ASHP Guidelines on the Safe Use of Automated Dispensing Cabinets

Cello, Ryan; Conley, Matthew P.; Cooley, T.; Torre, Charlie De la; Dorn, Mitchell; Ferer, Darren S.; Nickman, Nancy A.; Tjhio, David; Urbanski, Chris; Volpe, Gwen

doi:10.1093/ajhp/zxab325

Cited by 15 publications

(4 citation statements)

References 6 publications

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“…ADC overrides should be assessed periodically to prevent misuse. For example, the reason for each ADC override should be documented and the ADC override medication list should be periodically re-examined [27]. These measures require pharmacists and clinical medical staff discussions to determine the specific methods suitable for each hospital.…”

Section: Discussionmentioning

confidence: 99%

Reducing Medication Errors by Adopting Automatic Dispensing Cabinets in Critical Care Units

Shan

et al. 2023

J Med Syst

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Medication errors can have severe consequences and threaten patient safety. The patient safety-related benefits of automated dispensing cabinets (ADCs) have been reported by several previous studies, including a reduction in medication errors in intensive care units (ICUs) and emergency departments. However, the benefits of ADCs need to be assessed, given the different healthcare practice models. This study aimed to compare the rates of medication errors, including prescription, dispensing, and administrative, before and after using ADCs in intensive care units. The prescription, dispensing, and administrative error data before and after the adoption of ADCs were retrospectively collected from the medication error report system. The severity of medication errors was classified according to the National Coordinating Council for Medication Error Reporting and Prevention guidelines. The study outcome was the rate of medication errors. After the adoption of ADCs in the intensive care units, the rates of prescription and dispensing errors reduced from 3.03 to 1.75 per 100,000 prescriptions and 3.87 to 0 per 100,000 dispensations, respectively. The administrative error rate decreased from 0.046 to 0.026%. The ADCs decreased National Coordinating Council for Medication Error Reporting and Prevention category B and D errors by 75% and category C errors by 43%. To improve medication safety, multidisciplinary collaboration and strategies, such as the use of automated dispensing cabinets, education, and training programs from a systems perspective, are warranted.

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Section: Discussionmentioning

confidence: 99%

Reducing Medication Errors by Adopting Automatic Dispensing Cabinets in Critical Care Units

Shan

et al. 2023

J Med Syst

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“…With a range of technologies available including in‐pharmacy robotics, ADCs, unit dose packaging equipment and controlled substances cabinets, there are many options for monitoring and evaluating drug utilisation 69 . Having these technologies as standalone solutions does provide some benefits; however, integration with pharmacy systems and EHRs provides much more comprehensive and accurate data 70 . Visibility on medication usage across organisations can be maximised to improve understanding of drug usage and associated costs 71 .…”

Section: Theme 5 — Funding Modelsmentioning

confidence: 99%

“…69 Having these technologies as standalone solutions does provide some benefits; however, integration with pharmacy systems and EHRs provides much more comprehensive and accurate data. 70 Visibility on medication usage across organisations can be maximised to improve understanding of drug usage and associated costs. 71 Use of these technologies has also been shown to minimise unnecessary stock wastage.…”

Section: Summary Of Findingsmentioning

confidence: 99%

Pharmacy Forecast Australia 2022: key findings

Levy

2022

Pharmacy Practice and Res

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“…Their institution did not require BCMA in the Radiology area. While there are general recommendations that directly address these areas, 22,24,25 TMSBP Best Practice 7 is designed to be very targeted and addresses risks that could persist even after implementing more general safety interventions. It also represents more feasible risk mitigation compared with larger system changes.…”

Section: Benefits Of Disclosurementioning

confidence: 99%

A failure in the medication delivery system—how disclosure and systems investigation improve patient safety

Lucas

Pollak

Makowski

2022

J of Healthc Risk Manag

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A recent medication error at Vanderbilt University Medical Center contributed to the death of a patient. The ensuing criminal indictment of the administering nurse has shaken the medical community. This has led to clinical staff questioning whether they can disclose patient safety incidents without fear of criminal prosecution. However, because of the publicity of this case, hospitals can benefit from the lessons learned and mitigate the risk of this and similar events at their facilities. To uncover the most impactful and relevant safety recommendations, the Vanderbilt case is examined from a systems investigation perspective using the available public information gathered from media reports, the Tennessee Bureau of Investigation report, and Vanderbilt's corrective action plan submitted to CMS. We present an example of how hospitals can benefit from disclosure: Henry Ford Health used the Vanderbilt case study as part of its medication safety continuous improvement initiatives, which are underpinned by available medication safety recommendations from the Institute for Safe Medication Practices. Using this experience and the lessons learned from the Vanderbilt case, a proactive action plan is presented for hospitals nationwide to prevent the recurrence of this medication error. Without disclosure, these analyses and safety recommendations would not have been possible.

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ASHP Guidelines on the Safe Use of Automated Dispensing Cabinets

Cited by 15 publications

References 6 publications

Reducing Medication Errors by Adopting Automatic Dispensing Cabinets in Critical Care Units

Reducing Medication Errors by Adopting Automatic Dispensing Cabinets in Critical Care Units

Pharmacy Forecast Australia 2022: key findings

A failure in the medication delivery system—how disclosure and systems investigation improve patient safety

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