Implement strategies to improve dispensing safety
Steps could help small hospitals, as well
Most hospitals, large and small, have medication dispensing cabinets. But the question is: Are you using these devices to maximize their safety potential?
Nearly 83% of all U.S. hospitals, including more than 70% of hospitals with less than 50 beds, use automated dispensing cabinets (ADCs), according to a recent survey.1
However, hospital pharmacists could help their health systems improve the way the cabinets are used and eliminate many of the common medication errors that occur with their use, says Michelle M. Mandrack, RN, BSN, director of consulting services at the Institute for Safe Medication Practices (ISMP) in Horsham, PA.
"ISMP held a summit around improving safety when using medication dispensing cabinets," Mandrack says. "We brought users and vendors together to look at the core characteristics that would make the cabinets' use safer."
ISMP developed a 2008 "Guidance on the Interdisciplinary Safe Use of Automated Dispensing Cabinets," which can found at www.ismp.org/Tools/guidelines/ADC_Guidelines_Final.pdf.
Some of these strategies may be more challenging for small and rural hospitals to implement given that they may not have pharmacy services 24/7, Mandrack adds.
In small and rural hospitals there may be a perceived need to store greater variety and quantity of medications in the automated dispensing cabinets to cover periods when pharmacy is not on-site, she adds.
"However, having large quantities of medications on the clinical units poses some risk," Mandrack says.
"In the event the nurse inadvertently makes a calculation error, if there is enough medication in the cabinet to prepare an overdose, then those errors may be more likely to reach the patient," she says.
Here are a couple of ways health care vendors and hospitals can improve dispensing cabinet safety, as outlined among the 12 core processes in the ISMP guidelines:
1. Design the display screen to improve safety.
In the ISMP 2008 guidelines, this change relates to the core process of "Identify information that should appear on the ADC screen."
The ADC screens sometimes list information in a way that can cause confusion, such as truncating patient names or using abbreviations.
For instance, when twins or triplets are born in a nursery, there will be multiple listings for patients with the same last name and perhaps only a first name designation of "A" or "B." Or in some rural areas, there are common family names, so nurses could select the wrong patient on the screen if there are multiple choices of patients with the same or similar last names, Mandrack says.
The solution is to have the ADC screen display a complete patient name, ensuring there are a sufficient number of characters in the field, and to use a second identifier.2
The second identifier could be a medical record number or a date of birth, Mandrack says.
The guidelines also recommend that the screen show patient allergies and patient location.2
The medication information should be displayed by listing the medication's name, both generic and brand when appropriate, and including safety font enhancements like tallman lettering, along with the patient-specific dose and route of administration.2
"What may not be recognized initially is the difference between the patient's specific dose and what is provided in the cabinet," she adds. "For example, if I need to give 10 mg of a specific medication, the cabinet might not contain 10 mg tablets, so I may have to get out two 5 mg tablets."
So the next line on the screen should include any instructions for preparing the dose, such as "two times 5 mg tablets equals 10 mg."2
The screen also should display any special instructions regarding whether the medication should be taken with meals, and it should identify the specified ADC pocket for the medication.2
Having the instructions spelled out on the display will help prevent the kind of medication errors that occur when staff are distracted.
"Nurses get interrupted so often when they are administering medications, and the dispensing cabinets often are in the hallway where a patient's family or a doctor might stop to ask the nurse questions," Mandrack notes.
So a safer solution is to design the dispensing cabinet screens to identify the patient-specific dose and to provide instructions on how the nurse needs to administer that dose, she says.
Other best practices related to medication information on the display screen include providing the time the last dose was removed, active alerts such as when a medication is selected to which a patient has an allergy, and potential warnings for high-alert medications.2
2. Ensure ADC system override is only for emergency needs.
A hospital's pharmacy department typically validates physician prescription orders, making certain the dosages are within guidelines, the patient has no allergies to the ordered medication, and that there are no harmful drug-drug interactions.
"Once that process is done then the information is communicated to the automated dispensing cabinet and the drugs can be accessed by nurses," Mandrack says.
However, some medications may need to be obtained in an emergency before there is time for a pharmacist review of the orders. Also, some smaller hospitals do not have 24-hour pharmacy services, so the ISMP guidelines address establishing criteria for ADC system overrides.
The criteria recommended in the guidelines include ensuring medications available for override are unit-specific and removed only when there is emergent need.2
The guidelines also recommend pharmacies implement strategies to reduce the risk of error when an override is used, including the following:2
- limiting the quantity and number of available drug concentrations;
- minimizing use of multi-dose containers;
- using a process where the drug and dose are checked against the patient's allergies and weight;
- providing preparation instructions if the nurse is required to dilute or reconstitute medications;
- requiring an independent double-check with another health care provider when removing high-alert medications on override;
- developing staff competency assessment related to safe use of overrides;
- reviewing and approving all override policies through a pharmacy, medication safety, or other committee;
- routinely reviewing override reports to identify and address barriers to the pharmacist's review of medication.
References
- Pedersen CA, Gumpper KF. ASHP national survey on informatics: Assessment of the adoption and use of pharmacy informatics in U.S. hospitals—2007. Am J Health-Syst Pharm 2008;65:2244-2264.
- Institute for Safe Medication Practices (ISMP) Guidance on the Interdisciplinary Safe Use of Automated Dispensing Cabinets. 1-21. Available at www.ismp.org/Tools/guidelines/ADC_Guidelines_Final.pdf. Accessed Dec. 21, 2008.
You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content