Automatic dispensing cabinets and governance of controlled drugs: an exploratory study in an intensive care unit.

BACKGROUND: Governance of controlled drugs (CDs) in hospitals is resource intensive but important for patient safety and policy compliance. OBJECTIVES: To explore whether and how storing CDs in an automated dispensing cabinet (ADC) in a children's hospital intensive care unit (ICU) contributes to the effectiveness and efficiency of CD governance. METHODS: We conducted a mixed-methods exploratory study, comprising observations, interviews and audits, 3 months after ADC implementation. We observed 54 hours of medications activities in the ICU medication room (with 42 hours of timed data); interviewed nurses (n=19), management (n=1) and pharmacy staff (n=3); reviewed 6 months of ICU incident reports pertaining to CD governance; audited 6 months of CD register data and extracted logs of all ADC transactions for the 3 months following implementation. Data analysis focused on four main CD governance activities: safekeeping/controlling access, documenting use, monitoring, and reporting/investigating. RESULTS: Nurses and pharmacists perceived spending less time on CD governance tasks with the ADC. The ADC supported CD governance through automated documentation of CD transactions; 'blind counts'; automated count discrepancy checks; electronic alerts and reporting functionalities. It changed quality and distribution of governance tasks, such as removing the requirement for 'nurses with keys' to access CDs, and allowing pharmacists to generate reports remotely, rather than reviewing registers on the ward. For CDs in the ADC, auditing and monitoring appeared to be ongoing rather than periodic. Such changes appeared to create positive reinforcing loops. However, the ADC also created challenges for CD governance. Most importantly, it was not suitable for all CDs, leading to workarounds and parallel use of a safe plus paper registers. CONCLUSIONS: ADCs can significantly alter CDs governance in clinical areas. Effects of an ADC on efficiency and effectiveness of governance tasks appear to be complex, going beyond simple time savings or more stringent controls

Evaluation of an Automated Dispensing Cabinet in Paediatric Intensive Care - Focus on Controlled Medications

Evidence is limited of automated dispensing cabinets (ADCs) impact on effectiveness and efficiency of controlled drugs' (CDs) governance processes. We carried out a mixed-methods study of an ADC in an intensive care unit. We found ADC improved effectiveness and efficiency of governance of CDs through secure storage, alerts and automated recording of transactions. Limitations were associated with ADC design and 'fit' between ADC and some types of CDs

Cellular automaton model of precipitation/dissolution coupled with solute transport

Precipitation/dissolution reactions coupled with solute transport are modelled as a cellular automaton in which solute molecules perform a random walk on a regular lattice and react according to a local probabilistic rule. Stationary solid particles dissolve with a certain probability and, provided solid is already present or the solution is saturated, solute particles have a probability to precipitate. In our simulation of the dissolution of a solid block inside uniformly flowing water we obtain solid precipitation downstream from the original solid edge, in contrast to the standard reaction-transport equations. The observed effect is the result of fluctuations in solute density and diminishes when we average over a larger ensemble. The additional precipitation of solid is accompanied by a substantial reduction in the relatively small solute concentration. The model is appropriate for the study of the r\^ole of intrinsic fluctuations in the presence of reaction thresholds and can be employed to investigate porosity changes associated with the carbonation of cement.Comment: LaTeX file, 13 pages. To appear in Journal of Statistical Physics (Proceedings of Lattice Gas'94, June 1994, Princeton). Figures available from author. Requests may be submitted by E-mail ([email protected]) or ordinary mail (Paul Scherrer Institute, CH-5232 Villigen PSI, Switzerland

Challenges of Digital Commons: A Qualitative Study of an Automated Dispensing Cabinet in a Paediatric Intensive Care Unit

Missed medication doses can affect patient safety in hospitals. The use of automated dispensing cabinets (ADC) in clinical areas may reduce the occurrence of medications being unavailable at the time of need by alerting pharmacy to replenish stock. However, workarounds in ADC use can affect this capability. We studied nurses' use of an ADC in a paediatric intensive care unit with  54 hours of observation, semi-structure interviews (19 nurses; 4 pharmacy/management staff) and review of reported incidents. We found running out of medication a recurrent problem despite the ADC. Contributing factors affecting data entry in the ADC, and therefore replenishment alerts to pharmacy, included: the organisation of medication activities in the ward, nurses' information needs, patients' medication needs, and ADC design. Running out of medications was a 'tragedy of the commons'. Effective solutions may require going beyond user training and directives for accurate data entry, to work process redesign

Medication safety incidents in paediatric oncology after electronic medication management system implementation

Objective: To explore medication safety issues related to use of an electronic medication management system (EMM) in paediatric oncology practice, through the analysis of patient safety incident reports. Methods: We analysed 827 voluntarily reported incidents relating to oncology patients that occurred over an 18‐month period immediately following implementation of an EMM in a paediatric hospital in Australia. We identified medication‐related and EMM‐related incidents and carried out a content analysis to identify patterns. Results: We found ~79% (n = 651) of incidents were medication‐related and, of these, ~45% (n = 294) were EMM‐related. Medication‐related incidents included issues with: prescribing; dispensing; administration; patient transfers; missing chemotherapy protocols and information on current stage of patient treatment; coordination of chemotherapy administration; handling or storing medications; children or families handling medications. EMM‐related incidents were classified into four groups: technical issues, issues with the user experience, unanticipated problems in EMM workflow, and missing safety features. Conclusions: Incidents reflected difficulties with managing therapies rich in interdependencies. EMM, and especially its ‘automaticity’, contributed to these incidents. As EMM impacts on safety in such high‐risk settings, it is essential that users are aware of and attend to EMM automatic behaviours and are equipped to troubleshoot them

On the Upscaling of Reaction-Transport Processes in Porous Media with Fast Kinetics

This report is organized as follows: Provide a brief review of the upscaling constraints of the type (2) for a typical diffusion-reaction system. In this an analogy with two-phase flow in porous media was drawn. Then, using the methodology of QW a problem at the unit cell for the computation of the effective mass transfer coefficient, in processes where local thermodynamic equilibrium applies was derived. This problem is found to be different than in QW, as it depends on the gradients of the macroscale variable, and can be cast in terms of an eigenvalue problem. Two simple, examples, one involving advection-dissolution and another involving drying in a pore network, was presented to illustrate the coupling between scales and to show the quantitative effect in case this coupling was neglected. Finally, similar ideas and an illustrative example was applied to reaction-diffusion systems with fast kinetics, where an equilibrium state is approached

Automatic dispensing cabinets and governance of controlled drugs: an exploratory study in an intensive care unit

Background Governance of controlled drugs (CDs) in hospitals is resource intensive but important for patient safety and policy compliance. Objectives To explore whether and how storing CDs in an automated dispensing cabinet (ADC) in a children’s hospital intensive care unit (ICU) contributes to the effectiveness and efficiency of CD governance. Methods We conducted a mixed-methods exploratory study, comprising observations, interviews and audits, 3 months after ADC implementation. We observed 54 hours of medications activities in the ICU medication room (with 42 hours of timed data); interviewed nurses (n=19), management (n=1) and pharmacy staff (n=3); reviewed 6 months of ICU incident reports pertaining to CD governance; audited 6 months of CD register data and extracted logs of all ADC transactions for the 3 months following implementation. Data analysis focused on four main CD governance activities: safekeeping/controlling access, documenting use, monitoring, and reporting/investigating. Results Nurses and pharmacists perceived spending less time on CD governance tasks with the ADC. The ADC supported CD governance through automated documentation of CD transactions; ‘blind counts’; automated count discrepancy checks; electronic alerts and reporting functionalities. It changed quality and distribution of governance tasks, such as removing the requirement for ‘nurses with keys’ to access CDs, and allowing pharmacists to generate reports remotely, rather than reviewing registers on the ward. For CDs in the ADC, auditing and monitoring appeared to be ongoing rather than periodic. Such changes appeared to create positive reinforcing loops. However, the ADC also created challenges for CD governance. Most importantly, it was not suitable for all CDs, leading to workarounds and parallel use of a safe plus paper registers. Conclusions ADCs can significantly alter CDs governance in clinical areas. Effects of an ADC on efficiency and effectiveness of governance tasks appear to be complex, going beyond simple time savings or more stringent controls