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News Release

ISMP Issues Call to Action to Prevent Errors with Automated Dispensing Cabinets

Standardization and Smarter Logic Needed to Prevent Drug Name Selection Errors

A recent call to action from The Institute for Safe Medication Practices (ISMP) points to the need for additional technological changes to reduce the risk of drug name selection errors with automated dispensing cabinets (ADCs). Since 2019, ISMP has recommended entering a minimum of the first five letter characters of a drug name during ADC searches. While some ADCs now offer configurable search functions, current research shows that further advancements are necessary.

“Requiring a five-character minimum remains a valuable interim strategy for reducing the risk of drug name selection errors with ADCs, and ISMP continues to support its use,” says ISMP President Rita K. Jew, PharmD, MBA, BCPPS, FASHP. “However, a more comprehensive approach, including dynamic search function capability, is needed to truly mitigate risks.”

ISMP’s safe practice recommendations include calling for vendor support for dynamic search function and standard medication names. Recommendations for healthcare organizations include:

  • Require indications for certain override medications, since indications are the most impactful product characteristic to differentiate between similar medication names.
  • Analyze workflow, especially the searchability of emergency medications, and conduct a failure mode and effect analysis (FMEA) to identify and manage potential challenges before implementing the five-character search requirement.
  • Use simulation to educate staff before implementing any drug name search changes, which allows users to gain familiarity and confidence with the new functionality, particularly in time-sensitive situations such as emergencies.
  • Establish a feedback mechanism to obtain input from frontline staff before implementing any changes in drug name searches and collect data after implementation to assess any unintended consequences.
  • Stay informed about vendor updates to ensure earliest possible access to the latest safety improvements offered.

For a copy of an article summarizing ISMP’s recommendations, click here


Renee Brehio, Medication Safety Analyst and Editor,

About the Institute for Safe Medication Practices

The Institute for Safe Medication Practices (ISMP) is the nation’s first 501c (3) nonprofit organization devoted entirely to preventing medication errors. ISMP is known and respected for its medication safety information. For more than 30 years, it also has served as a vital force for progress. ISMP’s advocacy work alone has resulted in numerous necessary changes in clinical practice, public policy, and drug labeling and packaging. Among its many initiatives, ISMP runs the only national voluntary practitioner medication error reporting program, publishes newsletters with real-time error information read and trusted throughout the global healthcare community, and offers a wide range of unique educational programs, tools, and guidelines. In 2020, ISMP formally affiliated with ECRI to create one of the largest healthcare quality and safety entities in the world, and ECRI and the ISMP PSO is a federally certified patient safety organization by the U.S. Department of Health and Human Services. As an independent watchdog organization, ISMP receives no advertising revenue and depends entirely on charitable donations, educational grants, newsletter subscriptions, and volunteer efforts to pursue its life-saving work. 


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