News Release

ISMP Issues Updated Guidelines for the Safe Use of Automated Dispensing Cabinets

Recent tragic events, including criminal charges for a Tennessee nurse involved in a fatal medication error and cases of overprescribing opioids for critically ill patients in Ohio, have involved the use of automated dispensing cabinets (ADCs). ADCs currently are being used for medication distribution in the majority of U.S. hospitals and health systems, and the Institute for Safe Medication Practices (ISMP) believes healthcare organizations have an obligation to ensure that this technology is being optimized to promote safe patient outcomes. To help healthcare practitioners accomplish that goal, ISMP has released updated Guidelines for the Safe Use of Automated Dispensing Cabinets.

The guidelines were first issued in 2009, and have been revised following the review of errors reported to the ISMP National Medication Errors Reporting Program, professional literature, professional standards, and input from vendors, industry experts (BD and Omnicell) and interdisciplinary members of the Medication Safety Officers Society, followed by public comment. The document is designed to support healthcare organizations in their safe use of ADCs through adoption of standard practices and processes that are directly associated with improved ADC design and functionality.

Key areas covered in the 2019 guidelines include structural elements for ADC safety, including environmental conditions, security, and cabinet configuration. Recommendations for designing safer systems, such as optimal inventory management, as well as frontline procedures for stocking and return as well as withdrawal of medication, also are presented. The guidelines specifically address ADC system overrides. In addition to ISMP’s guidelines, ADC vendors can provide extensive guidance on how to set up, evaluate, manage, and monitor overrides.  

Click here to view the updated ISMP Guidelines for the Safe Use of Automated Dispensing Cabinets.

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In the wake of recent criminal charges being filed against a registered nurse in Tennessee who was involved in a fatal medication error, ISMP is emphasizing that the focus should be on identifying and fixing imperfect systems instead of unjustly blaming the individual healthcare practitioner.