PA PSRS Patient Saf Advis 2005 Dec;2(4):2-3.
Letter to the Editor: Automated Dispensing Cabinets

We received the following letter from a Director of Pharmacy at a Pennsyl­vania Hospital:

In reviewing the article "Problems Associated with Automated Dis­pensing Cabinets” [in the September 2005 Advisory] with several multidisciplinary healthcare workers, many came to the conclusion that these automated dispensing cabinets created the problems that were listed and that the problems were not seen prior to use of the automated cabinets. Many workers were left with the impression that the non-automated floor stock method was just as safe.

The article did lack two significant points: First, that the automated dispensing cabinets are a large improvement over the original non-automated floor stock method due to better drug security, better drug tracking, better drug reporting, and improved retrospective review capability—all of which will lead to better patient outcomes and increase patient safety. Second, automation itself allows the shortcomings to be tracked as well as they are. Without the automated cabinets, the data points that were quoted within the arti­cle would be severely limited or nearly non­existent.

The article never gave the impression of a "step-in-the-right direction" and left people with the thought that these types of errors were never seen in traditional/original non-automated floor stock scenario still used in some hospitals. The automation actually highlights the frailty of the systems used prior to their creation.

Editor’s note:

We, too, believe automation, technol­ogy and automated dispensing cabinets (ADC) are a "step in the right direction" and have the potential to improve the safety of the medication use proc­ess. The writer makes a strong point that the fea­ture of ADCs that allows tracking of medication re­moval provides us insight into the types of errors that occur not only with ADCs but also those that likely have been occurring with traditional, non-automated floor stock systems. As the writer sug­gests, the intent of the original article was not to say that the types of errors described never occurred in traditional, non-automated systems - but rather that ADCs are not a panacea for the prevention of these types of errors, especially if safety upgrades have not been put in place.

Based on reports submitted to PA-PSRS, we feel that the implementation, design, and use of ADCs often limits the safeguards we all believe ADCs can deliver. Though upgrades to ADCs, such as warn­ings on interactions, drug duplications, and other safety alerts offer advancement for medication safety, many facilities still use older systems that only control access or storage. This would not be an issue except that many healthcare facilities have replaced medication exchange cassettes with ADCs without incorporating the most recent safety enhanced software upgrades. We hope facilities will use the article not to justify a step away from this technology, but rather to realize the benefit and im­portance of the available ADC safety features and to move forward implementing them to improve the safety of the medication-use process.

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