Robots Can't Beat Risky Practices

Careful use and maintenance are needed to ensure that automated systems successfully reduce the risk of medication errors.

Automation and computerization of medication use processes and tasks can lessen human fallibility by limiting reliance on memory. One example is the use of robotic prescription preparation and dispensing technology. Robotic dispensing can reduce the risk of medication errors if the system is properly installed, maintained, and refilled. However, errors can reach many patients if safeguards are not utilized to assure the correct drug is stocked in the robot.

Refilling Errors

The Institute for Safe Medication Practices recently received a report in which a patient received from a community pharmacy a prescription vial that contained 2 different medications. During the follow-up investigation, the pharmacy established that both medications were dispensed via their robot. When they examined the cells for those drugs, they found a mixture of both tablets in one of the cells.

The standard process for refilling a specific cell in the robot requires the pharmacy technician to scan the cell and then scan each bottle of medication added to the cell. This accomplishes 2 things: the system verifies that the correct drug is added to the correct cell, and the system can maintain an accurate count of tablets in the cell. In the case above, it is thought that the technician only scanned the first bottle of medication she added to the cell and skipped scanning the second bottle, which was a different medication. Thankfully, the patient discovered the mistake before it caused any harm.

Restocking Errors

In a separate case, an inpatient nurse discovered fenofibrate (TRICOR) in a unit-dose package labeled “nifedipine extended release 30 mg.” The hospital’s pharmacy department typically repackaged nifedipine specifically for use with robotic dispensing equipment, but fenofibrate was packaged in unit doses using a different system. Pharmacy investigation revealed that all packaging logs and expected inventories for both medications were correct.

Upon closer examination, the nurse who discovered the error noted that the nifedipine package seemed to have a slight tear in it. It was learned that another patient who had been taking both fenofibrate and nifedipine had refused a dose of fenofibrate. Subsequently, that patient’s nurse inadvertently inserted the unused fenofibrate tablet into the empty nifedipine package, and then returned it to the patient’s medication drawer.

The medication, labeled as nifedipine, was then returned to pharmacy, and eventually restocked into the robotic dispensing machine with other nifedipine doses. Because the bar code remained intact, the robot dispensed the medication (labeled nifedipine but now containing fenofibrate) to the second patient, where the error was discovered prior to administration.

Developing Error-Reduction Strategies with Robotics

When errors like these occur, educational efforts should be widespread among all personnel involved in the process, rather than remedial and directed at only the personnel involved in the error.

Pharmacy staff should inspect packaging carefully before allowing the return of any drug product to stock. Once a drug is removed from packaging, it should never be returned to that package. Rather, it should be appropriately discarded.

Managers and/or regional personnel for chain pharmacies should periodically perform quality control checks by observing the processes involving robotics and automation to ensure adherence to the standardized work practices. Before selecting and installing robotics:

• Review the advantages and disadvantages of each type of system available
• Assess the size, location, and integration in the overall work flow of the pharmacy
• Consider vendor support and response time when system malfunctions occur

Making these considerations before incorporating a robotic system into your pharmacy can be a first step in preventing robotics-related errors.

Dr. Gaunt is a medication safety analyst and the editor of ISMP Medication Safety Alert! Community/ Ambulatory Care Edition.