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Survey of automated dispensing shows need for practice improvements and safer system design


From the June 16, 1999 issue

Vendors of automated dispensing devices may suggest that unit-based dispensing systems can increase drug security, reduce pharmacy labor and lower drug costs. However, such systems can't improve patient safety unless cabinet design and use are carefully planned to eliminate opportunities for drug selection and dosing errors. Results from 453 respondents to our recent Unit-based Automated Dispensing Cabinet Survey show that, often, cabinet design features that promote safety are not available in facilities and practitioner safety precautions have not been established in facilities that are using this technology (see tables below).

While about one quarter of the respondents indicate that automated dispensing cabinets are not used in their facilities, it's alarming that 62% of respondents who use automated dispensing systems never require pharmacists to enter and screen orders before drugs are removed from cabinets and administered - even for high alert drugs! Compounding this safety breech, over half the respondents are using automated dispensing cabinets for more than typical floor stock and controlled substances - 20% use cabinets as their primary medication delivery system and 32% use cabinets to supply first doses of typical or specified drugs. Thus, at least 10% are using cabinets to supply a vast assortment of drugs, yet never require pharmacy order screening before drug administration. Of those who require pharmacy order screening, only 26% have developed unit-specific lists of "override" drugs and only 4% always require "override" drugs to be double checked by another practitioner before administration. Further, 44% never analyze "override" reports to track patterns and identify problems.

Respondents report that the most frequent practitioner safety precautions include stocking cabinets with drugs specific to each unit (61% = always; 1% = never) and in ready to administer unit doses (50% = always; 0 = never). Still, it is clear that some medications are stored in bulk supplies, in multiple concentrations or in areas where their use is not necessary or safe. In fact, only 58% of respondents report that they use specific criteria for determining drug products and quantities that are stored in cabinets, 38% report criteria for determining the safety of drug strengths and 53% report criteria for identifying products considered inappropriate for storage in cabinets. Thus, the use of automated dispensing cabinets may inadvertently reverse a few significant advances in error prevention: limiting floor stock and unit dose dispensing.

While 56% of respondents report that a pharmacist always checks restock medications before placement in a cabinet, 15 % report that this check process never takes place and over half the respondents (54%) never verify correct drug placement in cabinets after restocking. Additionally, 16% report that nurses never return unused drugs to the cabinet.

Inadequate system design features further compromise patient safety. For example, 96% of respondents report that bar coding technology is not used when stocking cabinets and 89% report that open access bins and drawers may allow nurses to remove more than the specified drug.

Without requisite safety precautions, both in automated dispensing system design and professional practices, cabinets are simply high-tech floor stock systems which increase nursing access to drugs while bypassing the usual system of double checks. To maximize safe medication practices when using automated dispensing cabinets, see the article that appears in our December 2, 1998 edition of the newsletter.

Results of ISMP Nursing Unit-based Automated Dispensing Cabinet Survey (n = 453)

Table 1.

Current Use of Dispensing Cabinets

%

Not used

22%

Controlled substances distribution only

7%

Typical floor stock and controlled substances

49%

First doses of typical/specified drugs

32%

Primary medication delivery system

20%

 

Table 2.

Written Policies, Procedures, Guidelines

%Yes

Monitoring of drugs accessed through cabinets

83%

Criteria for determining cabinet storage:

  • drugs and quantities

58%

  • safety of drug strengths

38%

  • identifying inappropriate products

53%

Periodic review of cabinet contents

84%

Handling medications removed by not used

86%

Checking drugs for expiration dates

97%

Staff education and training

91%

 

Table 3.

Safety Precautions

Scale: 0=never; 1=frequently; 2=sometimes; 3=always

Always

Frequently

Sometimes

Never

Mean

Drugs stocked are specific to units

61%

34%

4%

1%

2.5

Unit doses are supplied

50%

45%

5%

0

2.4

Pharmacist checks drugs before restocking

56%

9%

20%

15%

2.1

Nurses do not return unused drugs to cabinet

16%

34%

33%

17%

1.6

Only selected drug can be removed

11%

19%

60%

9%

1.3

Multiple concentrations are not available

12%

52%

27%

8%

0.7

Drug placement in cabinet verified after restocking

11%

7%

27%

54%

0.7

Bar coding used for stocking cabinet

2%

1%

2%

96%

0.1

Pharmacy screens order before drug removal

12%

16%

10%

62%

0.8

  • "override" drugs are unit specific

26%

10%

13%

51%

1.1

  • "override" drugs are double checked before administration

4%

6%

30%

59%

0.5

  • "override" reports are routinely analyzed by management

17%

21%

19%

44%

1.1

Items other than drugs stored in cabinets

5%

10%

49%

36%

0.8

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