ISMP survey shows risks of using ADCs
Problems related to automated dispensing cabinets (ADCs) include both product design flaws and human errors, according to the 2007 ADC Survey from the Institute for Safe Medication Practices (ISMP) in Horsham, PA. There has been some improvement since the first ADC survey in 1999, but not enough.
The survey found these common problems with ADCs:
- Checking processes: In both years, just 18% of respondents reported that another person verifies drug placement in the ADC. The ISMP says these manual checking processes are important to prevent stocking and/or wrong drug retrieval errors, similar to the events occurring in Indianapolis and Los Angeles that led to harmful 1,000-fold heparin overdoses in neonates.
- Pharmacist review and overrides: Just 59% of 2007 respondents reported that all ADCs in their facilities are capable of profiling, which provides a direct interface between the pharmacy information system and ADCs so that pharmacists can profile, screen, and approve medications before they are removed from the cabinet for administration.
- Cabinet design: Only 50% of respondents noted that individual compartments for each drug are always or frequently available in the ADC cabinets.
- ADC stock: In both 1999 and 2007, 35% of respondents reported that they always or frequently encounter multiple concentrations of medications in ADCs. In 2007, respondents also reported that they encounter fewer ready-to-administer medications in ADCs than reported in 1999. Almost a quarter (23%) of 2007 respondents reported that nonmedications are being stored in ADCs, a 15% increase from 1999.
- Workflow and practice habits: Only two-thirds (69%) of frontline nurses reported that they always or frequently remove just one patient's medication at a time, implying that multiple patients' medications are removed one-third of the time a practice that is known to lead to drug administration errors.
The full ISMP Medication Safety Alert! newsletter article on the 2007 survey results is available online at http://www.ismp.org/Newsletters/acutecare/articles/20080117.asp.
Problems related to automated dispensing cabinets (ADCs) include both product design flaws and human errors, according to the 2007 ADC Survey from the Institute for Safe Medication Practices (ISMP) in Horsham, PA. There has been some improvement since the first ADC survey in 1999, but not enough.Article Limit Reached
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