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Automated dispensing systems for medications have been touted as a way to reduce medication errors and waste, but experts in reducing medication errors caution that an automated system is not a solution by itself. To effectively reduce medication errors and improve security, they say, you must incorporate design changes and new staff policies.
The warning comes from the Institute for Safe Medication Practices (ISMP), a nonprofit group in Fulton, MD. The ISMP recently conducted a survey of 453 acute care hospitals to determine how providers are using automated dispensing systems and how well those systems are achieving the desired improvements. The results suggest that many facilities are unable to incorporate the specific cabinet design features that promote safety, negating some of the potential benefits. Also, many facilities have not established appropriate staff practices, says Judy Smetzer, RN, director of risk management for the ISMP.
"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," Smetzer says.
More than half of the respondents said their institutions use automated dispensing cabinets for a wider variety of drugs, including controlled substances, than are typically stocked on floors. Adding to the safety problem, 20% use automated cabinets as their primary medication delivery system, and 32% use cabinets to supply first doses of typical or specified drugs. That means at least 10% are using cabinets to supply a vast assortment of powerful and potentially lethal drugs without the safety precaution of pharmacy order screening before drug administration, Smetzer says.
Even among the respondents who said their institution did require pharmacy order screening, only 26% have taken the precaution of designating unit-specific lists of "override" drugs. Also, 44% never analyze override reports to track patterns and identify problems. More than half of the respondents, 54%, said correct drug placement in cabinets is never verified after restocking.
"Unfortunately, the survey results show that the use of automated dispensing cabinets may inadvertently be reversing some significant advances in error prevention, such as limiting floor stock and unit dose dispensing," Smetzer says. "For instance, perhaps because of the convenience and accessibility of automated dispensing technology, some medications are being stored in bulk supplies, multiple concentrations, and in areas where their use is not necessary or safe. All of those are practices that have been shown to increase the possibility of medication errors."
The introduction of the automated cabinets has led many hospitals to forego what normally would be considered standard procedure in determining which medications can be stocked on the floor, Smetzer says. Only 58% of respondents reported that their institution uses specific criteria for determining which drug products and quantities may be stored in automated cabinets. Of that number, only 38% reported having set criteria for determining the safety of drug strengths, and 53% reported having set criteria for identifying products considered inappropriate for storage in cabinets.
Smetzer says the survey also turned up some disturbing practices that could threaten patient safety. Almost no one, only 4%, reported using bar code technology when stocking cabinets. In 89% of the responding facilities, nurses have access to open bins and drawers that allow them 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 that increase nursing access to drugs while bypassing the usual system of double-checks," Smetzer says.
Fast pace can cause corner-cutting
Similar concerns were expressed by Deborah Nadzam, PhD, RN, FAAN, chairwoman of the National Coordinating Council for Medication Error Reporting and Prevention (NCCMERP), a nonprofit group in Rockville, MD. Whether automated dispensing cabinets are used or not, the increasingly fast pace of health care is causing providers to cut corners when it comes to ensuring the safety of medication dispensing, Nadzam says. The result is that the risk of patient injury is increased, she says, along with the likelihood that drugs can be stolen.
"Given today’s fast-paced environment, medication errors are more apt to occur unless there are mechanisms in place to reduce and prevent those errors from reaching patients," Nadzam says. "One of our most crucial recommendations relates to the ever-quickening pace of medication dispensing today. The council emphasizes that the label be read at least three times before the medication reaches the patient."
The physical setting in which drugs are dispensed also influences the likelihood of medication errors, says Diane Cousins, RPh, council secretary and vice president for practitioner and product experience. Many of these errors can be prevented by simply providing a good working environment, she says. Facilities should provide proper lighting and appropriate temperatures in the dispensing area and minimize distractions such as noise, clutter, and telephone calls.
Both groups recently have offered tips on reducing medication errors. The ISMP says automated dispensing systems can improve efficiency and safety when used correctly, but the experts there make these recommendations to improve the safety of automated cabinets:
• Use systems that require pharmacy order entry. You should not allow override, but if you insist on doing so, you must develop a list of drugs and drug categories that should not be removed without pharmacy notification or clearance. Remember that it is easy to thwart your facility’s patient profiling system if staff do not enter pharmacy orders accurately and in a timely fashion.
• Use systems that have bar coding.
• Carefully select the drugs that are stocked in the cabinets, considering the needs of specific patient care area, staff expertise and familiarity with specific drugs, and the age and diagnosis of patients being treated.
• Minimize the drug supply, and stock drugs in the smallest possible doses and containers.
• Establish maximum dose ranges for "high-alert" medications and place this list on the automated dispensing cabinet for ready reference.
• Educate staff to remove only a single dose of ordered medication and never return drugs directly to cabinets. Return unused portions to the pharmacy.
• Develop a check system to ensure accurate stocking of cabinets and ensure it is followed every time.
• Place allergy reminders for specific drugs, such as antibiotics, opiates, and nonsteroidal anti-inflammatory drugs, on appropriate storage pockets or drawers.
The NCCMERP also recommends these steps to improve medication safety:
• Prescriptions and orders always should be reviewed by a pharmacist prior to dispensing. Any orders that are incomplete, illegible, or of any other concern should be clarified using an established process for resolving questions.
• Patient profiles should be kept current and contain adequate information that allows the pharmacist to assess the appropriateness of a prescription or order.
• The dispensing area should be designed to reduce errors. The design should include fatigue-reducing environmental conditions such as good lighting, air conditioning, reduced noise levels, and ergonomically correct fixtures. Distractions such as telephone and personal interruptions, clutter, and unrelated tasks should be minimized. The employer should provide sufficient resources for the workload.
• Product inventory should be arranged to help differentiate medications from one another. This may include the use of visual discriminators such as signs or markers. This is particularly important when confusion exists between or among strengths, similar-looking labels, and similar-sounding names.
• A series of checks should be used to assess the accuracy of the dispensing process before the medication is provided to the patient. Whenever possible, an independent check by a second individual should be used. Other methods of checking include the use of automation, computer systems, and patient profiles.
• Labels should be read at least three times. For example, the pharmacist should read the label when the product is selected from the shelf, when the product is being placed into packaging for patient use, and when the product is returned to the shelf. Automated and independent checks by a second person are encouraged for an extra measure of safety.
• Pharmacists should counsel patients. The counseling provides an opportunity to verify the accuracy of dispensing and the patient’s understanding of how to use the medication properly.
• Pharmacies should collect data regarding actual and potential errors to aid in continuous quality improvement.