2025 Southeastern Residency Conference

Title: Optimization of Automated Dispensing Cabinets to Reduce Medication Errors in the Emergency Department


Authors:  Kelly Bodine, PharmD; Aubrey Murphy, PharmD; John Patka, PharmD, BCPS; Laurie Cavendish, PharmD, BCPS; Debbie Vigliotti, PharmD, LSSGB


Objective: To describe the utilization of automated dispensing cabinets to determine the safety of emergency medication dispensing practices and to address modifiable sources of potential medication errors. 


Self Assessment Question: How can automated dispensing cabinet usage be modified for safety?


Background: A medication error is a preventable event that may lead to inappropriate medication use or patient harm. Automated dispensing cabinets (ADCs) have eliminated a significant margin of human error; however, safety measures are lessened in the emergency department (ED) to provide for timely treatment of critical patients. Less restricted access, fewer verification checkpoints, and retrospective charting are a few of the barriers to medication safety that exist in the ED. Nationally recognized organizations have recommendations for ADC use to help mitigate safety barriers and risk points. With a variety of individuals accessing ADCs, passing along medications, and providing direct patient care in the Grady Memorial Hospital (GMH) ED, optimized ADC storage and dispensing conditions are needed to ensure best patient care. The purpose of this study was to describe the utilization of ADCs to determine the safety of emergency medication dispensing practices and to address modifiable sources of potential medication errors. 


Methods: Retrospective review of ADC utilization and practices in the ED of a single institution between January 1, 2024 and March 31, 2024. Reports were generated for three ADCs located in emergent patient-care areas using software from BD Pyxis™. ADC layouts were evaluated, taking into consideration pocket type and medications contained within the ADC, including high risk and sound-alike-look-alike medications based on ISMP guidance and GMH policies and procedures. Override data was evaluated, including number of overrides, user profession, and medications overridden. Results were utilized to modify and optimize ED ADCs for both safety and efficacy, such as moving medications to an alternative storage pocket type. Interventions were quantified as part of the primary analysis. Secondary analysis included evaluating the impact of any measurable outcomes for modifications made.  


Results: 1,375 overrides and 342 medications stored among the 3 Pyxis stations were assessed. This study found that 25% of medications stored were in matrix drawers, however very few were high-risk or SALAD medications. Due to this, minimal changes were recommended to Pyxis storage design. Of the 1,375 overrides, 37% were for high-risk medications. No changes were recommended to overridable medications due to the location of these Pyxis stations. Lastly, few high-risk and SALAD medications were associated with Pyxis safety alerts, and adjustment efforts focused on alert optimization. 


Conclusion: This study found that Pyxis station design was previously optimized for safety surrounding high-alert and SALAD medications. Ultimately, optimization of Pyxis alerts and override warnings were needed to improve safe medication practices.