Challenges of Digital Commons: A Qualitative Study of an Automated Dispensing Cabinet in a Paediatric Intensive Care Unit
Open accessAbstract
Missed medication doses can affect patient safety in hospitals. The use of automated dispensing cabinets (ADC) in clinical areas may reduce the occurrence of medications being unavailable at the time of need by alerting pharmacy to replenish stock. However, workarounds in ADC use can affect this capability. We studied nurses’ use of an ADC in a paediatric intensive care unit with 54 hours of observation, semi-structure interviews (19 nurses; 4 pharmacy/management staff) and review of reported incidents. We found running out of medication a recurrent problem despite the ADC. Contributing factors affecting data entry in the ADC, and therefore replenishment alerts to pharmacy, included: the organisation of medication activities in the ward, nurses’ information needs, patients’ medication needs, and ADC design. Running out of medications was a ‘tragedy of the commons’. Effective solutions may require going beyond user training and directives for accurate data entry, to work process redesign.
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Although there is literature on the benefits of continuous cycles of training with ADC implementation, no studies have recommended the frequency with which training should be undertaken.
“Although there is literature on the benefits of continuous cycles of training with ADC implementation,33 no studies have recommended the frequency with which training should be undertaken.”
From Benefits and challenges associated with implementation and ongoing use of automated dispensing cabinet for medicines: A scoping review (2025) · cites this paper as [33]
The citation is attached to the claimed benefits of continuous training, not to the subsequent statement about training frequency. In §3.4, the paper says training and repeated calls for compliance did not seem to address the ADC problems; the Discussion and Conclusion says training is likely to have only limited effect unless work processes change. (LLM, conf=0.85)
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Experimental — accuracy not yet measuredA prevalent method of addressing user challenges was robust staff training.
“A prevalent method of addressing such user challenges was robust staff training.14,22,33”
From Benefits and challenges associated with implementation and ongoing use of automated dispensing cabinet for medicines: A scoping review (2025) · cites this paper as [33]
Section 3.4 says the solution to the ADC problems was sought in training and repeated calls for compliance, supporting training as an approach used in this case. It does not describe the training as robust or establish that it was a prevalent approach beyond this setting; it also says those interventions did not seem to address the issues. (LLM, conf=0.84)
Experimental — accuracy not yet measuredMedication management was complicated by user-related challenges.
“Medication management was also complicated by user-related challenges.”
From Benefits and challenges associated with implementation and ongoing use of automated dispensing cabinet for medicines: A scoping review (2025) · cites this paper as [33]
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Cites
Journal of Evaluation in Clinical Practice
(2010) · Journal of Evaluation in Clinical Practice · doi:10.1111/(issn)1365-2753 · Cited by 565 · see citing works
Work-arounds, make-work, and kludges
Koopman, P. J., & Hoffman, R. R. (2003) · IEEE Intelligent Systems · doi:10.1109/mis.2003.1249172 · Cited by 153 · see citing works
Enacting computer workaround practices within a medication dispensing system
Azad, B., & King, N. E. (2008) · European Journal of Information Systems · doi:10.1057/ejis.2008.14 · Cited by 138 · see citing works
Implementation and evaluation of an automated dispensing system
Schwarz, H. O., & Brodowy, B. A. (1995) · American Journal of Health-System Pharmacy · doi:10.1093/ajhp/52.8.823 · Cited by 72 · see citing works
The Australian Journal of Hospital Pharmacy
(2018) · Journal of Pharmacy Practice and Research · doi:10.1002/(issn)0310-6810 · Cited by 68 · see citing works
Rostami, P., Heal, C., Harrison, A., Parry, G. J., Ashcroft, D. M., & Tully, M. P. (2019) · BMJ Open · doi:10.1136/bmjopen-2018-028170 · Cited by 20 · see citing works
Hunt, K. V., Harding, A. M., Taylor, S. E., & Curtain, C. M. (2018) · Journal of Evaluation in Clinical Practice · doi:10.1111/jep.12944 · Cited by 11 · see citing works
Missed Doses An Evaluation in Two Drug Distribution Systems
Boyle, C. M., Maxwell, D. J., Meguid, S. E., Ouaida, D., & Krass, I. (1998) · Journal of Pharmacy Practice and Research · doi:10.1002/jppr1998286413 · Cited by 10 · see citing works
Reducing dose omission of prescribed medications in the hospital setting: a narrative review
Morley, C., McLeod, E., McKenzie, D., Ford, K., Walsh, K. D., Chalmers, L., Gordon-Croal, S., Bayer, G., & Peterson, G. M. (2016) · Drugs & Therapy Perspectives · doi:10.1007/s40267-016-0289-2 · Cited by 8 · see citing works
Revisiting the tragedy of the commons
Cerf, V. G. (2013) · Communications of the ACM · doi:10.1145/2507771.2507773 · Cited by 4 · see citing works
Flagged first, then by citations
Research works printed but not linked: 1
- Hardin G. The tragedy of the commons. Science 162 (1968), 1243-1248.
Cited by
Sorted by citations
Jung, Y. Y., Walsh, Á., Patel, J., & Lai, K. (2025) · Exploratory Research in Clinical and Social Pharmacy · doi:10.1016/j.rcsop.2025.100599 · Cited by 7 · see citing works
“33”
Influential
- Authors
- Lichtner, V., Prgomet, M., Gates, P., Franklin, B. D., & Westbrook, J. I.
- Affiliations
- UCL School of Pharmacy (GB)
- Macquarie University (AU)
- National Health Service (GB)
- Venue
- Studies in Health Technology and Informatics
- Publisher
- IOS Press
- Published
- 2021-12-15
- Volume
- 284
- Pages
- 244-248
- ISSN
- 0926-9630 (ISSN-L)
- 1879-8365
- OpenAlex
- W4200024905
- Cited by
- 1
- References
- 10
- Citations by year
- 2025: 1
- FWCI
- 0.00
- Type
- book chapter
- Language
- en
- Open access
- hybrid
- doi.org
- Licence
- Locations
- Studies in health technology and informatics (publishedVersion, cc-by-nc)
- PubMed (publishedVersion)
- Research Explorer (The University of Manchester) (publishedVersion, other-oa)
- White Rose Research Online (University of Leeds, The University of Sheffield, University of York) (acceptedVersion)
- UCL Discovery (University College London) (submittedVersion)
- Funders
- European Commission (HORIZON2020, 740131)
- National Health and Medical Research Council (1094878)
- Topics
- Health Sciences › Health Professions › Emergency Medical Services › Patient Safety and Medication Errors
- Health Sciences › Health Professions › Health Information Management › Electronic Health Records Systems
- Health Sciences › Medicine › Surgery › Healthcare Technology and Patient Monitoring
- Keywords
- automated dispensing cabinets, medication errors, pediatric intensive care, tragedy of the commons, workflow redesign, patient safety, hospital pharmacy
- MeSH terms
- Child, Humans, Intensive Care Units, Pediatric, Qualitative Research
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