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:
|
58%
|
|
|
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
|
|
