Tips to Improve Pediatric ADC Safety

May 2011 : Automated Dispensing Cabinets - Vol.8 No. 5 - Page #8

ISMP guidance on the interdisciplinary safe use of automated dispensing cabinets (ADCs) applies to pediatric patients as well as adults. All the same principles apply to pediatrics and should be used as the foundation for improving ADC safety. ISMP’s Self Assessment on ADCs ( can be particularly helpful in identifying site-specific safety gaps. The ISMP Web site also provides a quality improvement handbook that allows for comparison of your institution’s score to aggregate data based on other institutions’ responses.

Use separate ADCs for pediatric patients. Ideally, pediatric patients should be physically separate from adults in specific pediatric units, complete with unit-specific ADCs. In cases where the patients are not physically separated, different cabinets are recommended. When this is not possible, designate a specific drawer(s) for the pediatric population.

Review the concentrations and maximum quantities of all medications that will be stocked in the pediatric ADCs. Dosing errors are the most common harmful errors in pediatric patients; a child who accidentally receives an incorrect dose is more likely to have a poor outcome than an adult. Because of this heightened risk, lower concentrations and smaller quantities of medications should be stored in pediatric ADCs. It may seem simpler to keep large quantities of medications within an ADC to reduce restocking requirements, but this increases the risk of overdose. For example, fatal errors have occurred when the mL concentration was interpreted as the vial size, particularly with fosphenytoin. Limiting the number of vials can help prevent such errors. This may require more frequent restocking in order to reduce PAR quantities to 24-hour average use or less.

If open matrix drawers cannot be avoided, then separate different doses or strengths in individual drawers or doors. Open matrix drawers and doors on cabinets present the opportunity to choose the wrong medication. If they must be used, it is advisable to avoid stocking different concentrations in the same drawer or door. Some examples are albumin 25% versus 5% or ibuprofen 200-mg tablets versus 800 mg. This also applies to look-alike/sound-alike products, such as epinephrine and ephedrine. A helpful technique is to open each matrix drawer or cabinet door and scan for similar products. It is more difficult to do this successfully using only an inventory list.

Partial tablets should be packaged by pharmacy. Having half or partial tablets is a more frequent occurrence in pediatrics than for adult patients; these medications should be packaged by pharmacy and placed in the ADC or provided as a patient-specific dose. This approach averts the risk of giving the whole tablet rather than the intended portion.

Bulk vials and oral liquid bottles should not be used in an ADC. It is poor practice to require nursing to withdraw a smaller amount from a bulk container that is then returned to the ADC. If smaller unit-of-use containers are not commercially available, then the pharmacy should produce and stock these in the ADC. 

Avoid returns to ADC pockets. When medications are not used after retrieval from an ADC, they should go to a return bin in the ADC or directly to the central pharmacy bin, and not back into ADC drawers. Returning medications back into drawers increases the potential for errors in placement. Allowing pharmacy only to stock the ADC through their established procedures adds an additional layer of safety for patients. 

Controlled substances should be witnessed and wasted prior to administration. As mentioned earlier, dosing errors are the most common pediatric errors, and a contributing risk factor is using a unit dose that is larger than the patient’s dose. This not only increases the frequency and amount of wastage, it also provides the opportunity for 10-, even 100-fold overdoses. Requiring a witness and wasting before the medication is administered provides an opportunity to catch an error before it reaches the patient.

Prohibit the storage of nonmedications (eg, pagers, DVDs, keys, tracking rings) in the ADC as they require the use of overrides to retrieve them. This inadvertently encourages the use of overrides, which should be used only in the event of true emergencies.

Jared J. Cash, PharmD, BCPS, currently serves as a pharmacy clinical coordinator with Primary Children’s Medical Center in Salt Lake City, part of the Intermountain Healthcare system. He is a pediatric consultant to ISMP and an adjunct assistant professor of pharmacy practice at the University of Utah. He is also on the Pediatric Pharmacy Advocacy Group’s board of directors and is board certified in pharmacotherapy. Jared received his doctor of pharmacy degree from the University of Florida College of Pharmacy.


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