Automatic dispensing cabinets and governance of controlled drugs: an exploratory study in an intensive care unit

BACKGROUND

Governance of controlled drugs (CDs) in hospitals is resource intensive but important for patient safety and policy compliance.

OBJECTIVES

To explore whether and how storing CDs in an automated dispensing cabinet (ADC) in a children's hospital intensive care unit (ICU) contributes to the effectiveness and efficiency of CD governance.

METHODS

We conducted a mixed-methods exploratory study, comprising observations, interviews and audits, 3 months after ADC implementation. We observed 54 hours of medications activities in the ICU medication room (with 42 hours of timed data); interviewed nurses (n=19), management (n=1) and pharmacy staff (n=3); reviewed 6 months of ICU incident reports pertaining to CD governance; audited 6 months of CD register data and extracted logs of all ADC transactions for the 3 months following implementation. Data analysis focused on four main CD governance activities: safekeeping/controlling access, documenting use, monitoring, and reporting/investigating.

RESULTS

Nurses and pharmacists perceived spending less time on CD governance tasks with the ADC. The ADC supported CD governance through automated documentation of CD transactions; 'blind counts'; automated count discrepancy checks; electronic alerts and reporting functionalities. It changed quality and distribution of governance tasks, such as removing the requirement for 'nurses with keys' to access CDs, and allowing pharmacists to generate reports remotely, rather than reviewing registers on the ward. For CDs in the ADC, auditing and monitoring appeared to be ongoing rather than periodic. Such changes appeared to create positive reinforcing loops. However, the ADC also created challenges for CD governance. Most importantly, it was not suitable for all CDs, leading to workarounds and parallel use of a safe plus paper registers.

CONCLUSIONS

ADCs can significantly alter CDs governance in clinical areas. Effects of an ADC on efficiency and effectiveness of governance tasks appear to be complex, going beyond simple time savings or more stringent controls.

Impact of automated drug dispensing system on patient safety

Objectives

Automated drug dispensing system (ADDs) is an emerging technology positively impacts drug dispensing efficiency by minimizing medication errors. However, the pharmacist perception of the impact of ADDs on patient safety is not well-established. This cross-sectional observational study aimed to evaluate the dispensing practice and pharmacist perception of ADDs towards patient safety through a validated questionnaire.

Methods

A self-designed questionnaire was validated and the pharmacist perception of dispensing practice was compared between two hospitals adopting ADDs and traditional drug dispensing system (TDDs).

Results

The developed questionnaire had an excellent internal consistency (both Cronbach's α and McDonald's ω coefficients were >0.9). Factor analysis retained three significant factors (subscales) that explained pharmacist perception of dispensing system, dispensing practice, and patient counseling (p<0.001 for each factor). The average number of prescriptions dispensed per day, drugs contained in each prescription, average time for labeling each prescription and inventory management were significantly varied between ADDs and TDDs (p=0.027, 0.013 0.044 and 0.004, respectively). The perception of pharmacists using ADDs on three domains were higher than the TDDs. The pharmacists in ADDs agreed that they had enough time to review the medications before dispensing than TDDs and this difference was found to be statistically significant (p=0.028).

Conclusions

ADDs was highly effective in improving dispensing practice and medication review; however, the pharmacists need to emphasize the importance of ADDs to translate the pharmacists' freed-time towards patient care.

Homicidal poisoning series in a nursing home: retrospective toxicological investigations in bone marrow and hair

Homicidal poisonings remain rare and can be difficult to detect, especially in the elderly or in medical settings. In this atypical poisoning series, a young nursing assistant purposely poisoned thirteen residents of a nursing home and killed ten of them. The medications used were a mix of psychotropic medications (cyamemazine, loxapine, tiapride, risperidone, and mirtazapine), under liquid formulation, which were inducing malaise and coma. The forensic investigation included analysis of blood, urine, hair, and bone marrow and exhumations of seven corpses up to 3 years after the inhumation. Hair collected from a hairbrush of a cremated victim have been analyzed. Bone marrow sample preparation was based on a liquid/liquid triple extraction. Hair were incubated after decontamination overnight at 55 °C in methanol. Segmentation was possible for seven samples, except for delayed exhumation samples (n = 4) and hairbrush hair sample (n = 1). The extracts were then analyzed using gas chromatography coupled with mass spectrometry (GC-MS) for unknown screening and using liquid chromatography coupled with tandem mass spectrometry (LC-MS/MS) for a targeted screening and quantification. Screenings revealed the presence of the same mix of psychotropic medications. Cyamemazine, mirtazapine, loxapine, tiapride, and risperidone hair concentrations were 6-17,458 pg/mg, 74-1271 pg/mg, 9-1346 pg/mg, 13-148 pg/mg, and 3-5 pg/mg, respectively. Cyamemazine bone marrow concentrations were 229 and 681 ng/g and 152-717 ng/mL in blood. Patients' medications were also identified and quantified. This poisoning series provide analytical data that could support subsequent toxicological result interpretation in similar forensic cases.

The impact of introducing automated dispensing cabinets, barcode medication administration, and closed-loop electronic medication management systems on work processes and safety of controlled medications in hospitals: A systematic review

BACKGROUND

Technology in the form of Automated Dispensing Cabinets (ADCs), Barcode Medication Administration (BCMA), and closed-loop Electronic Medication Management Systems (EMMS) are implemented in hospitals to assist with the supply, use and monitoring of medications. Although there is evidence to suggest that these technologies can reduce errors and improve monitoring of medications in general, little is known about their impact on controlled medications such as opioids.

OBJECTIVES

This review aimed to fill this knowledge gap by synthesising literature to determine the impact of ADCs, BCMA and closed-loop EMMS on clinical work processes, medication safety, and drug diversion associated with controlled medications in the inpatient setting.

METHODS

Eight databases (Medline, Pubmed, Embase, Scopus, Web of Science, PsycINFO, CINAHL, and ScienceDirect) were searched for relevant papers published between January 2000 and May 2019. Qualitative, quantitative, and mixed-methods empirical studies published in English that reported findings on the impact of ADCs, BCMA and/or closed-loop EMMS on controlled medications in the inpatient setting were included.

RESULTS

In total, 16 papers met the inclusion criteria. Eleven studies reported on ADCs, four on BCMA, and only one on closed-loop EMMS. Only four studies focused on controlled medications, with the remainder reporting only incidental findings. Studies reported the elimination of manual end-of-shift counts of controlled medications after ADC implementation but cases of drug diversion were reported despite introducing ADCs. Three quantitative studies reported reductions in medication errors after implementing BCMA, but medications labelled with wrong barcodes and unreadable barcodes led to confusion and administration errors.

CONCLUSIONS

More quality, targeted research is needed to provide evidence on the benefits and also risks of implementing technology to safeguard against inappropriate use of controlled medications in the inpatient setting. Processes need to be in place to supplement technological capabilities, and resources should be made available for post-implementation evaluations and interventions.

Nurses´ perceptions of automated dispensing cabinets - an observational study and an online survey

BACKGROUND

Thirty-two automated dispensing cabinets (ADCs) were introduced in May 2015 in Kuopio University Hospital, Finland. These medication distribution systems represent relatively new technology in Europe and are aimed at rationalising the medication process and improving patient safety. Nurses are the end-users of ADCs, and it is therefore important to survey their perceptions of ADCs. Our aim was to investigate nurses' perceptions of ADCs and the impacts of ADCs on nurses' work.

METHODS

The study was conducted in the Anaesthesia and Surgical Unit (OR) and Intensive Care Unit (ICU), of a tertiary care hospital, in Finland. We used two different research methods: observation and a survey. The observational study consisted of two 5-day observation periods in both units, one before (2014) and the other after (2016) the introduction of ADCs. An online questionnaire was distributed to 346 nurses in April 2017. The data were analysed using descriptive statistics including frequencies and percentages and the Chi-Square test.

RESULTS

The majority (n = 68) of the 81 respondents were satisfied with ADCs. Attitudes to ADCs were more positive in the ICU than in the OR. Nearly 80% of the nurses in the ICU and 42% in the OR found that ADCs make their work easier. The observational study revealed that in the OR, time spent on dispensing and preparing medications decreased on average by 32 min per 8-h shift and more time was spent on direct patient care activities. The need to collect medicines from outside the operating theatre during an operation was less after the introduction of ADCs than before that. Some resistance to change was observed in the OR in the form of non-compliance with some instructions; nurses took medicines from ADCs when someone else was logged in and the barcode was not always used. The results of the survey support these findings.

CONCLUSIONS

Overall, nurses were satisfied with ADCs and stated that they make their work easier. In the ICU, nurses were more satisfied with ADCs and complied with the instructions better than the nurses in the OR. One reason for that can be the more extensive pilot period in the ICU.

Safety, time and cost evaluation of automated and semi-automated drug distribution systems in hospitals: a systematic review

OBJECTIVES

To systematically review automated and semi-automated drug distribution systems (DDSs) in hospitals and to evaluate their effectiveness on medication safety, time and costs of medication care.

METHODS

A systematic literature search was conducted in MEDLINE Ovid, Scopus, CINAHL and EMB Reviews covering the period 2005 to May 2016. Studies were included if they (1) concerned technologies used in the drug distribution and administration process in acute care hospitals and (2) reported medication safety, time and cost-related outcomes.

RESULTS

Key outcomes, conclusions and recommendations of the included studies (n=30) were categorised according to the dispensing method: decentralised (n=19 studies), centralised (n=6) or hybrid system (n=5). Patient safety improved (n=27) with automation, and reduction in medication errors was found in all three systems. Centralised and decentralised systems were reported to support clinical pharmacy practice in hospitals. The impact of the medication distribution system on time allocation such as labour time, staffing workload or changes in work process was explored in the majority of studies (n=24). Six studies explored economic outcomes.

CONCLUSIONS

No medication distribution system was found to be better than another in terms of outcomes assessed in the studies included in the systematic review. All DDSs improved medication safety and quality of care, mainly by decreasing medication errors. However, many error types still remained-for example, prescribing errors. Centralised and hybrid systems saved more time than a decentralised system. Costs of medication care were reduced in decentralised systems mainly in high-expense units. However, no evidence was shown that implementation of decentralised systems in small units would save costs. More comparable evidence on the benefits and costs of decentralised and hybrid systems should be available. Changes in processes due to a new DDS may create new medication safety risks; to minimise these risks, training and reallocation of staff resources are needed.

[Impact of an automated dispensing system for medical devices in cardiac surgery department]

To secure medical devices' management, the implementation of automated dispensing system in surgical service has been realized. The objective of this study was to evaluate security, organizational and economic impact of installing automated dispensing system for medical devices (ASDM). The implementation took place in a cardiac surgery department. Security impact was assessed by comparing traceability rate of implantable medical devices one year before and one year after installation. Questionnaire on nurses' perception and satisfaction completed this survey. Resupplying costs, stocks' evolution and investments for the implementation of ASDM were the subject of cost-benefit study. After one year, traceability rate is excellent (100%). Nursing staffs were satisfied with 87.5% by this new system. The introduction of ASDM allowed a qualitative and quantitative decrease in stocks, with a reduction of 30% for purchased medical devices and 15% for implantable medical devices in deposit-consignment. Cost-benefit analysis shows a rapid return on investment. Real stock decrease (purchased medical devices) is equivalent to 46.6% of investment. Implementation of ASDM allows to secure storage and dispensing of medical devices. This system has also an important economic impact and appreciated by users.

Comparison of medication safety systems in critical access hospitals: Combined analysis of two studies

PURPOSE

The role of pharmacist transcription, onsite pharmacist dispensing, use of automated dispensing cabinets (ADCs), nurse-nurse double checks, or barcode-assisted medication administration (BCMA) in reducing medication error rates in critical access hospitals (CAHs) was evaluated.

METHODS

Investigators used the practice-based evidence methodology to identify predictors of medication errors in 12 Nebraska CAHs. Detailed information about each medication administered was recorded through direct observation. Errors were identified by comparing the observed medication administered with the physician's order. Chi-square analysis and Fisher's exact test were used to measure differences between groups of medication-dispensing procedures.

RESULTS

Nurses observed 6497 medications being administered to 1374 patients. The overall error rate was 1.2%. The transcription error rates for orders transcribed by an onsite pharmacist were slightly lower than for orders transcribed by a telepharmacy service (0.10% and 0.33%, respectively). Fewer dispensing errors occurred when medications were dispensed by an onsite pharmacist versus any other method of medication acquisition (0.10% versus 0.44%, p = 0.0085). The rates of dispensing errors for medications that were retrieved from a single-cell ADC (0.19%), a multicell ADC (0.45%), or a drug closet or general supply (0.77%) did not differ significantly. BCMA was associated with a higher proportion of dispensing and administration errors intercepted before reaching the patient (66.7%) compared with either manual double checks (10%) or no BCMA or double check (30.4%) of the medication before administration (p = 0.0167).

CONCLUSION

Onsite pharmacist dispensing and BCMA were associated with fewer medication errors and are important components of a medication safety strategy in CAHs.

Implementation of automated dispensing cabinets for management of medical devices in an intensive care unit: organisational and financial impact

Background

Automated dispensing cabinets (ADCs) have been tested and approved for medication management in hospitals.

Objectives

First, to evaluate the logistics and organisational effect of a similar system for management of sterile medical devices in a medical intensive care unit (ICU). Second, to assess the cost savings of this new organisation for the sterile medical devices budget of this department.

Methods

The organisational effect was evaluated by comparing (1) the workload of head nurse, nursing auxiliary and pharmacy technician and (2) sterile medical devices emergency orders, 1 year before and after implementation of three ADCs and 100 wireless open-access devices. The hospital's costs (ADC, wireless devices and software) and benefits (stock value and resupplying value before and after implementation) were evaluated.

Results

Employment of ADCs led to organisational improvement: the total time saved by the pharmacy and ICU together was 34% of the time spent before introduction. The number of emergency orders decreased from 6% to 1% of total orders after 1 year. €55 000 were saved (stock value + resupplying value) 1 year after introduction of ADCs. These benefits were almost equal to the cost of introducing the system.

Conclusions

ADCs could provide an innovative and efficient solution for the management of sterile medical devices in hospitals. Further investigations are needed to complete the financial evaluation, and to develop this system to provide a secure a medical devices circuit.