The inmate population, just like the nation’s population, is growing and aging, and filling their medication needs is a more time consuming, expensive and labor intensive procedure than many outsiders might consider. Pharmacy regulations, time delays, safety, security, diversion, the lack of accountability, the transient nature of incarceration and a shortage of nurses have only compounded the situation. In an effort to streamline the process of distributing medications to inmates, some correctional institutions, including those in Los Angeles County and San Bernardino County (which alone is home to seven correctional facilities) have adopted automated systems of packaging, sorting and distributing medications. They go by many names: Automated Dispensing Cabinets, Unit Based Cabinets, Automated Dispensing Devices and Automated Dispensing Machines. The devices, common in hospitals since the 1980s (an American Society of Health System Pharmacists survey found that 83% of hospitals use them), have shown positive results in areas such as time and inventory control management, safety, accountability, accuracy and expediency in corrections. In fact, one of these systems, InSite, created by Talyst, a Bellvue, Washington-based company, was designed specifically for use in correctional facilities.
The devices are more than vending machines that dispense medication. The software and barcode technology involved is very sophisticated and capable of being adapted to meet emerging compliance and safety regulations. These computer-controlled units offer the ability to store, dispense, track and document the dispensing of medications at a decentralized (located at the point of care rather than at the pharmacy) location. They can also be made to interface with other databases such as admissions, billing and, in the case of the Los Angeles County Sheriff’s Department, the Jail Health Information System (JHIS).
L.A. County Sheriff
The L.A. County Sheriff’s Department Custody System houses between 18,000 and 20,000 inmates at any given time, one third of which require five medications a day. The amount of time required to prepare medications in correctional facilities, especially one that size, is a time-consuming and labor-intensive task. In an attempt to streamline the process of distributing the $1 million worth of medication the department purchases every month, the facility adopted the use of three AutoMed ADUs. These automated drug packaging systems contain cassettes with an option of 330 pills and capsules. Each unit can package 60 single prescription bags or 40 multiple prescription bags in a minute. When running at optimal efficiency, the three together can package nearly 11,000 bags an hour. The meds are packed according to the inmate’s name, facility, module, room and bed.
The AutoMed system interfaces with the JHIS into which the inmate’s medical information had been entered upon arrival. A pharmacist then verifies the dosage and potential interactions with other medications and releases the prescription. According to the County of Los Angeles Quality and Productivity Commission 20th Annual Productivity and Quality Awards Program, prior to the Sheriff’s Department Medical Services Bureau’s adoption of AutoMed, it was estimated that a single facility’s nursing staff spent nearly 3,900 hours a year preparing medications for inmates. After incorporating AutoMed into the JHIS, that preparation time has been reduced by one third.
San Bernardino realized similar results. As Terry Fillman, health services supervisor for the San Bernardino County Sheriff's West Valley Detention Center (WVDC) in Rancho Cucamonga, the first correctional facility to incorporate the technology, discussed with Elaine Rundle, staff writer at Government Technology, it used to take four nurses four hours a day to prepare the daily 10,000 doses of medication to be distributed to inmates. This was a daunting task when, even in a bitter cold economic climate, there still remains a shortage of qualified nurses. The remote dispensing unit reduced that time to about 45 minutes, thus freeing the nurses to focus on other tasks such as preparing injections, liquids and other medications.
Reducing Waste
Time is not the only factor affected by the implementation of the ADUs. One significant problem of dispensing medications in correctional facilities is waste. As a result of the transient nature of incarceration, such as inmates being transferred to other facilities, paroled or being released, many prescriptions go unused. Oftentimes the inmate is no longer housed at the facility by the time the prescription arrives, and regulations state that if the prescription has been prepared for a patient and that patient cannot be contacted, the prescription must be destroyed. Furthermore, prescriptions are often packaged in 30-count blister packs, any remainder of which must be disposed or destroyed upon an inmate’s release.
According to the L.A. County Sherriff’s website, it is estimated that the amount of wasted medications cost the county over $600,000 a year. Terry Fillman remarked to Government Technology that WVDC did not record exactly how much medication went to waste, but that the amount was “enormous.” Jason Spears, long term care and corrections market director notes that the adoption of the Talyst InSite system can “virtually eliminate expensive medication waste.” The incorporation of an ADU can make it possible for a central pharmacy to dispense on-demand packages of patient specific medication to a secure (InSite restricts access to stored medications with password-protection, biometric security and locking metal doors) dispensing unit on site. The prescription can follow the inmate from facility to facility.
So, in laymen’s terms, how do they work? As explained by Spears, “An InSite unit is located at the correctional facility and dispenses medications in patient and time specific packets. After a pharmacist has reviewed the inmate’s prescription, the medications are immediately available to nursing staff. Medications are dispensed on-demand and only as needed for a specific patient, unit, and/or medication pass.” The prescription emerges from the machine with the patient’s name, the name of the medication and other pertinent information. Spears further notes that, “The medication packets can be barcoded to create a completely closed-loop medication management system.”
The ADM contains hundreds of canisters containing bulk medications and a microchip. When a canister is running low, the central pharmacy is alerted, a new canister is filled, checked by the pharmacist, sealed for security purposes and delivered to the facility. This real time delivery capability could alleviate certain concerns, not only for the waste element, but for delivery of first dose and STAT medications.
Prior to developing the ADM system it might have taken between 24 and 48 hours for the doctor to write a prescription, the nurse to fax it to the pharmacist and for the medications to reach the patient. Now the nurse simply enters the prescription into the system and the pharmacist, after reviewing it, releases the meds. It is options such as this that might prevent incidents like the case of Ashley Ellis, a 23-year-old from Vermont who died two days into a 30-day sentence for negligent operation of a motor vehicle because, as a result of a communications breakdown, she did not receive the potassium for which she had a prescription, both from her personal physician as well as the prison’s physician. While the rise of ADMs has been promising, the process might not be flawless. One problem that arose at first at WVDC was the unavailability of wireless connectivity inside the thick block walls. Also, without human interaction certain face-to-face elements might be lost, such as instructions on how to use inhalers and questions for the pharmacist might be affected.
A 2006 study found that more than 123 medication errors related to ADMs had been reported to the United States Pharmacopeia-Institute for Safe Medication Practices Medication Error Reporting Program, but often the error was a result of the nurse not using the “profiling” function, which means that the patient’s order was not reviewed by a pharmacist. The Joint Commission on Accreditation of Healthcare Organization suggests that all orders should be reviewed by a pharmacist; a practice that both the Los Angeles and WVDC facilities follow.
Safety has always been a concern regarding medication. Poor handwriting, a decimal point in the wrong place, communication mishaps, wrong dosage, administration of the incorrect drug and overlooked allergies and drug interactions could have devastating effects. A nationwide study found that such events have contributed to more than a million serious medication errors annually.
Fewer Errors
ADMs have shown success in reducing these mistakes. Talyst’s Spears notes that the organization has taken “significant strides to eliminate dispensing errors.” Two independent studies were conducted on the accuracy of the InSite dispensers. Both showed an accuracy rate of 99.999%. Emily Theisen of Eden Prairie, Minn.-based InstyMeds, a system that is not currently being utilized in correctional facilities, noted that their ADMs have dispensed 1.4 million doses without error.
Clearly the technologies are not one-size-fits-all. Smaller and more rural facilities will not require the massive capabilities of larger institutions such as those in Los Angeles and San Bernardino Counties, which was not exactly “plug and play.” According to Spears, the Talyst InSite system used at WVDC was designed in conjunction with the San Bernardino County Sheriff’s Department and the Arrowhead Regional Medical Center to be used specifically in corrections. The standard automated dispensing cabinet was not appropriate for a corrections environment and the project, notes Spears, was “not a modified hospital solution.” The project began in 2006 and was budgeted for $3.8 million but came in $500,000 under budget.
It might sound as if ADUs are a technology bent on replacing the more traditional blister packs that have long been a mainstay in medication delivery, but that is not the case. Blister packs remain one of the most popular methods of pharmaceutical distribution in corrections and will continue to be so.
Bob Braverman of Medi-Dose/ EPS, a 40-year-old Pennsylvania-based leader in—among other things—blister pack unit dose systems, which allow pharmacists to package medication in unit dose form, notes that their company’s relationship with ADUs is actually symbiotic and that the method can likewise realize the savings of buying in bulk. “ADCs often use blister packs,” he notes. “Our blisters will fit in virtually all cabinets. We specifically designed a blister to fit the Omnicell cabinet, for instance. They [ADUs] are not competition to us. We complement them.”
Written by Michael Grohs, Contributing Editor
