Running head: ANALYSIS OF AUTOMATED DISPENSING CABINETS 1

Analysis of Automated Dispensing Cabinets

Michael W. Walker

University of San Diego

ANALYSIS OF AUTOMATED DISPENSING CABINETS 2

Automated dispensing cabinets are invaluable to healthcare facilities to help improve

quality of care, operational efficiency, and aid in regulatory compliance and security. These

automated dispensing cabinets were first developed in the 1980s as a result of concern with

dispensing errors through a traditional pharmacy (Ferencz, 2014). Today Nearly 58% to 70% of

hospitals nationwide use automated dispensing cabinets and global revenue exceeded $1

billion dollars in 2016 (IHS Market, 2017).

However, setup and use errors with these cabinets have caused concern in the industry.

Studies have shown human errors still exist like mislabeled drugs, wrongly filled dispensing

cabinets, correct medication administered to the wrong patient, and confusing user interfaces

on the cabinets. According to the Pennsylvania Patient Safety Reporting System, up to 15% of

errors reported cite automated dispensing cabinets as the source of the drug involved in the

error (Cramer, 2017). In addition, the Institute for Safety Medication Practices estimated that

over 20% of healthcare practitioners reported adverse patient effects due to inventory control

issues in their cabinets (Lukiniha, 2017).

The implications of these errors in the automated dispensing cabinets can be serious if

patients are being given the incorrect medication. According to a report by The Institute of

Medicine, medical errors were associated with up to 98,000 deaths and more than 1 million

injuries each year in the United States (Cramer, 2017). While these cabinets have helped solve

many errors in traditional pharmacies, there is still much room for improvement in improving

the quality.
ANALYSIS OF AUTOMATED DISPENSING CABINETS 3

The quest is on to improve the quality and user experience with these cabinets.

According to Ferencz (2014), the safest dispensing cabinet will abide by the “five rights”, which

includes right patient, right drug, right dose, right route, and right time.

In this paper we will be exploring the issues related to the automatic dispensing

cabinets, what we can do to improve patient safety with the devices, and any additional

functionality that could be added in for the benefit of the healthcare organizations and their

customers. The potential for these cabinets to be extremely safe is attainable with the right

standards and best practices.

Literature Review

Literature search into this topic yielded several quality studies and reviews. A couple of

the studies focused on compliancy of the automated dispensing cabinets with the guidelines set

forth by the Institute For Safe Medication Practices (ISMP). Another study looked at the

override functionality in the ADCs and whether they were causing unnecessary errors. Last,

there were two studies that compared error rates before and after implementation of ADCs in

Geriatric Units and ERs to determine if medication dispensing error rates were continuing to

decline.

According to Fanning et al. (2015), there are several factors in hospital emergency

departments that can lead to increased medication errors. These include being in a high-

pressure work environment and the demand for quick patient care and dispensing large

numbers of medications without all the vital information needed. Due to these factors, having

a system that can deliver medications safely and accurately is extremely important. This study

observed nurses completing medication selection and preparation both before and after the
ANALYSIS OF AUTOMATED DISPENSING CABINETS 4

implementation of the ADCs. Included in the study was the type of errors that occurred and

their severities. The results of the study of 808 patients showed that there was a 64.7%

reduction in medication errors after implementing the ADCs. Interestingly, two similar studies

occurred in a short-stay geriatric unit and medical intensive unit (MICU). While there was a

53% reduction in medication administration errors in the short-stay geriatric unit after

implementation of the ADCs, there was almost no difference in the MICU. Analysis of the

results showed that the implementation of ADCs can reduce medication administration errors,

especially in high-pressure environments, but to further reduce errors there should be

evaluations done of workflows in addition to the ADC analysis (Fanning et al., (2016).

According to Cousein et al. (2014), the previously-mentioned study performed at the

short-stay geriatric unit was completed as an observation study at a 40-bed facility both before

and after the implementation of ADCs and a unit dose dispensing robot. It was noted that

accurate medication delivery among elderly patients is extremely important due to the

increased sensitivity to adverse effects of the drugs. There were a total of 615 opportunities for

errors among 148 patients. The study concluded with a 53% reduction in medical

administration errors. Astonishingly, there was a 79.1% reduction in wrong dose errors and

93.7% reduction in wrong drug errors. It was noted that some errors occur outside the scope of

ADCs. For example, the order the physician prescribed does not match what was entered into

the system, or the prescribed medication conflicts with the recommendation according to

evidence-based guidelines. A possible solution to come from the study is to include checks into

the ADC interface to verify the medication matches what the doctor prescribed, perhaps by

incorporating the patient’s EHR with the ADCs (Cousein et al., 2014).
ANALYSIS OF AUTOMATED DISPENSING CABINETS 5

Another study focused on inventory control issues with ADCs and the resulting

medication stockout. According to Findlay, Webb, & Lund (2015), medication stockouts can

lead to a decrease in nursing, pharmacy, and patient satisfaction; a significant disruption in

pharmacy technician workflow; and a decrease in the quality of patient care by delaying

medication administration. Traditional inventory values are static and developed from average

doses per day and desired number of days of stock. Once medications drop below the periodic

automatic replenishment (PAR) standards, they are automatically scheduled for restocking

during the next stocking period. At the University of Wisconsin Hospital and Clinics, where the

study took place, the restocking process begins each morning when the ADCs electronically

transmits a message to the pharmacy with the list of medications that have fallen below PAR

levels. The medications are then restocked by 2 technicians throughout the day and usually

takes about 12 hours. However, depending on the medication, some may run out quicker than

they can be restocked and thus cause another medication stockout. Possible solutions to this

problem include making the inventory control process more dynamic as opposed to the current

process of entering PAR levels manually (Findlay, Webb, & Lund, 2015).

Bernier, Yu, Rivard, Atkinson, & Bussières (2016) reviewed the compliance of ADCs with

guidelines defined by the Institute for Safe Medication Practices (ISMP). The study focused on a

500-bed teaching hospital in Montreal, Quebec. Compliance scores were calculated at

implementation of the ADCs. The guidelines set forth by ISMP specify 12 core processes and 89

individual compliance criteria. The assessment was first done in 2010 and then re-assessed in

2015 with the same criteria. Results showed an increase in compliancy from 74% to 79%.

Issues still existing included a poor display of allergies, dosages and administration details
ANALYSIS OF AUTOMATED DISPENSING CABINETS 6

displayed on two screens, which could lead to nurses missing important information, and the

storage of multi-dose bottles when the ADCs can only handle single-dose. Points were also lost

because all medications were available for override and nurses were not required to document

the reasons for override. It was also interesting to note that the rate of medication errors did

not decrease in the 5 years despite the improvement in compliance. Solutions discussed

included a continued improvement on compliancy and implementation of bar codes on all

medications being entered into the automated dispensing cabinets (Bernier, Yu, Rivard,

Atkinson, & Bussières, 2016).

The solutions presented in the above studies and reviews all have a similar theme.

While the ADCs help with the reduction of medication errors, they are not a foolproof solution.

Issues still exist with medication stockouts and incorrect or mislabeled medications being pulled

from the cabinets. Healthcare organizations and ADC providers need to work together on a

solution to improve this functionality as it is a vital component to the cabinets, but also a main

source of errors related to them.

Identified Solution

The issue of medication stockouts in ADCs is an avoidable problem. The main advantage

of the cabinets is allowing care providers quicker access to the medication required. However,

delays in receiving the proper medication due to stockouts can lead to serious health concerns

with patients.

According to Findlay, Webb, & Lund (2015), a solution to the frequent stockouts is

moving to a dynamic inventory system, which uses an advanced algorithm to automatically

adjust max and PAR inventory levels. By using this system, the unnecessary stockouts caused by
ANALYSIS OF AUTOMATED DISPENSING CABINETS 7

delays in delivering medication to the ADCs can be avoided. The algorithm would adjust the

levels based on the frequency of each medication being dispensed. It would look at either the

average or peak dispenses and depending on the results, would either apply the average

dispenses per day over 30 days, or the peak number dispensed over the last 30-day rolling

window.

The results of the study at the University of Wisconsin Hospital and Clinics shows that a

combination of low inventory alerts and a dynamic inventory system worked best to both

reduce the number of stockouts and the duration of stockouts when they do occur. An

additional benefit of introducing these two automated features is a reduced need to hire more

employees for restocking as they implement additional ADCs (Findlay, Webb, & Lund, 2015).

An additional study showed that stockout percentages were decreased once PAR

inventory levels were increased, expansion of common medications in ADCs to ensure

inventory was on hand, and the removal of infrequently used medication from the cabinets to

make room for the more frequently used medications. Once the cabinets were optimized the

stockout percentage rate dropped from 3.2% to 0.5% (McCarthy & Ferker, 2016).

The identified solution of dynamic inventory control supplemented with low inventory

alerts, along with cabinet inventory optimized with higher PAR max levels for frequently used

medication will be the most beneficial to the patient. Imagine in the emergency room the

doctors and nurses need a medication immediately, but it’s not stocked in the cabinet. This

adds precious time that patients cannot afford. Implementing the above solution will greatly

reduce the number of stockouts by ensuring the correct medications that are frequently used

are well stocked in the cabinet and alerts are sent out before too much inventory has been
ANALYSIS OF AUTOMATED DISPENSING CABINETS 8

depleted. This solution will also benefit the doctors and nurses as the correct medication will

be on-hand when they need it.

ANALYSIS OF AUTOMATED DISPENSING CABINETS 9

Failure Mode Effect Analysis

Start
Failure
Modes
1. Gather Project
and
Requirements
Effects
Analysis
2. Develop Algorithm which
will dynamically adjust PAR
levels

3. Develop and unit test new

functionality for ADC
interface

4. Determine most and least

used medications
cycle to fix and test changes)
(Loop through development

5. Increase PAR inventory

levels for frequently-used
No

medications

6. Create testing environment

that simulates production

7. Execute QA Test Plans

QA
Passed?
Yes

8. Develop and implement

rollout plan

9. Rollout dynamic refill

program in stages

Stop
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Steps or Links in List All Potential Potential Causes Mitigation Strategies

Number (RPN)
Probability of

Detectability
Process Failure Modes (Recommended Redesign)

Risk Priority
Occurrence

Severity
1. Gather Project 1.1 Scope of Not all primary Conduct meeting(s) to identify
Requirements requirements is stakeholders are all primary stakeholders and
incorrect. identified and/or invite to design meetings.
4 6 6 144
involved Validate before development
starts that all stakeholders
have been involved.
1.2 Vital Proper review of Plan and execute review
requirements left requirements was not meetings with stakeholders
out. completed and/or not and developers that verify all
4 6 7 168
all primary requirements have been
stakeholders were identified and planned.
involved
1.3 Not all HIPAA Requirements were not Verify HIPAA expert is on team
requirements are verified against HIPAA and hire one if needed. Create
met requirements, or new task to validate requirements
2 6 9 108 functionality doesn't and new functionality meets
qualify under HIPAA HIPAA standards.
rules.
2. Develop 2.1 Algorithm isn’t Incorrect factors Validate that factors are
Algorithm which based on correct gathered during correct before developing
will dynamic adjust factors investigation phase, or algorithm. Unit test early in
4 4 8 128
PAR levels wrong information process to validate it's
provided to working.
developers.
2.2 Algorithm isn't Bad development Frequent review checks and
developed correctly work, improper testing quality unit tests of algorithm
6 7 10 420
by development of algorithm before handing to QA

2.3 PAR levels Review of documented Add task to project schedule

defined incorrectly levels failed to occur. to review current and future
3 4 8 96 Algorithm developed PAR levels.
correctly, but fails due
to incorrect values.
3. Develop and 3.1 New Incorrect requirements Before releasing to QA for
unit test new development work given to developers. test, validate new functionality
functionality for doesn’t match 4 6 8 192 Developers didn't code matches requirements from
ADC interface customer needs to specific requirement customer.

3.2 Numerous Bad coding practices Develop good coding

defects injected into and/or improper unit practices. Have developers
code which delays 5 5 8 200 testing implemented review each others code.
project and increases by developers. Have reviews for unit tests.
costs
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3.3 Insufficient unit Unit testing is scaled Implement code coverage

testing down due to tight exercises to validate unit
5 5 5 125 schedule, or tests do testing is covering all new
not properly test code. functionality.

4. Determine Most 4.1 Historical data Incorrect or out-of- Validate correct data is used
and Least Used isn’t used and wrong date data is used. and only from last 6 months.
Medications medications are 4 5 8 160
pulled from cabinet.

4.2 Wrong Incorrect or out-of- Validate correct data is used

medications are date data is used. and only from last 6 months.
selected for most Incorrect medication Validate correct medications
frequently used and 4 5 8 160 retrieved to fill cabinet. are added to cabinet.
cabinet is overloaded
with incorrect
medications.
4.3 PAR levels still set Historical data not used Validate correct data is used.
too low and to determine correct Verify expert with medications
stockouts occur 3 5 8 120 elevated PAR levels. and PAR levels is part of
Levels added to cabinet review team.
incorrectly.
5. Increase PAR 5.1 Historical data Historical data from Validate correct data is used
inventory levels for isn't used and most- farther back than 6 and only from last 6 months.
frequently-used used medications 4 5 8 160 months is used, or
medications aren't added to the incorrect data is pulled.
cabinet
5.2 Historical data Data pulled from last 6 Compare 6 months data with 1
from last 6 months is months isn't a true year data. If large
an anomaly 3 5 7 105 representation of discrepancies, schedule
most-used drugs over meeting to discuss and
time. develop action plan.
5.3 Wrong Wrong medication is Add validation task to pla that
medications are scanned and added to verifies correct drugs are
added to the cabinet 2 4 9 72 cabinet. No validation added.
performed

6. Create Testing 6.1 Environment Comparison between Perform validation steps for
Environment that doesn’t match QA and production comparing environments. Run
Simulates production environments isn't control tests to verify results
Production environment thorough enough and are the same.
4 7 7 196
vital environment
setting is missed.

6.2 QA test coverage Main-line use cases are Conduct test plan and test
is insufficient missed and not tested case reviews with
4 7 7 196 development and
stakeholders to verify
coverage is available.
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6.3 Funds or resources not Allocate resources and funds

Hardware/Software allocated for duplicate in advance of project
resources not environment. Delay in
available for 3 7 6 186 receiving
duplicate hardware/software
environment delays project.
7. Execute QA Test 7.1 Resources not Resource estimations Add buffer to schedule to
Plans available to complete were not correct and account for resource issues.
all testing 3 7 5 105 not enough people are
available to test.
7.2 Test quality is Test cases not Conduct test plan and test
subpar and does not structured well and case reviews. Invest in code
cover main 3 6 6 108 doesn't touch some of coverage tooling to validate
functionality the main functionality functionality is thoroughly
implemented. tested.
7.3 Test Plans Code is very buggy and Design action plan for blocking
blocked by major test case execution is defects to get them resolved
5 7 7 245
defects blocked by severe quickly so progress can
defects. continue.
8. Develop and 8.1 Rollout plan is Planning exercise didn't Add buffer to plan to account
Implement Rollout too aggressive and properly plan out each for unforseen rollout issues.
Plan deployment fails 5 7 9 315 task. Many defects Design plan to handle blocking
slow down process. defects.
8.2 Implementation Improper unit testing Validate test plan and unit test
fails due to technical or QA testing causes plan are testing all new
error 5 8 9 360 defects to slip into functionality. Validate high-
production severity defects are fixed.
8.3 Insufficient Documentation Schedule documentation
documentation leads generated is review with developers.
to failed deployment. 4 8 9 288 insufficient for users Conduct user experience
and incorrect. session to validate users
understand instructions.
9. Rollout Dynamic 9.1 Initial Rolling out to ER first Initial rollout should be to
Refill Program in department may not represent department that's a fair
Stages deployed into isn't same experience in representation of other
3 6 6 108
true representation pediatrics due to fast departments.
of other pace in ER
departments.
9.2 Stockouts Current issue we're Have contingency plans in case
increase in other resolving gets worse in schedule needs to be pulled in
departments and 2 7 7 98 other departments and to add other departments.
pressure mounts to action is needed faster.
deploy at same time.
9.3 Confusion Nurses who may work Develop good quality
between between departments documentation for each
departments as ADC see different process version of the cabinet. Host
process is different 5 6 5 150 with ADCs and are education sessions for
based on rollout confused with process. operation of new software vs
timing. old.
ANALYSIS OF AUTOMATED DISPENSING CABINETS 13

Quality Measure

The goal of our quality measures in this study is to analyze the results of our

implementation and see if our solution that incorporates dynamic inventory control and PAR

inventory adjustments into the ADCs is working as intended. Quality measures for this study

will measure both the outcome of reducing ADC stockouts, and the process to remove or add

frequently and infrequently used medications in the cabinets. Both measurements will utilize

the PDCA cycle to ensure proper consistency in planning, implementing, analyzing, and acting

on our measurements. Both measures will have their data collected daily over a 3-month

period and then compared against historical data to test improvements. Data collection will be

monitored by the QI team’s project manager using a QI dashboard.

The first measure we will look at, measuring the reduction of ADC stockouts, will

essentially determine if our algorithm was successful. The measurement will compare stockout

percent rates over a consistent time both before and after implementation. In addition, we will

also measure the number of stockout calls per day to technicians. The study will be confined to

only the emergency and pediatrics departments initially, and the data will be collected by the

facilities certified ADC technicians daily over a 3-month period. The stockout percent rate will

be determined based on the number of times the ADCs are used compared to the number of

calls that come into the technicians due to a stockout. The ADC technicians will be trained

during the planning stage on how to log calls and pull the ADC usage stats from the cabinets.

The second measure will verify if the process to increase PAR levels for frequently used

medications results in fewer stockouts for those medications, and that there isn’t an increase in

stockouts for reducing other medications in the cabinets. This measure will also be performed
ANALYSIS OF AUTOMATED DISPENSING CABINETS 14

in the emergency and pediatric departments by the trained ADC technicians. The technicians

will be trained to log counts for the medications when they’re added to the cabinets, in

addition to pulling data from the cabinets at the end of each day to determine inventory usage

for a 3-month period.

Once the data is collected for both measurements, the QI team will check the data

against historical results and determine if the solution should go into production for all

departments using ADCs, or be sent back to development for additional work and re-entered

through the PDCA cycle for further pilot programs and analysis.

Conclusion

Frequent stockouts in automated dispensing cabinets as a result of insufficient metrics

and inventory can be both frustrating, cause a decrease in nurse efficiency, and be potentially

dangerous to patients who need medications urgently. They can also cause workplace

frustration as the nursing staff and pharmacy lose confidence in each other (Cardinal Health,

2013).

Moving to a more logical solution where a dynamic inventory control system manages

the proper stocking counts for each ADC will both eliminate the guess-work in inventory

stocking counts, and ensure that the medications the nurses and doctors need are readily

available close by. Partnering this solution with increased adjustments to PAR levels for

frequently used medications will add an extra layer of confidence that the most important

medications will be there when the staff needs them. Consideration should be taken for future

improvements to the algorithm that will automate the manual process of increasing or

decreasing PAR levels for frequently or infrequently used medications based off recent metrics.
ANALYSIS OF AUTOMATED DISPENSING CABINETS 15

References

Bernier, E., Yu, L., Rivard, J., Atkinson, S., & Bussières, J. (2016, October 31). Compliance of

Automated Dispensing Cabinets with Guidelines of the Institute for Safe Medication

Practices (US): Comparison between 2010 and 2015. Retrieved from

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5085329/

Cardinal Health. (2013). Transforming the pharmacy into a strategic asset. Retrieved from

http://www.cardinalhealth.com/content/dam/corp/web/documents/brochure/Cardinal

Health-ASSIST-Automation-CaseStudy.pdf

Cousein, E., Mareville, J., Lerooy, A., Caillau, A., Labreuche, J., Dambre, D., . . . Coupé, P. (2014,

October). Effect of automated drug distribution systems on medication error rates in a

short-stay geriatric unit. Retrieved from

https://www.ncbi.nlm.nih.gov/pubmed/24917185

Cramer, J. (2017, August 18). Higher Medication Administration Errors Associated with

Automated Dispensing System Usage. Retrieved from

http://via.library.depaul.edu/nursing-colloquium/2017/Summer_2017/43/

Fanning, L., Jones, N., & Manias, E. (2015, September 7). Impact of automated dispensing

cabinets on medication selection and preparation error rates in an emergency

department: a prospective and direct observational before-and-after study. Retrieved

from https://www.ncbi.nlm.nih.gov/pubmed/26346850

Ferencz, N. (2014, August 20). Safety of Automated Dispensing Systems. Retrieved from

https://www.uspharmacist.com/article/safety-of-automated-dispensing-systems
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Findlay, R., Webb, A., & Lund, J. (2015, July 31). Implementation of Advanced Inventory

Management Functionality in Automated Dispensing Cabinets. Retrieved from

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4589858/

Lukiniha, D. (2017, April 25). Automated Dispensing Cabinets – strong growth ahead. Retrieved

from https://technology.ihs.com/591574/automated-dispensing-cabinets-strong-

growth-ahead

McCarthy, J. R., & Ferker, M. (2016, October 01). Implementation and optimization of

automated dispensing cabinet technology. Retrieved from

https://www.ncbi.nlm.nih.gov/pubmed/27646814