Pharmacies Should Review Automated Dispensing Cabinet Practices

Most of health system pharmacies provide services to a mix
of inpatient and outpatient care areas and use automated dispensing cabinets (ADCs). How ADCs are used varies slightly by facility, internal policies, and location. Many health systems use ADCs as their primary means of medication distribution and documentation throughout the campus.^1,2 Several vendors manufacture these ADCs and offer a wide variety of hardware and software configurations, features, and workflows. All configurations and products are designed to address differing needs across a complex distribution process. Also, during the pandemic, many facilities have used temporary staffing with differing levels of experience in using ADCs. These variations make it difficult to standardize practices among facilities. In addition, diversion and improving medication safety remain issues that health system leaders must address. Looking at how ADCs are used is paramount to addressing these concerns.

The Institute for Safe Medication Practices (ISMP) recently issued updated guidelines for safe use of ADCs. The goal of this guidance is to help ensure that pharmacies adopt standard practices and processes that complement ADC design and functionality specifications.³ Pharmacy leaders are encouraged to review institution-specific practices to ensure adherence to ISMP recommendations.

A full breakdown with case examples is available for pharmacy leaders on the ISMP website.

How ADCs are used at an institution can greatly affect the potential for a drug error. As access and volume increase, so does potential for an incident to occur. When reviewing or updating ADC policies, it is often smart to apply the ISMP best practices to existing policies to ensure that pharmacies are providing the safest possible environment for patients and staff members. It is also good internal practice to be proactive and periodically review in-house incidents and alerts issued through various notification systems as well as those involving nursing and pharmacy staff members. Educating staff members and taking preventive action where known hazards exist are good ways to improve overall safety and reduce risk in the pharmacy.

When reviewing internal policies and procedures, start with the core elements
of the ISMP Targeted Medication Safety Best Practices for Hospitals.³ Following are recommendations from those practices.

Engage nursing. Pharmacy staff members should work with nursing to develop best practices, competencies, and procedures for safely conducting transfers and withdrawals from ADCs for bedside administration. The use of barcode technology throughout this process adds a layer of safety.

Establish ADC system security. Pharmacy staff members should ensure that there is adequate oversight where ADCs are located. Conducting frequent audits, keeping high-risk and high-theft products as secure as possible, and removing former employees’ access are all important steps.

• The ISMP recommends using profiled ADCs and monitoring overrides for the system. This helps ensure that there has been a pharmacy review and that problematic items are identified quickly. Limiting the number of medications that can be removed by override is considered a best practice. This helps prevent administration of medications that do not have active orders while keeping emergency medications available. Pharmacy staff members should also proactively audit overrides to ensure that safe practices are followed and appropriate documentation is completed.^2,4
• Maintain optimal equipment and inventory configuration. Inventory should be reviewed frequently so that modifications can be made to ensure that each ADC configuration maintains the optimal inventory for the space available.
• Pharmacy leaders should ensure that environmental conditions for the safe use of ADCs are implemented. The ISMP recommends placing ADCs where there is adequate lighting, enhancing existing lighting, and ensuring the area is clean and free of debris. There should also be adequate space to complete tasks performed by aides, nurses, and pharmacy technicians such as documentation or electronic charting.
• Pharmacy staff members should ensure that all ADC areas are maintained in the appropriate configuration and functionality and updates are performed in a timely fashion. This minimizes variation and the associated risk that can occur from out-of-date equipment or software.
• Provide frequent education. Pharmacies should provide frequent staff education on ADCs, including areas of concern, ways to get additional information from pharmacy services or the software, and what is different or new. This includes the use of pop-up warnings.²
• Review internal ADC stocking and return processes. This ensures that staff members follow best practices, including using barcode scanning when available.
• Use safety alerts wisely. Pharmacies should use the ADCs to display and flag important patient and drug information, such as allergies, high-risk medications, and interactions, when the technology is available.

Regardless of how health systems use ADCs, pharmacies should periodically conduct thoughtful reviews to ensure that staff members are using recommended best practices. A continual competency and education program can help ADC managers ensure that staff members are adequately trained and performing according to these specifications.

Craig Kimble, PharmD, MBA, MS, BCACP, is an associate professor of pharmacy practice, administration, and research and director of experiential learning at Marshall University School of Pharmacy in Huntington, West Virginia.

References

1. Schneider PJ, Pedersen CA, Scheckelhoff DJ. ASHP national survey of pharmacy practice in hospital settings: dispensing and administration-2017. Am J Health Syst Pharm. 2018;75(16):1203-1226. doi:10.2146/ajhp180151

2. Rhodes JAM, McCarthy BC. Automated dispensing cabinet technology limitations compromise patient safety. Am J Health Syst Pharm. 2019;76(18):1372-1373. doi:10.1093/ajhp/zxz153

3. Targeted medication safety best practices for hospitals. Institute for Safe Medication Practices. February 9, 2022. Accessed February 22, 2022. https:// www.ismp.org/guidelines/best-practices-hospitals

4. Guidelines for the safe use of automated dispensing cabinets. Institute
for Safe Medication Practices. February 7, 2019. Accessed January 29, 2022. www.ismp.org/node/1372