Hello from Fulton County, Ohio.

We had a recent near miss/good catch reported by a nurse who obtained a medication from an open matrix drawer in our Omnicell. When attempting to administer using barcoded medication administration, she realized it was the wrong medication, sucralfate instead of isosorbide mononitrate. Upon further investigation, there was more of the wrong medication in the wrong pocket- the 2 medications were stored directly adjacent to one another in the Omnicell open matrix drawer.

I am wondering if anyone has best practices related to using open matrix drawers in their ADCs? We don't have very many open matrix drawers any longer- only a couple in each area as most are locked lidded drawers. We are aware of the risk points with open matrix, this incident being a perfect example of the possible failures.

We allow nurses to return non-controls to their bins and they are required to scan the bin, scan the drug upon restocking.

When pharmacy restocks, they only have to scan one item in their lot.

We don't require separating blister strips but I am thinking this could be where we failed... when the nurse removed sucralfate, they could have picked up a blister strip, tore off the one they needed, then placed the remainder in the wrong pocket. Does anyone require that pharmacy breaks up all blister strips before stocking? The techs tell me this will make counting a little less swift.

Thanks!

Rachel Durham PharmD RPh
Director of Pharmacy