How do computer-controlled dispensing systems decrease medication errors

This study was conducted in two of the eight hospitals run by HMC, HH, and NCCCR. It explored nurses’ perceptions of and satisfaction with the use of the ADC system in the two hospitals. The safety characteristics of ADCs have improved progressively over the years, but concerns about their use remain. Such worries include the potential to bypass safety features, managing overrides, queuing, making selection errors, storing high-alert medication, and using unsafe practices for medication removal and transportation to the bedside [7, 8]. It is important to improve working conditions for nurses, as this will improve their satisfaction with their work. The results of this study revealed that, overall, nursing staff were satisfied with the use of the technology and believed it facilitated their work and could contribute to safer healthcare and possible reduction in medication errors and “near misses”.

A cross-sectional study conducted in Canada found similarly positive perceptions. Nurses there considered ADCs made their work easier, and helped to provide safe patient care and reduce medication incidents or errors [5]. The majority of nurses agreed that they could do their job more safely using the ADC system, and that it made their job easier. ADCs can decrease the risk of medication errors, but only when cabinet use is carefully planned, and specific safeguards are consistently available and used. Profiled systems are one of the most important safety enhancements to be made to ADCs during the last decade. This safety feature provides a direct interface between the pharmacy information system and ADCs, so pharmacists can profile, screen, and approve medicines before they are removed from the cabinet for administration [7, 8]. Medicines with similar names or packaging, controlled substances, and high-risk medication can all be separated. High-risk medication can be linked to clinical warnings, and safety updates can be implemented easily across departments using the ADC system [8]. Automated dispensing machines eliminate the dispensing of unused “as-needed” doses, thereby lessening the potential for administration errors [1].

In this study, 48 nurses claimed that the ADCs prevented or reduced medication errors, but the impact was not investigated further, and more studies are needed to verify the claim. Although 86 % of the nurses agreed that all drawer types assured safe access and removal of medications, 12 nurses commented that the open matrix drawers were unsafe, and 16 suggested replacing the open matrix drawers with locked-lidded drawers. These can provide a higher level of security by allowing access to only one pre-selected medication at a time. High-capacity, low-security, matrix drawers, which hold large quantities and allow open access to all medicines in the drawer, should be used only for the lowest-risk medicines that otherwise cannot be stored in sufficient quantities [7]. In the 2007 survey by the Institute for Safe Medication Practices (ISMP), just 50 % of respondents said that ADCs were configured with individual compartments for each drug rather than matrix drawers with access to multiple drugs [7]. This suggests that additional controls and process improvements are needed to reduce risk [8].

The questionnaire contained five statements about training on ADC systems. Nurses agreed that they could use the system confidently after minimal training. The training materials provided were informative and adequate, and the nurses were adequately trained by the ADC representative or another nurse prior to the system going live. The nursing staff also agreed that the pharmacy personnel had been responsive in answering questions and resolving any issues. The ADC system managers at both hospitals had ensured that all nurses received standardized education materials and training, and nurses had only been given access to the system when they had passed a competency assessment. The majority of nurses therefore found the ADC system easy or very easy to use.

The majority of nurses also reported that the physical layout of the system was user friendly. The nurses were able to administer medication more efficiently, on time, and in the right dose using the ADC system. Profiled ADCs ensure that nurses can only administer medication that has been reviewed by a pharmacist. The ADC system also interfaces with the pharmacy management system, electronic medical records, and admission/discharge/transfer and materials management, all of which serves to support the medication process [2].

The majority of the nursing staff in both hospitals reported that there were rarely discrepancies when doing narcotics counts. According to the ISMP, ADCs are designed to contain high-risk medication [7]. Automated dispensing machines provide secure medication storage on patient care units, supported by electronic tracking of the use of narcotics and other controlled drugs. Reports can be generated to help identify and prevent potential problems. Automated dispensing machines save nursing time by eliminating the need for manual end-of-shift narcotic counts in these units [1].

A significant number of nurses agreed that they spent less time waiting for medication from the pharmacy than before the ADC system was installed. When nurses were asked to say what they liked about the system, 58 wrote that they valued being able to administer medication without delay and without waiting for them to be delivered from the pharmacy.

The time elapsing from when an order was written and sent to the pharmacy, and when it was available from the ADC system, was acceptable to nurses. There were 37 written comments that highlighted that the time required to fulfil a prescription was slow, especially for urgent or emergency medication requests. According to HMC’s medication policy, urgent medication should be administered within 30 min of being prescribed by a physician [9]. Pharmacists may therefore need to educate nurses to help them identify when medication is urgent. They should also audit and track urgent and emergency medication orders to review and improve the process.

Although 49 nurses commented that they disliked having to queue for patient medication, close to two-thirds of the nurses responded that they rarely had to do so. Queuing is a major difficulty frequently associated with ADC use. In the ISMP ADC survey (2008a), almost one third of frontline nurses reported always or frequently queuing to access the ADC [7]. Queuing is often a symptom of larger issues that lead to workflow barriers. ADC-generated reports can be used to determine if certain access points are being over-used. Data showing much more activity on one device than another can help support the need to provide additional access points.

The majority of the nurses agreed that the system would work better if the ADC system contained more drugs, and 60 nurses suggested adding all HMC’s formulary medication to the ADC system. About 95 % of formulary medications are available in the ADCs. Both hospitals’ Pharmacy and Therapeutics Committees have established criteria for including medication in the inventory. These include requirements that hazardous drugs, or medications that require extensive dilutions or calculations, should not be part of the ADC standard inventory. ADC system managers should continue to analyze ADC activity reports regularly to determine what drugs are not used often and could be removed from the ADC.

Most nurses in the study agreed that they had access to the medications they need, they were able to get all of their patients’ medication in one place, and that refrigerated medication is easily accessible. Accessibility was valued; 69 nurses commented that they liked the accessibility of the system most of all.

Around two-thirds of the nurses agreed that it was easy to obtain medication during an emergency. Automated dispensing machines enhance first-dose availability and facilitate the timely administration of medication by increasing accessibility on patient care units. This is particularly important in emergency departments and intensive care units [1]. At HH and NCCCR, override medication lists were developed and approved by the relevant Pharmacy and Therapeutics Committee. All medication distribution systems have medication withdrawal functions that allow nurses and other caregivers limited access to certain medications before order review and approval by a pharmacist, especially in cases of patient emergencies. This function is typically referred to as an “override”. Override data evaluation can help hospitals to improve the outcomes of automated dispensing device use by decreasing medication errors and potential adverse drug events. It should therefore be considered part of the routine management process for automated dispensing devices [2]. Nurse training should highlight the risks associated with the override facility.

Finally, the study found that overall, 91 % of nurses across the two hospitals were either very satisfied or satisfied with the use of the ADC system, which is very encouraging.

Strengths and limitations

As the first peer-reviewed study on this subject in the State of Qatar, and probably in the Middle East, this research has wide-ranging implications. The high response rate (80 %) was helpful to understand how nurses, as the end users, feel about the ADC system.

The study also had several limitations. It was conducted in only two hospitals, both of which are specialist hospitals (for heart and cancer patients). The sample size was not calculated. The findings can therefore not be generalized to other populations or settings in Qatar, or more widely. The study was a post-implementation survey and there was no information about the situation before implementation. No pre-post assessment was therefore possible.

Implications for practice

The change in the pharmacy distribution model with the use of the ADC system has had broad implications for the working practices of pharmacists, pharmacy technicians, and nurses, and associated patient safety issues. For nurses, ADC use can help improve medication safety, ensure pharmacists review orders prior to administration, and reduce or eliminate delays owing to medication availability, first-dose administration, missing doses, and time-consuming controlled substance counts. Pharmacists now spend less time dispensing drugs, and may have more time to collaborate with their nursing colleagues, check physicians’ orders against patients’ drug profiles, reconcile patient medication, participate in patient care rounds, and provide patient education.

The role of pharmacy technicians changed with the introduction of the ADC system. Nurses do not have to restock the ADC and manage medication expiry dates as this is done two to three times per week by the pharmacy technicians. The technicians have to go to the patient care unit to restock the ADC, a time-consuming activity, but one that supports better communication between the two departments. From a workload perspective, ADCs reduce pharmacists’ dispensing time, as inventory management is driven by the pre-established minimum and maximum levels and is handled exclusively by pharmacy technicians. Finally, the ADC system has improved compliance with many JCI standards around drug distribution, dispensing, and storage. It has built in methods to synthesize high-risk steps in the medication use process [10]. Profiled ADCs allow pharmacists to review and approve medication before it is available for selection and administration by the nurse, respiratory therapist, or physician. Computerized monitoring of drug administration to the patient by the nurse will provide accurate knowledge of patient medication history. This will help to optimize hospital drug distribution systems and enhance safe dispensing [11].

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From: Nurses’ perceptions of and satisfaction with the use of automated dispensing cabinets at the Heart and Cancer Centers in Qatar: a cross-sectional study

Characteristics Number (%) (N = 403) NCCCR (N = 142) HH (N = 261)
Staff nurse 345 (86) 124 (88) 221 (85)
Charge nurse 42 (10) 13 (9) 29 (11)
Head nurse 11 (3) 2 (1) 9 (3)
Others 5 (1) 3 (2) 2 (1)
Nursing unit
Medical ward 161 (40) 142 (100) 106 (41)
Intensive care unit 140 (35) 0 118 (46)
Emergency 84 (21) 0 19 (7)
Others 17 (4) 0 17 (6)
1:4 52 (13) 21 (15) 31 (12)
1:3 189 (47) 84 (59) 105 (40)
1:2 93 (23) 37 (26) 56 (22)
1:1 69 (17) 0 69 (26)
Diploma in nursing 201 (50) 70 (49) 131 (50)
BSc Nursing 195 (48) 68 (48) 127 (49)
MSc Nursing 5 (1) 4 (3) 1 (0)
Others 2 (1) 0 2 (1)
Years of experience
<5 87 (21) 31 (22) 56 (21)
5–10 144 (36) 46 (32) 98 (38)
11–15 109 (27) 35 (25) 74 (28)
>15 63 (16) 30 (21) 33 (13)
Have you worked with ADC system before joining HH/ NCCCR?
Yes 16 (4)   
No 386 (96)   
When have you started using ADC system at the NCCCR/HH?
>3 months 30 (7)   
3–6 months 181 (45)   
<6 months 191 (48)   
Never used the system 1 (0)