ISMP warns of errors with ADCs
Automation and high-tech systems often are touted as the solution for medication errors, but the Institute for Safe Medication Practices (ISMP) in Horsham, PA, is warning that you could be substituting one type of medication error for another when you use automated dispensing cabinets (ADCs).
ADCs are widely used in many health care systems for the storage and dispensing of medications. In a statement issued recently by the ISMP, the group acknowledges that this technology may offer many benefits, but it cautions that design and use of the system must be carefully planned and implemented to ensure the safe use of medications. In addition, there must be collaboration on ADC use between the health care professions, especially pharmacy and nursing personnel, since each holds a large stake in the medication use process, the ISMP says.
"Despite the growing popularity of this technology, little formalized, truly interdisciplinary guidance exists to direct organizations in its safe use," ISMP wrote.
To address those concerns, ISMP recently released the first-ever interdisciplinary guidelines to promote safe practices with ADCs. (Editor's note: For a copy of ISMP's Guidance on the Interdisci-plinary Safe Use of Automated Dispensing Cabinets, visit www.ismp.org/Tools/guidelines/ADC_Guidelines_Final.pdf.)
Guidelines developed
To develop the guidelines, ISMP convened a national forum of stakeholders this spring that included pharmacists, nurses, and ADC vendor representatives with extensive operational knowledge of the technology.
The group developed guidelines for safe ADC use that focus on a collaborative approach and are based on these 12 core processes:
1. Provide ideal environmental conditions for the use of ADCs.
2. Ensure ADC system security.
3. Use pharmacy-profiled ADCs.
4. Identify information that should appear on the ADC screen.
5. Select and maintain proper ADC inventory.
6. Select appropriate ADC configuration.
7. Define safe ADC restocking processes.
8. Develop procedures to ensure the accurate withdrawal of medications from the ADC.
9. Establish criteria for ADC system overrides.
10. Standardize processes for transporting medications from the ADC to the patient's bedside.
11. Eliminate the process for returning medications directly to their original ADC location.
12. Provide staff education and competency validation.
The guidelines provide specific safe process recommendations for each of those core processes. They should bring welcome advice to risk managers and others who are worried about ADC safety, and apparently there is plenty of worry. A recent survey by ISMP shows that safety improvements with ADCs have not kept up with the growing popularity of the technology. Providers keep adopting the systems at a rapid pace even though there are known safety flaws.
According to the 800 respondents to the ISMP's 2007 ADC survey, 94% of the surveyed providers are using ADCs in their facilities. Of those, more than half (56%) are using the technology as the primary means of drug distribution.
Automation and high-tech systems often are touted as the solution for medication errors, but the Institute for Safe Medication Practices (ISMP) in Horsham, PA, is warning that you could be substituting one type of medication error for another when you use automated dispensing cabinets (ADCs).You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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