Hospitals are in the business of improving and saving lives but how they do that is a constantly moving target. Many facilities are so bogged down managing nursing shortages, patient expectations, regulations and workflows that it can be hard to focus on delivering the best patient care. Hospitals are being asked to do more with fewer resources, causing them to look at both the macro and micro levels to find areas to increase their capabilities.
One such area is in medication delivery. The process of delivering and dispensing patient medications has room to improve. Pharmacy and nursing must work together, build trust, and optimize workflows. Simply by looking at how medication has been delivered in the past and what risk factors are inherent in that practice, hospitals can begin to mature their system of operation.
Many facilities have invested in automated medical cabinets. They have greatly improved the efficiency, accuracy,
The Nursing Crisis
Nurses at hospitals and skilled nursing facilities need all the help they can get. Nurses have more than one patient to care for, as many as 10 or more at one time, in fact, severely limiting their ability to deliver excellent patient care. The number of patients to nurses is so skewed and poses so much risk (as well as nurse attrition), California imposed a nurse staffing ratio law requiring all of its hospitals to limit the number of patients that its nurses could treat at any given time, depending on the hospital setting. This law became a movement and other states, such as Florida, New York,
While the ratio law is a start, it ignores the fact that the real problem is inefficiency. When nurses are so burdened with menial, non-patient-related tasks, they are challenged to be productive. They are doing the best they can, but mistakes are unavoidable when they can’t focus on the patient. Medication errors are often the result.
Even with the efforts to reduce nurse workload, the instances of a nurse inadvertently losing track of medications is alarmingly common. Nurses can also pick up the wrong medication for a patient, accidentally selecting one of their other patient’s medications. As can be imagined, giving a patient the wrong medication can threaten lives, particularly in pediatric hospitals when patients are so vulnerable.
The pharmacy is under constant pressure as supplies suddenly run low and they receive urgent medication refill requests that could have been avoided. With each urgent request, the filling of other patient prescriptions is pushed further down the list, delaying patient care and causing a bottleneck in pharmacy workflow. This often puts a strain on the relationship between nurses and pharmacy, frustrates doctors and lowers patient satisfaction.
The Institute for Safe Medication Practices (ISMP) says there are several factors that can lead to medication errors, many of which involve both nurses and pharmacists. Any “weakness” in these elements can directly impact the odds of a medication error occurring:
- Patient information
- Drug information
- Adequate communication
- Drug packaging, labeling, and nomenclature
- Medication storage, stock, standardization, and distribution
- Drug device acquisition, use, and monitoring
- Environmental factors
- Staff education and competency
- Patient education
- Quality processes and risk management
Digging deeper into the medication storage, stock, standardization, and distribution point, American Nurse Today says, “Many experienced nurses remember when critical care units kept a medication ‘stash,’ which frequently caused duplication errors.” Thankfully, those practices have been replaced with more secure medical cabinets. As of 2007, more than 80 percent of hospitals have replaced manual floor stock systems and/or medication carts that held a 24-hour supply of patient-specific medications in individual patient cassettes with automated dispensing cabinets.
Still, as the article says, “Errors can occur when automated dispensing cabinets are stocked by technicians.” If pharmacy technicians are still at risk for making errors and that is the only thing they are asked to do, how much more risk is introduced when nurses are being asked to do so many different tasks along with medication dispensing? It is poor practice to place the responsibility of dispensing medication from automated dispensing cabinets onto their already burdened shoulders.
Medication Cabinet Errors: A Case in Point
In a well-publicized and tragic case in 2006, the risk for medication mismanagement due to the improper stocking of a medical cabinet was front and center. Nurses in an Indianapolis hospital did what they were trained to do. They retrieved from a medcab what was believed to be the prescribed medication for several premature babies. With no verification process or software technology in place, the nurses didn’t notice the medication was not what was prescribed. They didn’t see that the pharmacy technician had inadvertently stocked the medication cabinet with heparin at a dose of 1,000 times stronger than what was prescribed and placed it in the wrong cassette in the medcab. The medication error cost three infants their lives and caused three more to overdose.
These types of errors are estimated to injure as many as 1.5 million Americans per year. These errors shed light on the issue. With technology embedded into the medication cabinets, the hope is these mistakes will dramatically decrease.
Technology-Enabled Medical Cabinets Provide Hope
Newer models of medical cabinets offer several elements that not only improve security but also provide tracking capabilities to improve inventory control, dispensing accuracy and easier audits. These “smart” medication cabinets have locks that can be accessed only by authorized personnel using employee-specific badges or the like. Once the nurse or pharmacy technician access the medcab, the software tracks which medications are stocked where and who accessed them and when. Using barcode technology, it is fast and easy to ensure an electronic match between the prescribed and selected medication before it is given to the patient.
Related: Talon Upgrades Point-of-Use Medication Storage Cabinet to Enhance Accessibility and Reduce Cost
If this technology had been in place in 2006, the horrific infant incident would likely have never happened.
Further Medical Cabinet Safety Implications
ISMP says automated medication dispensing cabinets are only effective if they are designed properly and used as intended. They go on to list several factors that influence patient safety:
When the medication cabinet is equipped with tracking and access software, it can be linked to the pharmacy computer systems. This gives the pharmacist greater visibility into new prescriptions and whether they and their prescribed dosages are safe for the patient before they can be removed from the medical cabinet and given to the patient. As ISMP says, “Without this feature, nurses may not be alerted to unsafe doses, potential allergic reactions, duplicate therapy, contraindications, drug interactions, or other important drug information.”
In cases of emergencies or time-saving efforts, it is possible for nurses to override the patient profiling feature. While the override capability was included with good intentions, there is room for misuse. Hospitals and skilled nursing facilities must, therefore, put into place some sort of protocol that keeps the override feature in check. Otherwise, nurses may remove medications for multiple patients or a larger quantity to save time. To reduce risk, it is critical they wait for the pharmacy to screen the medications prior to dispensing, even if it means implementing an “emergency” screening protocol to speed pharmacy approvals in an emergency.
Number and Placement of Medical Cabinets
The location of the medical cabinets can also make a difference. If the medcabs are centrally located yet away from a nurse’s rounds, it opens the door for the nurse to remove multiple patient medications at one time in order to limit travel back and forth from patient rooms to the cabinet. ISMP recommends the medication cabinets not be placed in “areas with high traffic or low illumination” that can lead to distractions and misread screens or labels. A good option is to have a medical cabinet located in each patient room.
How the medications are listed on the medcab screen can impact medication error rates. Many medications are spelled similarly yet do vastly different things. When listed alphabetically, it is easy for the wrong medication to be accessed. ISMP suggests the medical cabinets are integrated with the pharmacy computer system to prevent any drug from being dispensed to a patient if it does not appear on the patient’s profile.
Quantity of Drugs
Medication cabinets are meant to reduce errors, therefore, they should never contain excessive quantities of medications. With the software, however, pharmacists have the opportunity to screen medications to ensure the ones in the medcab are, in fact, prescribed as written in only the required dosages.
While pharmacy technicians should stock the medical cabinets, some hospitals allow nurses to return unused doses to the cabinet. This may be a common practice, yet the risk is obvious. Nurses, particularly when they are overworked and looking to save time, can inadvertently place the unneeded medication in the wrong location in the cabinet. In the infant death example, the location of the medication played a major role in the incident. Bar-coding technology can prevent this error from occurring.
Medication cabinets have dramatically improved medication management practices. Patients are better off and healthcare facilities greatly reduce their risk. The key, however, is to use them properly, including how they are stocked. Certain protocols must be in place and enforced by hospital administrators to ensure the medcabs actually reduce the risk for errors instead of introducing new threats.
Hospitals should place medical cabinets where they are most accessible so they are used properly. They should leverage available technology to protect and track access. The medcab technology needs to be integrated with pharmacy computer systems to establish a screening process. Finally, a clearly-defined best practices needs to be followed by all staff who accesses the cabinets, eliminating any instance of nurses stocking or returning medications to the medical cabinets. Only then can the full benefits of the medication cabinets be experienced without the associated risks.