Automated Dispensing Cabinet Functionality Expansion to Reduce Controlled Substance Inventory Discrepancies.

Background: Automated dispensing cabinets have the potential to create technology-induced errors that can arise during controlled substance medication dispensing. Despite enhancements made to the medication use process, the impact of ADC functionality on technology-induced controlled substance discrepancies have yet to be described. Objective: To evaluate the impact of ADC functionality expansion on technology-induced errors such as controlled substance discrepancies created during "blind inventory counts" and cassette dispensing errors. Methods: This quasi-experimental study was conducted over 18 months that evaluated the expanded use of dispensing cassettes within 8 ADCs at the University of Chicago Medicine. Unit-dose controlled substances with high usage were directed for inventory reassignment to cassettes. Controlled substance dispenses, blind inventory counts discrepancies and cassette dispensing errors were evaluated before and after cassette expansion. ADC discrepancy and Cassette Dispensing Error rates were calculated using 1-week segments across the study period. Results: Of the 64 040 dispenses during the study period, the proportion of cassette dispenses increased from 16% to 72% after cassette expansion. Controlled substance discrepancies decreased from 11 to 7 discrepancies for every 1000 dispenses (P < .0001). After cassette expansion, cassette dispensing errors increased to roughly 28 errors for every 1000 dispenses (P < .0001). Conclusion: Expansion of ADC functionality created opportunities for reduced technology-induced controlled substance discrepancy rates at the expense of increased cassette dispensing errors.

Quality improvement and reconciliation process for automated dispensing cabinet medication overrides.

PURPOSE: To describe a pharmacist-led reconciliation process for automated dispensing cabinet (ADC) medication override setting maintenance at an academic medical center. SUMMARY: ADC override management requires alignment of people, processes, and technology. This evaluation describes system-wide improvements to enhance institutional medication override policy compliance by establishing a formalized evaluation and defined roles to streamline ADC dispense setting management. A pharmacist-led quality improvement initiative revised the institutional medication override list to improve medication dispensing practices across an academic medical center campus with a pediatric hospital and 2 adult hospitals. This initiative included removal of patient care unit designations from the medication override list, revision of institutional override policy, creation of an online submission form, and selection of ADC override metrics for surveillance. A conceptual framework guided decisions for unique dosage forms and interdisciplinary engagement. Employing this framework revised workflows for stakeholders in the medication-use process through clinical pharmacist evaluation, existing shared governance structure communication, and pharmacy automation support.The revised policy increased the number of medications available for override from 80 to 106 (33% increase) and unique dosage forms from 166 to 191 (15% increase). The total number of medication dispense settings was reduced from 5,600 to 541 (90% decrease). The proportion of override dispenses compliant with policy increased from 59% to 98% (P < 0.001). Median monthly ADC overrides remained unchanged following policy revision (P = 0.995). ADC override rate reduction was observed across the institution, with the rate decreasing from 1.4% to 1.2% (P < 0.001). Similar ADC override rate reductions were observed for adult, pediatric, and emergency department ADCs. CONCLUSION: This initiative highlights pharmacists' role in leading institutional policy changes that influence the medication-use process through ADC dispensing practices. A pharmacist-led reconciliation process that removed practice area designations from our medication override policy streamlined ADC setting maintenance, increased the compliance rate of ADC override transactions, and provided a formalized process for future evaluation of medication overrides.

Medication discrepancy rates and sources upon nursing home intake: A prospective study.

BACKGROUND: Medication discrepancies at nursing home intake increase the risk of drug-related adverse events. Measuring discrepancy incidence rates and locating the origins of discrepancies can assist in identifying information exchange deficits for high-risk medications. OBJECTIVE: To determine class-specific discrepancy rates, to determine discordance between medication lists, and to explore patient and system-level factors associated with medication discrepancies discovered between the first and second medication reconciliations conducted at nursing home intake. METHODS: Medication discrepancy data were prospectively collected from four long-term care facilities over a 9-month period. Medication discrepancies were defined as mismatched prescribing orders between at least two medication history lists. Discrepancy locations were defined as the pairs or triads of facilities between which medication history lists were discordant. Unadjusted logistic regressions were used to identify medication classes with the highest discrepancy rates and patient factors significantly associated with any medication discrepancy. RESULTS: 40.8% of newly admitted or re-admitted residents and 6.3% of medications reviewed had at least one medication discrepancy discovered during the second medication reconciliation conducted at nursing home intake. Residents prescribed fewer than 14 medications were at less risk of discrepancies. Residents with Charlson Comorbidity Index of 5, COPD, HF, anemia or HTN were at greater risk of discrepancies. Respiratory and analgesic medications were twice as likely as other medication classes to be discrepant (OR = 2.2, 95% CI 1.2-4.4; OR = 2.2, 95% CI 1.3-3.5). Most discrepancies occurred between hospital and nursing home lists (44.9%), or between the hospital, nursing home, and community pharmacy lists (39.3%) CONCLUSIONS: Given the higher risk of discrepancies within respiratory or analgesics, transitions of care teams need to prioritize residents with respiratory conditions or pain. Although re-admitted residents' increased discrepancy risk is likely due to poorer health status, miscommunications across the nursing home, hospital and community pharmacy require further research to clarify system failures.