Board reports 1,173 licensed automated drug delivery systems; 47 facilities submitted 799 ADDS‑related medication errors

The committee received an update on automated drug delivery systems (ADDS) on June 11 showing the board licensed 1,173 ADDS units as of April 30, 2025 and that reporting of ADDS‑related medication errors remains incomplete and inconsistent.

Janice Dang, chief of enforcement, summarized ADDS types and licensing categories and reported that the board licensed 1,169 ADDS in category 1 (ADDS located at skilled nursing facilities, medical offices, correctional facilities, emergency rooms and adjacent to pharmacies), three ADCS (ADDS operated by pharmacies at covered clinics) and one ADE (an ADDS operated by an emergency medical service). Dang said the board received 163 ADDS applications and issued 154 licenses in the reporting year for category 1 devices.

On reporting, Dang said 47 facilities submitted ADDS‑related medication error reports totaling 799 medication errors this fiscal year. By location, the largest number of ADDS errors came from correctional facilities (535 reported errors), followed by hospital pharmacies (177 errors) and pharmacies servicing skilled nursing facilities (68 errors).

Dang described common ADDS error types: wrong drug, strength, quantity or patient; unauthorized dispensing (for example, nursing staff using an override function to access drugs before pharmacist review); and packaging errors in systems that package pouches for med‑pass times. Correctional facilities reported heavy labor burdens to reconcile errors because their pharmacy and prison medication administration systems are not linked and a manual reconciliation is often required.

Members and commenters said the board’s ADDS reporting appears to be subject to underreporting and inconsistent data fields. Chair Maria Serpa and several members called for a standardized quality‑assurance reporting template to improve data completeness; Janice Dang noted that roughly 25 percent of reports received lacked sufficient detail to determine the error type. Members asked staff to keep any template tight and focused on the data elements required by regulation so that reporting is easier to complete and easier for staff to review.

Public commenters from hospitals and health systems described robust local medication‑error review processes and asked for clarity on how board reporting intersects with peer‑review protections, near‑miss definitions and other reporting systems. Commenters requested clearer guidance on which facilities must submit ADDS QA reports and on how unlicensed ADDS (for example, counting/robot devices used for filling) must be reported at facility license renewal.

Ending: The committee directed staff to review FAQs and consider a short, standardized reporting template and educational outreach to improve ADDS QA submission rates and completeness.