A Pharmacy Transformation and Lean Concepts


Pharmacy transformed at Women and Children's Hospital

Here is a story about a Buffalo hospital that designed a new pharmacy space. The article doesn't mention Lean… although I know of many hospitals that have used Lean methods in a pharmacy space and process redesign.

The need for safety measures and error proofing is critical in any pharmacy, yet alone one that serves children. As the article highlights:

In April, researchers reported that new detection methods showed that medicine mix-ups, accidental overdoses and bad drug reactions harm roughly 1 in 14 hospitalized children in the United States. That translates into 7.3 percent of hospitalized children, or about 540,000 children each year, based on government data.

While technology is not a “silver bullet,” it certainly can help in pharmacies, in a number of ways (picture below added by me, not in the original article):

At the core of the 4,000- square-foot facility is a Pyxis Carousel, which electronically sorts and stores pharmaceuticals and employs a bar code scanner to make sure that prescriptions are properly filled.”

It replaced the antiquated method of arranging drugs alphabetically on open shelves, which can lead to mistakes just because many medicines look or sound alike.

The carousel ensures “that when drugs come in, they go to the right place, and when we take them out, you have the correct dose,” Kalita said.

I've seen many pharmacies that are organized alphabetically, much the same way a stockroom in any factory might be set up. Alphabetical organization can lead to a number of risks, including the wrong medication being chosen or the wrong dose. I've seen cases where a 10mg dose pill has fallen into the adjacent 5mg dose bin. Staff have to constantly double check as they're pulling meds since they can't trust that the right med is always in the right place. Relying on inspections and “being careful” isn't a good strategy for perfect quality.

I've worked in factory warehouses that knew they shouldn't store parts in numerical sequence because of the risks involved in picking the wrong item. Pharmacies that do not yet have automated cabinets should consider adapting that methodology. You need a good cross-reference pick list to tell people where the meds are located… it might not seem as easy as being alphabetized, but it can work.

The carousel is also a space-saver. “We'd need 10 times as much shelf space to hold everything we have in there,” Kalita said.

This is true. The carousel makes much more efficient use of space and can help reduce pharmacy technologist walking a great deal. With the traditional rows of shelves, techs might walk many miles a day inside the walls of the pharmacy, chasing down different meds.

With the carousels, you have to be careful that people don't get lax because of having technology. There are still opportunities for process errors. With many of these systems, the “automatic” loading means that the correct shelf presents itself, but there is still a risk that the person puts the med into the wrong BIN on that shelf. This might seem obvious, but scanning a bin doesn't assure quality 100% if somebody manually loaded a medication or a single pill into the wrong bin on the carousel.

When it comes to dispensing drugs, the Variety Club Pharmacy, which opened in January, “is 99 percent foolproof,” declared Richard Goldstein, the charity's executive director

Oops, the use of the word “foolproof” (and why just 99%? That's still alot of errors).

I've written about this before and talk about it all the time during training sessions. The preferred terms are “mistake proofing” or “error proofing.” We don't have fools or idiots or dummies working in hospitals. The focus has to be on reducing opportunities for error by improving the process, rather than focusing on the “fools” who make errors.

Toyota learned this lesson early on when they shifted from saying “baka yoke” (which translated to fool proofing) and started using the term “poka yoke” (which translates to mistake proofing). Don't confuse that distinction with simple political correctness. I think the poka yoke term and concept is a much better reflection of reality — and it shows “respect for people.”

Though it is not possible to eliminate every mistake — human error will always be a factor — “any technology we can put in place to minimize that, we will,” Kalita said.

“It only takes one mistake to produce a bad outcome, so we strive for 100 percent,” he said. “Is that realistic? Probably not, but that's our aim.”

I'll end by posing a question — in the previous quote, is that a recognition of reality that human error can't be totally eliminated, or is it self-defeating talk? Do you feel comfortable with talk about “zero defects” being the goal, even if it's “not realistic?” Shouldn't we challenge ourselves harder than saying “well, some errors are bound to happen”?? What do you think?


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Mark Graban
Mark Graban is an internationally-recognized consultant, author, and professional speaker, and podcaster with experience in healthcare, manufacturing, and startups. Mark's new book is The Mistakes That Make Us: Cultivating a Culture of Learning and Innovation. He is also the author of Measures of Success: React Less, Lead Better, Improve More, the Shingo Award-winning books Lean Hospitals and Healthcare Kaizen, and the anthology Practicing Lean. Mark is also a Senior Advisor to the technology company KaiNexus.


  1. I am working with a pharmacy that has just installed a robot.

    The robot is loaded simply by putting every box of medication that arrives in to a chute. There is a little conveyor along the bottom of the chute that takes the medications in to the robot where it scans the bar code. If it can not read the bar code it spits them out.

    Once they are in the robot randomly distributes them across the three aisles. So it ensures that there are equal amounts of all of the drugs in each aisle but randomly distributed within the aisle.

    The robot rotates the stock by expiration date and picks on a first in first out basis.

    A pharmacist places a order in the electronic Rx system, this is communicated to the robot which picks the drugs and then sends them by conveyor back to the PC on which they were ordered in a little under 15 seconds. Once piece flow.

    The robot is located about 30 feet away from the pharmacy, the other side of a corridor but all the conveyors run above the ceiling and the drugs are delivered swiftly to the correct PC.

    The system of gates is very much like that used at Terminal 5 at heathrow, though somewhat more successfully.

    I have to say I am quite impressed with the technology, it eliminates picking errors, ensures only one drug at a time for a patient is picked, saves stocking items on shelves and then picking them.

    They are some very clever pieces of kit.




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