Since automated dispensing cabinets (ADCs) were originally introduced in hospital pharmacies in the 1980s, the idea they embody—keeping patients safer by improving the storage and dispensing of medications—has not changed, but the technology that powers these machines is continually evolving. As ADC design and functionality improves to meet pharmacy demand, attendant safety mechanisms must remain abreast.
Brigham and Women’s Hospital (B&W) in Boston—a 750-bed, tertiary academic medical center—has 45,000 admissions and 57,000 visits to the emergency department (ED) each year. As well, our pharmacists review over four million orders and prepare over 500,000 sterile products each year. In the course of these activities, approximately 2,500 nurses and 250 anesthesiologists depend upon 120 ADCs throughout the facility. ADCs are used in inpatient areas (in both intensive care and nonintensive care units), recovery rooms, procedure areas, outpatient clinics, the ED, and operating rooms. The nursing staff use our electronic bar code medication administration (BCMA) system in all inpatient areas of the hospital, and we aim to roll out BCMA in other areas (ie, recovery rooms, labor and delivery, and the ED) starting in 2012.
Evolving ADCs Safety Initiatives
We have used ADCs at B&W since 1996. During that early period, ADCs functioned like locked medication cabinets from which nurses simply took whatever medications they needed, much like a vending machine. Over time, ADCs have evolved to include various safety features and monitoring capabilities that have allowed us to improve this condition.
By interfacing with the pharmacy information system (PIS), we were able to institute patient profiling based on pharmacist review of orders. Our ADCs are now configured to allow access to emergency medications, with approval from the P&T committee, without pharmacist review; however, nonemergency medications are restricted. Improved reporting capabilities also have allowed better monitoring and tracking of both controlled and noncontrolled substances. ADC alerting features denote high-risk medications and communicate relevant information to the nursing staff, and our most recent safety initiative incorporates bar code scanning features during the stocking process.
Bar Code Verification for Restocking
While our previous system of filling ADCs worked well, it was not perfect. The process entailed technicians filling from restock labels generated by our inventory system. A pharmacist then would check the product and the technician would bring the medications to the floor and restock the ADCs. Too often we found that the correct medications would be sent to the cabinet but would then be stocked in the wrong locations. Given that high-risk medications such as insulin, anticoagulants, and potassium chloride bags were among the products being restocked, it was clear we needed a more rigorous system.
To address this problem we decided to use the bar code scanning capabilities on the cabinets during the restocking process. Because our PIS dictionary did not interface with the ADC dictionary, all the medication bar codes had to be individually scanned and added to the ADC dictionary. As part of this process we were able to assess which bar codes did not work in the system. We also determined that the scanners on our ADCs were able to handle one-dimensional (1D) bar codes, but not two-dimensional (2D) bar codes. This meant that any packages created by our pharmacy system could not use the bar code scanning feature, as our pharmacy system only produces 2D bar codes, which capture the lot and expiration date in addition to the NDC number. It took a few months to scan all the medication bar codes into the system and identify the 1D bar codes that could not be activated for scanning once we were ready to go live.
In order to accurately gauge if additional restock time would be needed to accommodate the bar coding step, we piloted the practice with only a few cabinets. Like any new process, it took some time for the technicians to familiarize themselves and determine the most efficient approach. During the trial process it became clear that some workflow changes were necessary. Because we were opening a new building on campus at the time, we had the benefit of two new technician positions available to us. While there was some expansion of services, the two positions, along with adjusting and balancing the workflow, made rolling out the bar code implementation easier.
After all our technicians were trained on the new ADC scanning feature, we used the ADC reports to review the staff members’ scan rates and identify unscannable items. This helped us pinpoint which staff needed further education on the process. It also clearly identified the items that were inadvertently missed when we completed the initial scanning or that were entered incorrectly. As new items arrive at the pharmacy, they are added to the ADC dictionary, ensuring they will scan properly at the cabinet.
Scanning Medications Out of the ADC
Since BCMA is in place in our inpatient areas, we do not require those nurses to scan medications out of inpatient ADCs. However, we chose to require scanning upon issue from all ADCs on units where BMCA is not in place, such as the postanesthesia care unit, the ED, labor and delivery, and at any other procedural or clinic-based ADC. Following a review of incident reports, a group of incidents were identified in which the implementation of bar code scanning upon issue from the ADCs could have prevented the wrong medication from reaching the patient. While scanning upon issue is not as complete a process as our BCMA system, it was clear that an additional safety step was needed for the interim period until BCMA is implemented in these units.
To ensure buy-in to this process change, we met with the nurse managers and nurse educators to develop ideas regarding new workflows for issuing medications. Most nurses felt that the new step was easy to implement and did not add much time to the issuing process. We prepared a short presentation detailing the exact process adjustment and the benefits of the change. The nurse educators made sure all staff using the ADCs saw the presentation and were trained on the new process. We use override reports and scan rate reports, which identify any products scanning incorrectly, to track our progress and make any necessary adjustments.
For most item returns issued from our ADCs we use a return bin; nurses return items to the bin and not to the actual storage location. For a few larger sized and low-risk medications, we do allow nurses to return directly to the ADC stock locations, using the bar code scanning feature to help ensure the proper medication has been returned. Items in this category include sodium bicarbonate liter bags and bacitracin liter irrigation bottles.
Areas for Future ImprovementTaking advantage of the bar code scanning features on ADCs is certainly beneficial to reducing the risk of restocking errors. We have seen a decrease in the number of restocking errors reported since implementing this approach, and bar code scanning on issue has been a good interim step while preparing for BCMA implementation in other areas of our institution. We are confident that these steps, along with restock scanning, can prevent some of the errors associated with the incorrect stocking of medications in ADCs.
While ADC scanning improvements have helped, there are additional areas where cabinet manufacturers can upgrade their systems. As more drug manufacturers add lot and expiration dates to their product bar codes, ADC scanners need to be able to read multiple types of bar codes. They also should be programmed to fully use the information contained in these bar codes. Including an alert that informs staff of an expired medication during the stocking or issuing process would be useful. Another option we would like to see is the ability to program the ADC so that each individual medication package being stocked or issued would require a bar code scan.
For example, when ten potassium chloride bags are restocked (or issued), the system requires only one of the ten bags be scanned, despite the possibility that one of the nine unscanned bags could be incorrect. While scanning each individual package may increase restocking time, the ability to assign a forced function requiring certain medications be scanned item by item should be made available. High-risk medications are a particular safety concern; an ADC setup whereby high-risk drug packages are scanned one by one would be quite valuable.
While taking advantage of technology such as BCMA is an important safety measure, improved technology alone does not guarantee patient safety. Failure to use technology appropriately, employing workarounds, and overriding alerts are all concerns when BCMA is in use. Pharmacy should systematically review BCMA reports to evaluate overrides and identify system weaknesses, as well as monitor and measure compliance to identify and remove barriers to proper ADC usage.
ADCs have changed a great deal from the quasi-vending machines of previous decades. Technology has dramatically improved many features of these units, including security measures, the ability to meet regulatory requirements for proper storage, inventory control, and bar code scanning to prevent errors in stocking and issuing medications. Although there are ADC improvements that still need to be developed, when used in conjunction with other types of automation (computerized physician order entry, BMCA, smart pumps, etc), ADC technology is an important tool for ensuring patient safety.
Michael C. Cotugno, RPh, worked at Brigham and Women’s (B&W) Hospital for 17 years as a clinical pharmacist and pharmacy supervisor before assuming his current role as the director of pharmacy, patient care services. He received his BS in pharmacy from Northeastern University in 1991 and is a member of ASHP and the Massachusetts Society of Health-System Pharmacists.
Angela Triggs, RPh, has worked at B&W for 14 years as a perioperative staff pharmacist and supervisor. For the last seven years she has been the operations manager for central pharmacy distribution, including controlled substances and ADC operations. Angela received her BS in pharmacy from Massachusetts College of Pharmacy in 1991 and is a member of ASHP and the Massachusetts Society of Health-System Pharmacists.
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