The use of ADCs undoubtedly improves medication safety and security; however, the possibility of stocking the wrong medication in the wrong ADC pocket—risking patient medication error—necessitates increased scrutiny of ADC stocking processes. The deaths of several infants in an Indiana hospital in 2006 due to an ADC heparin stocking error exemplifies the vital importance of verifying stocking accuracy, a need the Institute for Safe Medication Practices emphasizes with its recommendation of bar code scanning during ADC stocking.¹

Somerset Hospital is a 120-bed facility in Pennsylvania with a pharmacy staff of eight pharmacists and ten technicians. As part of a hospital-wide strategy to increase automation use, Somerset implemented ADCs in the ER in 2004, and then implemented ADCs in inpatient units in 2006 and surgical units in 2012. In early 2011, Somerset began implementing BCMA and CPOE; today, BCMA is used throughout the hospital, and the implementation process for CPOE is ongoing. In a continuing effort to improve patient medication safety, Somerset decided to implement bar code scanning during cabinet stocking to ensure medications dispensed from the ADCs are correct; this process began in 2005 and was completed in 2011, after we began using facility-generated bar codes for BCMA.

Developing an Overall Strategy 
The principle benefit of utilizing bar code scanning during the ADC restocking process is that verifying the medication and ADC location prior to placing the medication in the cabinet reduces the likelihood of medication error. From the outset, the technology has proven extremely valuable at our hospital. For example, an alarming incident occurred in which two order numbers—01 and 10—were transposed, resulting in the wrong medication being ordered from the vendor. When the drug arrived in the pharmacy, the error was not identified, as the packaging and labeling were similar except for the concentration, and the medication was added to pharmacy stock. The error was caught when the medication was scanned at the ADC and did not match any inventory items in the cabinet. Had this medication reached the patient, it could have resulted in a ten-fold dosing error. Due to bar code scanning we were able to uncover the error during the ADC stocking process, and immediately correct it. 

Another strategy we utilize to ensure safety is a strict no-returns policy. At Somerset, nurses are not permitted to return unused medications directly to the ADC; instead, all unused medications must be placed in a return bin located externally on the side of the ADC or internally in a designated ADC drawer, which pharmacy technicians collect and return to the pharmacy. Creating a policy and procedure (P&P) requiring use of the returns bin can lessen the possibility of stocking errors by nursing. 

Unit dose packaging is used whenever possible, but if a multiple dose container, such as insulin, must be returned to the cabinet, nurses scan the bar code prior to returning the multiple dose medication to the ADC to ensure the medication is returned to the correct bin. 

We also implemented a no override policy for technicians when stocking the ADCs. If a medication does not scan, it is returned to the pharmacy and the cause of the problem is investigated. If the medication is a new drug and the bar code is not included in the database, the pharmacist adds the medication to the database. All medications dispensed from the pharmacy must be bar coded and scanned when stocked in the ADC; pharmacy staff apply facility-generated bar codes to medications not bar coded by the manufacturer.

Somerset’s pharmacy is open from 6AM to 8:30PM Monday through Friday and from 6am to 4:30pm on weekends. Because we do not have 24/7 pharmacy services, pharmacy stocks select first doses in ADCs, and uses a central ADC as a night cupboard. Remote order entry services are used in tandem with profiled ADCs, ensuring that nurses still have the benefit of pharmacy medication review when the pharmacy is closed. 

Improving Scanning Accuracy
For bar coding implementation to be successful, it is essential that every product picked by nursing has a bar code and scans correctly. Providing nursing with unscannable bar codes is akin to sending the message that scanning an alternate label, a potential workaround that negates the safety benefits of bar code scanning, is an acceptable practice. P&Ps that forbid this practice must be in place. Pharmacy can best prevent this workaround by ensuring that all products have accurate bar codes that scan correctly the first time. Thus, pharmacy works diligently to bar code and test every product before it is sent to the unit. 

Each nursing unit has superusers who have been trained to assist other nurses in reconciling scanning problems. If a medication fails to scan, the nurse fills out a paper scanning ticket, which is sent to pharmacy along with the faulty bar code, if available. If the pharmacy is open at the time, the nurse will call the pharmacy for assistance. Tickets are placed in the pharmacy pickup bin on the nursing units and are collected by pharmacy technicians early in the morning and on hourly rounds. Pharmacy investigates the cause of the failed scan. For example, we recently encountered an error in which the nurse’s scanner was programmed incorrectly, reading one type of bar code as a 16-digit number rather than the 11-digit number required by the medication administration application. Pharmacy worked with nursing to reprogram the scanner. We encountered another scanning failure in which a nurse attempted to scan the last drug in a ten-dose card, but the card had been torn unevenly so that part of the bar code was missing.  

Addressing scanning issues quickly and skillfully assures nursing of pharmacy’s dedication to a seamless medication administration workflow, as well as ensuring the patient safety benefit of scanning 100% of medications and patient wristbands.

Addressing Inventory Concerns
Implementing bar code verification upon stocking prompted a reevaluation of which products should be stocked in ADCs in various units. Because ADCs are utilized throughout the hospital and serve specific patient populations, we evaluated each department’s ADC medication usage to determine which medications should be included. In areas where medications are very specific to the conditions being treated, such as behavioral health and OB, the most commonly utilized drugs are stocked in ADCs to prevent excessive patient-specific dispensing. We use a hybrid drug distribution system on the floors, with nurse servers in patient rooms for maintenance medications, while narcotics and PRNs are stocked in ADCs. Thus, nurses know where to retrieve which drugs.

Medication location within the ADC also required review. When evaluating the placement of medications in ADCs, be sure to situate frequently used drugs in a convenient location for nursing to retrieve. For example, we initially placed acetaminophen in a lower drawer, which required frequent bending for nurses retrieving this commonly used medication. We now stock it in a higher drawer. Narcotics and other high-security medications, such as propofol, are housed in locked bins.

ADC placement within each unit must be considered carefully. In our ER we initially located the ADC in a central area, but due to renovations it was moved into its own room. However, this solution proved inconvenient for nursing when a double check was required to waste narcotics. Consequently, we implemented a remote medication management application, which provides nurses the option to remotely access an ADC from any hospital computer or workstation. Nurses can now waste narcotics from any PC in the emergency room. ADC locations in other areas of the hospital are determined on a case-by-case basis. On a closed unit, such as OB, the ADC is located in a central location, while the after-hours ADC is located in its own locked room with restricted access. When the P&T committee reviews a drug for formulary status, it also determines if the medication will be dispensed from the after-hours ADC. In addition, we utilize medication kits for certain disorders, including a tissue plasminogen activator (TPA) kit for stroke, a tenecteplase (TNK) kit for myocardial infarction, and a diabetic ketoacidosis kit. The P&T committee determines which drugs are approved for use in these kits. 

Creating a Culture of Safety
To gain staff acceptance of change, it is important to create an environment in which staff is cognizant of the reasons behind the initiative and aware of their expected compliance to P&Ps. Thus, a robust staff training program is an essential element supporting our hospital-wide culture of safety. New pharmacy technician hires receive a step-by-step orientation training process, beginning with clerical functions and progressing through IV compounding, medication and supply ordering, and ADC stocking and dispensing. A competency checklist is required at the conclusion of each section (see Figure 1). In addition, competency is validated on an annual basis to ensure continual adherence to P&Ps. 

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Although implementing bar code scanning upon stocking may at first appear time-prohibitive, we did not confront this challenge. Our experience has been that scanning upon restock takes approximately the same amount of time—or possibly even less time—as traditional stocking. In our system, the guiding lights on the ADC bins identify the correct bin location immediately, which facilitates an efficient workflow. 

We continually evaluate our processes to determine if we can eliminate tasks that are outdated or add efficiencies to free up time for new initiatives. For example, the adoption of ADCs eliminated the need for manual charging of floor stock drugs, freeing technician time for other activities.

Future Goals
Implementing bar code scanning upon stocking has significantly improved medication safety at Somerset, but there is always room for improvement. For example, our ADCs currently require scanning of only one drug per location; in other words, when stocking ten of the same vials into the ADC, only one vial needs to be scanned. Additional functionality enabling pharmacy to scan every dose into the ADC would provide further safety benefits. 

Somerset Hospital soon will evaluate additional medication safety enhancements, including the implementation of anesthesia workstations and a controlled substance management system, automating the catheterization laboratory, and purchasing analytical software for ADCs to allow us to track medication trends and possible diversion, further improving patient safety.

Reference

1. ISMP. Infant heparin flush overdose. ISMP Med Safety Alert! 2006 Sept;19:1-2.

Michele Russic, RPh, has served as director of pharmacy at Somerset Hospital in Somerset, Pennsylvania, for the past 26 years. She received her BS in pharmacy from Duquesne University.