Patient Safety Advisory Reprinted from the PA-PSRS Patient Safety Advisory—Vol. 2, No. 3 (Sept. 2005) Produced by ECRI & ISMP under contract to the Pennsylvania Patient Safety Authority Problems Associated with Automated Dispensing Cabinets T raditionally, hospital pharmacies provided medi- cations for patients by filling patient-specific cas- settes of unit-dose medications, which were then de- macy. Below are examples that have been reported to PA-PSRS: livered to the nursing unit and stored in medication A patient was ordered ZOSYN (piperacillin carts. The Automated Dispensing Cabinet (ADC), a and tazobactam). The first dose was given in computerized point-of-use medication management the emergency department, and a second system, is designed to replace non-automated floor dose was given on the medical unit. Both stock storage, offer better control of medications that doses were retrieved from an ADC prior to are available in the patient care area, and/or support review by the pharmacy. However, when phar- the traditional patient cassette exchange drug delivery macy reviewed the order, it was noted that the system. However, such systems cannot improve pa- patient had a documented allergy to penicillin. tient safety unless cabinet design and use are care- fully planned and implemented to eliminate opportuni- An order was given for a stat dose of mor- ties for wrong drug selection and dosing errors. phine. The patient had a documented allergy to this drug. A pharmacist caught the error and PA-PSRS has received a number of medication error contacted the physician, but not before the reports that cite an ADC as the source of the medica- nurse had used the override function to take tion. In fact, nearly 15% of all medication error reports morphine out of the ADC and administered it cite ADCs as the source of the medication, and 23% to the patient. of these reports involve high-alert medications. Many of these reports describe cases in which the design Luckily, neither of the above patients experienced and/or use of ADCs has contributed to the errors. The serious adverse effects due to these errors. types of errors include wrong drug errors, stocking/ storage errors, and medications being administered to Overrides are not the only examples of workarounds patients with a documented allergy. used to access medications from ADCs. Other types of workarounds include the removal of medications Examples of contributing factors that may have led to using the “inventory” function (designed to determine these errors include: the current number of doses of a particular medica- tion on hand) to gain access to medications for pa- • Lack of pharmacy screening of medication tients without pharmacy screening, removing a larger orders prior to availability for administration. quantity of medications than ordered for one patient, and removing medications for multiple patients while • Excessive use of overrides in cabinets with the cabinet is open. patient profiling, placing the patient at risk of allergic reactions, drug interactions, and other Choosing the wrong medication from an alphabetic hazards. pick list is another common contributing factor for • Failure to recognize look-alike names in the medication errors arising from medication names that design of an ADC’s alphabetic pick list or look alike. For example, one organization reported to storage compartments, which can lead to choosing the wrong medication. This article is reprinted from the PA-PSRS Patient Safety Advisory, Vol. 2, No. 3—Sept. 2005. The Advisory is a publication of the Pennsylvania Patient Types of Errors Safety Authority, produced by ECRI & ISMP under contract to the Authority as One unsafe practice with the use of these devices part of the Pennsylvania Patient Safety Reporting System (PA-PSRS). includes the excessive use of overrides and work- Copyright 2005 by the Patient Safety Authority. This publication may be re- arounds to bypass pharmacy screening of medication printed and distributed without restriction, provided it is printed or distributed in orders prior to administration. The use of overrides, its entirety and without alteration. Individual articles may be reprinted in their except in an emergency, results in circumventing the entirety and without alteration provided the source is clearly attributed. pharmacy verification process in order to obtain and To see other articles or issues of the Advisory, visit our web site at administer medications prior to delivery by the phar- www.psa.state.pa.us. Click on “Advisories” in the left-hand menu bar. ©2005 Pennsylvania Patient Safety Authority Page 1 Reprinted from the PA-PSRS Patient Safety Advisory—Vol. 2, No. 3 (Sept. 2005) Problems Associated with Automated Dispensing Cabinets (Continued) the USP-ISMP Medication Errors Reporting Program A prescriber ordered HYDROmorphone 0.5 (MERP) three errors regarding mix-ups between di- mg IV for a patient. However, when the ADC azepam and diltiazem removals from the ADC in their drawer was opened both morphine and HY- intensive care unit. In one case, diazepam was given DROmorphone were available for retrieval. at the ordered diltiazem dose. In another, a physician The healthcare practitioner mistakenly re- noted the amber color of the diazepam vial as the trieved morphine and administered it to the nurse was drawing up the dose (of what the nurse patient. thought was diltiazem). Storing excessive quantities of medications in ADCs The organization concluded that once the wrong drug can set practitioners up to make errors. For example, was chosen, the cabinet seemed to “confirm” that the in a report submitted to the MERP, an order was writ- correct drug was chosen since the nurse assumed ten for “calcium gluconate 1 g IV,” but a nurse mis- the correct drug was chosen from the menu and read the label on the medication vial and believed thought the correct drug was in the drawer that that ten vials of 10% calcium gluconate were needed opened. The nurse “relied” on the ability to choose (each 10 mL vial containing 98 mg/mL of elemental the right drug from the pick list and, in these cases, calcium, or 980 mg total). Ten vials of medication no physical check of the product or reading of the (each containing 98 mg/mL) could have been re- label was done. Also in these cases, the cabinet did moved from the ADC, but this error was avoided be- not contain a patient profile system, which may have cause the cabinet contained only six vials of calcium prevented this error. For example, the cabinet would gluconate. The error was detected when the nurse not have allowed entry if diltiazem had been picked contacted a pharmacist at home to obtain additional from the screen display since diazepam had been vials.3 This error highlights the importance of limiting entered on the patient’s profile. stock in ADCs. Storing medications with look-alike names and/or The process of restocking medications into an ADC is packaging next to each other in the same drawer or primarily a pharmacy function. Unfortunately, cabinets bin is one of the major contributing factors leading to that do not have bar coding capabilities must rely on errors.1 A common cause of these mix-ups is what individual vigilance or the use of a double check in- human factors experts call “confirmation bias,”2 in volving two individuals. That leaves the process vul- which one “sees” what one expects to see. When nerable to errors, as illustrated by the following re- confirmation bias occurs, it is unlikely that the practi- ports submitted to PA-PSRS: tioner would question what is being read. This can occur both in the removal of medications and in the A patient was ordered BUPRENEX restocking of the ADC. (buprenorphine) 0.3 mg as needed for pain. The nurse found that NUBAIN (nalbuphine) Examples of these type errors from PA-PSRS in- was stocked in the Buprenex drawer. The pa- clude: tient was medicated with the correct medica- tion which was found in a storage compart- During a cardiac catheterization procedure, a ment beside the Buprenex compartment. nurse received a verbal order for IV LOPRES- SOR (metoprolol). However, when retrieving A patient was ordered FIORINAL (aspirin, caf- the medication from the ADC she withdrew feine, and butalbital). However, the wrong LEVOPHED (norepinephrine) instead due to medication, FIORICET (acetaminophen, bu- these look-alike medications being stored in talbital, and caffeine), was stocked in the Fiori- adjacent bins. The patient received the incor- nal compartment. The patient received one rect medication and required an increased dose of Fioricet instead of Fiorinal. The patient level of care. experienced no adverse effects. A nurse took a verbal order from a physician A nurse noted HYDROmorphone 4 mg injec- for hydroxyzine 25 mg IM every 3 hours as tions had been stocked in the morphine 4 mg needed for itching and wrote the order cor- compartment in the ADC. Pharmacy was noti- rectly in the patient’s chart. However, when fied and it was found that two patients may she went to the ADC, she pulled hydralazine have received the wrong drug. and administered 25 mg IM to patient, result- ing in a significant decrease in blood pressure. Page 2 ©2005 Pennsylvania Patient Safety Authority Reprinted from the PA-PSRS Patient Safety Advisory—Vol. 2, No. 3 (Sept. 2005) Problems Associated with Automated Dispensing Cabinets (Continued) In this last case, a serious error could occur if HY- multidose vials, bulk oral solutions). Instead, DROmorphone (DILAUDID) was used in place of an try stocking drugs in ready-to-use unit doses. ordered morphine dose since HYDROmorphone is several times more potent than morphine. • Using individual cabinets or storage drawers to separate pediatric and adult medications. The MERP has also received reports of similar occur- • Developing a check system to help ensure rences. For example, one hospital reported placing accurate cabinet stocking. Another staff the muscle relaxant tizanidine (ZANAFLEX), in the member from pharmacy or nurse on the unit ADC compartment intended for tiagabine (GABITRIL), can verify accurate stocking by having phar- an anticonvulsant. The typical starting doses for each macy provide a daily list of items added to the of these medications are similar as are their generic cabinet. Employing bar-code technology dur- names, so the error was not discovered for a number ing the stocking process can also help assure of days; one patient received four incorrect doses but accuracy. fortunately suffered no ill effects. In another hospital, a nurse found an Abbott Carpuject syringe of digoxin • Placing allergy reminders for specific drugs, 0.25 mg/mL in the drawer that was to contain ke- such as antibiotics, opiates, and nonsteroidal torolac 30 mg. Many of the Carpuject syringes look anti-inflammatory drugs (NSAIDs) on the similar to one another, which could easily result in a cabinet screens or with each individual medi- mix-up during the stocking process. Until barcode cation’s cube. Some systems allow staff to technology is utilized during the stocking process, a build alerts that appear on the screen when check process after restocking automated dispensing attempting to access selected drugs. cabinets may be as important as the check process • Limiting the override function to emergency conducted in the pharmacy.4 situations. A list of medications that can be obtained without pharmacy profile is not Strategies to Improve ADC Safety needed. Lists can give the false impression Consider the following strategies to promote the safe that certain medications may always be ob- use of ADCs:3 tained rather than incorporating an under- standing that only medications needed in an • If your organization is purchasing an auto- emergency situation can be obtained via mated dispensing cabinet, consider those override. that allow for patient profiling so pharmacists can enter and screen drug orders prior to • Routinely running and analyzing override re- their removal and administration. ports to help identify changes that need to be incorporated in the system. • Consider purchasing or upgrading to systems that utilize bar-code technology for restocking • Removing only a single dose of the medica- of medications. tion ordered. If not administered, returning the dose to the pharmacy or ADC return bin to • Ensuring medication orders are screened by allow pharmacy to replace it in the cabinet. the pharmacy for the appropriateness of the drug, dose, frequency, and route of admini- • Periodically reassessing the drugs and quan- stration, therapeutic duplication, allergies or tities stocked in each unit-based cabinet. sensitivities, interactions between the pre- Notes scription and other medications, food, and 1. ISMP. ISMP Medication Safety Alert!® Acute Care Edition. 6 laboratory values, and other contraindica- October 1999;(4)20. tions. This is particularly important for “high- 2. Cohen MR. The role of drug packaging and labeling in medica- alert” medications stored in ADCs. tion errors. In: Cohen M, ed. Medication errors. Washington (DC): American Pharmaceutical Association; 1999. • Considering the needs of each patient care 3. ISMP. ISMP Medication Safety Alert!® Acute Care Edition. 2 unit as well as the age and diagnoses of pa- December 1998;(3)24. tients being treated on each unit when decid- 4. ISMP. ISMP Medication Safety Alert!® Acute Care Edition. 6 ing what drugs will be stocked in each unit’s February 2003;(8)3. ADCs. • Avoiding bulk supplies of medications (e.g., ©2005 Pennsylvania Patient Safety Authority Page 3 Reprinted from the PA-PSRS Patient Safety Advisory—Vol. 2, No. 3 (Sept. 2005) An Independent Agency of the Commonwealth of Pennsylvania The Patient Safety Authority is an independent state agency created by Act 13 of 2002, the Medical Care Availability and Reduction of Error (“Mcare”) Act. Consistent with Act 13, ECRI, as contractor for the PA-PSRS program, is issuing this newsletter to advise medical facilities of immediate changes that can be instituted to reduce serious events and incidents. For more information about the PA- PSRS program or the Patient Safety Authority, see the Authority’s website at www.psa.state.pa.us. ECRI is an independent, nonprofit health services research agency dedicated to improving the safety, efficacy and cost-effectiveness of healthcare. ECRI’s focus is healthcare technology, healthcare risk and quality management and healthcare environmental management. ECRI provides information services and technical assistance to more than 5,000 hospitals, healthcare organizations, ministries of health, government and planning agencies, and other organizations worldwide. The Institute for Safe Medication Practices (ISMP) is an independent, nonprofit organization dedicated solely to medication error prevention and safe medication use. ISMP provides recommendations for the safe use of medications to the healthcare community including healthcare professionals, government agencies, accrediting organizations, and consumers. ISMP's efforts are built on a non-punitive approach and systems-based solutions. Page 4 ©2005 Pennsylvania Patient Safety Authority