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October 28, 2021

Illuminate 2021: Common Medication Safety Hazards with Automated Dispensing Cabinets

Len Hom
Director, Product Marketing, Omnicell

While there are many benefits to using automated dispensing cabinets (ADCs), such as increased inventory control and efficiency in drug dispensing practices, limits on configuration and functionality combined with underutilization of safety procedures can pose serious risks.

Experts from the Institute for Safe Medication Practices (ISMP) recently hosted an interactive discussion during Omnicell Illuminate 2021 about common medication errors related to these systems.

According to Christina Michalek, BSc Pharm, RPh, FASHP, Medication Safety Specialist, and Susan Paparella, MSN, RN, Vice President, there are common practitioner biases associated with healthcare technology, such as systems and environments. The most influential factor involves user interface issues that affect how users interact with the technology. This is especially true when it comes to automated dispensing cabinets.

Healthcare practitioner biases with technology can lead to inherent risks, including staff trying workarounds, shifting behaviors, and complacency, thus leading to errors. ISMP has established guidelines and tips to address medication safety hazards associated with ADC use to help navigate these risks and support safe patient care.

One issue for ADC users to consider is their cabinet layout, tower configuration, and refrigeration. Many medications come in look-alike packages, while there is also a need to manage high-alert medications or those that require assembly before administration.

ISMP recommends using secure storage configurations to minimize exposure to risk. They state that it's best to maximize the use of locking lid bins and secured compartments, instead of storing high-alert medications in open matrix drawers or refrigerated units, as these are all susceptible opportunities for diversion. Matrix drawers should only be used for non-controlled substances.

Security is equally important. Limiting access and defining user privileges for specific practitioner types, along with implementing procedures to manage ADC discrepancies, and support better tracking of medication.

Anesthesia dispensing systems are a vital part of an operating room. ISMP recommends that you work with others to hold one another accountable for workflow management and monitoring metrics so that all medications can be accurately dispensed and administered.

Trying to keep track of inventory is a difficult task. The process becomes easier when you use effective management techniques like creating standard nomenclature for naming, reviewing existing names, and brand names versus generics to ensure that your drugs match the Medication Administration Record (MAR).

The safety of patients and staff is a top priority at all healthcare facilities. Before removing any drugs from the ADC, you must have an electronic order submitted and verified by pharmacy or another method to confirm it with appropriate clinical staff. Leveraging software that is interoperable with your MAR can help to alleviate inaccurate selections and streamline workflow.

In the end, safe ADC use must be fundamental. You can achieve safer practices by:

  • Learning from the experiences of others about preventable events
  • Creating awareness of technology biases
  • Sharing examples in safety huddles and reports
  • Optimizing functionality
  • Using the guidelines from ISMP to enhance your ADC safety profile

Visit the Omnicell Illuminate 2021 replay page to view the full webinar "Addressing the Top Ten Medication Safety Hazards with ADC Use."

The views and opinions expressed in this blog are those of the authors and do not necessarily reflect the official policy or position of any other agency, organization, employer, or company. Assumptions made in the analysis are not reflective of the position of any entity other than the author(s). These views are always subject to change, revision, and rethinking at any time and may not be held in perpetuity.