ISMP warns of errors with ADCs
ISMP warns of errors with ADCs
Automation and high-tech systems often are touted as the solution for medication errors, but the Institute for Safe Medication Practices (ISMP) in Horsham, PA, is warning that you could be substituting one type of medication error for another when you use automated dispensing cabinets (ADCs).
ADCs are widely used in many health care systems for the storage and dispensing of medications. In a statement issued recently by the ISMP, the group acknowledges that this technology may offer many benefits, but it cautions that design and use of the system must be carefully planned and implemented to ensure the safe use of medications. In addition, there must be collaboration on ADC use between the health care professions, especially pharmacy and nursing personnel, since each holds a large stake in the medication use process, the ISMP says.
"Despite the growing popularity of this technology, little formalized, truly interdisciplinary guidance exists to direct organizations in its safe use," ISMP wrote.
To address those concerns, ISMP recently released the first-ever interdisciplinary guidelines to promote safe practices with ADCs. (Editor's note: For a copy of ISMP's Guidance on the Interdisci-plinary Safe Use of Automated Dispensing Cabinets, visit www.ismp.org/Tools/guidelines/ADC_Guidelines _Final.pdf.)
Guidelines developed
To develop the guidelines, ISMP convened a national forum of stakeholders this spring that included pharmacists, nurses, and ADC vendor representatives with extensive operational knowledge of the technology.
The group developed guidelines for safe ADC use that focus on a collaborative approach and are based on these 12 core processes:
1. Provide ideal environmental conditions for the use of ADCs.
2. Ensure ADC system security.
3. Use pharmacy-profiled ADCs.
4. Identify information that should appear on the ADC screen.
5. Select and maintain proper ADC inventory.
6. Select appropriate ADC configuration.
7. Define safe ADC restocking processes.
8. Develop procedures to ensure the accurate withdrawal of medications from the ADC.
9. Establish criteria for ADC system overrides.
10. Standardize processes for transporting medications from the ADC to the patient's bedside.
11. Eliminate the process for returning medications directly to their original ADC location.
12. Provide staff education and competency validation.
The guidelines provide specific safe process recommendations for each of those core processes. They should bring welcome advice to risk managers and others who are worried about ADC safety, and apparently there is plenty of worry. A recent survey by ISMP shows that safety improvements with ADCs have not kept up with the growing popularity of the technology. Providers keep adopting the systems at a rapid pace even though there are known safety flaws.
According to the 800 respondents to the ISMP's 2007 ADC survey, 94% of the surveyed providers are using ADCs in their facilities. Of those, more than half (56%) are using the technology as the primary means of drug distribution.
Devices no good without training
Crystal A. Riley, PharmD, RPh, director of professional affairs for the National Community Pharmacists Association in Alexandria, VA, points out that automated dispensing cabinets were intended to create less risk of errors and greater efficiency in medication dispensing within healthcare facilities, but that is not always the result.
"Without proper training on use of the systems and practice guidelines to follow to ensure that each area of concern in the use of automated dispensing cabinets is addressed, there is little to no benefit to having these machines within a facility," Riley says. "In releasing guidelines for the safe use of automated dispensing cabinets, ISMP has brought forth a number of important considerations for their correct use and stressed the importance of pharmacist involvement, not only in the dispensing function, but in inventory control as well."
Riley says thorough training for pharmacists and other health care workers with access to automated dispensing cabinets will help in minimizing medication errors related to their use, and the ISMP guidelines provide a good basis for training.
Jack E. Fincham, PhD, RPh, professor of pharmacy practice and administration in the School of Pharmacy at the University of Misssouri-Kansas City, says the ISMP guidelines are a good step forward because they address many of what he considers the primary concerns with ADC safety.
"The guidelines are most definitely a good step in the right direction," Fincham says. "What I also like is the multidisciplinary and facilitative role that ISMP has played."
In addition to the ISMP guidelines, Fincham offers Healthcare Risk Management readers these key elements of an ADC safety plan:
1. Multidisciplinary assessment of needs, placement, utilization, policies, and procedures. This should include nursing, medical, pharmacy, technicians, and respiratory therapy staff input.
2. Failsafe, secure access and record keeping. Those goals can be achieved with passcode access, automated processes for medication reconciliation, and two-signature sign-off policies.
3. Allowing placement in a secure area, with a minimum amount of distractions preferable. There should be decreased foot traffic and ample room to open and analyze dispensing needs.
4. Allowance of a sufficient number of ADCs to minimize staff necessary travel to unit and distance to patient area.
5. Electronic monitoring as a necessary prerequisite, such as through automated medication administration records.
6. Drug references available and easily accessible.
7. Ample opportunity to contact pharmacists easily and quickly. This can be done by phone, e-mail, or any other reasonable means.
8. Adequate planning and procedure development in the case of an unforeseen emergency. Contingency plans may address power outages or a technical failure in the ADC itself, for instance.
9. Synchronicity with automated pharmacy systems.
10. Institution of regular pharmacy audits.
Check actual use against policies
Mary Beth Navarra-Sirio, RN, MBA, vice president and patient safety officer for San Francisco-based McKesson, says all health care providers utilizing ADCs would be well served to have qualified staff members from the patient safety office, quality assurance, risk management, pharmacy, and nursing review the organization's policies around the use of ADCs.
"More importantly, they should conduct candid observations and interviews to determine how the devices are actually used in daily patient care activities," she says. "These findings should be compared with the ISMP guidelines, and a gap analysis should be conducted by the team. Identified gaps can be ranked and prioritized by risk and incorporated into a plan of action that may include creating new or modifying existing policies, reorienting pharmacy and nursing staff to proper ADC use and policy, developing reporting and monitoring functions, and scheduling equipment upgrades and modifications."
Sources
For more information on ADCs and medication errors, contact:
- Jack E. Fincham, PhD, RPh, Professor, Pharmacy Practice and Administration, School of Pharmacy, University of Misssouri-Kansas City. Telephone: (816) 235-5909. E-mail: [email protected].
- Mary Beth Navarra-Sirio, RN, MBA, Vice President and Patient Safety Officer, McKesson, San Francisco. Telephone: (415) 983-8300.
- Crystal A. Riley, PharmD, RPh, Director, Professional Affairs, National Community Pharmacists Association, Alexandria, VA. Telephone: (703) 600-1174.
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