WORK
ANALYSIS OF DRUG-DISPENSING PROCESS IN A HOSPITAL EMERGENCY PHARMACY
Caroline Brum Rosso
Universidade Federal do Rio Grande do Sul, Brazil
E-mail: caroline.brumrosso@gmail.com
Letícia Canal Vieira
Universidade Federal do Rio Grande do Sul, Brazil
E-mail: leticiacvieira@gmail.com
Sabrina Letícia Couto da Silva
Universidade Federal do Rio Grande do Sul, Brazil
E-mail: sabrina.silva@poa.ifrs.edu.br
Fernando Gonçalves Amaral
Universidade Federal do Rio Grande do Sul, Brazil
E-mail: amaral@producao.ufrgs.br
Submission: 07/10/2015
Accept: 02/11/2015
ABSTRACT
The work organization performs a
crucial role in activities that involves problem resolution and decision
making. A hospital emergency pharmacy consists in an example where the work
environment has several kinds of demands that might be inconsistent and
influenced by overcrowding – common situation in Brazilian hospitals – causing
harm to work organization and suitability of workload. The objective of this
study is to evaluate labor conditions of professionals that work in the
emergency pharmacy of a university public hospital, seeking improvement
opportunities. A transversal study was developed with a descriptive character
to analyze the work conditions. An ergonomic work analysis was conducted and, for
fulfillment of its steps, observations in loco were performed and methods
Deparis, RULA and ABC analysis were used, pursuing to analyze data collected
and rearranging the work situation. The findings allowed propositions of
improvement, related mainly to the process of drug dispensation, organization
and arrangement of the work environment. The ABC analysis presented itself as a
valuable method for improving drug organization in the pharmacy and might be
useful in other work situations where accessibility of items is necessary, but
many items must be positioned.
Keywords:
Deparis; RULA; Ergonomic Work Analysis; ABC analysis; pharmacy.
1. INTRODUCTION
In
the process of work evolution concepts, parameters, goals, objectives and ways
of seeing and perform activities were changed. The work was reshaped to new
configurations of reality and society, adapting itself to the tasks and its
demands (ABRAHÃO; TORRES, 2004).
When
the nature of the activity comprehends problem resolution and decision making,
the case of a pharmacy in a hospital emergency, work organization (WO) has an
important role, contributing to task execution and process improvement. Through
WO it is established the norms and parameters that determine all kinds of labor
procedures: who, what, how, when and with what will perform activities, as well
as, how long, until when, how much and with what degree of quality.
The
hospital pharmacy has an important position in assistance context of the
Brazilian health system being responsible for activities related with
medications and instruments, which have a higher impact in the quality and cost
of hospital care. That importance becomes more evident when the pharmacy is
inserted in a context of emergency, where higher demands, that usually surpass
its capacity, might result in disorganization of pharmacy activities,
generating a negative impact in mental and physical health of workers (COELHO
et al., 2010).
The
activities that comprise the emergency pharmacy are composed by all the ones
presented in the regular pharmacy care, contemplating: drugs selection; demand
prevision, acquisition and proper storage of drugs; manipulation or development
of drugs that are not available in the market; distribution and dispensation
with security; supervision of drugs use, guidance to patients and health staff
(OSÓRIO-DE-CASTRO; CASTILHOS, 2004).
Errors
that might take place in drugs administration in the hospital pharmacies are
strongly influenced by work place conditions. Factors related to these errors
includes inadequate space, poor lightening, high temperatures, inappropriate
storage of drugs, high workload and the speed demanded for drug dispensation
(ANACLETO et al., 2005; KEERS, 2013). Messeder et al. (2007) estimated that the
higher level of interdependence between activities in hospital environment,
results in higher influence among activities. In this way, if an activity in
the emergency is not properly conducted the emergency pharmacy will suffer
negative influence.
Anacleto
et al. (2007) pointed out that drug dispensation is a sensitive process, where
it is fundamental to have organization, security and effectiveness, thus,
appropriate conditions of WO are essential. To guarantee these conditions
during the task performance, evaluations must be made to verify proper
execution, avoiding problems in the workers’ health (ONUKA et al., 2011).
In
this way, it is important to monitoring and executing periodical evaluations of
processes that comprises activities conducted in a hospital emergency pharmacy,
allowing the investigation of necessary developments on service quality,
something crucial for improving financial aspects, resilience and well-being of
the ones involved (SAURIN et al., 2015). One way of describing the work
environment and promoting continuous improvement is through the use of
Ergonomic Work Analysis (EWA).
According
to Guérin et al. (2001), EWA questions the methods typically used to define how
work is conducted; in many cases, variations and specific characteristics of
workers end up being neglected. In this way, a better form of attending this
diversity and variability is pursued, resulting in improved working conditions.
Errors and accidents that might occur are now seen as product of situations
that must be transformed and not as product of mistakes committed by workers.
Although,
when work conditions in Brazilian hospitals are analyzed, especially in the
emergency service, a contradiction is faced, once it can be perceived
inadequate work conditions inside institutions that have as their main goal health
care. The present study in an emergency pharmacy is justified by the fact that
a hospital is concerned with the health of its patients and community, but many
times neglects the health of its workers, who are daily exposed to inadequate
work conditions, resulting in possible impairment of health even inside a
hospital.
The objective of this study is to evaluate work
conditions of professionals that work in the emergency pharmacy of a university
public hospital and identify improvement opportunities to the establishment of
a more efficient and comfortable work place.
2. BIBLIOGRAPHIC REVIEW
According to Guérin et al (2001), the ergonomic action
searches for improving the reality of performed work, looking for solutions to
inadequate work regarding singularities of each person, comprising relations
between constraints of work situations, activities develop and consequence of
these activities to all actors involved. Poor fitting of work occurs mainly due
to projects of production systems, processes, work organization and tasks,
based on predefined stereotypes. Another aspect that must be emphasized is that
when work is being structured, usually the pressures of financial, technical
and organizational aspects prevail, instead of ergonomic aspects.
Hence, the essence of
the ergonomic action is the capacity to using knowledge and methods, adapting
to every situation found in work routine, understanding work to transform it
(GUÉRIN et al., 2001). It is not only about applying methods, execute measures,
doing observations or conducting interviews, it is necessary to take into
consideration the whole context. To achieve this goal in the process of work
transformation, it is vital participation of different actors involved and
analyzing their points of view. One important characteristic is that
ergonomists always seeks for an intervention, not being satisfied only by
production of knowledge about work conditions (DANIELLOU; BÉGUIN, 2007; GUÉRIN
et al., 2001).
To conduct an ergonomic
intervention in work there are several methods that can be used, although the
researcher must have conscience of the potential and objective of the method
that will be used (STANTON; YOUNG, 2003). Ergonomic
Work Analysis receives higher attention for being a method of task analysis
that allows comprehension of relations between work conditions and workers’
health, helping to improve the organization of sociotechnical systems,
resulting in a better performance of the company as a whole (GUÉRIN et al., 2001; PIZO; MENEGON, 2010).
2.1.
Ergonomic
Work Analysis
The EWA has the
characteristic of analyzing a real activity in a certain moment under specific
conditions (COCKELL; PERTICARRARI, 2008). The methodology proposed by Guérin et
al. (2001) divides the EWA in five steps (Figure 1) – Analysis of demand and
context, Exploration of company functions and characteristics, Analysis of
technical process and tasks and Global and local diagnosis of transformation
process. These steps are not essentially followed in a linear manner, allowing
the analyst to retake some of the steps in order to comprehend fully problem
causes (COCKELL; PERTICARRARI, 2008).
Figure 1: EWA steps
Source: Guérin et al., 2001.
The first step of the EWA, Analysis of
demand and context, seeks to comprehend the origin of
the analysis necessity. Demands are formulated in the
origin of work conception, which will alter the workers activity, or can come
from the constant evolution of work analysis (GUÉRIN et al., 2001).
The second step of the EWA, Exploration of
company functions and characteristics, elaborates the first hypothesis
directing the choice of situations to be analyzed. The dimensions to be
evaluated are: economic and commercial; social and demographic; laws and
regulations; geographic environment; technical; production and its organization
(GUÉRIN et al., 2001).
The analysis of technical process and
tasks, allows the comprehension of the observed, increasing possibility of
action in the process of technical transformation as well as its credibility.
The pre-diagnosis is a result of hypothesis formulation based on registers
collected in previous steps, followed by formulation of an observation plan
(movements, look's direction, communications, postures, flux of communication
and materials, among others).
The local diagnosis is the product of the
analyses that summarizes observations, measures and interviews results. The global diagnosis is based in the
precise information of the local diagnosis, presenting
a broader vision of problems that were identified in the steps related to
demand analysis and company function (GUÉRIN et al., 2001). At last, the
process of transformation occurs by introducing modifications in work
situations (GUÉRIN et al., 2001).
3. METHOD
The study was conducted in an emergency pharmacy of a
large university hospital. This transversal study had a descriptive character,
consisting on observations and data collection performed in the period from
November 2014 to February 2015. Target population was pharmacy workers consists
in pharmaceutics and pharmacy technicians. An EWA starts with the demand
analysis and knowing better how the system being studied operates.
For analyzing the work environment and conduct the
preliminary diagnostic, the method Deparis (MALCHAIRE, 2002) was used for
investigating the current working conditions in the pharmacy. This method
composes the Screening step of SOBANE (Screening, Observation, Analysis,
Expertise) strategy from the same author. It was chosen because it approaches
in an objective way a larger number of risks that can exist in the work
environment, being orientated to questioning how workers felt, allowing main
issues that need to be resolved to become exposed.
Visits were conducted to analyze physical work space.
They aimed to identify work stations, furniture disposition and space
available. Also, pictures were taken of technicians conducting their normal
working routine, so that work postures could be analyzed latter, as well as
physical space restriction and infrastructure.
Procedures conducted in the pharmacy were also
observed and characterized, allowing identification of main ergonomic problems
related to procedures and workstations. This analysis permitted the
identification of which items from Deparis method should be a priority for
improvement actions.
After the application of Deparis, it became clear that
workers were exposed to risks related to workstations layout and the fact that
work was repetitive. In this way, an analysis of workers’ risks to acquire
injuries in upper limbs was conducted with the Rapid Upper Limb Assessment
(RULA) method (MCATAMNEY; CORLETT, 1993), this consisted in the step Analysis
of technical process and tasks of the EWA.
RULA was developed to ergonomic investigation in
workstations where there is the possibility of developing musculoskeletal
diseases in upper limbs. RULA is based in a diagram of body postures and three
tables that evaluate exposure level to risk factors, where main constructs are:
number of movements, static posture, strength, work posture imposed by
equipment and furniture and pause time. The methodology is executed in three
stages: (i) identification of work postures; (ii) score system application; and
(iii) application of risk level scales.
In this way, pictures taken of workers in their normal
routine on workstations were analyzed through the RULA protocol, thereby
generating a final risk score of developing injuries in the upper limbs. The
photographical observation respected all ethic issues. The sector manager
authorization was acquired and the workers signed a Term of Consent, presenting
the objectives of the study and ensuring secrecy and confidentiality of data.
The RULA analysis indicated that postural problems
were emerging due to localization of medications in the pharmacy. To identify
medications that have a higher demand and need to be dispensed often, an ABC
analysis was conducted. The ABC analysis is commonly employed in materials
classification and is based in the Pareto’s principles, considering the
importance of materials, quantity used and their demands.
4. RESULTS
4.1.
Work
characterization
The hospital emergency service is characterized by
constant overcrowding. There are occasions that capacity is surpassed two or
three times. This scenario results in overloading to all workers associated
with the emergency, including the emergency pharmacy, subject of this study.
The main function of the pharmacy is dispensing
medication prescribed by doctors; this task might be accomplished by two
distinct fluxes. One flux is through a document denominated Internal Communication
(IC), which is taken by the nursing technician (NT) responsible for the patient
to the pharmacy. After receiving the IC,
the pharmacy technician (PT) searches for the medication in the stock and
delivers to the NT.
The second dispensation flux of medications involves
patients hospitalized in emergency. In these cases, the doctor evaluates the
patient condition and defines treatment for the next 24 hours, doing
prescription through the system. This prescription is called “next day
prescription” and will be valid from 8 PM of current day to 8 PM of next day.
The pharmacy receives the prescription that is evaluated by the clinical
pharmacist, for verifying if medications do not present any risk to the
patient, observing, for example, occurrence of drug interaction.
When the prescription is approved by the pharmacist,
the medication is dispensed by the PT. Dispensation comprises searching for
medication in the pharmacy stock, reading the bar code through the system,
packing medication and delivering to the NT.
Dispensation demand is influenced by the time of
physicians prescription, in this way, an agreement was made that physicians
must do next day prescription until 4 PM, allowing time for the medication
arrive to the patient until 8 PM. This agreement generates a demand peak,
because prescriptions are usually done all at the same time and must be
dispensed in the interval between 4 and 8 PM.
4.2.
Preliminary
diagnosis
As a result of
observations and talks with the PT it was possible to define main risks that
were perceived by them. To guide this process, criteria presented in Deparis
method were used. Each criteria can be classified as satisfactory (J), intermediate (K) and
unsatisfying (L). Attention must be held on items that were
classified as intermediate or unsatisfying; in the latter case immediate
changes must be made. Table 1 presents the classification established for each
criterion, according to the work developed by PT.
Table 1:
Preliminary diagnosis.
|
Criteria evaluated by
Deparis |
|||
|
1. Work zones |
J |
K |
L |
|
2. Technical organization between work stations |
J |
K |
L |
|
3. Places of work |
J |
K |
L |
|
4. Risk of accidents |
J |
K |
L |
|
5. Commands and signals |
J |
K |
L |
|
6. Work tools and materials |
J |
K |
L |
|
7. The repetitive work |
J |
K |
L |
|
8. Handlings/weightlift |
J |
K |
L |
|
9. Mental load |
J |
K |
L |
|
10. Illumination |
J |
K |
L |
|
11. Noise |
J |
K |
L |
|
12. Temperatures |
J |
K |
L |
|
13. Biological and chemical risks |
J |
K |
L |
|
14. Vibrations |
J |
K |
L |
|
15. Working relationships |
J |
K |
L |
|
16. Social environment |
J |
K |
L |
|
17. Work content |
J |
K |
L |
|
18. Psycho social environment |
J |
K |
L |
Source:
authors.
Items classified as intermediate are related to proper
illumination, medication organization, communication between staff, monotonous
work and psychosocial environment. It appears to be necessary evaluate
medication displacement according to its frequency of use, seeking to make them
more accessible. Besides that, improvements in visual communication and time
management would be positive for workers, taking into account different shifts
and times that need to be fulfilled. Regarding content of work, it can be
characterized as monotonous, but it is not considered as something critical.
Items that were evaluated as unsatisfying
are related to work zones, work place, repetitive work and biological and
chemical risks. The work stations are not in best displacement, they are small
and several boxes are clogging the space. The pharmacy has no windows and there
is no visual contact with other colleges, besides that, the great number of
black boxes around make the place darker, increasing the poor illumination
problem. It was also perceived that it is necessary to reach for objects in
different heights, demanding from workers constant trunk twisting and arms
lifting. The objects manipulated usually are not heavy, but continuous
repetition may cause pain and musculoskeletal discomforts.
An evident risk that can be observed is due to the
pharmacy location, contiguous to the emergency. There is no proper air
circulation, making the workers exposed to biological risks. The only window
present faces to the corridor were patient’s stretchers passes.
Pharmacy’s layout is presented in the Figure 2, were
PT’s workstations are in the two chairs on upper left corner. The other two
workstations are where pharmacists stay. There are almost no free walls, being
all occupied with cabinets.
In each PT’s workstation (Figure 2) there are one
computer for receiving the prescriptions to be dispensed, one barcode reader,
one printer and one chair with adjustable height. Each workstation has its
medication stock, located in a shelf above the computer and between
workstations. Yet, these stocks are not replicated, when compared with each
other. The workstation one has 125 boxes of stock and the workstation two has
133 boxes, each box has one type of medication.
A stock of medication
that is less used also exists in this area (74 boxes), it is located in the
left side of workstation one. In this space is also located the refrigerator,
that contains medications that need refrigeration. In the section were
pharmaceutics work, the main stock of the emergency pharmacy is placed, the PT
pick up there medications for supplying workstations stocks.
Criteria evaluated as unsatisfactory are related to
quality of the workstations and postural issues, becoming clear that a more
in-depth analysis was necessary, seeking to support improvement propositions.
To execute this analysis the RULA method was applied. The RULA analysis allowed
a quantitative classification of postural problems that was diagnosed by
Deparis. In this way, problem existence was confirmed and critical aspects of
workstations identified.
Figure 2: Pharmacy layout.
4.3.
Workers
posture analysis
The postures analyzed with RULA, were the ones that
workers do with more frequency. Frequent postures done in the two workstations
and in the stock area were observed. Figure 3 presents images utilized in the
analysis and the results are in Table 2.
Figure 3: Work postures analyzed.
Table
2: RULA analysis results.
|
RULA |
Workstation
1 |
Workstation
2 |
Stock |
|||||||
|
Position
1 |
Position
2 |
Position
3 |
Position
4 |
|||||||
|
Value |
Adjust |
Value |
Adjust |
Value |
Adjust |
Value |
Adjust |
Value |
Adjust |
|
|
Arm |
3 |
1 |
4 |
1 |
3 |
1 |
3 |
1 |
3 |
1 |
|
Forearm |
2 |
1 |
2 |
1 |
2 |
1 |
2 |
1 |
2 |
1 |
|
Fist |
3 |
|
3 |
|
3 |
|
3 |
|
2 |
|
|
Neck |
2 |
0 |
4 |
|
1 |
|
1 |
0 |
4 |
0 |
|
Torso |
2 |
1 |
1 |
|
1 |
1 |
1 |
1 |
1 |
2 |
|
Twisted fist |
1 |
|
1 |
|
1 |
|
1 |
|
1 |
|
|
Legs |
1 |
|
1 |
|
1 |
|
1 |
|
1 |
|
|
Muscular use of arms |
0 |
|
1 |
|
0 |
|
0 |
|
0 |
|
|
Load A |
0 |
|
|
0 |
|
0 |
|
0 |
|
|
|
Muscular use of torso |
1 |
|
|
1 |
|
1 |
|
1 |
|
|
|
Load B |
0 |
|
|
0 |
|
0 |
|
0 |
|
|
|
Final Score |
6 |
7 |
4 |
4 |
6 |
|||||
Source: Authors.
According to RULA, a score equal or superior to 5
demands immediately change. Looking to the results and images, it is possible
to perceive simple changes that can be done, so that workers will have a better
posture. It is hoped that these changes will lower the score to 4, which does
not characterize an ideal situation, but makes it more favorable. These
measures can be taken in a short span of time and are of lower cost.
First, the need to altering the monitor height is
perceived, so the head will be upright when looking the monitor, being on this
way aligned with the torso, generating a better analysis result. The barcode
reader is used constantly during the task execution, presenting itself as one
of the main work instruments; however its position is not adequate.
It is necessary that it be centralized in the table,
in front of the computer screen, closest as possible of the worker. This would
reduce torso twist for reading barcodes. It was also realized that many times
the worker leans to the front for reaching the barcode reader, this way in none
of the analyzed positions he is sitting with his torso leaning against the back
of the chair. It is expected that changing the barcode reader position will
also improve the torso position, generating a better score.
Several medications are placed in higher places, which
makes that some postures present high scores. It is not possible to place all
medications in the most suitable height, due to space limit constraints,
whereas it is viable to identify medications that are dispensed with more
frequency and place them in most comfortable heights. Use of boxes with smaller
dimensions is also possible, resulting in more places available in appropriated
heights. Another solution that might reduce the need of fist twist is use
sloping shelves, facilitating the grip of drugs.
The workstations 1 and 2 have similar dimensions, but
the results of the workstation 2 are more adequate then the workstation 1, due
to the height of the PT that works in this workstation. This emphasized the
need of changes so that the configuration is proper for everyone.
4.4.
Improvement
proposals
To reduce the frequency of arm lifting movements, or
even the necessity to reach for objects in inappropriate heights, drugs must be
placed in a way that the ones used more often are in more accessible positions.
To discover drugs that are dispensed more frequently, data of mensal
consumption was analyzed.
Figure 4 presents consumption distribution of each
drug for the month of October 2013, seeking to exemplify the analysis that was
conducted. Using the ABC analysis, it was possible to verify that 404
typologies of drugs were consumed, whereas 80% of the consumption is
concentrated in 77 types of drugs. On this way, it is practicable to rethink
drugs placement, so that the ones used with more frequency are placed in easy
access positions.
The number of drug units dispensed that are in the 80%
interval is 135 units for the month of October 2013. Seeking to guarantee an
interval of confidence, medications with consumption superior to 100 mensal
units were considered in the analysis. After that, it was observed which drugs
were part of this group in the months of September 2013 to September 2014. When
the typologies of drugs were compared it was possible to identify that they
were the same over the months, with few exceptions, generating a total of 86
drugs that represent around 80% of the total pharmacy consumption.
Figure 4: Distribution of drugs consumption (October
2013).
For drugs that were in the 80% group it was calculated
the average consumption in the period, subsequently they were classified in
descendent order of consumption. The places more suitable for the PT are
located in the shelf between the workstations. Figure 5 presents the position
that the drugs should have. The grey scale represents the easiness of access,
where darker tones represent better places.
Other modifications recommended are related to air
circulation, positioning of work instruments and comfort increase. Avoiding
direct air exchange between the pharmacy and the area where patients stays is
important. Thus, placing a glass structure in windows might be useful for the
insulation and biological protection of workers. It is also suitable think in
an analysis of the pharmacy air quality, being possible to confirm the
existence of biological risks.
Simple modification as repositioning the monitor to
eyes height, placement of the barcode reader in front of the monitor, closest
as possible of the PT, and placing the printer in opposite side of the drugs
shelf, are changes that might generate improvement in workers posture and
efficiency. Lastly, replacing the black boxes for transparent ones will make
the atmosphere cleaner, improving the visual management, and corroborating for
a better control on need of drug supply.
Figure 5. Workstation shelves and best drug
displacement.
5. CONCLUSIONS
The pharmacy analyzed
in this study is inserted in the environment of a hospital emergency, where
demands are from different natures and do not have constancy. Overcrowding is
recurrent and results in a workload that most of times is not suitable and do
not have a regular distribution.
Observations conducted
in the pharmacy work environment resulted in realization that workers share a
limited space with problems of organization and layout. Besides, workers are
exposed to biological risks, executing monotonous and repetitive tasks that
require high attention. These aspects are limiting and damaging the work
execution, once work environment can have high influence in results that will
be reached.
The findings allowed
improvement propositions related in great deal with organization and
disposition of the work place. It is important that these measures be
implemented in order to support an adequate work environment, more comfortable
and that increases collaborators' efficiency. Also, the measures suggested in
this study are in its majority of low or no cost, which will not result in a
considerable financial impact for the institution, since, in many occasions,
the financial aspect might be seen as an obstacle for pursuing improvement
actions.
After implementation of suggested changes, it is
advisable that new observation be performed, as the ones executed in this
study. New analyses with the methods Deparis and RULA are fundamental to verify
if improvement proposals were effective regarding the workers comfort and
better work organization, acting as well as an opportunity to identify new
improvement measures. Whereas, it is important to observe the period demanded
for adaptation to new routines and layout changes. Execution of trainings to
adequate workers actions to the new scenario is also necessary.
Regarding the instruments used in this study, it is
important to emphasize the use of ABC analysis. The ABC analysis presented
itself as a valuable method for improving organization of drugs in the pharmacy
and might be useful in other situations where accessibility of items is
necessary, but many items must be positioned. In this way, as a suggestion for
further studies, the use of the ABC analysis is recommended to organize stocks
and improve ergonomic work conditions.
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