The ADCs of Floor Stock

Back in the early 1980’s, a typical nursing unit at your local hospital would be overflowing with medication known as “Floor Stock.”

The contents would vary depending on the type of nursing unit, but it usually included Aspirin and Xylocaine, and everything in-between. The goal was to decrease the turnaround time for pharmacy delivery by having medications immediately available for patients when needed. For instance, if a patient complained of heartburn, an antacid such as Maalox or Mylanta would be prescribed and the nurse would administer the medication after obtaining it from the floor stock cabinet. A similar scenario would occur if a patient spiked a fever and was ordered Acetaminophen or Aspirin. These medications were readily available; however, the pharmacist was factored out of the equation when it came to initially reviewing the order for allergies, drug interactions and dispensing.

Unfortunately, additional injectable and oral medications such as Potassium Chloride and Digoxin were added to the floor stock inventory, and soon the stock cabinets resembled mini-pharmacies. Predictably, medication errors increased when the pharmacist was not involved in the process, and in some instances the errors caused serious harm or death. Hospital pharmacy thought leaders quickly put forth recommendations to eliminate or limit the amount of medications stocked on the nursing unit with the goal of having a pharmacist review ALL medication orders prior to dispensing. The recommendations became mandates and the corrective action was applauded because it was the right thing to do. So, how did we get fully loaded Automated Dispensing Cabinets (ADCs) back up on the nursing units twenty-five years later?

ADCs were also introduced in the 1980s and primarily designed to replace non-automated floor stock storage. One of their benefits included capturing patient charges for medications that were typically overlooked like Milk of Magnesia. Also, ADCs could store and capture charges for controlled substances that were not dispensed in the patients’ unit-dose medication drawer.

Adoption of this technology had some resistance initially and only about 50% of hospitals were using ADCs in 1998-1999. By 2007, more than 80% of hospitals were utilizing ADCs for floor stock storage or placing the cabinet in an out-patient setting or Emergency Department. Many healthcare facilities have taken the application further and are using ADCs as their primary method of drug delivery. This means we are back to fully loaded cabinets not only for floor stock items, but in many cases for first-dose dispensing of maintenance medications.

The difference is technology this time around, but that’s not a panacea for medication error reduction. One of the most important ADC safety features to evolve over the past decade has been a patient profiling system that allows the pharmacist to review and approve all medication orders BEFORE they are available for selection from the ADC and administered by nursing. This is also known as a “first-dose” review by the pharmacist and meets the medication management standard issued by the Joint Commission.

However, the first-dose review is typically done remotely, so the actual dispensing function that the pharmacist previously provided has been eliminated. What, if anything, do we do about that?