Additional updates are needed to reduce the risk of medication errors associated with automated dispensing cabinets, the Institute for Safe Medication Practices said May 31.
Since 2019, ISMP has recommended clinicians enter at least the first five characters of a drug name during dispensing searches, especially in override situations where the medication isn't yet in the patient's profile. Both Omnicell and BD Pyxis have since added five-letter search functions to their dispensing cabinet products, though hospitals must opt in to the feature.
Calls to magnify the safety surrounding automated dispensing cabinets intensified after Radonda Vaught, a former nurse at Nashville, Tenn.-based Vanderbilt University Medical Center, was criminally charged over a fatal medication error she made in 2017. Court documents indicate that when trying to withdraw the sedative Versed, Ms. Vaught typed "VE" into the search function of a dispensing cabinet, not realizing the drug was listed under its generic name, midazolam. When the cabinet did not dispense Versed, Ms. Vaught triggered an override that unlocked access to a larger selection of drugs. After searching for "VE" again, she accidentally withdrew vecuronium, a powerful paralytic.
ISMP said a more comprehensive approach that includes dynamic search function capability is needed to effectively mitigate risks of medication errors. The institute shared numerous recommendations for health systems to promote safer use of dispensing cabinets, including implementing training simulations before rolling out drug name search changes and requiring clinicians to select an indication for high-alert medications.
See the full list of recommendations for healthcare organizations here.