In today’s hospital pharmacy practice, the use of automated dispensing cabinets (ADCs) is practically universal. Since first being introduced, numerous upgrades and developments to both the hardware and software components of ADCs have allowed for this technology to enable significant improvements to hospital pharmacy operations. While the ability to securely stock medications outside of a central pharmacy location and closer to patients is the primary function of ADCs, there are many other benefits that can be reaped by maximizing the potential of the software that accompanies this technology.
As an 851-bed, comprehensive tertiary referral hospital, Lakeland Regional Medical Center (LRMC) in Lakeland, Florida, operates a Level II trauma center, a Level II neonatal intensive care unit, and the state’s busiest single-site emergency department with over 1,300 annual trauma visits. The pharmacy comprises approximately 120 FTEs (pharmacists and technicians included) and our distribution model features bar code verification from wholesaler to bedside, enabled through a perpetual inventory management system that includes carousels, a unit dose packing machine, and 95 ADCs.
Transparent Inventory Control
LRMC began using ADCs in 2000 when 63 units were installed on the medical floors. However, the ED was not part of this initial roll out. Over the years, as the number of ADCs rose to 95, we began implementing them in the ED, where we now have 22 in use. The ADCs have proven quite helpful in the ED, mainly due to expedited access to critical medications for nursing. When using EHR-assisted treatment plans, the stocking of ADCs with products consistent with those plans allows our nurses immediate access when an order is received. Furthermore, we expect the number of ADCs used in the ED to grow subsequent to an upcoming ED expansion and the addition of a new pavilion for women’s and children’s care. In addition to increasing the number of ADC units, the percentage of drugs dispensed through ADCs has grown from approximately 70% in 2000 to 90% today (all other medications come from the central pharmacy in a batch fill process). Given the growing number of ADCs and the increased reliance on them for the vast majority of our medication distribution, transparent inventory control became essential to a safe medication management program.
Along with our increased dependence on ADCs, we began analyzing medication use patterns in order to help optimize the inventory in each cabinet. Through the system software, ADC administrative users can issue daily reports to help determine whether medications not currently stocked should be added to the ADC, whether par levels need to be adjusted according to usage, and whether there are seldom-used medications that should be removed. This activity is especially important if areas of the facility experience a change in patient population. For a facility like ours which is undergoing significant physical growth, we are able to easily move ADCs to adjust to new operations and specialties.
Value of Communication
The basic goals of medication inventory management are to reduce discrepancies, identify trends that can help streamline distribution, and minimize product expiration and stock outs. Vital to enabling these goals is training staff to pay close attention during stocking and dispensing processes. Although bar code verification during both ADC product stocking and removal can provide ample security against erroneous product selection, the process is not foolproof—a product’s bar code may fail to scan, the product may have the wrong bar code label attached to it, or some other human error or workaround may lead to the selection of the wrong product. Thus, placing emphasis on and encouraging communication between nursing and pharmacy in the event of an unexpected dispense is paramount. Likewise, pharmacy should have clear and strong communication pathways to nurse managers in the event a discrepancy is discovered by the pharmacy first.
Beyond this, restocking ADCs can be particularly facilitated through the use of custom reports that not only show drug usage for each area, but also the time frame of usage, or the average time it takes for a medication to run out in a specific area. Keep in mind, there is a fine line between loading too much inventory into an ADC (thereby creating waste) and loading too little to accommodate nursings’ needs. To maintain distributive efficiency at LRMC, we attempt to restock specific medications no more often than every three days, as this helps avoid the downtime that can result from more frequent stocking. To further minimize such delays, no more than five registered nurses are assigned to any single ADC, thereby minimizing queues at the ADC.
Using the report that lists expiration dates by area/ADC, we can determine medication use trends in comparative areas and then redistribute medications nearing expiration to other areas of need. Our stocking technicians are well aware that rotating medications among ADCs is key to reducing waste and maximizing stock. Furthermore, maintaining a strict and transparent view of stock goes a long way in reducing diversion opportunities. In this regard, we regularly compare the administration event record documented by the nurse with the dispense event record from the ADC software. Any issues or discrepancies found therein are quickly investigated and resolved.
To improve nursing’s utilization and satisfaction with ADCs, we place extra emphasis on nurse training for medication management. Even though ADC systems can be intuitive, thorough initial nursing-staff training is critical to proper use going forward. There should be an established method, documented in a written policy, for correctly logging into the system, retrieving a medication, and recording the process in as little time as possible. Additional written protocols must be in place if unused or wasted medications are returned to the ADC. Emphasizing teamwork and interdepartmental collaboration gives nursing staff a sense of ownership and a direct link for any questions or concerns. Identifying super users within the nursing staff to answer questions and troubleshoot after training also will significantly enhance employee satisfaction.
When it comes to the connection between regulatory compliance and ADC usage, the most common inquiries are related to controlled substances management and diversion prevention. As mentioned, we regularly review dispensing-versus-administration records for discrepancies—a process that includes a standard deviation threshold—and we also run an annual inventory summary to meet our controlled substance inventory requirement (this report includes non-controlled items as well). The most utilized report reviews current velocities for drugs in a specific area, which simplifies the process of establishing recommended minimums and maximums according to how often a particular drug is stocked.
To make sure the devices are working properly, the pharmacy should run an ADC system-settings audit upon initial installation and after the release of any new software updates. Also make sure both management and end users understand the breadth of any software updates so as not to disrupt proper usage. As ADCs have become more sophisticated over the years, they are no longer simply seen as storage receptacles. With powerful reporting, trending, and security features now commonplace, this technology can be quite useful in all areas requiring quick and consistent access to medications, including busy ED settings. The key is maintaining vigilance and listening to questions and complaints from front-line employees to ensure the technology is used to its fullest potential.
Alison Kagel, CPhT, has been a pharmacy technician at Lakeland Regional Medical Center in Lakeland, Florida, for almost 12 years. She is a nationally registered pharmacy technician through the Pharmacy Technician Certification Board.