As with all automation technology considerations, automated dispensing cabinets (ADCs) should be viewed both in light of the safety measures they provide, as well as the risk scenarios they introduce, as both situations are certain to arise in almost any technology upgrade. Likewise, certain technologies rely upon the capabilities of other systems for their benefits to be fully realized, and this too is a concept that needs to be reviewed prior to selecting new technology. At Huntsville Hospital, an 881-bed, not-for-profit institution in Huntsville, Alabama, we have countless nursing staff that interacts with the pharmacy on any given day. In order to better manage our inventory and offer fast and efficient access to medications, we implemented ADCs facility-wide in 1996.
While these devices introduced significant improvement to the standardization and control of medications throughout our facility, no technology is impervious to error, and a proper understanding of how these systems work directly with the pharmacy, as well as with each other, is essential to effective usage. These days, it is easy for a pharmacy director to focus almost entirely on the logistical processes involved in researching, justifying, purchasing, and implementing new technology, but lose focus on how that automation will drive safety. Gaining a full understanding of the technology for yourself and impressing upon your staff the reasons why—not just how—it is being implemented will go a long way in gaining acceptance and ownership.
Take a Global View of Improvement
When researching a new technology, view it from a broad safety perspective and establish exactly what issues you are attempting to reconcile through the adoption of that technology. If the issue involves a nurse going into the wrong patient room with the wrong medications, new ADCs are not going to fix this issue. If the facility is having problems making sure the nurse gets the right drug for the right patient in a timely manner, then ADCs will likely provide significant help. Similarly, if the facility is experiencing medication administration issues at the bedside, then perhaps a different technology such as bar coded medication administration (BCMA) would provide a better resolution.
Many pharmacy directors turn to ADCs to address an issue considered unrelated to patient safety concerns: shortening the time it takes to get medications to patients. While providing access to medications is a logistical challenge, safety must drive the solution. Using ADC technology is inherently safer than traditional unit dose exchange carts that allow unfettered access to all medications just by searching through the cart. However, the focus for both managers and staff needs to remain on safe processes, not simply on how the technology works.
I have seen several medication errors caused by end-users—not just nurses—that thought a patient had an order for, say, Pepcid, but it really was for another similar-sounding product. Still, that user went shopping for Pepcid, administered it to the patient who did not have that order, and created a missing dose and a delay of therapy for the patient whom the Pepcid was originally intended. With an ADC system, the drug is already available on the unit, and as soon as the order is reviewed, the drug is released for the patient without delay. This is a logistical improvement over an open cart or ward system, but unless governing safety measures are fostered among staff, ADCs will simply add a level of security for users to work around. Among the logistical benefits of ADCs that bring tangential benefits to safety is the fact that having readily available medications on the units will significantly reduce the number of calls and disruptions to the central pharmacy, thereby reducing the number of errors made in that setting.
A Joint Approach to Product Selection
If the determination has been made that ADCs are the proper technology to satisfy your needs, the purchasing phase should be a joint effort between pharmacy and nursing. This collaboration is vital not only to selecting a product that the majority of users like but also to gain a group commitment to using the product properly. It is important to view ADCs as a nursing product that pharmacy manages rather than a pharmacy product that nursing uses.
The implementation and use of ADCs can be fairly far reaching, so developing a committee to review and execute the necessary tasks is advantageous. The committee should be established a year out from the target implementation date to allow for vendor review and selection, and then should remain viable during installation and for the first few months post-rollout for troubleshooting. The key is involving representatives from all areas that will be affected by the new technology—in this case, pharmacy and nursing are the most affected and should have the greatest input. However, other groups, such as anesthesiology and respiratory therapy, might need to be involved as well. Such involvement fosters accountability and any problems that arise will be seen as joint problems. Leaving out affected parties will strip those parties of responsibility and ownership of the project, leaving future processes vulnerable to error.
When making a list of final vendor candidates, another important area to review is the systems’ upgrade ability. Even though the new technology should address your current and foreseeable needs, it should be flexible enough to adopt upgrades, as well as properly interact with future operational and safety improvements. For example, in 2009 and 2010, our hospital employed two upgrades, effectively adopting newer versions as they had been released. We did not do this just because there was a newer product available; rather, these successive upgrades have allowed us to add the ability to scan upon stock, to scan upon removal by nursing, and to fine tune at the station level what medication restrictions are capable of being overridden. This process demonstrates how safety measures should drive product implementation and upgrades as opposed to simply chasing the latest product.
Build Supporting Processes
The main advantage of ADCs—particularly in a profile dispensing environment —is that users are unable to access a medication without a specific order. Depending on the configuration of your cabinets, however, this restriction may still allow access to other medications. With matrix drawers, the nurse will receive a patient-specific drug order which triggers the machine to open, leaving 30 to 50 different drugs openly available in that matrix drawer. Thus, the error prevention measures are mitigated, as the nurse is once again expected to pick the right drug from many choices. Consider this situation: the nurse pulls a ten pack of a particular drug and tears off a single dose per the order, but replaces the remaining nine doses in the wrong matrix pocket. The next nurse will expect that all the drugs are in the correct location, and perhaps in a hurry will not read the label, creating a medication error. Remember that having new technology can foster a false sense of security and that without supporting processes, real safety measures can degrade over time. In order to help address this at Huntsville, we have been converting our matrix drawers to pockets that open individually to restrict access to a single medication at a time.
Continuing to limit the options that an end user has will help cut back on errors, but any system that ultimately relies on human actions is susceptible to failure. Hence, supporting systems become even more important. I am sure we all remember the infants who died in Indianapolis in 2006 due to massive Heparin overdoses, as well as the well-publicized Quaid twin overdoses just a few months later. Ironically, approximately two months prior to the Indianapolis incident, Huntsville had instituted bar coding upon restock to defend against placing the wrong drug in the wrong slot. As it turns out, most errors involving wrong drugs being placed in ADC drawers occur upon restock. To avoid this, the simple answer is to educate users to never return any product—whether it was removed by accident or any other reason—to the ADC itself, and instead create a process for users to place unused or wrongly pulled medications in a return bin that is governed by pharmacy. End users should never replace products directly back in the dispensing area of an ADC once they have been removed.
Ensure Safe Stocking Processes
Although Huntsville Hospital is in the process of adding BCMA to our operations, we do not currently have that system in place. However, this does not keep us from using bar code scanning to improve safety in lieu of system-wide BCMA. For us, safety processes for stocking ADCs begin in the main pharmacy where we use a carousel system that has a sophisticated bar code process. Restocking is driven via an interface between our ADCs and the carousel, wherein batch restock orders are sent electronically to the carousel as needed. For example, if 0.1 milligram tablets of Clonidine need to be replaced in a specific cabinet, there are no points in the transmission of that order where human error can cause a mistake; the order is direct from one system to the other, which of course has been tested for fidelity.
At this point, a pharmacy technician is notified that there is a restock that needs to take place. The technician selects the proper batch refill at the carousel, which produces the correct drugs in the appropriate amounts. The technician scans each product label for accuracy, as well as the bin it is delivered in, before placing the medications in a bag that is also bar coded with a label generated by the carousel and scanned. When the product reaches the specific ADC, the technician will scan the bag’s bar code with the ADC scanner, which indicates whether the technician is delivering to the right cabinet. If it is correct, the screen will indicate an affirmative, the appropriate pocket will open, and its corresponding bar code will be scanned to confirm that it should hold the drug being stocked. This process establishes bar code scans at no fewer than four points during stocking and ensures the right medication has been retrieved and is stocked exactly where it should be, every time.
So while we do not yet have a formal BCMA process in place, we have incorporated the safety of bar code scanning into the stocking process. We have a similar scanning system in place for stocking medications in the carousel. Likewise, the nurse or end user will scan any products mistakenly pulled in order to place them in the ADC’s return bin, and the technician scans them again to restock the carousel with returned items.
Communicate with Your Vendor
Just as intercommunication is vital to hospital departments working together, having as transparent a communication line as possible with your vendor is also very important. Keep in mind that for the most part, automation vendors focus on bringing about an intended series of actions for that piece of technology and do not necessarily focus on the safety benefits it will bring. The vendors may tout safety benefits, but in my experience, they have done a poor job of developing a way to measure such benefits. The reason for this is likely twofold; first, most customers are not asking vendors to provide these measurements, and second, it can be very difficult to establish a baseline for improvement because there is no way to track errors under traditional, manual systems. As vendors, they lack the incentive to provide extra services that may be expensive to enact and that no one is asking for.
Another issue to resolve through open communication with vendors is unreadable or illegible bar codes printed by the manufacturer. Pharmacies commonly receive bar coded products that no scanner can actually read due to poor printing. At Huntsville, we administer roughly 14,000 doses a day, and if you account for 20% without a readable bar code—or no bar code at all—that equals 2,800 doses that need to be manually bar coded each day. It is easy to gripe about the manufacturer, but in reality, we should be providing feedback to those manufacturers and if necessary, stop doing business with them until they correct the issue. We ask for feedback on our own internal processes, so we should be willing and able to provide beneficial feedback to our vendors. Unreadable bar codes lead to work-arounds and a loss of faith in the system in general, which then negates all the goals of the system in the first place.
Too often, pharmacy directors, especially new ones, are so focused on the processes involved in bringing new technology on board that we overlook opportunities to consider how we can use automation to drive safety. Directors are sometimes unaware that systems such as ADCs should be able to generate reports on, for example, successful scan rates, so few of us ask the vendors to provide these services as a matter of course. If we are not collectively pushing vendors to provide the capabilities we need, then they have no incentive to do so. While ADCs are a very mature technology, there is always room for improvement, just as there is with clinical pharmacy practice. Finding the right balance between efficient implementations and measurable safety improvements is the key.
Michael R. McDaniel, RPh, MBA, FASHP, is director of pharmacy services at Huntsville Hospital in Alabama. He is a 1977 graduate of the University of Oklahoma College of Pharmacy and received his MBA in general business in 1990 from the Amberton University in Dallas. Also in 1990, Michael was named an SKB-Fellow of the Leonard Davis Institute of Healthcare Economics, University of Pennsylvania, Wharton School of Business. In 2000, he was named a Fellow of the American Society of Health-System Pharmacists.