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Board reports 1,173 licensed ADDS units; QA submissions show 799 medication errors with underreporting from hospitals
Summary
The Board reported licensing and error reporting numbers for automated drug delivery systems (ADDS), found most reported errors originated in correctional facilities, and noted widespread underreporting from hospitals; staff proposed outreach and a standardized QA template.
The Committee reviewed a fiscal‑year report on automated drug delivery systems (ADDS) and related quality assurance (QA) reports at its June 11 meeting.
Janice Dang, chief of enforcement, told the committee the Board had licensed 1,173 ADDS across three license categories as of April 30, 2025: 1,169 ADDS in the primary category (facility ADDS located at skilled nursing facilities, medical offices, correctional facilities, adjacent to pharmacies, psychiatric facilities and other licensed locations), three clinic ADDS (ADC) and one ADE used by an emergency medical service to restock paramedic trucks.
Dang summarized errors reported under California Code of Regulations section 17.11(f). The Board received QA submissions from 47 facilities reporting a total of 799 ADDS‑related medication errors for the fiscal year. By location, correctional facilities reported 535 errors, hospital pharmacies reported 177 and pharmacies serving skilled nursing facilities reported 68.
Reported error types included administration or dispensing of the wrong drug, strength, quantity or patient; unauthorized dispensing (nursing staff using override functions to remove drugs before pharmacist review); and packaging errors. Dang said correctional‑facility errors were often labor‑intensive to investigate because prison medication administration systems were not electronically linked to pharmacy systems and required manual reconciliation.
Committee members and public commenters noted significant underreporting from hospitals and urged staff to improve guidance. Chairperson Maria Serpa reminded hospitals that licensed ADDS QA records must be submitted to the Board within 30 days of completing a QA review, and that facilities operating unlicensed ADDS must submit an annual QA report at the time of facility license renewal. Members asked staff to consider a standardized template for ADDS QA reports to improve consistency and completeness; Dang said many submissions lacked sufficient detail and that staff would pursue education and outreach.
Public commenters representing hospital systems described overlapping reporting obligations (for example, to the state public health authority) and raised concerns about ambiguity in definitions and peer‑review protections. Commenters urged the Board to coordinate reporting requirements and to reduce duplicative burden while preserving actionable QA detail.
The Committee directed staff to review FAQs and consider a streamlined reporting template and additional outreach to hospitals and facilities that operate ADDS.
