Running Head: AUTOMATED DISPENSING CABINET SETUP AND USE ERRORS: 1

Automated Dispensing Cabinet Setup and

Use Errors May Cause Medication Mishaps

ENLC-556-02A-FA17 – Management of Health Care System Quality Outcomes and

Patient Safety

Amrit Virdee
University of San Diego
October 22nd 2017
AUTOMATED DISPENSING CABINET SETUP: 2

Automated dispensing cabinets (ADCs) are a form of computerized drug storage cabinet

designed to be used in various healthcare settings but more predominantly designed for use in

hospitals. In the 1980s, there was an increased concern with regards to dispensing errors in a

pharmacy hence giving rise to the development of dispensing devices and systems (Ferencz,

2014). A report published by the American Journal of Health-System Pharmacy (AJHP) stated

that ninety-seven percent of hospitals in the US use automated dispensing cabinets in their

medication distribution systems (Pedersen, Schneider et Scheckelhoff, 2015). There are

numerous benefits in using ADCs such as improving timely administration of medication,

medications can be locked up hence improving safely especially for controlled medications,

tracking of stocking and distribution of medication hence improving inventory control, and

allowing the storage of medications near the point of care.

Drug distribution is an integral part of the pharmacist’s role and ADCs are often stocked

by a pharmacy technician who has a supply of medication that has been checked by the

pharmacist. There are generally two types of ADCs; centralized and decentralized. This paper is

going to focus on decentralized systems. Decentralized systems exist outside the pharmacists

direct control, but the pharmacist is still responsible for ensuring that the correct drug dose is

available in the ADC. Decentralized systems are often used as the source for the patients first

dose, for time-sensitive medications such as antibiotics and are also available for use at the point

of care.

The increased use of ADCs has improved the efficiency of medication administration

however various studies have shown that the use of ADCs has not reduced the potential number

of errors, one study compared the compliance of ADCs between 2010 and 2015 showed that the

total number of reported medication incidents and accidents did not decline and instead increased
AUTOMATED DISPENSING CABINET SETUP: 2

over that time period (Bernier et al, 2016). Another study conducted by the ECRI Institute

reported that during January through September 2016, 227 patient safety events associated with

ADCs were reported.

Medication errors can cause significant harm to patients and can result in a larger

financial burden for both the hospital and the patient. The purpose of this paper is to review

current medication errors as a result of using an ADC, to establish why these errors may be

occurring and to propose recommendations on how medication errors as a result of using an

ADC can be minimized.

Literature Review
The search strategy first involved using the Copley Library and inputting ‘health’ in the

search section, this yielded a number of databases and I chose the Ovid Online Databases which

accessed the complete listing of databases available through Ovid including Journals@Ovid and

Medline. Ovid is an internationally recognized leader in medical information services and from

within the database I searched ‘automated dispensing cabinets (ADCs)’. From the list of results,

I reviewed articles that reviewed error rates when using ADCs and to articles that would provide

solutions in reducing errors and also in improving efficiencies which include reducing costs and

improving on hand inventories.

The first article ‘A comparison of automated dispensing cabinet optimization methods’

published by the American Society of Health-System Pharmacists, which looked at comparing

two methods of optimizing ADCs at an 805-bed academic medical center located in Chapel Hill,

North Carolina. The article looked at two types of models, a ‘centralized’ model that revolved

around the pharmacist checking a patient-specific unit dose product in a centralized location

from which the product is then delivered to the patient and a ‘decentralized’ model that revolved
AUTOMATED DISPENSING CABINET SETUP: 2

around a pharmacist checking a non-patient specific unit dose product in a centralized location.

The main basis of the article was to view how ADCs can best be optimized. The article stated

that optimization revolved around four actions 1) increasing the stock of frequently used

medications, 2) removing the stock of unused medications by reviewing usage over the last 180

days, which in turn also helps to reduce ‘out of date’ medications from being kept in the ADC, 3)

adjusting desired on-hand levels to decrease ‘out of stock’ issues and 4) moving stock to suit

customer needs where the article stated that it is important for medications to be placed in a

compartment appropriate for their size and quantity which further helps with a reduction in

potential medication errors (especially for look alike, sound alike medications) and the

possibility of broken machinery. The article also stated that the most challenging and time-

consuming aspect of optimization was changing the location of medications for end user

satisfactions. The article concluded that optimization of ADCs had a positive impact on

inventory costs, refills and out of stock percentages.

The second article ‘Impact of automated dispensing cabinets on medication

selection and preparation error rates in an emergency department: a prospective and direct

observational before-and-after study’ reviewed a 377-bed public teaching hospital in Australia

that introduced an ADC, Omnicell from Mountain View, California into their emergency

department. The introduction of ADCs into the emergency department at this hospital allowed

the opportunity to measure the quality and safety of ADCs by assessing the impact on the

prevalence of medication error rates in the emergency medicine setting. The article using a more

resource intensive direct observational method and further reduced the impact of the Hawthorne

effect by having observational periods unannounced. The article classified medication errors

into three categories, 1) wrong medication, an administration of a dose of medication not yet
AUTOMATED DISPENSING CABINET SETUP: 2

been ordered, 2) wrong dose where an administration contained an incorrect volume, quantity

and strength and 3) wrong dosage form which involved an administration of medication in a

form different from the form prescribed by the doctor. Data analysis involved calculating the

medication error rate using a formula and using chi-squared statistical tests were performed on

data collected, using two-sided t tests. The article stated that after deployment of ADCs with the

emergency department there was an observed reduction in medication selection and preparation

error rates pre and post-intervention. The article also stated that they saw a decrease in all types

of medication errors. The article stated that the physical separation of similar medications, use

of alerts and guiding light technology are important features that help improve the safety

elements of ADCs. It further stated that the use of ‘pop-up’ alerts when selecting a product can

help improve safety in look-alike-sound-alike medications and for medications available in

various formulations.

The third article reviewed was titled: ‘Nursing Best Practices Using Automated

Dispensing Cabinets: Nurses’ Key Role in Improving Medication Safety’. Pharmacists mainly

focus on the dispensing and distribution of medication when related to ADCs however Nurses

perform the majority of transactions related to ADCs and thus place a key role in ensuring their

safe use. The article stated that a Nurse’s input on ADC configuration and location can help

avoid unsafe practices such as storing certain medications close to each other, particularly look-

alike/Sound-alike drugs and also on more practical aspects such as more frequent medications

being placed higher in the cabinet. The article also stated that another study showed that almost

50% of medication errors involved distractions (Hicks, Becker, & Cousins, 2008) and that most

ADCs were not located in areas where there is less distraction. The use of a so called ‘sterile

cockpit’ environment is recommended where in one case tape is place on the floor around the
AUTOMATED DISPENSING CABINET SETUP: 2

ADC to indicate a ‘quite’ and ‘do not disturb’ zone to ensure the Nurse is not distracted at the

crucial time of removing the medication from the ADC. The article concludes that continuing

education is critical in ensuring that Nurses and all other staff members are using the available

features, streamlining processes and adhering to best practices.

The forth article titled ‘Compliance of Automated Dispensing Cabinets with Guidelines

of the Institute for Safe Medication Practices (US): Comparison between 2010 and 2015’ which

reviewed compliance scores for the ADCs, in relation to guidelines issued by the Institute for

Safe Medication Practice (ISMP) which were calculated at implementation and after the ADCs

had been in service for 5 years, the same methodology was used to evaluate the current

compliance with the ISMP guidelines. The ISMP guidelines specify 12 core processes and 89

individual compliance criteria that help to ensure patient safety. The article stated that at the

study hospital, the total number of reported medication incidents and accidents did not decline

between 2010 and 2015, despite the introduction of ADCs. This is also despite an increase to

79% of ADCs adhering to ISMP guidelines in 2015 compared to 67% in 2010. The article

however does state that hospitals should be encouraged to perform such compliance auits not

only during the implementation phase but also periodically once the technology is in place.

Although the ADCs may appear easy to implement, they require sustained efforts and repeated

audits to ensure optimization of their use.

The articles reviewed show that the setup and use of ADCs involves a complex

collaboration between various healthcare providers and administrative staff to ensure that all

aspects such as location, whether they are centralized or decentralized, the input from the main

users of ADCs mainly Nurses providing their input on the setup, location of mediations within

ADCs and in the proposal of best practices and adhering to ISMP guidelines in order to ensure
AUTOMATED DISPENSING CABINET SETUP: 2

that ADCs are utilized in order to improve efficiency and minimize errors. The primary aim of

ADCs is to improve efficiency whilst still maintaining a level of safety, for that reason I would

like to review further the utilization of ADCs in an emergency department where I believe they

would have the most impact.

Identified Solution

The primary aim of automated dispensing cabinets (ADCs) is to improve efficiency

whilst still maintaining a level of safety, both elements are crucially important in the emergency

department (ED) where quick decisions and easy access to medications are needed. ADCs are

commonly used in ED settings which allow medications to be stored and dispensed at the point

of care. Access to the medications in the ADC in a timely manner is a concern as one study

where dispensing a medication in a key based ADC took 7.5 minutes (Ragoo et al, 2016). The

most common type of errors revolves around medication-retrieval errors which involve the

selection of the wrong medication or dose and/or errors associated with restocking the ADC with

the incorrect medication (Weant, Bailey & Baker, 2014). The availability of an ‘override’ option

is also a concern where medications can be removed for any patient. Although this may be

considered as an advantage it can also be considered as a disadvantage.

There are various solutions that can address the issues mentioned above. The use of a

fingerprint controlled ADC reduced the dispensing time by 6.4 minutes to 1.1 minute which is

crucial in an ED environment (Ragoo et al, 2016). Reducing potential errors can also be

accomplished by only having medications in the ADC that are required to be used in an ED

environment, this should be determined by a joint healthcare professional panel that includes

doctors, nurses and pharmacists. The use of guiding light technology will guide the nurse to the

right cell where the medication is located hence reducing errors with look-alike-sound-alike
AUTOMATED DISPENSING CABINET SETUP: 2

medications or if medications are available in various strengths or formulations. The use of the

‘override’ feature should only be allowed with the incorporation of an ‘override’ protocol which

lists what medications can be utilized through this feature. This will ensure consistency and also

reduce the number of medications that can be accessed via this feature. Implementation of the

solutions above will help to improve efficiencies and safety in the use of ADCs in an ED

environment.

Failure Mode Effect Analysis

(intentional gap in order to have the flow chart on a full page)

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START

1)Does HealthCare Provider NO 2)Report to relevant authority for

(HCP) have access to system? update/approval/inclusion

YES

3)Does HCP have fingerprint access? NO 4)Manual input by HCP

YES

5)Does the HCP have a MAR sheet to 6)Does this medication require an
NO NO
verify patient and medication? override?

YES YES

6)Does the facility have an override

NO
protocol in place?

YES

6)Is the required medication on the

override protocol list? NO

STEP B
YES
 AUTOMATED DISPENSING CABINET SETUP: 2

9)Double verify location with another

START STEP B
HCP

7)Does the ADC provide the location of NO 8)Is the location of the medication on the
NO
the required medication on the screen? MAR sheet?

YES YES

7 Re-verify the location of the medication

10)Does the ADC have guided light NO with that on the ADC screen/MAR sheet
technology to re-confirm location?

YES

Does the patient require more than one NO Retrieve medication from
medication? the allocated location

YES
For safety reasons only 1
medication should be retrieved
at 1 time. A protocol should
11)Is there a protocol stating only 1
medication should be retrieved at 1 NO be initiated to enforce this
safety procedure. Proceed to
time?
retrieve the first medication
and start the process again to
retrieve any additional
YES medications

Retrieve 1st medication from

allocated guided location and
start process again to retrieve
additional medications
AUTOMATED DISPENSING CABINET SETUP: 2

Quality Measure

The primary aim of automated dispensing cabinets (ADCs) is to improve efficiency and

safety. All improvement is change but not all change is an improvement (Mainz, 2003) hence

when looking at what quality indicator to measure with respect to improving ADCs, it is critical

to ensure that the quality indictor being considered is one that will bring improvement in a

process. The proposed solutions for improving safety of ADCs in the ER were 1) the availability

of an override feature 2) implementing and regularly reviewing an override protocol 3) only

having medications in the ADC that are required to be used in an ER environment.

In this case two process and one structural indicators were chosen and each indicator was

broken down into a description, who will monitor the indicator, how the data will be collected,

how often the data will be collected and the outcome goal. The table below depicts the design of

the three indicators

Indicator Description Who will How will data How often will Outcome goal
monitor be collected the data be
collected
Process The override ADC computer Electronically via Data collected 100% compliance
function should will relay ADC computer through each in override use as
only be used as information to override per policy
per protocol Head of ER occurrence and provided weekly
department pooled into a
weekly report
Structural Review if the Head of ED Yearly protocol Yearly protocol Review of the
override protocol department review review override protocol
is reviewed every on a yearly basis
year to ensure it is target month:
up to date every January
Process Reviewing Head of Electronically, no Data is collected Target goal of
medication usage Pharmacy of bays used, % on a continuous 85% of bays
in an ADC to of active use per basis and pooled being utilized
ensure a right mix bay, % of to provide a where 60% of the
of medications are medication weekly and medications are
available returns per bay, % monthly usage being used
of out of stock report constantly
medications in the
ADC
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Conclusion

Automated dispensing cabinets (ADCs) are a form of computerized drug storage cabinet

that are predominantly used in hospitals and have various benefits such as improving efficiency,

safety and allowing the storage of medications near the point of care. This paper specifically

focused on decentralized ADCs which exist outside the pharmacists direct control and are often

used as the source for a patient’s first dose, for time-sensitive medications and for use at the

point of care such as in an ED. The use of ADCs has proved to be beneficial in the ED because

they can improve efficiency whilst still maintaining a level of safety, both elements being

crucially important in the ED where quick decisions and easy access to medications are needed.

The most common type of errors with respect to using ADCs revolves around

medication-retrieval errors which involve the selection of the wrong medication or dose and/or

errors associated with restocking the ADC with the incorrect medication (Weant, Bailey &

Baker, 2014). Medication retrieval errors are also compounded by the availability of an

‘override’ option where medication can be retrieved without a pharmacist checking and

approving the release of the medication.

There are various solutions that can be utilized to reduce retrieval errors from ADCs such

as the use of fingerprint access ensuring that only authorized personnel can access medications

from the ADC, only having medications stored in an ADC that are tailored for use in an ED, this

should be determined by a joint healthcare professional panel that includes doctors, nurses and

pharmacists, the use of guiding light technology helping guide nurses to the right cell where the

medication is located hence reducing errors with look-alike-sound-alike medications or if

AUTOMATED DISPENSING CABINET SETUP: 2

medications are available in various strengths or formulations and the incorporation of an

‘override’ protocol which lists what medications can be utilized through the ‘override’ feature.

The use of the flow diagram as shown in the failure mode effect analysis section helps

allow for a structured approach when accessing an ADC that will help to prevent retrieval and

access errors hence helping in improving patient outcomes. The flow diagram also suggests

what needs to be done if there is a gap in the recommended structured approach. By following

the structured approach there should be an increase in efficiency and a decrease in retrieval

errors. Future course of action should include investigating the use of voice control or iris

recognition for access control, allowing electronic submission to the pharmacy for all

medications that were obtained via ‘overrides’ so that they can review and notify the nurse if a

follow up is needed.
AUTOMATED DISPENSING CABINET SETUP: 2

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Appendix

FME A t e mp lat e

STEP FAILURE MODE FAILURE CAUSE FAILURE EFFECT LIKELIHOOD LIKELIHOOD SEVERITY ACTION TO REDUCE
OF OF (1-10)
OCCURRENC DETECTION
E (1-10) (1-10)
1 No access code Lack of access Unauthorized access 2 7 10 All HCPs require individual
requirement protocol access via codes and fingerprint
access to access the ADCs
1 Only relevant staff Staff not trained or Unauthorized access 5 7 10 Only approved staff should have
should have access to approved can access access to ADCs
ADC ADC
2 No method of Inadequate reporting Unable to report hence 7 1 8 Clear protocol on what to do if
reporting structure unable to fix issues there is an opportunity to report
inadequacies needs to be established
3 Fingerprint input Inadequate Bypassing fingerprint 4 5 5 Proper setup will ensure
process time fingerprint setup access accuracy and improve efficiency
consuming
4 Can input another Manual codes are Probable use for 2 5 10 Setting up finger print access
staff member code easier to replicate diversion or other minimizes the possibility of
manually reasons unauthorized access
4 Forgetting manual Forgetting, too many Increase in timely 5 1 7 Setting up finger print access
access code codes to remember dispensing of required will minimize forgetting access
medication codes
5 MAR sheet not Lack of time to Inadequacies in patient 6 5 8 MAR sheet updates provide
updated with new update MAR MAR sheet confirmation that medication
drug information have gone through the right
processes
6 Overutilization of Perception that it is Increases likelihood of 7 5 7 Override protocol should be
overrides easier to retrieve errors established to ensure that it is
medication used for the right reasons
6 Lack of override Ability to retrieve any Access to all 7 5 8 Override protocol ensures that
protocol medication in an medications there is an approved override
ADC process in place
6 Lack of approved Ability to retrieve any Access to all 7 5 8 The override protocol should
override medications medication from the mediations in an ADC have an approved list of
on protocol ADC medications that can be
retrieved by the override
function
7 No medication Inadequate setup or Increases likelihood of 8 5 8 The ADC should provide the
location information lack of information retrieving the wrong location of the medication i.e.
on the ADC screen available medication Cell A Drawer B
8 No medication Inadequate setup or Increases likelihood of 8 5 8 The MAR sheet should provide
location information lack of information retrieving the wrong the location of the mediation if
on the MAR sheet available medication the ADC does not
9 Inability to double Lack of appropriate Increases likelihood of 8 5 9 Initiate a protocol which ensures
check medication safety measures; retrieving the wrong that either the MAR sheet and/or
location if not on unable to locate medication ADC screen displays the
ADC screen or on another staff member location of the medication
MAR sheet to re-verify
10 No guided light Cost of installation Increases likelihood of 4 1 6 Install guided light technology
technology installed retrieving the wrong to improve accuracy
on ADC medication
11 Ability to retrieve Lack of protocol Increases likelihood of 9 5 8 Ensure there is a protocol that
more than 1 enforcing retrieving 1 retrieving the wrong enforces retrieving 1 medication
medication at a time medication at a time medications at a time from the ADC