Manual to Automated: Overcoming Medication Challenges in Long Term Care

Nursing and pharmacy workforce shortages continue to make top headlines in the acute care setting. ^1,2 These shortages have also impacted other settings, including long term care (LTC). If shortages in human capital weren’t worrisome enough, rising costs of healthcare operations bring additional complexities.³ As the “Silver Tsunami” hits the United States and the demand for care at LTC facilities grows,⁴  these underfunded and often overlooked facilities may reach their breaking point.  The management of medications in LTC facilities is particularly vulnerable and may be greatly impacted due to the resource shortages. Strategic considerations should be made that address healthcare workflow and operational efficiencies in these settings, including consideration of the implementation of automation for medication management.

Closed Door Pharmacies (CDP) are a specialized pharmacy that service long-term care facilities and serve as the primary source of medications from a central medication “hub” which provides medications to many “spokes” (LTCs). Typically, patient medications are delivered in the form of patient specific blister cards or pouches for maintenance medications, as well as emergency kits stocked for first and emergency doses. Due to the large geographical area in which the CDPs may service, efficiencies in the workflow associated with this model are of high importance. For example, when inventory becomes unavailable at a LTC facility, sending a representative to replenish inventory of first dose and emergency supply can be an expensive business model. A CDP could be hundreds of miles away, making these reactive trips to replenish emergency medication kits costly and time consuming. Additionally, delays in treatment can lead to negative patient outcomes.⁵ Due to the reliance on primarily manual methods for inventory management in LTC facilities, this scenario happens all too often. It is for this reason, with patient safety in mind, that organizations should consider utilizing Automated Dispensing Cabinets (ADCs) at their facilities. ADCs can help decrease time for medication retrieval (as it relates to first dose and emergency dose) and decrease time for pharmacy staff to complete tasks related to medication availability.⁶

Automated Dispensing Cabinets

ADC usage is supported by the ASHP since it is recognized that they provide an essential service to support patient care and improve patient safety.⁷ Although literature often focuses on the acute care setting, the benefits of ADCs may be transferable across the care continuum. These benefits include workflow efficiencies, enhanced medication security, optimized inventory and improved patient care.^8,9

Benefits of Automated Dispensing Cabinets

Efficiency and Accuracy

ADCs streamline medication dispensing processes, reducing the potential risk of errors. ⁸ They provide accurate dosing and minimize manual handling.¹⁰ The manual medication management processes, which are often used today in the LTC and CDP settings, are labor intensive and can lead to errors. When nursing and pharmacy workflows are augmented by automation, there is a reduction in time and steps taken to maintain inventory and obtain medications. Recent literature shows ⁶:

• A 70% workload reduction for CDP pharmacy technicians and an 87% reduction for CDP pharmacists when they switched from manual processes to ADCs.  
• Reduction in nursing medication retrieval workflow was also observed.
  • Mean time to access a noncontrolled medication was reduced by 71%, associated process steps were reduced by 54% (7 steps).   
  • Controlled substances workflow was reduced from nearly 14 minutes to less than 2 minutes with the ADC system, a reduction of 87%.  

Automation can also be utilized as a safety mechanism to reduce error potential, by separating look-alike sound-alike (LASA) medications, which may be intermingled in manual e-kit methodology, into separate lock-lidded containers⁷ as well as isolating high-alert medications.¹¹

Enhanced Security

ADCs offer secure storage for medications, aiding in prevention of unauthorized access.⁸ Controlled substance (CS) management creates unique challenges especially as it relates to diversion and regulatory compliance requirements.¹² ADCs allow for remote oversight that manual processes may not. This includes increased traceability, control of appropriate access and ability to more immediately recognize and resolve discrepancies. Data provided by ADCs can lead to improved accuracy for CS discrepancy reconciliation and can be synthesized into reports that support DEA compliance requirements.¹²

ADCs also provide the ability to limit access to only the required controlled substance, rather than providing access to multiple controlled substances stored in the manual medication kit typically used in CDP and LTC settings. Additionally, ADCs can provide discrepancy reporting for controlled substances and require blind counts, where all who access the medication must count and record the physical inventory without knowing what the current recorded inventory in the system is. This helps ensure timely identification of unexpected variances by CDP and LTC staff. Furthermore, the system features tools to demonstrate regulatory compliance to auditors.⁶

Optimized Inventory Management

ADCs manage medication inventory efficiently, ensuring timely availability of medications while minimizing waste (e.g., expired medications).¹³ Real time data provided by ADCs allows the CDP to analyze LTC inventory on hand and decrease stock of unused medications while adding supply for commonly needed medications.⁶ Literature also shows that utilizing automation helps to improve the management of standing medication inventory. In a study by Black et al. conducted over a 90-day period at 2 LTC sites, there was a combined reduction of standing inventory of over $10,000 while simultaneously increasing the stock of unique medications available at the facilities when switching from manual methods to automated dispensing cabinets.⁶

Improved Patient Care

ADCs enhance patient care by ensuring timely access to medications.¹¹ The Black et al. (2024) study observed a substantial rise in controlled substances dispenses after the implementation of ADCs in LTC facilities, "suggesting that while improving security and regulatory compliance by functional design, the ADC removed perceived barriers to access controlled substances, which may increase the potential for more timely medication administration.” Literature on ADC implementation in the inpatient setting  shows that ADCs decreased stockout percentages and improved medication turnaround times.⁹ Recognizing the gap in the literature for the LTC space, the results of the Black et al. (2024) study related to reduction in unscheduled deliveries and increased quantity of CS dispenses after ADC implementation suggest that the  improvement of timely access noted in inpatient literature could be transferable to LTC settings as well. Reductions in multiple types of medication errors have also been associated with use of ADCs including dispensing errors and narcotic use.¹⁴

Conclusion

The adoption of ADCs in non-acute settings offers substantial advantages to both users and patients by streamlining workflows, enhancing security and reducing time to prepare and dispense medication.^6,8 Patients experience benefits such as increased availability of medication ⁶ and decreased dispensing errors.¹⁴ If not for the other advantages that ADCs provide, for the sake of patient safety alone organizations should consider utilization of ADCs at facilities across the care continuum to take a preventive approach to tragic medical errors and strengthen their commitment to provide safe, efficient care for their patients.