PTCB Certified Pharmacy Technician (PTCE)Patient Safety and Quality AssuranceMedium
A pharmacy technician is restocking the automated dispensing cabinet (ADC). They scan a medication and the ADC indicates a mismatch. The technician visually confirms the medication in their hand is 'metoprolol 50 mg' but the ADC screen shows 'metoprolol 25 mg' as the expected item for that bin. What is the most appropriate next step?
- AManually update the ADC inventory to reflect the 50 mg strength for that bin.
- BRemove the 50 mg tablets and investigate why the system expected 25 mg for that bin.
- CPlace the 50 mg tablets in a different bin clearly labeled for metoprolol 50 mg.
- DOverride the system and place the 50 mg tablets in the bin, assuming a system error.
Show answer & explanationAnswer & explanation
Correct answer: B. Remove the 50 mg tablets and investigate why the system expected 25 mg for that bin.
A mismatch alarm in an ADC is a critical safety feature designed to prevent medication errors. The technician must investigate the discrepancy to determine if the medication is incorrect, the bin is mislabeled, or the system needs updating. Overriding or making assumptions can lead to serious errors.
Why the other options are wrong
- A. Manually updating the ADC without understanding the root cause could perpetuate an error or create a new one.
- C. Placing the medication in a different bin, even if correctly labeled, does not resolve the original discrepancy and could indicate a larger inventory management issue.
- D. Overriding the system without investigation bypasses a safety check and can lead to a medication error.
Automated Dispensing Cabinet (ADC) Mismatch Protocol
A procedure for handling discrepancies identified by an ADC during restocking or dispensing.
- ADCs use barcode scanning for verification.
- Mismatch alarms signal potential errors.
- Investigation is required before proceeding.
Memory trick: ADC Alarm Rings, Investigate the Things!