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Right Place, Right Drug, Wrong Strength

Valentina Jelincic, RPh, and Julie Greenall, RPh, MHSc | February 1, 2018
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The Case

A 2-year-old girl was admitted to a hospital burn unit for a 10% total body surface area burn on her face, upper chest, and back. She was being treated with oral acetaminophen around the clock and nonsteroidal anti-inflammatory drugs as needed for pain and discomfort. The patient underwent dressing changes and burn inspection every third day. On these days, she was also given oxycodone, which was highly effective and allowed her to rest the whole day.

One week into the hospital stay, the mother noticed the patient's breathing was very shallow after a dressing change. On examination, the patient was difficult to arouse and lethargic, and an arterial blood gas revealed CO2 retention and hypoxemia. While preparing to intubate, the physician reviewed that day's medications to identify possible causes of this sudden change in respiratory status. He discovered the patient had received oxycodone 3 times in less than 8 hours (1 dose prior to the dressing change and 2 doses after). The nurse checked the automated dispensing machine in which the oxycodone was stored and was surprised to find a higher concentration of oxycodone solution stored in place of the typical, lower concentration pediatric solution. Consequently, the dose administered to the patient was almost 5 times what was ordered.

After the physician and nurse recognized the error, the patient immediately received multiple doses of naloxone. Her breathing improved quickly, and intubation was avoided. The patient was monitored in the hospital for 1 week after the incident, did well, and was safely discharged home.

Root cause analysis (RCA) by the safety committee determined the higher concentration of oxycodone solution was incorrectly placed in the automated dispensing machine by a pharmacist who was working per diem. The RCA also found that the nurse did not check the concentration of the medication to be administered against the order written by the physician.

After the incident, multiple checkpoints were established in the pharmacy and a new protocol was established, with a special focus on pediatric medication doses. In-service training was provided to all the pharmacists, including those who work irregular shifts (e.g., overnight).

The Commentary

by Valentina Jelincic, RPh, and Julie Greenall, RPh, MHSc

Whether it is a pill, a vial, a syringe, or a bottle of liquid, having the wrong item in a familiar location can lead to error. Particularly when that item is stored in a secure cabinet, confirmation bias can prevail. Individuals see what they expect to see, or they may not even look, presuming that the item they have selected is what is typically there and what they need. It is therefore no surprise that automated dispensing cabinet (ADC) setup and use came in eighth in the ECRI Institute's "Top 10 Health Technology Hazards for 2017." Specifically, "wrong drug or dose in an ADC pocket" was identified as an important contributor to medication errors.(1)

Automated Dispensing Cabinets and Errors in the Medication-use System

In the United States, use of ADCs in hospitals has increased steadily. There are multiple brands and configurations of ADCs: profiled versus nonprofiled single-drug pockets versus multidrug/matrix drawers, and systems that utilize barcoding technology.(2) This rise in ADC utilization is driven by the data supporting the premise that the use of these systems can improve both efficiency and safety of medication use. In fact, medication errors most commonly reduced by the use of ADCs include missed doses, wrong patient, wrong drug, and wrong administration time.(3,4)

Nonetheless, ADC-related medication errors can still occur. Studies of ADC-related errors report on diverse patient populations with various control factors and assessment parameters. While it is clear that such errors occur in a range of pediatric populations, the incidence of ADC-specific errors in pediatrics has not been well studied or described.(5-7) A 2016 review identified the following factors as contributing to errors reported in pediatrics: a high number of medications, patients' inability to communicate, long hospitalizations, communication failures, and human error.(8) For these and physiological reasons, we generally consider the pediatric population to be particularly vulnerable to harm.(9)

Health care professionals and patients expect that integrated checks will ensure accuracy at all steps and all handoffs in medication-use systems. However, despite technology and procedural safeguards, human checks and safety processes can fail.(10)

Avoiding Medication Errors

Reducing the possibility of medication errors reaching patients requires the use of automation plus critical thinking. A profiled ADC setup releases only drugs that have been ordered and verified to the cabinet patient profile and can only be accessed on a patient-specific basis, which adds more than one level of safety. Ideally, a complete automated medication-use loop is in place: the hospital information system allows for practitioner entry of medication orders, which are verified by a pharmacist before being transmitted to the ADC and electronic medication administration record (MAR). Following transmission, the patient profile is updated, the MAR is populated, and orders are ready to dispense from the ADC. The nurse retrieves orders by logging into the ADC and selecting the patient and medication from the updated profile, which prompts the ADC to open the corresponding drawer or pocket containing that medication. The ADC is replenished on a daily basis, typically by pharmacy technicians, with either a human or automated doublecheck.

Most ADC systems incorporate barcoding as the doublecheck for replenishment, and barcode-assisted medication administration (BCMA) can provide yet another check at the patient bedside by requiring the nurse to scan the barcodes on a patient's identification band and on the medication to be administered. If there is a discrepancy against the MAR for the patient, drug, dose, or timing, the system will trigger an alert for a potential error. Barcoding technology can therefore add accuracy at earlier steps in the medication-use process, including drug receiving, retrieval for dispensing, and ADC replenishment, as well as at removal from the cabinet and at the point of drug administration (i.e., BCMA).(11)

As a result, more than 88% of respondents to a 2014 American Society of Health-System Pharmacists survey reported that BCMA was in use in their institutions.(2) Barcode-assisted medication administration has had an overall positive impact on patient safety; however, BCMA, like ADCs, is not necessarily foolproof. The Pennsylvania Patient Safety Authority highlighted a number of possible failure modes in the BCMA process, most of which relate to human failures such as workarounds and overrides.(12) Thus, the Institute for Safe Medication Practices has developed a self-assessment tool for ADC implementation to assist institutions with maximizing patient safety.(13) Ultimately, successful use of barcoding depends on the procedural compliance of its users and on the underlying dispensing system. The latter has to be counted on to ensure that the right drug is available.(14)

In addition to errors that can arise at the human–technology interface, improving medication safety is often enhanced by minimizing product and concentration options in the hospital formulary, especially for high-alert drugs such as opioids. Such standardization can reduce the likelihood of wrong product selection. Providing standardized or ready-to-administer drug doses (15,16) can also facilitate dispensing processes and simplify selection and administration activities. These actions remove some of the possible errors that can occur in the process of bedside decision-making. Therefore, they are likely to be more robust safety initiatives than training or procedural changes.

Addressing these themes may help to avoid ADC-related medication errors in both pediatric and adult settings. As with all safety initiatives, it is important to understand the role of the personnel and their workflow and to apply continuous quality monitoring of processes.(14)

Take-Home Points

  • Safety can be enhanced through the use of barcode technology for verification at drug receiving, storage, preparation, and dispensing, as well as in patient care areas for drug retrieval and before patient administration.
  • Even in technologically advanced medication management systems, it is worthwhile to try to minimize the number of available concentrations of high-alert drugs. If more than one concentration is needed, consider auxiliary or explicit labeling, as well as separate or electronically managed storage, so that products are not confused by the user.
  • Provide medications, especially high-alert products and oral liquids, in standard or ready-to-administer doses.
  • Assess automated dispensing cabinet safety practices with the ISMP Medication Safety Self Assessment for Automated Dispensing Cabinets.
  • Share and provide feedback on medication incident reports and experiences. This allows staff to learn, offer solutions, and become more aware of safety in their work processes.

Valentina Jelincic, RPh Consultant Institute for Safe Medication Practices Canada

Julie Greenall, RPh, MHSc Director of Projects and Education Institute for Safe Medication Practices Canada


1. Top 10 Health Technology Hazards for 2017. Philadelphia, PA: ECRI Institute. [Available at]

2. Pedersen CA, Schneider PJ, Scheckelhoff DJ. ASHP national survey of pharmacy practice in hospital settings: dispensing and administration—2014. Am J Health Syst Pharm. 2015;72:1119-1137. [go to PubMed]

3. Murray MD. Automated medication dispensing devices. In: Shojania KG, Duncan BW, McDonald KM, Wachter RM, Markowitz AJ, eds. Making Health Care Safer: A Critical Analysis of Patient Safety Practices. AHRQ Publication No. 01-E058. Rockville, MD: Agency for Healthcare Research and Quality; 2001. [Available at]

4. Oren E, Shaffer ER, Guglielmo BJ. Impact of emerging technologies on medication errors and adverse drug events. Am J Health Syst Pharm. 2003;60:1447-1458. [go to PubMed]

5. Kaushal R, Bates DW, Landrigan C, et al. Medication errors and adverse drug events in pediatric inpatients. JAMA. 2001;285:2114-2120. [go to PubMed]

6. Sears K, O'Brien-Pallas L, Stevens B, Murphy GT. The relationship between the nursing work environment and the occurrence of reported paediatric medication administration errors: a pan Canadian study. J Pediatr Nurs. 2012;28:351-356. [go to PubMed]

7. Miller MR, Robinson KA, Lubomski LH, Rinke ML, Pronovost PJ. Medication errors in paediatric care: a systematic review of epidemiology and an evaluation of evidence supporting reduction strategy recommendations. Qual Saf Health Care. 2007;16:116-126. [go to PubMed]

8. Krzyzaniak N, Bajorek B. Medication safety in neonatal care: a review of medication errors among neonates. Ther Adv Drug Saf. 2016;7:102-119. [go to PubMed]

9. Matlow AG, Cronin CMG, Flintoft V, et al. Description of the development and validation of the Canadian Paediatric Trigger Tool. BMJ Qual Saf. 2011;20:416-423. [go to PubMed]

10. Reason JT. Human Error. New York, NY: Cambridge University Press; 1990.

11. Seibert HH, Maddox RR, Flynn EA, Williams CK. Effect of barcode technology with electronic medication administration record on medication accuracy rates. Am J Health Syst Pharm. 2014;71:209-218. [go to PubMed]

12. PA-PSRS Patient Saf Advis. Medication errors occurring with use of bar-code administration technology. December 2008;5(4):122-126. [Available at]

13. Gann M. How informatics nurses use bar code technology to reduce medication errors. Nursing. 2015;45:60-66. [go to PubMed]

14. Ontario Critical Incident Learning. Designing effective recommendations. Toronto, ON: Institute for Safe Medication Practices Canada; 2013. [Available at]

15. 2018–2019 Targeted Medication Safety Best Practices for Hospitals. Horsham, PA: Institute for Safe Medication Practices; 2017. [Available at]

16. Medication Safety Self Assessment for Automated Dispensing Cabinets. Horsham, PA: Institute for Safe Medication Practices; 2009. [Available at]

This project was funded under contract number 75Q80119C00004 from the Agency for Healthcare Research and Quality (AHRQ), U.S. Department of Health and Human Services. The authors are solely responsible for this report’s contents, findings, and conclusions, which do not necessarily represent the views of AHRQ. Readers should not interpret any statement in this report as an official position of AHRQ or of the U.S. Department of Health and Human Services. None of the authors has any affiliation or financial involvement that conflicts with the material presented in this report. View AHRQ Disclaimers
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