PSO Compass Points

"Upon review of the automated dispensing cabinet, it was found that heparin 5000 unit per mL was in the same bin as glucagon. The bin has a printed label and a smaller, less noticeable handwritten label. A high-alert medication was placed in the same bin as another medication; there's a high potential for a medication error."

Situation

Medication errors and near misses associated with the use of automated dispensing cabinets (ADCs) may occur from stocking errors or insufficient planning when configuring the drawers.

Background

From January to September 2016, ECRI Institute PSO received 227 reports of events involving ADCs. These included:

• Pockets containing the wrong medication, wrong concentration (dose) of the correct medication, two different medications or two concentrations of the same medication, and expired medications.
• Drawers containing medications with similar names or packaging, high-alert medications in an unsecured area (e.g., an unlocked drawer or pocket), medications inappropriate for the care area, or lack of medications needed in the care area.
• Placement of look-alike/sound-alike medications or similar concentrations of medications within the wrong pockets, such as ephedrine instead of epinephrine, phenobarbital instead of dronabinol, oxycodone XL instead of oxycodone IR, albuterol 2.5 mg instead of albuterol 0.5 mg, ketorolac 60 mg/ 2mL mixed with ketorolac 15 mg/mL, and insulin NPH stocked instead of insulin aspart.

Assessment

Poor stocking or restocking practices and insufficient attention to planning when configuring an ADC have resulted in delays in patient care, the administration of incorrect medications, and the incorrect concentration of a medication that, in turn, have resulted in severe injury and the need for additional monitoring. Attention to ADC configurations and staff training for best practices can prevent delays in patient care and patient harm.  

Recommendations

• Review the inventory (i.e., the formulary) within the ADC to verify the appropriateness of each drug for that care area.
• Only stock medications necessary for the specified care area.
• Stock medications that might be needed for urgent situations.
• Carefully plan where medications will be located within each drawer and how those medications can be accessed.
• Ensure that high-alert drugs, in particular, are stored only in secured drawers or pockets.
• Store look-alike/sound-alike medications in physically distinct areas of the cabinet—for example, in different drawers or within different lidded pockets.
• Avoid stocking drugs in drawers alphabetically, and vary drug dose forms in adjoining sections to increase visual contrast.
• Use clear signage as well as distinct placement within the ADC to separate and indicate different concentrations of the same medication.
• Consider using barcode scanning, which can help prevent mix-ups when stocking the cabinet and when dispensing medications.
• Establish a training program on ADC systems that emphasizes the importance of verifying that the medication retrieved from the cabinet is the intended medication, the importance of returning diverted or unused medications back to the ADC return bin, and the value of reporting ADC-related errors and near misses.
• When using an ADC in the operating room, ensure that medications are dispensed only when the patient is in the room, and limit the pre-dispensing of medications for later patients.