Three pharmacy safety problems solved

ADCs don't have to get the best of you

One of the most common mistakes found in Joint Commission surveys is expired medications, says Yosef D. Dlugacz, PhD, of the Krasnoff Quality Management Institute at the Long Island Jewish Health System in New Hyde Park, NY. It's something that everyone agrees is a bad thing and seems like it would be simple to get a handle on. Yet survey after survey finds that old medications are still on the shelves — or worse, getting through to patients. How can that be?

Dlugacz says it comes down to humans being part of the health care system. They think they'll remember what to do and when to do it, but they skip a step. Or they think that something that expired yesterday is still safe. Or they just plain don't look at the expiration dates.

Still, there are hospitals that have gotten a handle on how to address this and other common safety issues that affect the pharmacy, including problems with automatic dispensing cabinets (ADCs) and shortages of medications that are increasingly common.

At Decatur County Memorial Hospital in Greensburg, IN, expired medications were a problem a few years ago, explains Denise Fields, Pharm.D., director of pharmacy services for the facility. "About five years ago, the board of health found that we had some nutritional products that had expired, so we had to look more closely at it."

At the time, the expiration checks were done on paper, with only broad instructions — check the pharmacy, check the units. If someone new was involved in the checking, he or she might not know that in the pharmacy, there were multiple refrigerators to check. A notation to check the med-surg unit might leave someone who is new to the facility unaware of all the places on the unit where drugs are stored. Further, until all the clipboards were returned at the end of the month, Fields says she didn't really have any idea if there was a problem.

Now, she says she makes sure to break the process down into smaller steps — check the med-surg nutritional cabinet, the med-surg refrigerator. "I lead them to all the places on the med-surg unit where drugs or supplements might be."

Another problem was the constant movement of products around the pharmacy. Someone looking for IVs that were out of date might miss some if they had been moved. Now, rather than having a just checklist of places to look, Fields has added to it a checklist of items — IVs, capsules, nutritional supplements.

But perhaps the most important change made was putting a degree of accountability in place. Previously, troubles with the bedside barcode scanning would result in workarounds and staff bypassing the system, which could potentially let expired medications get through to patients. Now the staff are judged during annual review in part on their scanning percentages. That encourages them to report problems and barriers to using the scanning software rather than simply bypassing it.

Joe Sacco, RPH, director of pharmacy at Spaulding Hospital in Cambridge, MA, says his facility uses a sticker system, in which colored, prominent expiration date stickers are put on medications as they are stocked in the automated dispensing cabinets. These are checked on a regular rotation and drugs are pulled as they expire.

Lately the news has been full of stories about how drug shortages may affect patients if things don't change. But Fields says she is already working to ensure that they don't affect patient care.

If a drug is in short supply and she decides to use a compounding pharmacy, she makes sure to note whether the new version will fit in the ADC drawer that the manufactured product used. If not, she has to rework the physical location. Likewise, drug kits may need new forms.

Her worst nightmare is when an existing concentration isn't available — say the normal 25 mg Phenergan dose isn't available, but the 50 mg is. "You have to build in alerts for all staff that this is a two-fold dose," she explains. "I have to update the ADC formulary and all standing physician orders."

Create a checklist for what you will do in the event of a drug shortage, she says. "If you don't, you won't remember all the steps." Don't forget to include how you will revert to old processes when a drug in short supply is available again.

With ADCs, common problems include medications going out of stock despite your best efforts. Other issues may fly under the radar just because no one bothers to assess how their drug dispensing program is functioning.

Automated dispensing is a great way to save money and time and potentially improve patient safety. When Spaulding Hospital went from just narcotic and PRN drugs being dispensed through ADCs to all drugs over the course of a year, the facility saved an estimated 22,000 nursing hours that had been spent locating medications. In addition, patients are getting their medications sooner — especially those who are receiving new orders or getting their first dose, Sacco says. There are no more complaints of running out of meds, of needing something urgently, or of waiting for something the patients requires, he says.

In the last 10 months, the only change that Spaulding had to make to the system was finding new places for some of the drugs to better meet the ergonomic needs of nurses. Short nurses were having trouble doing the daily counts for narcotics, which were kept in the higher drawers. Sacco says to be sure to keep the most-used meds in the most convenient drawers, too.

Know what you use most by doing an audit of the medications prescribed in the last few months, he advises. "If you do your homework, you get it mostly right," says Sacco, who acknowledges that no ADC will be able to stock 100% of what you need.

Both Sacco and Fields have used the Institute for Safe Medication Practices (ISMP) ADC self-assessment tool to judge whether their programs are working well. Both will be using it again to do further gap analyses.

Fields says she used it when it first came out to figure out where there were problems that needed addressing. Through it, she developed a list of several performance improvement projects and problems to address. For example, one involved getting in touch with the vendor about making changes that would create hard stops preventing dispensing if a patient has an allergy. The initial ADC had active alerts that a certain drug was contraindicated, but a nurse could still dispense it by overriding the system. The newer iteration from that vendor now includes a hard stop for contraindicated medications. Another change that the assessment suggested was needed was to decrease distractions around the cabinet. Near the location of one, there was a phone that was necessary in case a nurse had questions. But it would ring often — and if no one answered, a nurse who was in the midst of dispensing drugs might stop what she was doing and answer it. The distraction was potentially a safety issue. The fix was simple: Turn the ringer all the way down so that nurses wouldn't be tempted to answer it. To further limit distractions, Fields also created a box with red tape in front of the ADC. No one is allowed to talk to any nurse when she is in that taped off area.

Thousands of hospitals have made use of the ADC self-assessment tool, says Allen J. Vaida, Pharm.D., FASHP, executive vice president of the ISMP. It was developed using information from the National Medication Errors Reporting Program and onsite work with hospitals. Vaida says they also created a committee of stakeholders from around the country to help develop the tool in 1999, and then revamped it in 2004 and 2011.

In the first two iterations, more than 3,000 hospitals sent in their data from the assessment, and Vaida says there are several peer reviewed articles that illuminate the positive effect that completing the assessment has had on organizations. "It has spurred many of the National Patient Safety Goals from The Joint Commission," he says, "and it has been used by the National Quality Forum in their medication safety best practices, and by other organizations to improve their medication safety practices."

For more information on this topic, contact:

  • Allen J. Vaida, Pharm.D., FASHP, Executive Vice President, Institute for Safe Medication Practices, Horsham, PA. Telephone: (215) 947-7797. Email:
  • Joe Sacco, RPH, Director of Pharmacy, Spaulding Hospital, Cambridge, MA. Telephone: (617) 573-7000.
  • Denise Fields, PharmD., Director of Pharmacy Services, Decatur County Memorial Hospital, Greensburg, IN. Telephone: (812)663-1378.
  • Yosef D. Dlugacz, Ph.D., Krasnoff Quality Management Institute, New Hyde Park, NY. Telephone: (516) 472-5000.