Nurses’ perceptions of and satisfaction with the use of automated dispensing cabinets at the Heart and Cancer Centers in Qatar: a cross-sectional study

This study was conducted in two of the eight hospitals run by HMC, HH, and NCCCR.
It explored nurses’ perceptions of and satisfaction with the use of the ADC system
in the two hospitals. The safety characteristics of ADCs have improved progressively
over the years, but concerns about their use remain. Such worries include the potential
to bypass safety features, managing overrides, queuing, making selection errors, storing
high-alert medication, and using unsafe practices for medication removal and transportation
to the bedside 7], 8]. It is important to improve working conditions for nurses, as this will improve their
satisfaction with their work. The results of this study revealed that, overall, nursing
staff were satisfied with the use of the technology and believed it facilitated their
work and could contribute to safer healthcare and possible reduction in medication
errors and “near misses”.

A cross-sectional study conducted in Canada found similarly positive perceptions.
Nurses there considered ADCs made their work easier, and helped to provide safe patient
care and reduce medication incidents or errors 5]. The majority of nurses agreed that they could do their job more safely using the
ADC system, and that it made their job easier. ADCs can decrease the risk of medication
errors, but only when cabinet use is carefully planned, and specific safeguards are
consistently available and used. Profiled systems are one of the most important safety
enhancements to be made to ADCs during the last decade. This safety feature provides
a direct interface between the pharmacy information system and ADCs, so pharmacists
can profile, screen, and approve medicines before they are removed from the cabinet
for administration 7], 8]. Medicines with similar names or packaging, controlled substances, and high-risk
medication can all be separated. High-risk medication can be linked to clinical warnings,
and safety updates can be implemented easily across departments using the ADC system
8]. Automated dispensing machines eliminate the dispensing of unused “as-needed” doses,
thereby lessening the potential for administration errors 1].

In this study, 48 nurses claimed that the ADCs prevented or reduced medication errors,
but the impact was not investigated further, and more studies are needed to verify
the claim. Although 86 % of the nurses agreed that all drawer types assured safe access
and removal of medications, 12 nurses commented that the open matrix drawers were
unsafe, and 16 suggested replacing the open matrix drawers with locked-lidded drawers.
These can provide a higher level of security by allowing access to only one pre-selected
medication at a time. High-capacity, low-security, matrix drawers, which hold large
quantities and allow open access to all medicines in the drawer, should be used only
for the lowest-risk medicines that otherwise cannot be stored in sufficient quantities
7]. In the 2007 survey by the Institute for Safe Medication Practices (ISMP), just 50 %
of respondents said that ADCs were configured with individual compartments for each
drug rather than matrix drawers with access to multiple drugs 7]. This suggests that additional controls and process improvements are needed to reduce
risk 8].

The questionnaire contained five statements about training on ADC systems. Nurses
agreed that they could use the system confidently after minimal training. The training
materials provided were informative and adequate, and the nurses were adequately trained
by the ADC representative or another nurse prior to the system going live. The nursing
staff also agreed that the pharmacy personnel had been responsive in answering questions
and resolving any issues. The ADC system managers at both hospitals had ensured that
all nurses received standardized education materials and training, and nurses had
only been given access to the system when they had passed a competency assessment.
The majority of nurses therefore found the ADC system easy or very easy to use.

The majority of nurses also reported that the physical layout of the system was user
friendly. The nurses were able to administer medication more efficiently, on time,
and in the right dose using the ADC system. Profiled ADCs ensure that nurses can only
administer medication that has been reviewed by a pharmacist. The ADC system also
interfaces with the pharmacy management system, electronic medical records, and admission/discharge/transfer
and materials management, all of which serves to support the medication process 2].

The majority of the nursing staff in both hospitals reported that there were rarely
discrepancies when doing narcotics counts. According to the ISMP, ADCs are designed
to contain high-risk medication 7]. Automated dispensing machines provide secure medication storage on patient care
units, supported by electronic tracking of the use of narcotics and other controlled
drugs. Reports can be generated to help identify and prevent potential problems. Automated
dispensing machines save nursing time by eliminating the need for manual end-of-shift
narcotic counts in these units 1].

A significant number of nurses agreed that they spent less time waiting for medication
from the pharmacy than before the ADC system was installed. When nurses were asked
to say what they liked about the system, 58 wrote that they valued being able to administer
medication without delay and without waiting for them to be delivered from the pharmacy.

The time elapsing from when an order was written and sent to the pharmacy, and when
it was available from the ADC system, was acceptable to nurses. There were 37 written
comments that highlighted that the time required to fulfil a prescription was slow,
especially for urgent or emergency medication requests. According to HMC’s medication
policy, urgent medication should be administered within 30 min of being prescribed
by a physician 9]. Pharmacists may therefore need to educate nurses to help them identify when medication
is urgent. They should also audit and track urgent and emergency medication orders
to review and improve the process.

Although 49 nurses commented that they disliked having to queue for patient medication,
close to two-thirds of the nurses responded that they rarely had to do so. Queuing
is a major difficulty frequently associated with ADC use. In the ISMP ADC survey (2008a),
almost one third of frontline nurses reported always or frequently queuing to access
the ADC 7]. Queuing is often a symptom of larger issues that lead to workflow barriers. ADC-generated
reports can be used to determine if certain access points are being over-used. Data
showing much more activity on one device than another can help support the need to
provide additional access points.

The majority of the nurses agreed that the system would work better if the ADC system
contained more drugs, and 60 nurses suggested adding all HMC’s formulary medication
to the ADC system. About 95 % of formulary medications are available in the ADCs.
Both hospitals’ Pharmacy and Therapeutics Committees have established criteria for
including medication in the inventory. These include requirements that hazardous drugs,
or medications that require extensive dilutions or calculations, should not be part
of the ADC standard inventory. ADC system managers should continue to analyze ADC
activity reports regularly to determine what drugs are not used often and could be
removed from the ADC.

Most nurses in the study agreed that they had access to the medications they need,
they were able to get all of their patients’ medication in one place, and that refrigerated
medication is easily accessible. Accessibility was valued; 69 nurses commented that
they liked the accessibility of the system most of all.

Around two-thirds of the nurses agreed that it was easy to obtain medication during
an emergency. Automated dispensing machines enhance first-dose availability and facilitate
the timely administration of medication by increasing accessibility on patient care
units. This is particularly important in emergency departments and intensive care
units 1]. At HH and NCCCR, override medication lists were developed and approved by the relevant
Pharmacy and Therapeutics Committee. All medication distribution systems have medication
withdrawal functions that allow nurses and other caregivers limited access to certain
medications before order review and approval by a pharmacist, especially in cases
of patient emergencies. This function is typically referred to as an “override”. Override
data evaluation can help hospitals to improve the outcomes of automated dispensing
device use by decreasing medication errors and potential adverse drug events. It should
therefore be considered part of the routine management process for automated dispensing
devices 2]. Nurse training should highlight the risks associated with the override facility.

Finally, the study found that overall, 91 % of nurses across the two hospitals were
either very satisfied or satisfied with the use of the ADC system, which is very encouraging.

Strengths and limitations

As the first peer-reviewed study on this subject in the State of Qatar, and probably
in the Middle East, this research has wide-ranging implications. The high response
rate (80 %) was helpful to understand how nurses, as the end users, feel about the
ADC system.

The study also had several limitations. It was conducted in only two hospitals, both
of which are specialist hospitals (for heart and cancer patients). The sample size
was not calculated. The findings can therefore not be generalized to other populations
or settings in Qatar, or more widely. The study was a post-implementation survey and
there was no information about the situation before implementation. No pre-post assessment
was therefore possible.

Implications for practice

The change in the pharmacy distribution model with the use of the ADC system has had
broad implications for the working practices of pharmacists, pharmacy technicians,
and nurses, and associated patient safety issues. For nurses, ADC use can help improve
medication safety, ensure pharmacists review orders prior to administration, and reduce
or eliminate delays owing to medication availability, first-dose administration, missing
doses, and time-consuming controlled substance counts. Pharmacists now spend less
time dispensing drugs, and may have more time to collaborate with their nursing colleagues,
check physicians’ orders against patients’ drug profiles, reconcile patient medication,
participate in patient care rounds, and provide patient education.

The role of pharmacy technicians changed with the introduction of the ADC system.
Nurses do not have to restock the ADC and manage medication expiry dates as this is
done two to three times per week by the pharmacy technicians. The technicians have
to go to the patient care unit to restock the ADC, a time-consuming activity, but
one that supports better communication between the two departments. From a workload
perspective, ADCs reduce pharmacists’ dispensing time, as inventory management is
driven by the pre-established minimum and maximum levels and is handled exclusively
by pharmacy technicians. Finally, the ADC system has improved compliance with many
JCI standards around drug distribution, dispensing, and storage. It has built in methods
to synthesize high-risk steps in the medication use process 10]. Profiled ADCs allow pharmacists to review and approve medication before it is available
for selection and administration by the nurse, respiratory therapist, or physician.
Computerized monitoring of drug administration to the patient by the nurse will provide
accurate knowledge of patient medication history. This will help to optimize hospital
drug distribution systems and enhance safe dispensing 11].