Nursing Returns to Automated Dispensing Cabinets

Many areas of healthcare have seen major labor shortages since the onset of the COVID-19 pandemic. COVID has simply removed a portion of the population that normally would be working in many sectors, and because of extenuating circumstances, no longer can. This means operational leaders have to be as creative as possible in coming up with workflows that decrease variation and waste, while increasing efficiency. One idea for improving efficiency, is having nursing return non-narcotic medications that they dispense from automated dispensing cabinets (ADCs), back to the pocket which they pulled it from, if they are not going to administer the medication. For instance, if a nurse pulls Tylenol for a patient, and when they get to bedside the patient refuses, it is more efficient for a nurse to place the Tylenol back into Omnicell than to drop into a physical pharmacy return bin. If this medication is returned to pharmacy it has to be sorted, returned to our medication carousel, redispensed when the ADC reaches at minimum par restock level for that medication, then delivered and restocked into the ADC. If nursing returns directly to the ADC, all of these steps are avoided, and we decrease the opportunities of medications being stocked out of the ADC.

This idea right off may seem rudimentary to some. After all, why wouldn’t a facility implement this function as a standard? Historically, there have been two concerns that are usually roadblocks from implementing this initiative: 1) Nursing leaders not wanting to add more tasks and responsibilities on their nursing staff and 2) Safety concerns for nursing accidentally returning an item to the wrong location. The best way to get buy-in from nursing leaders, is to emphasize that if nursing is placing returns back in their ADCs, this will help decrease the number of times those cabinet pockets stock-out of medications. Miralax packets are a great example of this. Physicians tend to order this medication on every patient as a default, then when nursing brings it to the room and explains what it is, the patient refuses. The packets are large, and unless it has a shelf space, you could probably only fit about 10 packets in an average size ADC pocket, which would cause it to stock out quickly. As for the safety concern, in my opinion, this is what barcode scanning is for. Should a nurse accidentally return an item to the wrong bin on the shelf, it should still be caught when they scan the medication at bedside before administration.

We implemented this function in our hospital in February 2022.  The University of Chicago Medical Center is an 811-bed level 1 trauma center. We utilize Omnicell as our automated dispensing cabinet. We currently have over 100 omnicell cabinets dispersed over our three hospitals on campus. From March 1^st to April 30^th, 2022 nursing returned 14,438 doses to our Omnicell ADCs that would have normally been returned to pharmacy. In order for us to better understand how much room for improvement we have to increase these numbers, our pharmacy automation team utilized a report in Epic called “Unreconciled dispenses.” This report shows how many medications were dispensed from Omnicell, and do not have an administration or charting on the eMAR. Our data shows that over the same two-month period, our unreconciled dispenses totaled 40,929 items. This means that despite the high number of returns we have seen early on in this initiative, we are currently only returning about 26% of the possible medications that could be returned. Some of these doses may have been wasted, or fallen to the ground, etc. However, a number this low shows that there is still room for improvement, and utilizing the unreconciled dispenses report gives nursing managers a way to gauge how well their units are doing with this initiative.

Through its first two months, the nursing return medications to Omnicell initiative has been a very successful collaboration between nursing and pharmacy in our institution. Some of the highest returned items are shown in the table below.

Just looking at 3 of the highest returned items, out of what has been hundreds of medications returned, we saved 3865 individual items from having to come back to pharmacy, get sorted into their respective carousel return bins, re-dispensed, and then reloaded into the Omnicell ADCs on our patient floor med rooms. Further, there is no telling how long these items would have remained in bins waiting to be returned to our carousel stock, which means they would have likely been reordered by our purchasing team. Implementing nursing returning non[1]controlled medications to ADCs is an overall win for the entire institution.