Guidelines for the Safe Use of Automated Dispensing Cabinets
Draft Document

Posted October 16, 2007. Comments accepted until December 31, 2007

Background

Automated dispensing cabinets (ADCs) are computerized drug-storage devices or cabinets that control and document drug distribution. ADCs were introduced in hospitals in the 1980s to help with medication dispensing, storage, security, and retrieval documentation. Adoption of this technology in healthcare started slowly, with only about 50% of hospitals using ADCs in 1999, but by 2005, close to 72% of acute care facilities had implemented them.1 ADC use has since expanded to ambulatory care centers and other types of healthcare facilities as well.

ADCs can now provide near total access of medications needed in patient care areas, which has been reported to decrease the turn around of medication delivery from the pharmacy to the patient care area, ensure greater control of the charge capture of medications, and potentially reduce overall medication errors.2

One of the most important safety enhancements that has evolved in ADCs over the last decade is profiled systems, which support The Joint Commission medication management standard for pharmacist review of all new orders. 3  This added safety software change provides direct interface with pharmacy information systems--pharmacists can profile, screen, and approve medication orders before medications can be accessed from the cabinet.

The advent of pharmacy-profiled ADCs was a precursor to the adoption of alternative delivery models for medications, including the decision by some organizations to use ADCs as their primary method of drug delivery rather than supplementing patient-specific 24-hour cassette exchange by the pharmacy. This change in the pharmacy distribution model has had broad implications for pharmacist and nurse workflow and the safety of associated practice.3

Advanced ADC systems provide additional clinician support aimed at enhancing patient safety, including machine-readable bar-codes for restocking medications and for drug selection; integration into automated refilling systems; drug safety alerts and decision support when selecting medications from the cabinets; and the utilization of telepharmacy for after-hour drug verification and distribution. For example, ADCs can support safe administration by providing warnings such as “do not crush” or suggestions for monitoring parameters that should be checked and recorded prior to medication administration.3 Access to advanced ADCs can be limited to designated users by requiring a log-in with a unique passwordor fingerprint identification that supports security measures.4

ADCs are now used in the majority of hospitals and have become more prevalent in the outpatient setting. Despite their growing popularity, there is little formalized guidance available to direct healthcare facilities in the safe use of this automation. To help healthcare organizations promote safe practice when establishing new technology, the Institute for Safe Medication Practices (ISMP) convened a group of stakeholders in spring 2007 to address the development of guidelines for the safe use of ADCs. 

ISMP, a 501c3 public charity based in suburban Philadelphia, is uniquely qualified to address ADC safety issues. ISMP is devoted entirely to medication error prevention and safe medication use. The organization is known as the premier resource for impartial, timely, and accurate medication safety information. Today, a continuously expanding core of knowledge in medication safety, provided through errors reported to the USP-ISMP Medication Errors Reporting Program and onsite consultations with healthcare facilities, fuels the Institute’s highly effective initiatives to improve the medication-use process. These initiatives, which are built upon a just culture approach and system-based solutions, fall into five primary areas:  knowledge, analysis, education, cooperation, and communication.

Stakeholder Collaboration

In 2005, ISMP began discussions with the primary vendors of ADCs to determine what resources were available to direct practitioners in the safe use of these devices. In May of 2006, ISMP invited vendors of ADCs to attend an informal meeting held at its headquarters in Huntingdon Valley, PA. Five vendors participated and agreed that universal guidelines around safe ADC processes were needed. The group formulated a plan to bring together pharmacy and nursing practitioners who were familiar with the use of ADCs, to discuss current practices and prepare a document on safe practice recommendations that would be available to US hospitals and health systems. After the preparation and public review of the document, the group envisioned the creation of a self-assessment tool to help disseminate the information and provide a baseline of current ADC practice in US hospitals. During the meeting, the attendees developed a list of core processes that, by consensus, were felt to significantly influence the safer use of ADCs. These core processes would be the basis for the questions posed during the expert forum, and for the content of the document.

In March of 2007, ISMP invited an interdisciplinary group of practitioners from thirteen hospitals across the US, along with representatives from three ADC vendors (who agreed to financially support the symposium), and practitioners from ISMP, to meet and share their experiences and opinions toward the development of ADC safe use guidelines. This forum was comprised of pharmacists and nurses with extensive operational knowledge of ADC systems, representing large regional groups, academic medical centers, freestanding hospitals, specialty hospitals (such as pediatrics), and critical access hospitals. (Appendix A lists all participants’ names and respective institutions.) All hospital participants and vendor representatives were volunteers, received no compensation except for travel and meeting expenses, and gathered with the intent of creating safer systems for the use of ADCs. ISMP is indebted to this group of practitioners for their wisdom and ongoing support of this project.

Cardinal Healthcare, McKesson, and Omnicell generously provided funding and support to cover all expenses associated with the ADC forum. ISMP is grateful for their vision and their participation. 

Consensus Guidelines

The focus of the ADC forum was to create guidelines for the safe use of ADCs.  Questions posed for the forum were organized and divided among core processes that were believed to significantly influence the safe use of ADCs. Each core process was defined by one or more key characteristics of a safe medication system, as defined by ISMP’s conceptual model, The Key Elements of the Medication Use System.5 Each expert attendee participated in two break-out sessions to discuss individual core processes. Safe ADC use processes were developed by group consensus, with final analysis and oversight of the recommendations by ISMP staff. Due to the time constraint of the forum, some additional processes were discussed internally by ISMP staff and are also included below. These recommendations are based on ISMP’s knowledge and understanding of the common causes of medication errors, from the analysis of numerous error reports received both from practitioners in the US and internationally, and also through direct observations made by the ISMP consulting teams during onsite hospital risk assessments.

Core Processes

The further development of each core process below includes a description of the element of practice discussed at the forum, a rationale for the process, and when available, examples of errors that have been reported to ISMP. These guidelines are intended to be universally incorporated into practice, in an effort to promote safe ADC use and subsequently improve patient safety. 

The immediate implementation of all elements of the Guidelines for Safe Use of Automated Dispensing Cabinets, as defined below, is an ambitious goal. Realistically, these ADC guidelines are meant to support organizations (facilities and vendors) in making future resource decisions and strategic planning around the use of ADCs, as well as to facilitate steady safety enhancements in ADCs existing processes/products/applications. ISMP is not a standards-setting organization, and as such, the results of the forum and the subsequent document are not purported to represent a minimum standard of practice and should not be considered as such.

Core Process # 1:     Provide Ideal Environmental Conditions for the Use of ADCs

Rationale:  The environment in which the ADC is placed can have a dramatic effect on medication errors. In 2004, data submitted to the USP-ISMP Medication Error Reporting Program suggested that poor environmental conditions contributed to errors. Specifically, the work environment and a busy, chaotic work area were cited as the top two contributing factors in medication errors.6 Place the ADC in a location such that those practitioners involved with refilling the ADC, identifying correct medications, removing medications from the ADC, and documenting medications can do so without interruption. In addition, a secure, well-designed work area with adequate clutter-free workspace, adequate lighting, and comfortable temperature will facilitate a smooth transition from one task to the next.7

• Location and Number of ADCs
  • Purchase a sufficient quantity of ADCs, depending on their intended use (e.g., limited narcotic and unit stock versus total drug distribution), and install ADCs in areas that are easily accessible to staff and in close proximity to patients in order to reduce excessive walking and work-arounds by staff.
  • Locate ADCs in an isolated “sterile cockpit” environment or an area of limited foot traffic, where a minimal number of distractions would be the norm.
  • Locate ADCs in close proximity to IV tubing, supplies, and refrigerated medications.
  • Ensure sufficient space around ADCs to allow for the opening of access doors to the medication area and medication drawers in the cabinet. Provide space for the use of medication administration records (MARs) and patient charts, and for the movement of staff without encumbrances.
  • Ensure adequate ventilation and temperature control of the area or room where ADCs are placed to avoid overheating of the electronic systems and to maintain proper storage temperature for medications. 
  • Provide sufficient overhead lighting to allow for easy reading of the ADC screen, medication label, and the MAR. Auxiliary lighting should be available day or night. (Even on low-light units, there should be the ability to brighten the medication areas around ADCs, as needed for short periods, to prepare and dispense medications.)
  • Ensure ADCs are placed in locations that are secure when cabinets are not being used.
• Auxiliary Resources
  • Utilize adequately-sized ADC tower units as necessary for additional storage of large volume IV infusions and other equipment.
  • As necessary, install an additional computer monitor screens that are readable from each ADC to review electronic MARs (e-MARs). If manual/paper MARs are used, then provide sufficient space to place the MARs in a location where they can be read during the ADC transaction. 
  • Ensure that a phone is readily available near the ADC, for outgoing calls only.
  • Store drug information texts, charts, and other drug information resources in close proximity to the ADC.
  • Within close proximity to the ADC, provide refrigerated storage for medications and vaccines.
• Downtime Procedures
  • Ensure that there are well-designed backup procedures in case of software or hardware malfunctions, drawer failures, or unexpected power loss to ADCs.
    

Core Process #2        Ensure ADC System Security

Rationale:  Security processes must be established to ensure adequate control of medications outside of the pharmacy and to reduce the potential for medication diversion from ADCs. 

• Establish a clear process of how passwords will be assigned (e.g., establish security clearance, department(s) responsible, how updated and/or renewed) within the organization.
• Develop procedures that prohibit the use of temporary passwords, the sharing of passwords, and the reuse of passwords.
• Define user privileges based on the need to limit access t specific medications for specific practitioners or patient care areas.
• Update the system database daily to remove passwords that should no longer be active and to update new passwords issued within the hospital or healthcare system.
• Utilize biometric user identification or, at a minimum, change user passwords quarterly.
• Provide a remote locking mechanism for refrigerated storage associated with the ADC.
• Document the destruction of medication waste at the time of removal of the medication whenever possible. Record this waste via the ADC, and match the administered dose with ordered dose. Have a process to routinely review/reconcile the documented medication waste:
  • Narcotic waste may require two signatures
• Conduct random medical record audits to verify that removed medications were administered and documented as dispensed
• Proactively monitor drug usage patterns, waste reconciliation, and discrepancies
• Address any discrepancies with medication counts and waste at the time of discovery.
  

Core Process # 3       Use Pharmacy-Profiled ADCs

Rationale:  The use of a “profiled” ADC ensures that the pharmacist will validate the new medication order, including first doses, in the pharmacy computer system prior to the medication being dispensed, or accessed by the nurse or other healthcare professional.

• Provide all ADCs with pharmacy-profiling functionality. This would include outpatient areas (e.g., the Emergency Department [ED], same day surgery, outpatient clinics) even if the software may not be immediately utilized fully for all medications.
• Store only a limited variety and quantity of medications in “non-profiled” ADCs. At a minimum, implement policies requiring an independent double-checks when removing organization-identified high-alert medications from ADCs.

Core Process #4        Identify Information That Should Appear on the
ADC Screen

Rationale:  Having sufficient patient information and drug information when dispensing and administering medications is key to the safety of the medication use process.7 Because there is limited space available on the ADC screens, it is important to focus on presenting the information that is of the greatest value to practitioners, allowing for the clear identification of specific patients, their active medication profile, and supporting information for safe drug use.

• Have the ADC screen display the patient demographics, including:
  • Complete patient name (Ensure there are a sufficient number of characters in the field to avoid abbreviations or initials.)
• At minimum a second organization-defined identifier to be used before medication administration
• Patient allergies
• Patient location
• Ideally, display medication information in the following fashion:
  • List name of the medication (brand and generic including any safety font enhancements [e.g., tallman lettering] when appropriate) along with the patient-specific dose and route of administration.
• The display and name of medication on the screen should match the medication, pharmacy label, and the MAR.
• Abbreviated or truncated drug names should not be used
• On the next line, include any instructions for preparing the dose. (e.g., 2 x 10 mg = 20 mg.)
• Provide special instructions (e.g., do not cut or crush, take with food or meals).
• Identify location of the medication (e.g., specified ADC “pocket”, refrigerated storage).
• Display the time that the last dose was removed.
• Use active alerts (compared to flat text) whenever possible (e.g., having an ADC alert appear when attempting to select a medication for which the patient is allergic versus relying on the nurse to read the allergy field and determine if the drug should be used).
• Display selective warnings for medications that require a double check or witness for withdrawal (e.g., high-alert medications, look- and sound-alike confusion, or other safety information).

• Supplemental Information
  • Profiled system icon that indicates that the ADC is online, suggesting to the user that the ADC is actively connected to the pharmacy information system and that recent updates have been received.
• Drug information icon providing the ability to research any drug or a direct link from the current medication listed on the screen to associated drug information.
• Flag orders on the ADC screens that are new or changed.
• Provide a summary screen listing the medication, dose, and dosage form selected for a specific patient during the current transaction.

Core Process #5        Select and Maintain Proper ADC Inventory

Rationale:  Inventory of ADCs should be determined based on the needs of the patients served and replenished on a regular basis. Medications should be routinely reviewed and adjusted based on medication prescribing patterns, utilization, and specific unit needs (taking into account typical patient ages and diagnoses). Standard stock medication should be identified, and approved, for each patient care area.

• The Pharmacy and Therapeutics (P & T) Committee should have oversight of drug availability in the ADC, both for initial and subsequent modifications to the inventory.
• Criteria should be established for including or excluding medications in the inventory. Medications that require extensive dilutions or calculations, or hazardous drugs should not be part of ADC standard inventory. Bulk drug supplies should be avoided and all medications including oral solutions should be in ready-to-use, unit-dose or unit-of-use containers.
• ADC activity reports should be analyzed to determine what medications have low usage and can be eliminated from storage. 
• Maximum par levels should be established and are appropriate to prevent multifold overdosing.
• Monthly pharmacy audits of complete inventory should be performed.

Core Process #6        Select Appropriate ADC Configuration

Rationale:  Restricting access to medications limits the potential for inadvertently selecting the wrong medication. These may be high-alert medications, high-cost medications, or those where it is important to ensure that only the right drug is selected in an emergency (e.g., reversal agents). For these reasons it is important that each drug have its unique and segregated location within the ADC, so only the specific drug is accessible.
 

• An individual medication and strength should be stored in an individual lidded ADC compartment that opens only when the specific medication is selected.
• If matrix drawers (compartments) must be utilized they should be limited to medications such as non-opiate analgesics (e.g., acetaminophen, ibuprofen) and antacids. 
• Matrix drawers, including open storage in refrigerated units, should not be used to store high-alert medications, reversal agents, and drugs prone to diversion.
• Avoid placing non-medications, (e.g., keys, cameras, patient belongings) in ADCs at the expense of storing additional medications.  

Core Process #7        Define Safe ADC Restocking Processes 

Rationale:  The restocking process encompasses a number of sub-processes that can involve both pharmacy and nursing staff. It is important that the process contains redundancies to assure that the correct medication is placed in the correct location within the ADC. In the past, errors in drug selection resulting from mis-stocked items have resulted in fatal medication errors.5 It is also important that the process be defined and organized so staff involved can only follow the correct pathway and the potential for process variation is limited.  

• Recommended processes within the pharmacy
  • Create a sequestered location in the pharmacy for all stock designated for ADC distribution
  • Ensure there is a sufficient supply of the medications
    • Par levels should reflect real-time notification of low ADC inventory
    • Establish a process to notify pharmacy when par levels reach low critical levels
  • Select one medication at a time for ADC distribution.
• Unit-dose products should most closely match the usual doses used by the associated patient care area (e.g., prepare/package commonly-used ½ tablets in the pharmacy to stock in the ADC). Patient-specific doses should still be provided by the pharmacy, if they are not available in the ADC
• Bar-code scanning should be used to confirm the medication selected for distribution to the ADC matches the medication listed on ADC fill report.
• The same drug name nomenclature should be used throughout the entire medication-use process; this includes the identical expression of the drug name and dosage units in the pharmacy computer system, on pharmacy shelving units, on the ADC inventory print out, on the ADC screens, on pharmacy-generated labels, and on the MARs.
• Assign an individual(s) (daily, weekly, permanently) to process inventory requests for ADCs. 
• Develop a check process prior to dispensing
  • Provide an area for review without interruptions or distractions
  • Ensure that the medication is appropriate for the patient population served. 
  • Place each line item, representing a specific medication, dose, and dosage form, in a separate bag. Organize medications by patient care unit, drawer, and bin.
  • Arrange medications sequentially for easy/accurate checking.
  • Provide an independent double-check of all medications to be distributed to ADCs ensuring the right drug, strength, dosage form, correct count, and expiration dates with the final check performed by a pharmacist. It is recommended to use a bar-code system to automate these processes.
• Drug selection for ADC distribution should be audited to ensure accuracy.
• Recommended processes for the delivery of medications to the ADC 
  • Segregate and secure all medications designated for an individual ADC during transport
  • Plan a time of delivery in conjunction with the workflow of the patient care area, avoiding restocking during scheduled medication times.
  • Ideally, use bar-code scanning to identify the correct drawer and pocket/container and to scan the drug being delivered to promote accurate placement in the designated ADC location. When bar code restocking is not available, have a nurse verify the accuracy of restocking for high-alert medications and narcotics.
  • Process/restock one individual medication and strength at a time.
  • Use “blind counts” for narcotics.
  • Take steps to differentiate look- and sound-alike medications within the ADC. This may include a more secured configuration of lidded drawers or locked-lidded drawers. Other options may be to separate these medications or make the bins more distinctive (e.g., using brightly-colored adhesive tape to outline neuromuscular blocking agent storage bins)
  • Avoid multitasking during the restocking process.
  • Create/utilize an audit tool to evaluate the distribution proces

Core Process #8        Develop Procedures to Ensure the Accurate Withdrawal of Medications from the ADC

Rationale:  Develop a process that reduces the risk or mitigates the harm associated with the administration of the wrong medication, dose, route, or frequency due to retrieval errors of medications from the ADC. The contents (variety, concentrations, and volume) and configuration of the ADC play a large role in the practitioner’s ability to safely select and remove medications from the ADC.

• To limit the risk of wrong selections from the ADCs:
  • Configure all ADCs in the inpatient units (and ideally outpatient areas) to dispense in a pharmacy-profiled mode, which only allows medication retrieval after orders have been verified by a pharmacist. Do not allow users to select medications using the inventory or unit stock mode, unless in an emergency.
• Include, as part of orientation and annual competency assessments, education and training on the risks associated with drug selection from ADCs.
• Only fingerprint biometrics or individual passwords should be used to access ADCs.
• Investigate and correct any identified discrepancies between the ADC screen, the MAR, and the pharmacy or medication label prior to the selection of the medication.
• Only medications that are available for administration should initially appear on the active profile. (Medications that need to be renewed before administration or those recently selected should appear to the user as initially unavailable for use. If the practitioner determines it is necessary to select a dose of a medication prior to its scheduled time, then additional strategies [e.g., an independent double-check for high-alert medications, and documentation of rationale for the override] should be implemented.)
• ADCs screens should indicate to the user the location of the medication to be removed. If it is not contained on the ADC screen, the location of the medication should appear on the MAR. For example, display the associated drawer designation as a letter and the bin designation as a number (e.g., location “A‑9” to indicate “drawer A, bin 9”). Avoid using all numbers (e.g., “drawer 3‑pocket 4”) which can be easily confused. Different vendors may have their own proprietary methods of identifying specific pockets.
• Do not allow for the selection of a patient’s medications from more than a single ADC at a time. 
• Refer to Core Processes #4, which describes the information which should appear on the ADC screen.

• Require that practitioners remove medications from the ADC one patient at a time.
  • Upon removal from the ADC, validate that the correct drug has been selected with visual verification of the actual label by comparing the drug label to the MAR/medical record (human check). This manual check should include:
    • Proper drug identification (chemical name and/or brand if available)
    • Validation of drug concentration, dose, and dosage form (Usual ADC selection involves removing no more than three [3] vials, capsules, tablets, or ampules. Larger doses should indicate the need to investigate the original order and the product.)
    • Configure the ADC to require a blind count of the remaining product for the removal of narcotics or controlled substances from multi-dose bins. Upon withdrawal, require the user to manually count the remaining product and enter this information as part of the transaction. (Do not provide the user with the tallied count of remaining medication requiring a single yes or no confirmation.) 
    • Promptly report all discrepancies discovered between the ADC screen listing of medications and the MAR, or the ADC and the contents of the ADC.
    • Ideally, limit the user’s access to selected items.
    • Whenever possible only have patient-specific, unit-doses available, requiring little or no manipulation by the user (e.g., ½ tablets; prepared oral syringes with oral liquid medications).
    • Display PRN medications separately in a different section of the ADC drug profile screen.
    • Return all medications to a common secure one-way return bin and not to an individual pocket or bin within the ADC. 
    • Document narcotic medication waste and record this waste with an independent witness.
    • Create/utilize an audit tool to evaluate the withdrawal process. 

Core Element #9        Establish Criteria for ADC System Overrides

Rationale:  Use of ADC overrides should be situationally dependent, and not based merely on a medication or a list of medications. While there may be a list of drugs with the potential to be obtained emergently, there may be many other situations when there is sufficient time for the pharmacist to review the medication prior to retrieving the dose. Emergency access should be available in circumstances in which waiting for a pharmacist to review the order before accessing the medication could adversely impact the patient’s condition.

• Medications available for override should be unit specific and removed based only on emergent need.
• Implement strategies that reduce the risk of error when an override is used including:
  • Limiting the quantity and number of drug concentrations available
  • Minimizing use of multi-dose containers
  • Providing a process where the drug and dose are checked against the patient’s allergies and weight (as appropriate), to determine if the drug and dose are appropriate
  • Providing preparation instructions if the nurse is required to reconstitute or dilute medications
  • Requiring an independent double-check with another licensed healthcare provider of all high-alert medications
  • Requiring documentation of override rationale
  • Developing a required staff competency assessment related to the safe use of overrides
  • Reviewing and approving all override policies through the P&T Committee, Medication Safety Committee, or their equivalent
  • Routinely reviewing override reports to identify and address barriers to the pharmacist’s review of the medication order prior to drug administration
  
  

Core Process #10     Standardize Processes for Transporting Medications from the ADC to the Patient’s Bedside

Rationale:  Develop a process that reduces the risk of medications being administered to the wrong patient at the wrong time as it relates to the transportation of medications from the ADC to the patient. Supporting safety may require the availability of additional ADCs or the placement of ADCs in strategic locations to prevent workarounds. (Not having sufficient ADCs, or having them located far from patient rooms, fosters the at-risk behavior of taking medications for more than one patient at a time or taking medications for more than one scheduled administration time.) The safety of this practice is also impacted by the organization’s ability to secure medications during transport between the ADC and the patient’s bedside.

• Transport medications in their original unit-dose package. (Practitioners need the ability to clearly identify the patient’s medications at the time of administration for the purpose of bar-code point-of-care systems, last minute check of the medications while at the bedside, and performance of patient education.)
• Secure transport:
• Hand-carry a single patient’s medication for one administration time directly to the patient’s bedside.
• If during a single medication administration time more than one patient’s medication must be transported, use computers on wheels (COWs), mobile carts, or workstations on wheels (WOWs) with labeled patient-specific drawers and the ability to lock if unattended.
• Avoid transport of medications in clothing pockets, attached to clipboards, inside medical records, or in MAR binders.
• Medications transported from the ADC should be in a ready-to-use form for administration. (Whenever possible, a patient-specific, unit-dose should be prepared by the pharmacy and available to the nurse for administration, negating any manipulation.)
• Have the MAR (manual or electronic) available at the bedside to support safe administration. 
• Open packages at the patient’s bedside. The only exception may be for medications that need to be crushed, measured, or wasted.
• Create/utilize an audit tool to evaluate the transportation process.

Core Process #11     Eliminate the Process for Returning Medications Directly to their original ADC location

Rationale:  One source of misfills and subsequent error selection is to allow practitioners to return a medication directly to the ADC bin or pocket. Occasionally medications are inadvertently returned to the wrong pocket, either because of user distraction, look- and sound-alike medications in a matrix bin, or through a slip in procedure. For this reason, limiting this return to a designated ADC bin will help to eliminate this source of error.

• All medications should be returned to a common secure one-way return bin that is maintained by pharmacy and not to an individual pocket or bin within the ADC.

Core Process #12     Provide Staff Education and Competency Validation

Rationale: All users of the ADCs (pharmacists, technicians, nurses, respiratory therapists, designated physicians, and others) must be educated and have regular competency validation in the safe use of the device in order to meet expectations around use. Most often this education occurs during the practitioner’s orientation period, or upon ADC installation, but additionally may require annual update in order to ensure ongoing appropriate use. Users who are not properly oriented to the device may develop practice habits and device workarounds that are considered unsafe.

• The ADC user is informed (during orientation to the ADC, and annually through on-going education and competency validation) of the risks associated with drug selection. These educational requirements apply to all ADC users.
• Share with staff lessons learned from the regular review and discussion of ADC-related medication errors and near misses reports. In addition, use external sources of error information to promote safe practice.

References

1. Pedersen CA, Schneider PJ, Scheckelhoff DJ. ASHP national survey of pharmacy practice in hospital settings: dispensing and administration. 
AM J Health Syst Pharm. 2006; 63:327-45.

2. Murray MD. Automated medication dispensing devices. In: Shojania KG, Duncan BW, McDonald KM et al, eds. Making Health Care Safer: A Critical Analysis of Patient Safety Practices. Evidence Report/Technology Assessment No.43 [book online]. Rockville, MD: Agency for Healthcare Research and Quality; 2001. http://www. ahrq. gov/clinic/ptsafety/chap11. htm. Accessed July 16, 2007.

3. Grissinger M, Cohen H, Vaida AJ. Using technology to prevent medication errors. In: Cohen M, ed. Medication Errors. 2nd ed. Washington DC: American Pharmacists Association; 2007:413. 

4. Institute for Safe Medication Practices (ISMP). Look-alike names and packages are at the root of most stocking errors in automated dispensing cabinets. ISMP Medication Safety Alert! 2003 Feb; 8:2.

5. ISMP’s Key Elements of the Medication Use System FAQs page. Institute for Safe Medication Practices Web site. Available at: http://www.ismp.org/faq.asp#Question_9. Accessed October 3, 2007.

6. Institute for Safe Medication Practices (ISMP). Infant heparin flush overdose. ISMP Medication Safety Alert! 2006 Sept;19:1-2.

7. Smetzer J, Cohen M. Preventing drug administration errors. In: Cohen M, ed. Medication Errors. 2nd ed. Washington DC: American Pharmacists Association; 2007:235. 

Appendix A

Appendix B

Glossary

ADC    A drug storage device or cabinet that electronically dispenses medications in a controlled fashion and tracks medication use. Automated dispensing cabinet is equivalent to unit-based cabinet (UBC), automated dispensing device (ADD), or automated dispensing machine (ADM).

Blind count    Upon the withdrawal of a controlled medication, the ADC prompts the user to physically count the number of remaining product in that location and enter this count at the time of drug removal. 

High-alert medications    Drugs that bear heightened risks of causing significant patient harm when used in error.

Lock-lidded drawers    A drawer configuration which is used to isolate medications from one another and provide a high level of security by restricting access to one pre-selected medication at a time.

Matrix drawers    A high-capacity, low-security drawer, suitable for large quantities of less-controlled medications. Its configuration allows the user open access to all medications within the drawer.

Override    A process of bypassing the pharmacist’s review of a medication order to obtain a medication from the ADC, when assessment of the patient indicates that a delay in therapy to wait for a pharmacist’s review of the order would harm the patient.

Passwords    Passcodes used to provide security and limit access to the ADC.

Profiled ADC    A pharmacy-profiled ADC is one in which a practitioner can select a drug from a patient-specific list on the ADC screen and obtain a medication only after the order has been verified by a pharmacist.

Tallman lettering    The use of mixed case or enlarged font size to visually distinguish the differing portions of look-alike drug names.

Work-arounds    An action by a practitioner whereby normal safe processes are bypassed, trading efficiency/convenience for safety.