John M. Allen, PharmD, FCCM
Andrew C. Fritschle, BCPS, PharmD, BCCCP
Anne Rain Tanner Brown, PharmD, BCPS, BCCCP
The medication use process in hospitals is often complex; however, technology and automation have made medication use more efficient and have enhanced safety. Automated dispensing cabinets (ADCs) are among the most widely used technologies to improve medication safety in the intensive care unit. ADCs provide rapid access to commonly used medications and allow for real-time inventory management. ADCs are associated with reduced medication errors during the dispensing phase of the medication use process. Despite these advantages, ADCs do not make the system completely fail-safe. Their safe use is limited to the functionality of the ADC software and hospital uptake of best practices.
One particular method by which ADCs can be helpful in preventing medication errors is integration of processes that easily identify and provide interactive alerts and warnings for sound-alike, look-alike Drugs (SALADs) and high-alert medications (HAMs). The Institute for Safe Medication Practices recently published guidelines on the safe use of ADCs and identified nine core processes that hospitals can implement to promote safe use.
Development of hospital policies to standardize best practices surrounding the use of ADCs should be a critical step for all health systems. These policies should be developed using recommendations from best practice guidelines to ensure optimization of technology to aid in the medication use process. Policies should include ADC storage configurations, barcode scanning, actionable alerting, routine monitoring of SALADs, medication storage, and routine maintenance and review of hospital-wide override lists. Using a multifaceted approach to storage and technique can help maximize safety.
Dispensing Cabinet Storage Configurations
HAMs that are not controlled substances should be placed in sensing, locked-lidded, or dispenser bins whenever possible. When not possible, barcode scanning on removal should be enabled as appropriate.
Routine Monitoring of Look-Alike, Sound-Alike Drugs
SALADs should be placed in separate matrix drawers or on separate shelves whenever possible or in sensing, locked-lidded, or dispenser bins. When not possible, barcode scanning on removal should be enabled as appropriate.
Unique workflows should be followed to safeguard high alert items. One example of a safeguard is implementation of a two-step process for obtaining HAMs, such as the use of a key found in the ADC to access locked storage containers containing HAMs.
Hospitals and pharmacy departments should perform routine maintenance and review of hospital-wide override lists. Current override medications, as well as any new requests, must be scrutinized with the highest level of precaution to ensure the absolute need for the override.
Despite guidelines for the safe use of ADCs, there are several opportunities for improvement and advancement of technology, including:
- Individualization of override lists at the cabinet level
- Character limits for ADC medication searches
- Requirement of a minimum of four to five letters for medication search fields
- Listing the generic medication name first if both brand and generic names are populated in a search field
- Implementation of interactive warning on ADCs when removing HAMs
- Requiring a witness for overrides
- Incorporation of situational cues
- Integration of warnings into the task when the hazard might occur so the warning sounds at the most relevant times
Effective systems include those that interact and complement one another. The use of HAMs should require physical interaction that interrupts the clinician’s task and requires an additional step to continue the task. There is an identified need for medication-related warning systems to accurately and effectively alert providers when unsafe conditions may be present. We must insist on safe process designs for new technology that mitigate the risk of medication errors and assist in providing safe care. Furthermore, linking barcode medication administration about the ADC and bedside is key to providing safe and accurate delivery of medications to patients.