ASHP Guidelines on the Safe Use of Automated Dispensing Cabinets

Abstract

Address correspondence to Bruce Hawkins ([email protected]). Automated dispensing cabinet (ADC) technology is used to improve patient care, enhance the efficiency and accuracy of medication dispensing in the medication-use system, support medication storage and security, and provide evaluation of ADC-user interactions. ADC use has become widespread in healthcare institutions, with 93% of hospitals using ADCs in their medication-use systems,1 and 70.2% using ADCs as a primary method of maintenance dose distribution.2 Implementation steps and objectives to support an ADC system include the following: Software and hardware technology for optimal operations are available and supported by knowledgeable staff; ADC maintenance is supported with adequate personnel, minimum downtime, and analytical reporting for ordering and restocking; Staff education and competency on ADC operation are supported at a high level. Interfaces to other technologies supporting medication use (eg, intravenous [IV] infusion systems) are created to enable efficient workflows and enhanced medication diversion detection; Interoperability is established with the electronic health record (EHR) and related systems; Safe and secure operation is ensured with real-time reporting functionality of medication diversion; Mechanical operation and inventory management capabilities exist to allow efficient, accurate, and optimized availability of medication; Employment of other technology is used, eg, barcode scanning, biometric identification, special storage and alerting features; and ADCs in procedural and non-acute extended patient care areas (eg, long-term care, ambulatory clinics) have the same standard of medication control as traditional patient care areas. These guidelines address components of ADC technology implementation and important detailed steps to meet and maintain basic ADC requirements. Appropriate, accurate, and timely distribution of medications to patients is a well-established responsibility of pharmacists. Use of ADCs has become the standard of care for the medication-use process in healthcare systems.2 ASHP supports use of ADCs, because they are essential to provide quality patient care, secure storage of medications, and ensure viability of the medication-use process in healthcare organizations. These ASHP guidelines reflect the evolving and increased use of ADCs to improve patient safety and allow secure access to a broad selection of medications. Consideration of the use of ADCs must include serious evaluation of existing and potential opportunities for error and the implementation of mitigating strategies to minimize or prevent such errors. Pharmacists have a professional responsibility to ensure that appropriate policies, procedures, and quality assurance programs are in place to address the safety, accuracy, security, and patient confidentiality of automated pharmacy systems, including ADCs.3 ADCs must provide accurate and controlled storage, dispensing, and monitoring of medications while providing medications in an efficient and safe manner. The ability of ADCs to accomplish these requirements has improved since their introduction in the late 1980s, leading to the technology becoming the primary means of medication distribution.1,2 To be successful at implementing and sustaining ADC benefits, an organization must ensure that the ADC will help optimize the medication-use process and meet financial, operational, and clinical goals of the organization. Technical infrastructure that will best support the system and allow for smooth operation and future growth is of utmost importance. Infrastructure requirements include servers, interfaces, upgrades, integration with other systems, and security. It is essential to ensure that both physical and personnel infrastructure necessary to maintain the system are in place. Servers are typically client-hosted but are becoming increasingly cloud-based as health systems move away from owning and maintaining their own servers.4 Regardless of the hosting approach, servers should be readily available and highly reliable to minimize workflow interruptions. Servers must be adequately sized to store both formulary and user information, as well as transactional information for analytics and reporting, and should be scalable to allow for future growth. Consideration should also be given to minimizing the amount of redundant software maintenance (eg, formulary maintenance). Depending on an organization’s size, an ADC server might be a single standalone server. Larger organizations and integrated delivery networks (IDNs) may employ integrated servers that work together but physically separate different data components into separate servers. Options for server redundancy to offer protection and limit interruptions in the event of unplanned downtime must also be considered. A range of options are available, from data refreshes every few hours to more frequent data refreshes that support minimal losses in the event of unplanned downtime. Partnering with the information technology (IT) department is essential for proper server maintenance, such as operating system patches and security software to protect against viruses and malware, as well as the integrity of frequent data backups. Maintenance may be supplied internally by the system for virtual machines or by the vendor (more commonly for standalone servers). In either case, IT should be engaged to assist and help coordinate proper server security. Finally, an organizational downtime and recovery policy and procedure should be developed and implemented to minimize disruptions in patient care. With the growth of large healthcare IDNs and proliferation of multiple electronic clinical applications used within healthcare systems, ADC vendors have moved toward integrated platforms that simplify and standardize system maintenance. The ADC system must work seamlessly with other clinical systems, which include at a minimum EHRs, pharmacy information systems (PISs), and admission/discharge/transfer systems. Each of these other systems serve as the source of primary data for the formulary, barcodes, patient information, medication profile, and medication orders. The ADC provides source information for other clinical systems through interfaces based on Health Level Seven International (HL7) standards. Affected clinical systems include inventory information for the PIS, dispense information for billing systems (for organizations that charge on dispense), usage information for inventory management systems, and user information for a domain management system. Finally, many systems also use interface engines to streamline system connectivity, especially when multiple systems come from the same vendor. During the build phase of ADC system implementation, all interfaces must be thoroughly tested to ensure that both accurate and current information is transmitted into the ADC system. In addition to the ADC vendor, the organization and EHR vendor play important in successful implementation and maintenance of the ADC system. the ADC and EHR vendors have for the implementation which should be used in with the organization’s and all will be to successful is a in EHR or ADC vendor, interfaces and a of dispense data for to be In addition to clinical systems integration of systems with the ADC system must be they are dispensing such as pharmacy or ADC may inventory management systems used to a inventory based on all and within the pharmacy must also be considered. These systems may dispensing and also be used for both within a or a healthcare system. Finally, many healthcare organizations also use a controlled system that provides secure storage for and with the ADC system to provide secure management within the ADC system maintenance of information to ADC including ADC barcodes, user and In these are typically all to streamline support and allow for of ADC formulary, barcodes, and user are in which IDNs are to maintain separate at (eg, separate different ADC but typically the is to all on a single ADC hardware hardware are timely software may to the of These may allow for hardware to in place with an of or within the while software may also be the of the cabinet while the system that the for functionality and to the user interface while minimizing by the healthcare organization to using existing will also to the operating system, which include security patches and necessary hardware to be to ensure safe and secure operation of ADCs include but are to access medication and dispensing, the and of medications, ADC and Safe and secure operation of ADCs with for and maintaining user technology for user management through the IT or pharmacy A domain management system for control of access to multiple while the user the same for ADC systems, the domain management system must allow for of access an is or The ADC should also have a to of have within a The organization’s ADC access policy should address of all clinical or medications, including A single ADC system supports multiple within an and should use the same user and policy to the organization. may be available for an ADC system. Staff should be to use and a are to be the use of user and or an workflow by and organizational policy should be Use of biometric data must meet requirements for security and user should for and of medications from the ADC by the including and when medications are supplied to the ADC and The and of storage areas within the ADC ensure the and are or medications are barcode technology should be used to ensure medication is in the storage ADCs be that personnel an ADC are to both the medication and the storage to minimize the of ADC errors. The barcode is a to ensure safe ADC use when and medications to the The pharmacy department should for addition and maintenance of in the and should to the pharmacy the barcode and a the or the barcode is as by medications from the pharmacy should have a medications have a barcode by the pharmacy is for for or and with barcode may be by special or with a or other technology should be used when a medication from an ADC for should be against the for a to on medication technology of the ADC is with that limit access to a medication and barcode is for medications to the the of a medication is a is a medication to the barcode should be used to the medication and storage ADC systems may allow of medication The process a to patient medications for while away from the ADC by the process through EHR integration or a medications are in the the access at the access to the ADC should be a to and allow of may also and of medications the EHR or at the should for workflow and with and ADCs be as either or machines allow access to medications a medication or In medications have access to all medications in the The for Safe the use of should be to areas are to medication (eg, and to and that of medication by pharmacists. have in the department have more to ADCs should be to to limit for of an ADC to access be by with personnel to appropriate and a medication in a ADC is but is an on the patient profile, to may be is have access by or to ensure they are and available for or A of medications should be by the organization’s pharmacy typically the pharmacy and for is available both from and A policy should be developed to the by which a medication be to the and the with which the be of patient care against the by of the medication The for an must be when a medication that data be for A should be to the of and of medications in a of medications or from ADCs should be to a minimum of using at a medication to the of medication on the The and of should be for process and of safety must and standard that and for medications or using an The ADC be to of the for a for medication should be developed to support data and process the ADC be to to the storage or to a separate medication and barcode should be to ensure the medication is to the proper ADCs on and are typically with a are necessary to for dispensing medications in the event of an extended The of to and are important the of ADCs in patient care including of patient medication distribution and other and distribution and vendor will an appropriate ADC for care ADCs should be in areas that are well and to patient care to the and systems, supplied with and have efficient with a ADC is also a in may be to and may ADCs to be in a ADC systems allow for or and to clinical should be and an using a and developed with for The process for should include from will the and of other safety in place for a alerting should provide information that is at the of the on of a medication from the on should be and including and and the should the of the of when and maintaining of ADCs be highly on and organizational may be with or a of in Options may include integrated on or other selection and are by including the organization’s distribution available for and of medications to be control and the care of the the of storage may and include or with that to medications or allow of is the primary when medication within the access to medications through appropriate the potential for the ADCs should be to prevent medications from into (eg, ADC to prevent medications from in ADCs for and of medications, medications with and and to diversion within a or is Each medication and should be in an ADC that when the medication is must be in ADCs a care, or organizations should standardize storage by in with a on the that should also using an that to or information for of the (eg, for patient also be used to when other medications and are or medications, and medications with multiple should be the to minimize or to medications should be through the ADC system and may be an integrated or that provides access to information and should be for of medications that with a of should be with the appropriate and in a away from the or or of the To address safety, medications should be in an of the ADC that is for both pharmacy and of used medications toward the of the ADC should be to the for or to or The pharmacy as of an that provides medication safety should for medications and that will be different of access control in of or other should be based on the organization’s medication distribution and of patients and should address all in storage should be and based on and a of ADC should be in the event they are for a medication or other and of medication use of medications to be for in ADCs, such as with with special or storage that or are for medication safety and control of medication availability in the such as the pharmacy and of the for or formulary on a and to ensure they and interface with other or applications and as of many that improve safety in use to prevent and minimize the of medications to the ADC by to the potential for error for policies, procedures, and education current medication The of accuracy and integrity of to medications that are from an ADC but used to for medication for and and on storage for medications to patient care and patients that ensure accurate of ADCs, such to ensure the ADC system use of to medication in or on and including software and use of or systems that support safe access to ensure of to limit process automated dispensing to be reporting, and include but are to inventory diversion and detection; and medication dispense ADCs have become a source of should be in and should be to ADC inventory should be to that of to inventory should include which the user to the of in the and information into the ADC to the will that of must be in and when on a by may be for to a of since the inventory of every and a inventory of a should be to prevent or of that are used will inventory of in diversion of or and a a for or electronic biometric should be for and to the ADC to a should be policy should that the user either the or the to the ADC to as a In the event is to the pharmacy for should be in place to maintain proper of the Implementation of a or system that and may help standardize the and should include is of the ADC to minimize the potential for inventory and that to and are to minimize process and to and with to and the be of that by of be by pharmacy and patient care with within The ASHP on of provide on or that is at for reporting or diversion are providing adequate and of a diversion should a diversion and diversion that will in dispensing, and Staff in diversion should to ADC user that may data and are and diversion software options should be and to the security in medication that provide a of ADC has also become a in many It is important to work with the organization’s security and to and that might the use of such as well as the organization’s and security dispensing from ADCs of many which may include and ADC as by and should be at by the diversion or as by the organization. monitoring and should include a of ADC dispense with the medication record to or to are in or potential be when to a and the dose is to the dose as amount of as or These should be in a timely the of a work event be a and should support that minimize the of such as the following: from storage and the of and and is is or available the dose to be healthcare operating within the of their may dispense and are from the ADC for patient at a The dispensing from the ADC is also the and the medications of into a is ADCs maintenance and monitoring to ensure safety and and related to proper and maintenance are necessary to ensure the system is used and for optimal and inventory The process of ADC access and for which of user related to system security. and many basic as they with the In addition to the system must be on or on the organization’s and availability of organizations to use basic for while in analytical platforms to streamline the management process and to provide into ADC Regardless of the approach, a of basic pharmacy and be in ADC controlled ADCs hardware maintenance, as well as software upgrades, and In vendors may be to provide maintenance to ADC operating system and software It is important to the operating system, and should be in a timely and a for the health system IT department to ensure efficient use of the It is important to have a maintenance that the following: of and and of inventory in optimal based on barcode and maintenance, monitoring and policies, system maintenance, and control and software and hardware the existing of ADCs in to patient care and medication-use process will future may ADCs, may ADCs, and may to be and are with existing systems and systems will help on is for a or and are important and necessary with automated system implementation or and standard components of a and must be for of and of to system should be given to of and that meet the of user and as well as workflow patient care areas. should include but also the and supporting proper use (eg, the should provide standard support for and Health systems should personnel that and existing on an strategies should include as well as through either a vendor or the organization’s should be highly will be to and should be used to to ensure education access to might be to a for or education may be for to with The or should the to which and at and to ensure accurate of all adequate of should be available to the and may be as to be to provide education to of also provide support to when are large of to be should be with the and they will and may also serve as support and might and ADC implementation and is is important to for for and existing and for as and of the ADC as they move to or the organization should also be or best and help are important to provide support and to It is to provide the help with a to and be by the help and to other of should be or as by the organization’s and procedures, especially when ADC software include may a ADC for and Health systems may ADC and the be used to education and will with a vendor, including medication and and vendors and an of workflow from vendor to vendor will be to ensure the current and future Use of ADCs in areas is to the for health systems to inventory improve and improve for and controlled and in the are typically ADC to for these standard ADCs that are to or ADCs, which the of an automated and are typically used in and procedural A to when an ADC medication distribution system into the is which will be using the A will their ADC access and in the standard ADCs are in areas operating for use by or In the of may access (eg, and A healthcare will be and medications. are medications from the ADC based on ADCs used in the are machines that store many medications for place in These be used as storage for medications that are either large to in machines or are and be of in ADCs for use by and procedural in functionality when to standard These ADCs have in and access to medications as primary and are different from their standard ADC ADCs medications, and care to be in these medications are in ADCs, including to other medications, use of use of and of virtual to help ensure appropriate selection of medications such as special to selection to implementing more ADCs in the include increased medication security, inventory medication and access to medications include with the process of to ensure accurate inventory and medication and ADCs also have the to interface with or that allow to more with The and of ADCs may assist in providing accurate medication the appropriate ADC and EHR interfaces have developed and to implementing ADCs include with based on availability of the and physical and electronic inventory ADCs are with to allow include and a source in of These allow for based on for is and is With increased the security of the ADC to be to ensure are of an ADCs have different requirements to the areas they appropriate is important in all of ADCs to ensure have access when but that are in place to prevent access while accurate user In the the be to be the on the to the for access an of to limit access to of user is important to ensure and security. in areas to be to ensure access to patients and limit of patient when patient include of patient in the access to patients in the ADC for and the to have access to all patients access for to ensure of use of for a patient in access to appropriate medications for and be through and management of medication in care areas. access to medications must also be to the of secure storage and dispensing of may best be by into a of a they access to ensure and access to for may also be to other medications in the and of such should be with to ensure adequate systems are in place to and is for for medication to the ADC must be with the department to ensure that workflow and prevent for medications by medications to a on the of the of medications to the and to the to be The store the has medications at the ADC the is to have pharmacy all physical also to be in place to ensure of for all and to ensure that in is and secure the Depending on the EHR and ADC may be available capabilities that allow information to from the ADC to the including and also have the for a at the of an that the to also accurate implementing ADCs, the organization will to a policy on to (eg, all to pharmacy for to with a Use of ADCs is from to non-acute such as long-term care ambulatory care standalone and of ADCs in non-acute areas has by the ability to and maintain all information and medication in and of the system for the enhanced security, accuracy, and of medications. In addition to of medications, ADCs store and of when may be from the pharmacy that The implementation of an ADC in a non-acute is by the same given to implementation in care but include in to inventory through management of and requirements of the requirements medications are and from pharmacy to the and management of for access to medications to to use of ADCs in areas of medications and maintenance of the ADC the pharmacy access and management that have access or may be of access to ADC or will medications pharmacy to is process for including steps to in the event of a or an and for access to medications system or medications to be of security of the ADC for for electronic of at the ADC on the ADC in care areas that are or or have patients for monitoring and to Address in vendors organizations and areas in and to system software to to and build automated dispensing systems may ADC systems Regardless of of ADCs that provide or options may be should be to minimize potential for error and for accuracy as a system. The of an ADC system should be a with appropriate to ensure safety, accuracy, and efficiency in the medication-use should be in place to quality of and operation of the system the of the organization and and for workflows within the organization and supported by and personnel must be with and ADC diversion and with ADCs are as organizations are for that vendors are to patient safety or diversion as they are to be to the and ADCs are by the and safety ADC use is of an integrated in the medication-use process and in With with other systems such as and EHRs, and the potential with these systems may be by the in the is that organizations appropriate steps to that may diversion or patient safety to vendors and appropriate to ensure appropriate evaluation and timely should that improve the safety, and efficiency of ADCs and enhance the medication-use process to ADC In vendors should have a method of and best and as well as with safe and efficient of medication distribution that with objectives and and ADCs are in store and medications as a primary in the medication-use and are becoming more with other systems and a ADCs to with technology workflow and which help organizations medication distribution systems safe for efficient for and in with and requirements. ASHP the organizations and for these guidelines Health of Pharmacists for for Safe of and The have potential of through the ASHP of and and by the ASHP of on These guidelines the ASHP on the Safe Use of Automated

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