By Ericka Wilhelms

MEDICATION DISTRIBUTION AND ADMINISTRATION METHODS DIFFER greatly from hospital to hospital, and although no approach has yet established itself as ideal, the use of automated decentralized distribution cabinets can reap positive results. Implementing cabinets can streamline billing processes, improve accountability of inventory and patient safety, and increase nursing and patient satisfaction.

Factors to Consider When Making a Cabinet Purchase
When making a cabinet purchase, according to Bill Droste, an automation specialist with Cardinal Health Pharmacy Management, “you have to look at how you’ll be using the cabinets before you can determine their most important features.” For instance, if you plan to use the cabinets primarily for the storage of PRN medications and narcotics on the nursing unit floor, line-item capacity isn’t necessarily the most important consideration, as the security, accountability, and availability of just those medications on the nursing unit may be the goals. In this case, consider a cabinet that has fewer drawers or pockets, but that can hold larger quantities of relatively fewer drugs. Droste contends that if the cabinet is to be used for the dispensing of all patient medications, you will need to place “a much larger variety of medications in the cabinet, but you won’t necessarily need as large a quantity of each medication.” In that case, consider a cabinet with numerous drawers and pockets. In addition, if you are dispensing controlled substances from the cabinets, locked, lidded, or other restricted-access drawers (which limit nurses’ access to only one medication at a time and medications that have been ordered by a patient’s physician and approved by a pharmacist) can decrease diversion and increase patient safety.

Droste also stresses the importance of the cabinets’ reporting capabilities, as they apply to pharmacy functions. Look for cabinets that can provide a “concise inventory report” that details the remaining number of doses, the last time a medication was dispensed, and whether or not a patient on the cabinet’s unit has been prescribed that medication. By examining that data across one report, pharmacy can streamline the inventory management process and remove drugs that haven’t been used within a certain time period, as long as patients are not scheduled to receive them in the immediate future. Reports that track drug diversion are also important, particularly if you are using your cabinets for controlled substances. As such, in selecting automated cabinets for your facility, research their reporting capabilities to determine if they suit your needs.

Bill Churchill, MS, director of pharmacy for Boston’s Brigham & Women’s Hospital, emphasizes the importance of service and software. He says, “Cabinets are like cars, and all cars are built alike. It’s the nuances in service that make a Ford different from a BMW.” Because cabinet malfunctions can lead to serious problems in units like the ER or OR, Churchill stresses that, in choosing a vendor, “service response time is of the utmost importance.” He adds, “The software functionality the vendors build in to improve control, access, and safety is key.” Churchill suggests you ask existing clients how responsive vendors are, and ask vendors how often they have revised their software to incorporate suggestions from customers, how they have enhanced the safety of their cabinets, how their product’s functionality addresses JCAHO’s National Patient Safety Goals, and how they have made strides to meet ISMP’s recommendations for controlling cabinet access and for bar code scanning during the cabinet-fill process.

Also consider the flexibility of a cabinet’s design. Because cabinets in different units will require different design configurations, search out a vendor that offers adaptable cabinets, with various modular components. Lastly, the price of different cabinets, in relationship to your budget and required functionality, should be considered before making a purchase.

The Benefits of Using Automated Cabinets Among the benefits of their use, automated cabinets enable health care providers to capture medication charges upon dispensing, thereby reducing the billing paperwork pharmacy is responsible for. In addition, nurses can note returned medications using the cabinets’ computers, enabling direct credits to patients’ accounts. These functionalities can eliminate some pharmacy labor.

In addition, because the cabinets track user access and dispensed medications, their use can improve accountability of inventory. The real-time inventory reports generated by many cabinets can simplify the fill process and help pharmacy to track expired drugs. By restricting individual drugs—particularly high-risk medications and controlled substances—to unique drawers within the cabinet, you can further increase levels of accountability and medication security. Assistant director of pharmacy services for Cincinnati’s The University Hospital, Caron Sue, PharmD, PhD, says, “Storing only one drug in each pocket leads to a nice level of accountability. You know who accessed that pocket and who had the potential to remove or add something.” Brad Ludwig, MS, assistant director of automation and operations for the University of Wisconsin Hospital and Clinics, attests that the use of locked, lidded drawer configurations for each individual medication affords the most control over medication access. He notes, “Because we can tell who was in a pocket and what they intended to dispense, we have an easier time following up on cases of suspected diversion.”

In addition, Caron Sue contends that the use of automated cabinets can lead to increased “patient satisfaction and nursing satisfaction.”

Because the cabinets store medications on the nursing units, “theoretically, the response time for nurses to get emergency drugs and pain medications to patients will be quicker,” says Sue. Of further benefit, features can be added to the cabinets’ functionalities to increase patient safety. For instance, The University Hospital’s cabinets display tall man and short man lettering, and send warning messages to notify nurses when high-alert medications are dispensed. Sue points out that those “safety features are only valuable if people read them,” so it is important to emphasize the significance of heeding those alerts during training sessions.

Ensuring a Successful Implementation
The first step to ensuring a successful implementation of an automated decentralized distribution system is sufficient training. In Caron Sue’s opinion, “you can never do enough training and you can never start early enough.” Set aside ample time to educate pharmacy and nursing staff on the use of the machines. Visit hospitals that already use cabinets successfully, and observe their practices. Learn from their implementation mistakes to avoid making them at your facility.
Furthermore, be careful not to underestimate the cabinets’ daily and routine maintenance requirements. In Sue’s words, “Automation gives you a lot of reports, but if you don’t plan for people to look at those reports, you don’t benefit from their advantages.” Plan to spend a good deal of time building the cabinets’ information databases and testing the cabinets before you go live, as well. Also, carefully plan the location of drugs within the cabinets’ drawers; avoid placing look-alike/sound-alike medications or different dosage strengths of the same medication in close proximity to one another. Such thoughtful planning can lead to increased patient safety after the system is rolled out.

Sue also recommends that you contact your state board of pharmacy about their requirements for cabinet use; in her home state of Ohio, the board requires users to present a positive ID—such as a fingerprint—before accessing medications in the cabinet. Acquaint yourself with such guidelines before making a purchase, and budget in advance for related expenses.

Creating an interdisciplinary team of nurses and pharmacists to establish policies and procedures can inspire buy-in from both departments for the system change. The IS department should also have a voice in the implementation, as the development of the system interfaces is often in their charge.

The move to automation should be methodical. Sue claims, “I would not implement a hospital-wide automated dispensing system all in one day.” Instead, work out any “unanticipated bugs” on one unit, enabling a smoother, more efficient roll out for the rest of the hospital.

Optimizing the Value of Automated Dispensing Cabinets
After implementing this technology, it is important to find ways to optimize its use. Work-arounds should be identified and addressed. In theory, nurses may pick two drugs from a matrix drawer or open pocket to avoid having to access that drawer or pocket again at a later time. Nurses may also get sloppy with their med counts. One solution to these work-arounds is to add a “blind count” feature to your cabinets’ software. Instead of asking the nurse to merely confirm the number of doses remaining after a dose is dispensed, the nurse has to manually perform the count and enter the number. In a decentralized distribution system, pharmacy may also find it difficult to regulate access to remote stock, such as refrigerated drugs. Nurses may access drugs in unlocked, remote locations without indicating their removal in the cabinet’s computer system, leading to billing and inventory discrepancies. Avoid this work-around by adding a software feature to your cabinet that locks remote locations until the nurse enters the dispense command on the cabinet.

Adding patient-profiling capabilities to your cabinets’ functions can improve medication safety and help to close the medication-administration loop. With profiling, pharmacy is responsible for reviewing physician orders and, if no potential interactions or adverse events exist, pharmacists enter the orders into patient profiles, and nurses can then access only the drugs on a patient’s profile from unit-based cabinets. Override medications may be available to nurses, but according to Bill Churchill, “JCAHO is looking to pare down those medications to only those that are life-saving or for emergencies.” Churchill strongly suggests that your organization work with the cabinet vendor to put “failsafe back-up and redundant systems” in place to maximize the benefits of patient profiling. After all, if your server goes down and you lose communication with your cabinets, you stand to lose the benefits of patient profiling, not to mention pharmacy’s ability to track and replenish cabinet inventory.

To realize the full benefit of the cabinets’ technology, Caron Sue insists that cabinet users “don’t just automate their current, manual practices.” Seek out efficiencies and improvements wherever possible. Pharmacy should also perform periodic reviews of the cabinets’ inventory activity, removing drugs that are seldom used and replacing them with drugs that are often rushed from the pharmacy to the nursing floor.

Pharmacy’s Involvement
Automated cabinets can streamline multiple processes for health-system personnel, including the pharmacy staff, and can be an integral part of successful closed-loop medication administration. According to Caron Sue, “pharmacy has to be intimately involved with the system if it’s going to work.” Because automated decentralized cabinets require pharmacists to maintain the formulary and numerous databases and files, their use will dramatically impact pharmacy’s workflow, and pharmacy will likely become an IT resource for nurses when technological problems arise with the cabinets. To avoid inconvenient and time-intensive troubleshooting, encourage nurses to directly contact the vendor’s customer support personnel. However, many hospitals prefer nurses to first contact pharmacy before contacting the vendor. As Sue says, “Sometimes the nurses aren’t familiar enough with the system to know the things that should be done prior to calling the vendor, like rebooting the system. Sometimes the problem isn’t a vendor problem, but rather a hospital system issue.” In either case, to further ease pharmacy’s postimplementation burden, educate the nursing staff on potential malfunctions and how to handle them before they occur.