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Evaluation and Enhancement of a Comprehensive Controlled Substances Management Process at an Academic Medical Center
Bailey E Eason1,2,3, Tyler A Vest3,4, Katherine D Mieure1
1Wake Forest Baptist Medical Center, Winston-Salem, NC, USA.
Journal of Pharmacy Practice
|June 16, 2021
Summary
This study evaluated controlled substances management, identifying a 62% compliance rate and 55 optimization opportunities. Direct observation and failure mode and effects analysis (FMEA) proved effective in improving medication use processes.
Area of Science:
- Pharmacy Practice
- Healthcare Management
- Medication Safety
Background:
- Controlled substances management is critical and highly regulated.
- Institutions require robust processes for a closed-loop system.
- Optimizing the medication use process (MUP) is essential for compliance.
Purpose of the Study:
- To comprehensively evaluate the current state of controlled substances management.
- To identify and propose optimization opportunities.
- To implement steps aligning the MUP with a defined desired state.
Main Methods:
- A two-phase evaluation was conducted.
- Phase 1: Assessed current state using gap analysis and failure mode and effects analysis (FMEA).
- Phase 2: Assembled a work group to prioritize opportunities using risk priority number (RPN) and formulate action steps.
Main Results:
- A desired state of 86 segments was defined.
- Direct observation yielded 13 current state process maps.
- A 62% compliance rate was found, with 55 actionable opportunities identified via FMEA.
Conclusions:
- Direct observation, gap analysis, and FMEA are effective for evaluating controlled substances processes.
- These tools enable pharmacy departments to identify and prioritize optimization opportunities.
- The study demonstrated successful implementation of corrective actions within an academic medical center.
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