How to Prevent Duplicate Medication Dispenses

Medication errors in hospitals is a serious and widespread issue that can have serious consequences for both the patient and the facility. One type of preventable error that occurs is when a patient is given duplicate medication due to being transferred to another unit or because of a shift change.

An Institute for Safe Medication Practices (ISMP) Medication Safety Alert newsletter item noted an example of such an error that occurred after a patient transferred to another unit.¹

Before transferring the patient, a nurse removed all the patient’s morning medications from the automated dispensing cabinet (ADC) and administered them to the patient. Because it was still early in the morning, the nurse on the receiving unit gave the patient the same medications, without first checking the patient’s medication administration record (MAR).

ASHP Weighs In

As an error such as this can have serious implications, organizations have stepped in to help reduce them. In Medication Misadventures, ASHP offers guidelines for processes to prevent medication errors in hospitals, including:

  • Ensuring sufficient personnel to perform tasks
  • Creating an ongoing systemic program of quality improvement and peer review
  • Tasking pharmacy with procurement, distribution and control of all drugs
  • Avoiding use of patient’s own/home medications

They also offer recommendations for prescribers, nurses, patients/caregivers and pharmaceutical manufacturers and approval organizations, since this is a pervasive issue that spans every area that comes in contact with drug distribution.

Minimize Errors with ADCs

To minimize errors, hospitals can choose to use ADCs equipped with safety features, such as these offered by Omnicell:

  • Last Issue Alert² – a hospital-wide alert–which is recommended by ISMP– that warns nurses when removing a medication previously issued for a patient within a set time period, regardless of the cabinet being used. The last issue date and time will be displayed in red, drawing the nurse’s eye to this critical information.
  • Scheduled Meds – a tab that displays the list of medication orders that are within the administration due time, including the early/late window. Once an ordered medication is issued from the cabinet within this time period, it is no longer displayed on the Scheduled Meds list.
  • Last Issue Status – a display shown during the medication selection process that presents the last date and time the medication was issued, the cabinet from which it was taken and who removed it

Reducing Risk to Improve Patient Safety

Greater opportunity for error occurs when care is transferred between nurses, when a patient transfers to a different level of care, or during nurse shift changes. The risk can increase when the patient profile is not available.

By implementing effective processes and the proper equipment, hospitals can minimize these errors, thus providing safer and higher quality care for its patients.

1 ISMP Medication Safety Alert newsletter, September 5, 2013.

2 Feature available with Omnicell software version 16.0 and above.

One thought on “How to Prevent Duplicate Medication Dispenses

  1. There is an even better way for Automated Dispensing Cabinets to minimize the opportunity for medication errors related to duplicate medications. The way to do this is with a Smart Profile. A standard patient profile on an ADC receives medication order information from the hospital’s pharmacy/CPOE system. This allows the ADC to know which medications a given patient is supposed to receive based up the patient current medications.

    A Smart Profile on an ADC not only knows the patient’s verified medication orders, but also information from the hospital’s eMAR (electronic medication administration record). This allows the ADC to “know” when any drug was last administered to the patient. This information can then be used to warn the nurse when an attempt is made to obtain medications prior to soon before the next administration time. This drug administration data would also be able to be used by the nurse when giving PRN (as needed) medications which are only allowed to be administered within specified time periods (e.g., every four hours, every six hours).

    An additional capability of the ADC with a Smart Profile is that it allows the ADC system to calculate whether all dispensed doses have been properly accounted for (i.e., either administered, returned, or wasted). When drugs have not been accounted for within a given nursing shift the ADC could alert the nurse and/or the nursing supervior that a dispense versus administration discrepancy may exist and allow it to be resolved before staff have left the hospital.

    Thus, an ADC with a Smart Profile enables true Closed Loop Dose Accountabilty.


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