Placing limits on drug inventory minimizes errors with automated dispensing equipment

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PROBLEM: Many hospitals have replaced medication carts or open floor stock systems with automated dispensing cabinets. These devices can streamline the distribution process, improve first dose turn-around time and aid in securing drugs. Yet, more and more, we are finding that access to a wide assortment of medications may increase the risk f errors since the usual system of double checks is bypassed. Orders may not be appropriately screened for allergies, duplicative therapy, drug interactions and maximum doses before drug administration. If the cabinet contains large quantities of specific medications, staff, unaware of maximum doses, may administer significant overdoses. Recently, we were reminded how simply minimizing the amount of drug stored in the cabinet can avert a potential drug overdose. In a small hospital, after the pharmacy was closed, an order was written for "1 gram calcium gluconate IV." The nurse misread the label and believed that each ten mL vial contained only 98 mg. Thus, she thought she needed 10 vials when each mL actually contained 98 mg, or 1 g per 10 mL vial. A ten-fold overdose was avoided because the cabinet contained only six vials of calcium gluconate, not ten. The error was detected when the nurse contacted a pharmacist at home to obtain additional vials. Other errors have been reported when staff fill cabinets without a double check system, or when nurses remove more medications than ordered and return unused doses to dispensing cabinets. Errors are likely if medications are accidentally stocked in or returned to the wrong location..

SAFE PRACTICE RECOMMENDATION: To prevent errors, the following procedural safeguards should be considered for use with automated dispensing cabinets in patient care areas:

• Consider using automated dispensing systems that require pharmacy order entry before nurses can remove drugs from the cabinet. Do not allow nurses to override this feature. While we highly recommend no overrides, if allowed, develop a list of drugs or drug categories, such as antibiotics, that should not be removed without pharmacy notification and clearance first. Since the safety feature of a patient profiling system depends on timely and accurate pharmacy order entry, these functions must be given priority.
• Consider using a system that has bar-coding capability for drug stocking, retrieval and administration.
• Carefully select the drugs that will be stocked in cabinets. Consider the needs of each patient care unit, staff expertise and familiarity with specific drugs, and the age and diagnoses of patients being treated.
• Minimize the drug supply and stock drugs in the smallest doses and containers possible.
• Establish maximum dose ranges for "high alert" medications and place this list on automated dispensing cabinets for reference
• Educate staff to remove only a single dose of the medication ordered. If not used, return the drug to pharmacy for replacement in the automated dispensing cabinet. Staff should never return drugs to cabinets.
• Develop a check system to assure accurate cabinet stocking. Checking could be accomplished by pharmacy staff members, or by staff on patient care units if they are supplied with a daily list of items added to the cabinet for verification. Make time for this important activity.
• Place allergy reminders for specific drugs, such as antibiotics, opiates and NSAIDs, on appropriate drug storage pockets or drawers.