Automated Dispensing Cabinets: Getting It Right in the Age of Automation

Barbara L. Olson, MS, RN-BC, FISMP


July 10, 2009

In This Article

Recommendations to Prevent Wrong Drug/Wrong Dose Errors With Automated Dispensing Cabinet Use

System Level Recommendations

System-level considerations that may diminish the risk of wrong drug and wrong dose errors when drugs are retrieved from ADCs include:

  • Evaluate unit geography when planning for ADC installation or upgrades;

  • Minimize the potential for ADC users who stock and remove drugs, to be distracted while working at the ADC;

  • Match ADC stock to unit needs meticulously, using unit-dose packaging whenever possible. Overstocking medications predisposes to wrong-dose errors, specifically overdoses, while stocking drugs that are not routinely used predisposes to wrong drug errors;

  • Store drugs with look-alike, sound-alike names in different locations within ADCs. Consult published lists such as the ISMP's list of frequently confused drug names to determine which medications stored in each of the facility's ADCs pose the greatest potential to be mixed up in the selection process;

  • Examine interdisciplinary workflow issues and eliminate scheduling conflicts so that routine drug stocking and retrieval activities do not overlap;

  • Establish procedures for medication administration that avoid distractions related to other duties, especially in settings where nurses care for multiple patients.[4,5] Drug selection is a high-stakes activity, one that may be compared to safety-sensitive tasks that occur during pre-flight activities in the aviation industry. System leaders should evaluate expectations, especially those that involve multi-tasking, to ensure that staff members are not routinely disrupted at high-stakes junctures in medication administration. (If you wouldn't want the captain of your airliner to greet passengers while simultaneously performing pre-flight checks, you should advocate for processes that allow nurse to similar attention to detail during drug selection);

  • Maximize the use of barcode technology with ADCs to make sure that the correct products (intended drug in the correct dose units or container size) are stocked in each clinical setting.[6] Bar-code product verification at point of retrieval (or point of administration) further diminishes the likelihood of wrong drug or wrong dose errors. When barcode verification is not possible, high alert drugs should be verified both by the person stocking the ADC and a unit-based nurse;

  • Ensure that patient medication administration records (MAR) are accessible to practitioners while they are removing medications from an ADC. To make this a practice norm, select workstations that can be positioned near the ADC. When purchasing hardware (such as wheeled workstations), weigh cost-benefits of integrated patient information repositories in light of nursing time and patient safety. (The process used to deliver food to your table at the average chain restaurant should not be more reliable -- and less cumbersome -- than the process used to bring ordered medications to your bedside in a community hospital);

  • The ADC should display drug information in a nonambiguous fashion, matching information provided on the MAR;

  • Require pharmacy review of medication orders (which includes measures such as checking the order against known allergies; reviewing appropriateness of the prescribed dose; and evaluating potential for drug-drug interactions) prior to removal of medications, except in emergency situations.[6] Once pharmacy review has occurred, a readily identifiable flag/symbol should signal "go" to frontline clinicians;

  • Use computerized alerts, ideally pop-ups that require a confirmation, when medications with high potential for mix-up (look-alike, sound-alike medications) in a given setting are selected. Bring the possibility of drug product confusion to the attention of the clinician at the point of retrieval, especially for other high alert drugs that have look-alike, sound-like qualities. For example, to minimize morphine and hydromorphone confusion risk, the ADC screen may prompt, "This is DILAUDID. Is that correct?" whenever hydromorphone is selected[7];

  • Monitor how well ADCs, as configured, support care goals established by frontline providers and expected by patients and other stakeholders. This may be accomplished through proactive order set/clinical pathway review and retrospective review of medication overrides. Investigate causes of ADC overrides, considering the possibility of production pressure, especially in settings where turnover goals may compete with meticulous adherence to safest medication practices;

  • Teach front line clinicians, especially those who participate in unit-based practice councils and multidisciplinary committees, the principles that inform safest use of ADCs, especially those that relate to medication stocking and availability. Solicit their input proactively to prepare for anticipated practice changes involving medication use and medication storage;

  • Consider providing unit-based practice councils and multidisciplinary teams in specialty units to review ADC metrics (such as results of override reports). With this knowledge, it will be possible to identify deviations from targeted benchmarks, identify barriers to compliance, and champion safest practices;

  • Ensure that knowledge of high alert medications and look-alike/sound-alike drugs (particular to a given clinical setting) are included in orientation and initial competency validation measures of individuals who dispense, stock, or administer medications; and

  • Create a culture in which concerns voiced by frontline clinicians are seen as valuable. Develop a visible "rapid response" when ADC near-misses or discrepancies are reported.

Individual Level Recommendations

Considerations for individuals that may diminish the risk of wrong drug and wrong dose errors when drugs are retrieved from ADCs include:

  • Recognize that medication retrieval from ADCs is a high-risk activity, one in which human error has the potential to cause irreparable harm;

  • Utilize bar-code scanning to the fullest extent possible in your practice setting. Report barriers to compliance immediately, using system-wide, near-miss reporting systems. For example, if barcode scanning is prevented by mechanical failures, battery life, or the availability of scanning equipment during high volume medication administration times -- these are reportable events;

  • Upon removal of a drug from an ADC, validate that the drug name on the label of the drug-in-hand matches the drug name displayed on the patient's MAR (or prescriber's order if MAR has not been generated);

  • Validate that the drug-in-hand is the ordered concentration, dose, and dosage form;

  • Be suspicious of any dose that would require removal of more than 3 packages/ampules/vials to administer a single dose;

  • Avoid excessive use of the override function; it should be limited to true emergencies;

  • Be aware that distractions undermine performance. Reduce distractions within your control when you are removing medications from ADCs. Although duties related to medication administration occupy a significant amount of nursing time, accurate performance cannot be assured simply because tasks are familiar. For example, answering cell phones while performing high-stakes activities impairs accuracy. Social exchanges with colleagues, patients, and family members should not occur at the ADC;

  • Advocate for practice models that promote the least amount of distraction during medication preparation and administration. If multi-tasking while accessing medications from an ADC is a performance expectation, use professional practice councils and near-miss reporting systems to call attention to this risk;

  • Become familiar with the rationale behind the system-level interventions (listed above) that promote safest use of ADCs; and

  • Report deviations from ideal or standard practices as near-misses. This may seem "picky," but having a highly reliable medication use system involves meticulous attention to detail, something which requires a high degree of standardization. A system that has to undergo individual interpretation to accomplish routine tasks -- like a 9:00 am medication pass -- is error-prone. Fixing a system is difficult, but possible (in a way that fixing a lethal wrong-drug medication error is not). Here are a few things worth reporting when you notice them: A discrepancy between the way the drug name is displayed on the MAR and on the ADC screen; for example, when tall-man letters used to differentiate a known look-alike, sound-alike drug pair throughout your organization are not used on the pick list of your ADC screen; or when you find a syringe labeled "hydromorphone" in a bin labeled "morphine."