An increasing number of U.S. hospital systems are implementing IV workflow management systems (IVWMS) in their sterile drug compounding, but adoption remains lower than medication safety experts’ recommendations.
According to data from the ASHP National Survey of Pharmacy Practice in Hospital Settings: Operations and Technology for 2023, the latest available, 31% of all hospitals had put in place some type of IVWMS, compared with 21.3% in 2020 and 12.8% in 2017 (Am J Health Syst Pharm 2024;81[16]:684-705).
When the smallest hospitals (those with <50 beds) are taken out of the equation, IVWMS penetration is significantly higher, ranging from 31% of hospitals with 50 to 99 beds to between 50% and 60% in hospitals with 300 to 600-plus beds, according to the ASHP survey. Pictures or videos of the compounding process are used by 38.6% of hospital pharmacies, a figure that has also increased significantly since 2020 (25.3%) and 2017 (12.5%). Gravimetrics to verify dose, amount and volume is significantly less common, used by 7.7% of hospital pharmacies overall in 2023, compared with 5% in 2020 and 5.5% in 2017.
Overall, 37.2% of hospitals do not use any technologies for compounding sterile preparations; that figure is 62% for hospitals with less than 50 beds.
“Practitioners and healthcare organizations have been seeing the importance and value of a simple barcode scan on ingredients and are adopting the technology,” said Michael Freudiger, PharmD, a compounding and regulatory compliance supervisor at Valley Children’s Healthcare and Saint Agnes Medical Center, in Fresno, Calif., and an adjunct professor of sterile compounding at the Keck Graduate Institute, in Claremont, Calif. “They say, ‘If we can do barcode scanning at the grocery store, why not in the pharmacy IV room?’ IV workflow systems further add to the safety in compounding. The pandemic really harmed budgets at small hospitals in particular, so that may have hampered adoption, but now we are starting to come out of that.”
Dr. Freudiger noted that a relatively recent near-fatal error at a Philadelphia hospital in 2021, in which a patient being treated for COVID-19 was given an IV mislabeled as remdesivir that was actually the paralytic cisatracurium, has served as yet another reminder of the importance of these systems. The patient survived, but was hospitalized for months and was left with significant disabilities; he and his family are now suing the hospital system.
Stephen Eckel, PharmD, an associate professor and the director of pharmacy innovation services at the UNC Eshelman School of Pharmacy, in Chapel Hill, N.C., agrees that IVWMS adoption rates are a mixed bag when it comes to overall uptake. “While I’m heartened that over two years, IVWMS adoption has increased by around 10%, recognizing all the financial headwinds that organizations have had to manage in that time, we still have a long way to go,” Dr. Eckel said. “The increase should really be more than 10% over two years, although I do wonder if the survey may be underrepresenting adoption to some extent.”
He noted, for example, that Epic’s Dispense Prep, “which is not as extensive as other systems but still is an IV workflow system, is integrated into its larger EHR [electronic health record] offering, and I wonder if some organizations using that may not think of it as IV workflow for the purposes of answering these surveys.”
In any case, “health systems need to recognize the impact on patient safety that could result from not prioritizing [IVWMS] implementation,” Dr. Eckel said.
Beware Overly Narrow Rollouts
Despite the overall growth in IVWMS adoption, medication safety expert and advocate Mark Neuenschwander, the founding director of the THRIV Coalition for IV accuracy, is concerned that the hospitals that have put these systems in place are not employing them as widely as they could. “I often hear that hospitals use these systems for ‘high-risk’ medications,’” he said. “However, using IVWMS for all IVs prevents errors from occurring when technicians accidentally receive high-risk medications or volumes for their ‘low-risk’ preparations.” Such an approach could have prevented the infamous error in Oregon in 2014, when a patient was prescribed the low-risk antiseizure medication fosphenytoin and instead was given the paralytic rocuronium, noted Mr. Neuenschwander, who is on the advisory board for Pharmacy Technology Report. (Errors with similar neuromuscular blocking agents have occurred even after the 2014 mishap, including a fatal error with vecuronium at Vanderbilt University Medical Center, in Nashville, Tenn.; bit.ly/3CTPyH1-PPN.)
Mr. Neuenschwander also noted that of THRIV’s five criteria for IVWMS (see box; bit.ly/4juJTal), the least mature remains volume verification (gravimetrics). “Even when right ingredients are verified via barcode scanning, if the volumes used are incorrect [because the volume wasn’t checked], that can affect quality of care and/or safety,” he said.
A key differentiator among IVWMS for many hospitals and health systems is the availability of a guided workflow, said Keith Streckenbach, the CEO of Pharmacy Stars, which provides compliance quality management systems to health systems and other compounding sites. “Most IVWMS solutions have video and photo verification, gravimetrics, and volumetrics.” Such systems provide fully guided workflow, which “ensures that everything is getting performed in exactly the right order. That’s what I am hearing that people want.”
Choosing a Vendor
As for market trends to keep an eye on, Mr. Neuenschwander noted that one commonly used IVWMS, Baxter’s DoseEdge, will be sunsetting in 2028. “I anticipate that many Epic users will shift to Epic Dispense Prep. However, EDP is the least mature of IVWMS regarding volume verification tools,” he said.
“This is an easy system to adopt for facilities already moving to the Epic EHR, but it is not actually IV workflow in comparison to other systems,” Dr. Freudiger agreed. “It is closer to an electronic compounding log with directions added to prepare the compounds. The most important feature that catches a lot of possible errors is the simple barcode scanning. I’ve always said that if we could just get everyone to commit to barcode scanning, then it would prevent almost all the errors because the ingredients would be verified.”
There may still be “some minor measurement errors with the correct drug,” Dr. Freudiger acknowledged. “But the most catastrophic errors which involve using the wrong drug would be prevented.”
Key Partnerships
Some partnerships are occurring between other vendors in this space. In June 2024, Wolters Kluwer Health announced a collaboration with ConsortiEX to offer Assure-Trak IV Workflow Management in its Simplifi+ suite for compounding compliance, branded as Simplifi+ IV Workflow Management, to support safer end-to-end compliance for compounded medications and more streamlined pharmacy workflows. “Simplifi 797 functions as a compounding log as well as a compliance program, including environmental monitoring and cleaning tasks,” Dr. Freudiger said. “ConsortiEX’s Assure-Trak is primarily an IV workflow system. In their partnership, they are creating an ecosystem where you can have the full suite of IVWMS and compliance software in your IV room.”
In 2022, BD acquired MedKeeper Verification to continue its expansion into automated pharmacy technology, including IV workflow management, announcing that it would sunset its BD Pyxis IV Prep (Cato). The system is now branded as BD Pyxis PharmacyKeeper Verification. “BD’s Pyxis IV prep is primarily an IV workflow system, and PharmacyKeeper has the features of barcode scanning, compounding log and compliance management,” Dr. Freudiger said. “This partnership will offer a full suite as well, integrating compliance management with gravimetrics and IV workflow.”
The final leading player in this space is Omnicell’s IVX Workflow, which is powered by Omnicell IVX Manager, a fully web-based software suite designed to handle all aspects of IV compounding workflow operations to enhance safety, efficiency and compliance. According to a company spokesperson, IVX Manager supports comprehensive formulary management through access to Omnicell’s Central Formulary, a database which includes specific gravity data and a consumable configuration.
For those who have budget or technology issues, PharmacyKeeper is probably the simplest and easiest of the products, Dr. Freudiger said. “All you need is an iPad and the internet, whereas with other systems, you have to buy all this hardware or get the lease for it, and then install it. You can start small with PharmacyKeeper and then just add on the hardware later if you choose to, which makes it easier to adopt.”
The sources reported no relevant financial disclosures beyond their stated employment.
This article is from the June 2025 print issue.