AJN, American Journal of Nursing:
Time-consuming procedures can lead to risky work-arounds.
Mary Elizabeth Stachowiak is an adjunct professor at the University of Medicine and Dentistry of New Jersey School of Nursing in Newark. Contact author: firstname.lastname@example.org. The author has disclosed no potential conflicts of interest, financial or otherwise.
Automated dispensing cabinets (ADCs) are quickly becoming the solution of choice for point-of-care medication administration. By 2007, more than 80% of hospitals had implemented them, according to the Institute for Safe Medication Practices (ISMP). Their benefits include improved nurse access to medications, more efficient medication billing and inventory management, greater medication security, and potential reductions in medication errors.
But ADCs can bring hidden costs. For example, not long ago a chief nursing officer and I were discussing nursing time spent at the bedside. She'd noted a queue of nurses at the pharmacy medication pick-up window and identified this as a waste of nursing time. Her solution was to place ADCs on every unit. While there were now no more lines at the pharmacy window, an unforeseen consequence was the line of nurses that formed instead at the ADCs on the units, as well as the time it took nurses to complete the process for withdrawing each patient's medication from the ADC.
In 2007, an ISMP survey found that only 9% of nurses never wait to access an ADC. The ISMP's recommended medication administration process is to print out the electronic medication administration record (eMAR) (some institutions provide a computer screen close to the ADC to view, but not print, the eMAR); go to the ADC; remove medications for just one patient at a time from the drawers (one medication at a time and one drawer at a time); administer the medications; open another computer and chart the administration; then repeat the process for each patient.
We know this is not the practice. I had student nurses follow the correct process; it took two hours for two students to administer medications to four patients. While it's true that students take longer to complete these unfamiliar tasks and are required to verify medications prior to administration, nurses commonly assert that following the correct process is too cumbersome.
In 2010, results from an ISMP survey about the Centers for Medicare and Medicaid Services (CMS) requirement that nurses administer medications within 30 minutes of their scheduled time indicated that nurses perceived multiple challenges and barriers to safely complying with this requirement, many related to lengthy ADC and electronic record keeping.
The rule has since been revised. Even so, many acute care patients have at least one medication requiring precise timing. The ISMP survey identified several work-arounds used by nurses, and anecdotal evidence suggests that these remain in wide use.
One reported work-around was to pull all assigned patients’ medications at one time and put them in cups, bags, or patient drawers; administer the medications at the different times they were due; and document later in the shift. This is a situation in which errors can be made and never recognized.
Many nurses like ADCs because they allow them to bypass the pharmacy. But at what risk is this time saved? Units often have only one ADC. Using the start-of-shift eMAR, nurses often pull medications for 10 am and 12 pm administration by 9 am. Medication orders may change during rounds, yet the patient may still receive what had been previously ordered.
Even if a seasoned RN is able to cut the administration to 15 minutes per patient, it would take 1.5 hours to administer medications to six patients and chart them (despite the CMS requirement that administration occur within 30 minutes of the scheduled time). In addition, this scenario would require that the nurse administer the medications without interruption; that the medications not need to be crushed or administered via feeding tube; that the patient takes less than five minutes to swallow the pills; and that there's no wait time for the ADC or a computer.
Nurses need to acknowledge the actual use, not the recommended use, of the ADC. Do we have to wait for patient harm to fix a process we know does not work in practice?