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Correspondence |
Medical College of Wisconsin, Milwaukee, USA, E-mail: hwoehlck{at}mcw.edu
To the Editor:
Automated drug dispensing machines (ADDMs) are promoted to reduce drug dispensing costs and to reduce medication administration errors.1,2 Although concern exists,3 few situations have been reported where ADDMs have impaired patient care. In the months preceding this report, our hospital began using ADDMs (Accudose, McKesson Automation, Pittsburgh, PA, USA) as the only source of anesthetic drugs outside regular business hours. Previously, additional drug sources were available in addition to ADDMs. Over a period of five months, we observed five instances involving six patients of approximately 8,000 (0.08%) where a delay in drug administration occurred during emergency situations.
Case 1
Our ADDMs contain generic and also brand name menus. A drug was not found in the brand name menu, and personnel were uncertain of the equivalent generic name, causing a delay in drug administration. We discovered that the drug was entered by its generic name in both menus because generic product was purchased by the hospital pharmacy. The pharmacy now enters brand names for ease of identification even if generic drug is supplied, but identifies the drug actually supplied as the generic equivalent in the brand name menu for accuracy.
Case 2
After placing a routine labour epidural, we were unable to obtain local anesthetic from any ADDMs on the labour and delivery ward. We discovered that when one ADDM was programmed to "profile dispense mode", whereby medications require pharmacy review before dispensing, multiple machines were simultaneously, but unintentionally restricted to that mode. This action took several hours to correct, and resulted in significant delays in delivering obstetrical anesthesia.
Case 3
Our operating rooms use drug trays kept in an ADDM for routinely administered anesthetic drugs. On a holiday weekend, the ADDM malfunctioned while attempting to obtain drugs for emergency surgery, resulting in substantial delays in commencing general anesthesia of two patients. At first, the ADDM became unresponsive to keyboard commands with all drawers open and unlocked. After rebooting the ADDM, which required additional personnel to pull the machine away from the wall and access the back of the ADDM, another malfunction occurred, resulting in the inability to withdraw drugs.
Case 4
An ADDM was in a Microsoft Windows startup screen during an emergency Cesarean delivery with regional anesthesia, rendering narcotics and sedatives unavailable for that operation, which resulted in considerable patient discomfort. It was suggested that someone accidentally closed the Accudose program by double touching the screen near the "Accudose Rx" icon. This was described as a troubleshooting functionality, not part of normal usage. Nobody in the hospital at that hour was trained in the use of the machine from this window, and the instruction guide on the machine had no information on resolving this problem.
Case 5
A patient in the recovery room required urgent treatment with an anticholinergic drug. On logging into the ADDM, a window appeared stating that a password change was required. Because drug treatment was urgent, we attempted to abort the password change, and do that at a later time. Cancelling the password change automatically logged the user out of the machine. Due to a typographical error in a second, hurried attempt at the password change, the logging failed again. Medications were obtained from alternate sources, causing a treatment delay. Pharmacy personnel confirmed that the password management activities pre-empt patient care functions.
Clinicians and pharmacy personnel should be aware that drugs may not be immediately available from ADDMs for many reasons. Since machine failures cannot be prevented, and unintended consequences of programming cannot always be predicted, a backup supply of critical medications should be made available for emergency situations.
Footnotes
Financial support was provided from institutional and/or departmental sources.
Conflicts of interest: Dr. Woehlck consults for W.R. Grace (Cambridge, MA, USA), Smiths Medical (Level-1 division, Rockland, MA, USA), and G.E. Medical (Datex-Ohmeda division and Marquette Medical Systems division, Madison and Milwaukee, WI, USA). Dr. Woehlck holds a grant related to cigarette smoking from the Anesthesia Patient Safety Foundation and a grant from W.R. Grace related to safety and efficacy of modern carbon dioxide absorbents.
Accepted for publication February 2, 2007.
References
1 Schmidt CE, Bottoni T. Improving medication safety and patient care in the emergency department. J Emerg Nurs 2003; 29: 12–6.[Medline]
2 Romero AV, Malone DC. Accuracy of adverse-drug-event reports collected using an automated dispensing system. Am J Health Syst Pharm 2005; 62: 1375–80.
3 Wagner DS, Golembiewski J. Meds on the move: from cupboard to machine. J Perianesth Nurs 2005; 20: 444–6.[Medline]
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