Teresa Blakely, PharmD
Automation Coordinator
Melissa C. Frank, PharmD
Assistant Director of Pharmacy
Steve Carlson, BS Pharm, MHA
Director of Pharmacy
Northeast Georgia Health System
Gainesville, Georgia

Carousel dispensing technology (CDT) is a popular method of storing and dispensing medications in hospital pharmacies. The overall reliability of CDT allows for safe and efficient dispensing of medications. However, because the CDT primarily relies on motorized machinery, there always is a risk for mechanical failure. Our institution, Northeast Georgia Health Center, implemented CDT in 2009 and had essentially no downtime until 2012, when a mechanical failure rendered the CDT unusable for several hours. After this event, we undertook a project to devise a comprehensive contingency plan for medication distribution in the event of unexpected or prolonged downtime of the CDT.

The first step in developing a contingency plan was to assess both the appropriateness of the medications stocked in the CDT and the potential clinical effect of a downtime that prevents access to those medications. Medications were reviewed based on clinical urgency and availability from other locations. Items were placed in 3 categories: those with high clinical urgency that should not be stocked in the CDT, such as crash-cart medications and antidotes for poisonings; those with moderate to high clinical urgency that are stocked in other locations within the facility (eg, automated dispensing cabinets [ADC], satellite pharmacy, etc.), and items with lower clinical urgency that could be safely obtained from the pharmacy wholesaler within 2 to 3 hours (Table).

Table. Medication Categories
For Storage Consideration
Items that should NOT be stored in the CDT
  • Medications with high clinical urgency not stocked in alternative locations:
    • Crash-cart medications
    • Zidovudine injection (laboring HIV+ patient)
    • Antidotes for poisoning (eg, acetylcysteine injection for acetaminophen overdose; cyanide antidote kit for cyanide poisoning)
  • Argatroban injection (HIT patients)
  • Methylprednisolone 1 g injection (spinal cord injury)
  • Medications packaged in a way that shifting could cause CDT malfunction
Items with moderate to high clinical urgency but are stocked in other locations within the facility (eg, ADCs, satellite pharmacy, etc.)
Items with lower clinical urgency that could be safely obtained from the pharmacy wholesaler within 2-3 h
ADCs, automated dispensing cabinets; CDT, carousel dispensing technology; HIT, heparin-induced thrombocytopenia

The categories were used to determine the most appropriate storage location for medications. We found that high clinical urgency medications should not be stored in the CDT. Although the CDT offers a convenient storage method, these high-urgency medications should be stored in an area with no barriers to access. Items with a moderate to high clinical urgency were considered for CDT storage as long as they were available from an alternate storage location within the facility (eg, ADC or satellite pharmacy). Items with a lower clinical urgency continued to be good candidates for CDT storage.

The review of the CDT contents resulted in the permanent removal of 4 medications from the CDT because they were deemed too time-critical to risk a delay due to mechanical failure. All crash cart medications packaged in single-use syringes were removed as well.

The pharmacy team then developed a formal contingency plan consisting of 3 key elements:

  1. A written downtime plan to clearly direct pharmacy staff to alternate locations for medications stored throughout the facility.
  2. Strategies for medication removal and storage if the CDT needs to be emptied until a repair occurs.
  3. The ability to place a predetermined emergency wholesaler order rapidly for immediate delivery. This order list is stored electronically on a shared drive that is accessible to key pharmacy personnel.

When developing these 3 elements, we focused on making clear, easy-to-follow guidance for managing downtime. The downtime plan directs staff to specific alternate storage locations for necessary medications. If the CDT needs to be emptied, staff has written directions on how to unload medications safely and quickly. finally, when developing the emergency wholesaler order, we put the most commonly dispensed CDT medications on the order list in quantities to last approximately 24 to 48 hours, depending on estimated repair time. The order list will be evaluated periodically to adjust for formulary changes.

Mechanical failure is rare with CDT, but it can and does occur. Although we have not had to use our contingency plan recently, having one in place ensures that staff can confidently launch the contingency plan to manage CDT downtime.