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in terms of manpower and increasing patient safety by reducing human error of dispensing wrong medications (Loy, 2016). In as much as
robots cannot solely operate without human intervention (Silva, 2017), the manpower needed to run the program is significantly lower than
the resources needed to run a manual system. However, Robots run through a computer program which requires a person behind the keyboard
giving commands to the computer. Software is coded by humans and a simple mistake in the code can result to mistakes when dispensing
drugs; however it is safer to use RMPDS because they have bar codes which makes it impossible for the robot to dispense the wrong
medication (Stojković, 2016).
Adopting such a system will improve the quality of care drug dispensation (Schneider, 2018); however, change has its
advantages and disadvantages; therefore, a risk analysis has been conducted because the quality of care provided to patients cannot be
compromised in anyways. Despite all the advantages that come with the use of a robotic medication pack dispensing system, quality and
safety concern are always looked at because every system has its pros and cons (Cheung, 2018). A thorough risk analysis on RMPDS has
been conducted below to ensure, there is quality and safe drug dispensation.
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Potential Risks Involved in the Initiative
[Please complete the table for at least three (3) risks you have identified]
Risk Description Risk Rating Analysis
Risk Source Where
the risk originates
[e.g. regulatory
requirements, political
changes]
Description
[Consider describing the cause(s) that results
in the event and the impact or consequences
they create.]
Severity Likelihood Risk Minimisation
[Summarise how potential
risks may be minimised.]
Evaluation
[Provide an indication of your
assessment of the relative
importance of the risk in
relation to the potential
benefits.]
Patient safety Patient safety is vital to service
delivery. Right medication, right
patient and right prescriptions are
the major aspects of safety concern
when it comes to robotic drug
dispensing system.
Subjecting
patient’s record
to a system that
cannot maintain
their privacy
may lead breach
of contract and
legal
During
programme
updates
patient
information
is fragile and
issues of
timely
To minimize the risk of
a machine dispensing
the wrong prescription,
updates should be done
when the facility is less
busy and it should be
done by licensed staff.
Also the facility should
When the required
safety measures are
taken, benefits of a robot
dispensing system
outweighs its risk.
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PHCM9748 Assessment 1, 2019
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consequences
for the
institution
(Davey, 2019).
dispensation
of drugs may
arise.
have a confidentiality
agreement which
protect patient’s data
(Khader, 2016).
Technological Robots are operated by a software
program which can fail abruptly.
Maintenance requires manpower
and extra cost, therefore slowing
down services delivery (Mettler,
2017). Computer programs require
constant and timely updates
because technology keeps on
changing.
Wrong coding in
the program
during an update
or unexplained
system failures
can result in
corrupted
devices and
misinterpretatio
n of the
commands.
Program
malware and
human error
can result in
unnecessary
system glitch
which may
result in
dispensing
error.
The maintenance
personnel should be
conversant with the
latest updates which are
faster and have
minimal error. Training
of the pharmacy staff
on how to deal with
system failure will help
decrease the risk.
The pharmacy staff
should be informed on
the timetable for system
maintenance, thereby
instituting strategies
which will ensure
smooth work flow
during this period.
Operational needs
such as regulatory
There are a variety of robots in the If rules and A pharmacy Complete adherent to It is vital to identify the
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PHCM9748 Assessment 1, 2019
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requirements market from different companies.
Some robots may meet the
regulatory requirements; others
may not. Adherence to rules
formulated by the regulatory bodies
is paramount to provision of quality
and safe health care.
regulations are
ignored, there
will be an
altered service
delivery will be
system and
mistakes during
drug
dispensation.
that is
patient
centred will
put its
client’s
health first
compared to
a pharmacy
that is
money
centred.
the regulatory bodies
results to quality
patient care,
The pharmacy policy
should humane and
socially acceptable.
requirements and
evaluate if the
organisation is capable
of meeting them all.
This way the importance
of the risk is appreciated
and can be avoided
(Graban, 2018).
Financial Running such a program requires a
financial plan which entails the
cost of installation and staff
education on how to how to use the
system (Qureshi, 2017).
The financial
burden accrued
by employing
more staff
cannot be
The health
facility is
likely to
spend more
when
The pharmacy will
incur cost during
acquisition of the
system, later on the
cost will decrease
Appreciating this risk
enables the institution to
acknowledge the
importance of finances
in the adoption of a
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PHCM9748 Assessment 1, 2019
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compared to that
of installing a
robotic
medication pack
dispensing
system
(Ramsey, 2018).
In the long run it
is more pricey to
employ staff.
installing the
system and
during on
job training
to train its
staff on how
to use the
system.
tremendously. The
pharmacy should come
up with a financial plan
and explore different
models offered by
different companies in
order to minimize the
cost of acquisition.
robotic system and with
proper financial
planning drug
dispensation can be
made easier, efficient
and safer when using a
robotic system
(Donaldson, 2018).
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References
Cheung, K. C. (2018). Medication errors related to automated dose dispensing in community pharmacies and hospitals: a reporting system study.
Learning from medication errors through a nationwide reporting programme,, 9(7), 111.
Davey, N. S. (2019). Pharmacy automation using autonomous robot. US: U.S. Patent Application No. 10/335,953.
De Luc, K. (2018). Developing care pathways:in handbook. Routledge.
Donaldson, L. (2018). Clinical governance: a quality concept. . In Clinical governance in primary care, 1-16.
Graban, M. (2018). Lean hospitals: improving quality, patient safety, and employee engagement. Denver: CRC press.
Khader, N. L. (2016). Pharmacy robotic dispensing and planogram analysis using association rule mining with prescription data. Expert Systems
with Applications,(57), 296-310.
Loy, M. L. (2016). Beyond the Use of Robotics: Operations and Supply Chain Control for Effective Inventory Management in a Health System
Pharmacy. In Advances in Healthcare Informatics and Analytics. Cham: Springer,.
Mettler, T. S. (2017). Service robots in hospitals: new perspectives on niche evolution and technology affordances. European Journal of
Information Systems,, 5(26), 451-468.
Qureshi, M. O. (2017). A study of integration of robotics in the hospitality sector and its emulation in the pharmaceutical sector. Health Science
Journal,, 11(1), 1.
Ramsey, J. G. (2018). Ergonomic evaluation of pharmacy tasks. India: cdc.gov.
Rodriguez‐Gonzalez, C. G.‐A.‐V.‐L.‐P.‐S. (2019). Robotic dispensing improves patient safety, inventory management, and staff satisfaction in
an outpatient hospital pharmacy. Journal of evaluation in clinical practice,, 25(1), 28-35.
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Schneider, P. J. (2018). The impact of technology on safe medicines use and pharmacy practice in the US. Frontiers in pharmacology(9), 1361.
Silva, S. D. (2017). Portuguese primary healthcare–sustainability through quality management. International Journal of Quality & Reliability
Management,, 34(2), 251-264.
Stojković, T. M.-G. (2016). Patient safety and medication errors in the provision of health care services-challenges for contemporary practice.
Acta medica Medianae, , 57-64.
Zeng, Y. T. (2017). An error-similarity-based robot positional accuracy improvement method for a robotic drilling and riveting system. The
International Journal of Advanced Manufacturing Technology, , 2745-2755.
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