Automated dispensers need personal attention

Don’t forget that routine double-check

As hospitals roll out automated drug dispensing to departments, ICU employees are learning that the machines can be a real timesaver and convenient, as long as precautions are taken to prevent errors.

The Institute for Safe Medication Practices (ISMP) warns that automation doesn’t take the place of a nurse’s careful eye, ensuring that the medication being administered is correct and in the proper dose.

"When nurses pull out medications from something that’s automated, they tend to think that because it’s automated, it’s right," says Hedy Cohen, RN, BSN, vice president for nursing for ISMP, a Huntingdon Valley, PA-based nonprofit organization that educates health care practitioners about adverse drug events and their prevention.

"But it’s a human being that’s stocking these little drawers," Cohen says. "It’s not that nurses don’t look at the label, but they think they’re going to see something and their eyes just confirm what they think they’re going to see rather than reading the label."

Cohen says the ATM-like drug dispensing units first were seen as a way to secure narcotics and more easily bill for them by patient. Now, they’re used for a growing number of routine medications.

Devices in use in hospitals include drawer modules that allow for drug storage either in individual drawers or in a drawer that allows a mix of different drugs, says Kevin Newton, vice president and general manager for Diebold, whose Cranberry Township, PA-based MedSelect division manufactures a line of the drug dispensing machines. Another product, a unit dose module, only doles out the necessary dose for a particular patient at a particular time.

In each case, access is controlled by requiring a nurse to swipe a card and type in an identifying number. From there, the nurse can enter a patient’s ID number, and choose from a list of that patient’s medications, or the nurse can call up a general list of all the drugs stocked in the unit.

When a selection is made, a drawer will open, or in the case of a unit dose module, the requisite number of pills will drop into a slot.

Easy use can lead to drug errors

But ISMP warns that ease of use can lead to errors using the drug dispensing units.

The problem, Cohen says, is that as some nurses get used to the convenience of the units, they may begin to overlook their routine double-checks — particularly for drug interactions or patient allergies.

While this information is maintained on patient charts and even in hospital pharmacy systems, the drug-dispensing units themselves don’t necessarily remind nurses of those dangers.

Cohen says nurses must also check that the drug they’re pulling out of a drawer is the drug that they think it is, and that the dosage they are using is correct.

Newton agrees. "If errors do happen, it’s a case of nurses blindly trusting what was dispensed by the machine. The nurse still needs to do the final check."

As the use of the drug dispensing machines has evolved, so have the safety features that help prevent errors.

Newton says the earliest drug dispensing systems, which tended to be used mostly for narcotics, included computer prompts that required nurses to count the drugs in a drawer both before and after removing a dose to help assure correct counts. While drawer-type units still have that feature, unit-dosing modules do not require it, since they count out the amount needed.

The University of Mississippi Medical Center in Jackson, which began a trial program with the MedSelect system in 1997, now has automated nearly all its nursing units, says Wayne Carpenter, BP, pharmacy supervisor. "It’s our goal to automate every site that’s reasonable to do."

Carpenter says the University of Mississippi Medical Center has configured its drug dispensing system to help eliminate some of the potential for errors.

Pharmacy technicians who load the drugs into the automated cabinets are careful not to put similar-looking drugs next to each other, and the cabinets’ narrow drawers don’t allow for too many confusing choices in one place.

"We have arranged them so that if you’re going after a little white tablet in a given drawer, you’ve got a choice of one," Carpenter explains. "It helps the pharmacy people in the loading, and it would help the users — nurses, doctors, or whoever — whenever they’re removing the drug."

Newton says newer software that can be added as a feature to the MedSelect system uses specially controlled drawers and flashing lights to carefully direct pharmacy technicians to put drugs only in the proper drawer.

ICUs still find advantages to automation

But some suggest that units go even further to ensure safety.

Patricia Lee, MS, a practitioner in residence on the staff of the American Society of Health-System Pharmacists in Bethesda, MD, previously worked for Pyxis Corp., a major manufacturer of automated systems, and was an educator in the pharmacy departments at the University of California at San Diego and San Francisco.

To help avoid errors, Lee suggests using a bar code system that can verify a drug is being administered to the proper patient, and configure drawers so that each drug is in a separate, secure area.

Most importantly, she says, don’t allow nurses to override the system, allowing access to drugs without a medication order or answering all of the safety questions posed by the computer.

"It can be possible to short cut any system, no matter how good or secure the system is," Lee says. "But don’t try to do it."

Despite the issues raised by automation, Lee still sees advantages in the automated systems and finds advocates among the ICU nurses she’s worked with.

"It probably goes back to the fact that they’ve had to search for drugs so much," she says. "I think nurses are delighted to have the drugs there and to know that they’re there."

Maxine Freeman, BSN, MSN, CCRN, director of nursing for critical care at the University of Mississippi Medical Center, says the machines can save valuable time in an emergency, allowing nurses to get medications without having to send an order down to pharmacy and wait for the drugs to come back.

"In a hospital this big, the pharmacy is open 24 hours a day and manned 24 hours a day, but still it may take up to 30 minutes to get an emergency medicine from the pharmacy, and the nurse may have to go down there herself to get it," Freeman says. "So, when you really are in a crunch and you need something, it’s nice to know that it’s there."

In fact, Freeman says the system at the University of Mississippi Medical Center can actually help decrease errors, in the form of delayed doses.

"Many times (without automation), you go to give your 9 o’clock meds and there will be one or two of them that are missing," she says. "You never know if somebody borrowed that for another patient or if it didn’t get put in the drawer by pharmacy. That drug would be delayed because you would have to wait to get it from [the] pharmacy."

The automated setup also allows pharmacy and nursing to keep careful track of where and when meds are being dispensed, and respond to the unit’s changing needs. Carpenter says it’s already helped his pharmacy better predict off-peak needs in the ICU.

In the ICU, plans are to eventually have the automated units dispensing all medications, Freeman says, describing a system that would include unit doses.

"At some point, we will have a system whereby you put the patient’s name in, and a drawer will open and all the 9 o’clock meds are there. But we’re not at that point, yet."

She says the only problem that has arisen in the rollout came when pharmacy began adding medications to the automated system that nurses weren’t used to finding there.

Some medications, such as ACE inhibitors in the cardiac unit, might be in the automated system, but others might be elsewhere, which can be confusing for nurses, Freeman says. "It was when they started mixing it up, when they started putting some of the routine meds in the machines, that it got difficult for the nurses. When we get it finalized and everything is in one place, it will be easier."

Carpenter says that when the system is fully implemented, only a few medications won’t be automated — primarily custom-prepared doses or those that are very rarely used. Those drugs already can be delivered to the floor from the pharmacy by a small robot. The robot, which carries a floor plan of the medical center on a computer chip, makes 30-minute rounds to designated locations, dispensing newly ordered drugs, or other unusual pharmacy deliveries.

Carpenter says by introducing all of that automation to the pharmacy system, the pharmacists themselves are free to do more important work, including consulting on the floors and providing patient education. "Eighty percent of the things we do are routine," he says. "If we can have that 80% run on automatic, we can use our people on the 20% where they are most valuable."