Hospital pharmacy directors have long identified ergonomic issues as important factors that impede productivity and contribute to the stress levels of pharmacy personnel involved in order entry functions. These factors include poor placement of work documents and computer monitors, improper lighting, and awkward postures and body movements.

In the design and construction of a new order entry facility at Summit Medical Center, our goal was to eliminate unnecessary stressors in the workplace that negatively affect employee productivity and job satisfaction, and to improve health- and safety-related factors. To achieve these goals, we evaluated job functions, provided state of the art equipment, and designed the job and environment to fit the worker. This article will focus on ergonomic improvements made in the order entry facility.

Summit Medical Center is a new, 204-bed community hospital and medical complex located near I-40 in Hermitage, TN, a Nashville suburb. Summit Medical Center is highly regarded as a first rate medical and surgical facility and is designed to focus on convenient outpatient services as well as intensive care. It is known for providing comprehensive diabetes management and obstetric services, progressive laparoscopic and other same-day surgeries, psychiatric care, neurosurgery, orthopedic care and pediatric services. Summit features all private rooms. Also among our features are one of Nashville's busiest Emergency Departments, a Women's Health Center and a dedicated Diabetes Center.

The Problem
Order entry errors by pharmacy personnel can be costly, both in dollars and human suffering. Stressors cause errors and, in turn, errors are stressors. Errors in order entry can be attributed to a number of factors. Omission errors can be caused by frequent interruptions of the pharmacist during order entry and by illegible and faint NCR copies of physicians' orders.

Frequent interruptions also contribute to unacceptable turn-around times in entering orders into a patient's profile for subsequent access by nurses from automated drug storage devices. Interruptions can be phone calls, walk-in business at the window, or the need to check technicians' work in the IV Additive Lab or Prepackaging Room. Interruptions may take the pharmacist away from order entry for several minutes at a time.

In most hospitals, pharmacies receive medication orders in three primary ways: 1) Technicians pick up NCR copies of physicians' orders on hourly rounds; 2) orders are faxed; 3) a pneumatic tube system is used. A small but growing number of hospitals use physician order entry to place medication orders in patient profiles. However, at this time none of the hospitals in the TriStar Health System, of which Summit Medical Center is a member, use physician order entry.

In cases other than physician order entry, pharmacy departments struggle with hard copies. Orders need triaging and prioritizing to identify and process STAT orders. After processing, all orders are physically filed. If a previous order is questioned the physical file system must be searched. Files are frequently discarded after several weeks, making retrieval of older documents impossible when investigating errors.

Facilities using facsimile machines are plagued with "fax wars." Fax wars occur when the sending department's perceptions differ from the receiving department's perceptions. Sometimes orders are not faxed or the receiving machine has a paper jam or runs out of paper or toner. In other cases, the receiving department misplaces the facsimile. Fax machines may also cause distortions unacceptable for critical work.

Pharmacists working on order entry in our central pharmacy have reported eyestrain, backaches, tight upper trapezius muscles, neck discomfort, and fatigue. As the Occupational Safety and Health Administration Act (OSHA) states that employers must provide their workers a workplace that is free from recognized hazards that are causing or likely to cause death or physical harm, we had an additional incentive to address ergonomics issues.

We recognized we were investing unnecessary man-hours in order entry due to interruptions, delays, clarifications, and the various processes necessary to handle hard copies. Work related physical ailments also decreased efficiency.

If we could address these issues with technology and ergonomics, we felt we could achieve lower error rates in order entry, reduce order entry time, improve turn-around time, and create a better working environment for the employees. We focused on many ergonomic aspects of the job, from physical stresses on muscles and joints to environmental factors affecting vision and hearing.

Several initiatives were undertaken in the year 2000, including automating drug distribution with drug storage devices. Automated unit-based cabinets were selected. The goal was to store virtually 100% of all doses needed. Expansion of Clinical Pharmacy Activities was another initiative approved for the year 2000. Finally, the construction of a new order entry facility was approved. Our construction costs were just under $80,000. The scanning system is leased from Pyxis Connect.

Analysis and Resolution
Job Functions: The first step was to physically isolate order entry from the other functions of the inpatient pharmacy department. In doing so, we could reduce or eliminate most of the interruptions and frustrations of the pharmacist doing order entry. In the past, three pharmacists scheduled for the first shift were all involved with order entry. The interruptions and miscellaneous tasks provided quite a bit of job variation. While variation can be a good thing, in this instance it was more of a frustrating hindrance than a benefit. One concern with relocating order entry to a new area was the isolation of the pharmacist, but the pleasant environment more than offsets the concerns about being located away from the pharmacy. The loneliness initially experienced in the new area was short-lived because we added the order entry functions of other hospitals to the facility. Consequently all pharmacists were able to interact with each other.

Because of the technology we used, all orders can be accessed from any of the order entry stations (at any hospital as well as the consolidated order entry facility). The utilization of the facility has undergone many changes as the participating facilities gain experience with the concept. Currently we have evolved to offering coverage from 6 p.m. to midnight for four hospitals in addition to Summit Medical Center. There is a current proposal for full midnight coverage, from 7 p.m. to 7 a.m. for the four hospitals that close on the midnight shift. This will allow them to meet JCAHO requirements of a pharmacist reviewing all orders before a nurse administers the medication. It also allows them to meet the requirements of the new electronic medication administration record (eMAR) system that requires pharmacist input before the nurse accesses the medication. The eMAR system allows the nurse to scan the med, scan the patient and scan the nurse for electronic charting, etc. Summit Medical Center, where the computerized order entering (COE) is housed, uses the facility during the day shift to input the majority of the orders generated from the hospital. The other facilities have used the facility during peak workload periods during the day, and now we are working on midnight coverage.

State of the Art Equipment: Installing computerized digital-scanning devices at every location where physician orders were generated eliminated the problems associated with facsimiles and hard copies. High quality flat plasma screen monitors to view the physicians' orders and high quality 17" monitors to view the pharmacy information system's functions were employed. Additionally, we purchased high speed PCs for each workstation, all to the great satisfaction of the pharmacists.

Digital Scanning: Digital scanning of original documents eliminated the distortion associated with facsimiles and NCR copies. That provided a clearer image that reduced eyestrain and reduced turn-around time in order processing. The 2.7 hours required for the pharmacy to provide a first dose intravenous antibiotic, prior to the scanning system, was reduced to an average of 14.2 minutes.

Computerized digital scanning allows for orders to be filed by both patient and account number for easy retrieval of old orders. That also eliminated "fax wars" because images are held in a computer queue. Scanned orders are no longer lost due to paper jams and exhausted paper supplies or toner.

Computerized digital scanning allows instant prioritizing of orders, placing STAT orders at the top of the queue in red to alert the pharmacist.

During the order entry process, the order image may be annotated to provide additional information. Orders awaiting clarification can be annotated so that subsequent pharmacists know exactly what needs clarification. Requests for clarification or notices of delays in order processing may typed on the image of the order and directed back to the scanner/printer that originally sent the order. Electronic "sticky notes" provide information to the pharmacy without being readable by any other department. Pharmacist feedback has been that the system and features are "slick." Notably, there was elimination of distractions and interruptions that pharmacists are plagued with during their work day, thus creating a source for order entry errors. The COE concept allowed one pharmacist to do more orders with less errors, as well as function in a much more pleasant atmosphere. Having a work station that was ergonomic with the employees' needs in mind was viewed positively by the pharmacists. They like working in the COE. We also accomplished one goal of doing the same number of orders in one-third less manhours.

Computerized digital scanning eliminates multi-part order forms, reducing form costs. Facilities that used facsimiles reduced toner and paper costs. Our 204-bed facility saved $8,800 per year on forms alone.

As a backup procedure when a system fails, we photocopy the physicians' order sheets and tube them to the pharmacy. Once the system is up and running again, we scan the photocopied sheets so they can be electronically filed. In case a single scanner goes down we scan the photocopy immediately after it arrives at the pharmacy. An alternative to copying is to fax the original order sheet to the pharmacy.

Ergonomic Concepts
To address employees' physical problems, we employed a variety of ergonomic concepts. Attention was paid to ergonomics in the workstation and seating design to improve working conditions. Space provided for each of the six workstations in the order entry facility provided plenty of space for each individual. The design provided for an L-shaped area 70" X 90" for each workstation. Our goal in the design was: no crowding or cramping, no disorganization and no poor lighting.

Viewing Distance: Computer workstation guidelines often recommend maximum viewing distances, some as close as 24 inches. Following them may actually increase eyestrain. One of the main reasons for computer-related eyestrain is the closeness of the monitor. When viewing close objects the eyes must both accommodate and converge. Accommodation is when the eyes change focuses to look at something close. Convergence is when the eyes turn inward to prevent double vision. The farther away the object, the less strain there is on both accommodation and convergence. The range of acceptable viewing distances varies, but it is generally much farther than 24 inches. If one can read the monitor, it is not too far away and if the monitor cannot be read, it is usually better to enlarge the image rather than to bring the monitor closer.¹ Consequently we purchased 17-inch monitors to allow for larger images.

We also found that locating the digitized image on the plasma screen portrait monitor at similar distances as the 17-inch monitor for the pharmacy computer system reduced issues encountered when rapidly moving the eyes back and forth between monitors.

Vertical Monitor Location: "Locate the top of the monitor at or slightly below eye level" is another myth perpetuated by ergonomic guidelines. The eyes improve their ability to both accommodate and converge by lowering their gaze angle. When looking upwards, the eyes tend to diverge...and when they look down, the effort to converge is much easier. A low gaze angle also results in reduced headaches due to eyestrain. While the eyes might be most comfortable looking horizontally at distant objects, we prefer a much more downward angle. Simply stated, directing the eyes downward in the usual reading position will be more comfortable when working at close distances.

Many computer users experience dry eyes. Lower monitor placement exposes less of the eyeball to the atmosphere and reduces the rate of tear evaporation.

Lower monitor placement increases the acceptable options users have for neck movement.² It is uncomfortable to maintain the same posture for an extended period of time. While bending the neck downward may be physically comfortable (as long as you are not forced to hold it in a fixed position), looking out of the top of your eyes at close objects is extremely uncomfortable. Having to extend one's neck will also cause discomfort and in some cases damage. With a low monitor position you can hold your head erect and look downward. When that posture becomes tiring, and it will, a low monitor will allow you to alternate between a wide range of flexed neck postures that allow good visual performance and will not increase postural discomfort.

Anyone who insists that the best ergonomic posture is with arms, torso, thighs and legs at 90 degree angles, the head perfectly erect and both feet flat on the floor, are simply wrong. Try it. No one can sit that long in such an awkward position. Alternating between several postures is natural and the best to remain alert and healthy.

The bottom line for most hospitals is productivity and two studies^3,4 found an improvement in productivity when the center of the monitor was changed from eye level to 35 degrees below eye level. By lowering the monitors below the desktop surface, we accomplished a comfortable downward gaze and also addressed HIPAA privacy concerns of unauthorized individuals reading patient information from the screen of a monitor located on top of the work surface. While we have a separate room with only order entry pharmacists present, the recessed-monitor workstations would be even more critical to ensure the security of patient information in areas accessible to other staff and the public.

Seating: Prior to the construction of this facility there was virtually no attention paid to the workers' seating. Throughout the day employees were switching chairs and taking each other's chairs if they felt uncomfortable. To promote postural changes and reduce discomfort without creating an excessively relaxed situation, we used ergonomic chairs with multiple adjustments and a lumbar support. The chair was designed to accommodate almost every worker. The new ergonomic chairs have eliminated the chair swapping.

Lighting: Our constructed order entry facility considered lighting as a factor in improving working conditions. Prior to the construction of this facility we used recessed fluorescent lighting, which caused obvious screen glare. In the new construction we used diffused lighting in the ceiling and indirect lighting by each workstation. Glare on the monitor screens was a prime reason for the lighting choices. After construction, we realized that even with diffused lighting, we still had glare on some of the monitors (especially with those we did not position completely under the work surface). For the workstations that completely recessed the monitor, glare was not noticed. Reflected glare is primarily due to extreme differences between light and dark areas. So, wherever there was a light fixture in the ceiling and ceiling tile surrounding it, we ordered a grid to direct the light straight down and not reflect on the monitor screens. This is expected to reduce the glare on the partially submerged monitors. If we were to construct another facility, we would use indirect lighting exclusively.

Although each pharmacist experimented with color choices on the monitor, we encouraged dark letters on a light background to increase contrast and reduce reflected images on the screen. A white background also reduces the luminance (brightness) difference between the screen and the surrounding background of a normally lighted room. That makes it easier on the eyes. Research⁵ has also showed a lower error rate with dark letters on a white background.

Other Considerations: Telephone headsets helped us increase performance and reduce neck pain caused by cradling a standard telephone while keying with both hands. Two types of headsets were evaluated. One that merely wrapped around the ear, and the other that wrapped around the top of the head. Having decentralized pharmacists on a beeper (cell phones could also be used) allowed the order entry pharmacist to use the one-button calling feature on the phone to contact the clinical pharmacist. This also reduced the time it took for the order entry pharmacist to locate a decentralized clinical pharmacist.

Discussion
Pharmacists working in the facility immediately realized the benefits of the ergonomic improvements. However, whenever new technology and systems are employed, new issues arise that need to be addressed. The most troublesome issues were the result of operator errors in scanning the orders. Personnel were placing the orders in the scanner backward (upside down), which resulted in a blank image. Others ignored the written instructions and pressed the scan and copy buttons at the same time. That caused the scanner/copier to copy but not scan. They thought they had scanned, but in reality they had not. The most frustrating operator error was when they began a scan and then pulled the order sheet back out. That damaged the paper feed and caused us to replace several scanner-feeding devices.

After several of these difficulties, personnel learned from their mistakes and began operating the equipment properly and the errors gradually declined.

Error rates were not possible to accurately compare because of the increased emphasis our hospital has put on reporting incidents, near misses and error prone issues. That increased emphasis, along with a new, "non-punitive" approach to reporting, resulted in an almost three-fold increase in reports. However, prior to the implementation of the new order entry processes, we received many calls and comments about line items missing on order sheets and incorrect frequencies and doses. Even with increased reporting, we receive fewer calls concerning this problem. We attribute the reduction in order entry errors to the reduced number of interruptions during order entry.

Manpower requirements for order entry were dramatically reduced. By locating order entry in an uninterrupted and peaceful atmosphere, the order entry pharmacist can accomplish much more. We used to have three pharmacists doing order entry on the first shift. All three were responsible for answering phones, and attending to the window and door. In addition, they were constantly being interrupted to check IVs and unit dose prepackaging, etc. We now have one pharmacist primarily involved with order entry. A second pharmacist remains in the central pharmacy to attend to all the tasks that formerly interrupted all the pharmacists. The second pharmacist keeps an eye on the queue in case the order entry pharmacist gets overwhelmed with orders; however, this is not that pharmacist's primary duty. The third pharmacist is now decentralized and involved with clinical duties. The redeployment of pharmacists allows us to begin our clinical program consistently every day, Monday through Friday.

Conclusion
The use of computerized scanning technology in an ergonomic order entry facility designed to service multiple hospitals has reduced order entry errors and man-hours in the order entry function, improved turn-around time, reduced employee frustrations and resulted in increased employee satisfaction.