Closed-Loop Medication Logistics: Smart Cabinets for Safety & Reduced Staff Burden

Smart cabinets support closed-loop medication logistics by reducing errors, enhancing patient safety and lowering staff workload. Despite proven benefits, adoption in German hospitals remains low due to lack of awareness, change resistance and staffing constraints. Studies show smart cabinets cut costs, improve efficiency and gain nurse approval, especially in high-pressure settings like ICUs. Integration with clinical pharmacists further boosts medication safety.

Key Points

• Smart cabinets reduce medication errors and improve patient safety in hospitals.
• Nurses report lower workload and more time for patient care with automated systems.
• Closed-loop systems ensure accurate drug delivery using digital tracking technologies.
• German hospitals show resistance due to limited awareness and digital transformation fears.
• Smart cabinets offer cost savings by reducing waste, errors and hospital stay lengths.

Introduction

Reducing healthcare costs has become a crucial concern for hospitals as well as for health policymakers and payers. Pharmaceuticals are recognised as an important cost driver in all developed healthcare systems. In Germany, expenditure on drug-related therapies amounted to €55.2 billion in 2024 (VDEK 2025).

A second major cost driver for hospitals is preventable adverse drug events. In German hospitals, between 19% and 35% of all incidents causing harm to patients are attributable to medication errors, leading to an estimated 15,000 patient deaths (von Eiff W 2021a). Furthermore, about 14% of the average length of stay in German hospitals is attributable to unplanned drug interactions, and 6.5% of all admissions to emergency departments are caused by adverse drug reactions (Schurig et al. 2018).

About 4.5% of acute care patients are victims of an adverse drug event (ADE)(Stausberg et al. 2011). Between 30% and 55% of these ADEs are considered as avoidable (von Eiff W 2021a). When admitted to hospital, 34% of patients suffer from side effects related to their drug therapy, of which only 29% were classified as "inevitable", so that the remaining 71% are the consequence of medication errors (von Eiff W 2021a). Several studies have shown that drug-related hospitalisations account for between 2.4% and 6.2% of all medical admissions (Schneeweiss et al. 2002; Pirmohamed et al. 2004; Just et al. 2020).

The consequences for patients range from nausea and vomiting to temporary health impairment, the need for additional therapies and prolonged hospital stay, along with an increasing risk of nosocomial infection. In the worst case, the patient may experience sustainable health impairments or die.

Regardless of the risks to patients, every non-fatal medication error leads to an average of €3,000 and €4,000 in additional costs. The length of stay (LOS) may be extended between 1.7 and 8.5 days per case. This leads to opportunity costs due to lost contribution margins ranging between €7,000 and €15,000, depending on the type of interventions (eg total knee arthroplasty, coronary artery bypass graft, transfemoral valve intervention) (von Eiff MC et al. 2019). The total annual cost of treatment caused by medication failures in Germany is estimated to range between €800 million and €1.2 billion (Sommer et al. 2018).

Complexity Causing Errors

In Germany, more than 104,000 different drugs are approved, of which 56,000 are prescription medications. Furthermore, 3,000 active ingredients and more than 6,600 known ingredient interactions make medication therapy a highly complicated and risky decision-making process (BMG 2021).

Also, the entire medication process, from drug anamnesis at admission to the decision on drug therapy at discharge, is a complex and highly collaborative workflow with many risks of failure. These include prescription errors by physicians, improper storage, inadequate monitoring of drug expiration dates, drug confusion, look-alike and sound-alike errors, inappropriate drug composition for individual patients and failures in drug administration. An important contributing factor to these failures is the increasing work burden for physicians and nurses, accompanied by time pressure and, as a consequence, a growing stress level.

Poor Organisation Leading to Failures

In most German hospitals, the medication management system is far from closed-loop safety requirements (von Eiff W 2021b):

• In 61% of hospitals, the pharmacy delivers the necessary drugs in bulk to the ward stock. From this stock, nurses allocate medication according to patient needs and physician prescriptions.
• In 57% of the hospitals, the matching between patient and medication is performed by nurses through visual checks.

Based on experience, both of these workflows are extremely prone to error.

Work Burden for Nurses: A Reason for Medical Errors

Nurses, who typically suffer from work overload, are particularly exposed to the risks of error-prone medication logistics. Between 26% and 44% of all failures occurring in the medication administration process emerge through activities in which nurses are substantially involved (Brinkrolf et al. 2013).

Nursing workload has increased significantly due to a gradual economisation of healthcare. In German hospitals alone, accumulated nursing overtime is equivalent to 17,800 full-time positions (von Eiff MC et al. 2022).

During the coronavirus crisis, working conditions deteriorated dramatically, especially for nurses caring for ventilated patients on the intensive care unit (ICU). Additional overtime, high patient mortality, resource-intensive and stressful care requirements have led to prostration and mental exhaustion.

As a result of this tremendous burden on nurses and physicians during the pandemic, up to 30% of these professionals reported inadequate working conditions and expressed their intention to quit their jobs. The focus of the complaints was the lack of digitalised equipment that could contribute to a safer and more resilient working environment.

In order to identify further reasons for unsafe drug administration, 80 nurses working in different German hospitals on various types of wards were surveyed by the authors. Their experiences with adverse drug events, as well as their knowledge of closed-loop concepts and the functionality of automatic drug dispensing systems (NURSE-DRUG Study; based on own research) were evaluated. The results were astonishing:

• Almost all respondents (95%) reported having encountered an ADE during their career, and 90% of this cohort attributed these events to human error.
• 19% stated that drug administration failures occurred every working day, and further 36% indicated such incidents happen at least once a week.
• Some 50% identified persistent staff shortage to be the most important cause of errors.
• 75% declared to have witnessed a case where a wrong patient received medication despite the preparation being patient-specific and correctly prepared.
• 65% characterised the process of ordering pharmaceuticals via hospital pharmacy as time-consuming.
• Some 46% of the nurses were unfamiliar about unit dose technologies and closed-loop concepts, while another 30% reported to have only limited knowledge about the functioning and workflow impacts of smart cabinets.

In summary, it seems necessary to familiarise nursing staff with drug dispensing technologies and their potential to simplify medication workflows, and to improve safety by reducing the risk of error.

A Need for Establishing Safety Standards in Legal Regulation of Medication Management

In order to overcome typical failure modes, the German government decided in 2020 to legally require hospitals to organise their medication management to be as error-free as possible (von Eiff W et al. 2023). A closed-loop administration system in combination with a unit dose approach was designated as the "gold standard" in medication management.

A closed-loop system is a feedback-controlled, robust and failure-tolerant self-steering system. Barcodes or RFID transponders are used to identify patient medications, ensuring the correct match between the patient and the medication.

To put the closed-loop process in order, electronic verification should be used to confirm "the six rights": the right patient, the right medication, the right dose, the right time, the right dosage form and the right documentation, based on digital recording technology at the bedside. All of these elements must align to ensure safe and accurate medication administration.

Closed-loop medication requires the entire medication administration chain to be electronic, with no point at which data is transferred via printed materials. All medication data must be accessible in real time to all professionals involved in the patient´s treatment process. This continuous electronic availability eliminates information gaps and significantly reduces the potential for errors.

Basically, unit dose attribution to the patient applies to orally administered drugs. Therefore, in every medication logistics system organised according to the "Closed-loop Medication Administration" principle, the challenge lies in addressing the following issues:

• How to manage the administration and flow of prepared or ready-to-use syringes, injectables, ampules and therapeutic ointments?
• How can drugs that need to be stored in a fridge be integrated into the workflow?
• How to administer and organise the flow of medications brought in by the patient?
• How is the therapeutic unit dose assembled and allocated to the patient? Is the "last mile", from the nurse’s preparation of the patient-specific therapeutic unit dose to its observed intake, organised in a "poka-yoke" (fail-safe) way?

To answer these questions, it is helpful to distinguish between three levels of medication process: production, provision and administration, and patient intake at the bedside (see Figure 1).

In order to ensure proper medication treatment under these conditions, smart cabinets (SC) are used as a backbone in a digitalised medication chain. The "final product" of a closed-loop system is the therapeutic unit dose, an RFID-tagged tray containing the complete medication arrangement (oral drugs, injectables, ointments etc.) to be administered to a specific patient at a defined date.

The different types of medication are retrieved from the smart cabinet by a nurse. This selection and withdrawal process is controlled by so-called guided lights, which ensure that only the shelves containing medication assigned to the specific patient can be opened. Combined with medication test software, this helps to prevent allergic reactions and incorrect medication intake.

From a logistical point of view, each medication withdrawal from the smart cabinet initiates an end-to-end routine checking minimum stock levels, triggering stock replenishment and billing processes automatically without requiring human intervention.

The Generic Process Map and the Role of Smart Cabinets

In order to establish an integrated medication administration process that meets all requirements for safe, efficient and effective drug delivery, including all medication types and administration forms, a Generic Process Map was developed (see Figure 2).

The generic process map explains the interdependencies between the processes of medication logistics and medication administration. It also demonstrates the pivotal role of a smart cabinet as an integrative element that controls the entire medication management system, oriented towards patient safety, economic efficiency and medical effectiveness. This process design is based on the Pull Principle, where patient needs act as the driving force behind demand—a concept well known from lean management (Liker 2004).

Implementing a closed-loop system in practice requires the fulfilment of well-defined criteria and proven functional characteristics (see Figure 3).

From the perspective of the German healthcare system, the most important precondition for establishing safe and effective medication management is the presence of a clinical pharmacist on the ward as a consulting resource for the physician. However, this basic requirement cannot be fulfilled because of a significant shortage of pharmacists. While in U.S. hospitals six pharmacists are assigned per 100 beds, and NHS hospitals in the UK maintain a ratio of a 4:100, German hospitals operate at just 3 pharmacists per 1000 beds (0,3:100 ratio) (AKWL 2024).

There is evidence that the number of clinical pharmacists working in close cooperation with clinicians directly affects the incidence of adverse drug events (Bond 2006). Currently, fewer than 50% of German hospitals employ clinical pharmacists on the ward to support a safer, patient-centred medication administration process (von Eiff MC et al. 2022).

Results

By analysing findings from the literature, the effects of smart cabinets (also referred to as electronic medication cabinets, EMC, or automated dispensing cabinets, ADC), used as the backbone of the medication administration process, have been identified. Several case studies show that electronic cabinets contribute significantly to improved patient safety in drug therapy and help prevent drug-related opportunity costs caused by extended hospital stays, worsened outcomes and the need for additional therapies, all in once.

The results are categorised into four areas of evaluation criteria:

Employee Acceptance and Satisfaction with Smart Cabinets

Smart cabinets (SC) significantly relieve nursing staff of all logistical tasks. This effect is an important reason for the acceptance of this new innovative technology that has the potential to reorganise workflows and to change the way different professional groups cooperate. Furthermore, from the engineering sciences, we know that employee acceptance is a major precondition for the efficient and effective technology use in day-to-day work processes (von Eiff MC et al. 2019).

Most nurses favour the implementation of an automated dispensing system because of a marked reduction in medication errors related to drug picking, preparation and administration, especially in intensive care units (Craswell et al. 2021; Chapuis et al. 2022). Nurses also report spending less time on medication-related activities, with one study indicating an average of 14.7 hours saved per day on a 33-bed ward (Chapuis et al. 2015).

In another study, 80% of nurses in an ICU and 42% in an operating room found SCs to make their work easier. On average, time spent on dispensing and preparing medications was reduced on by 32 minutes per 8-hour shift, so that more time could be spent on direct patient care activities (Metsämuuronen et al. 2020).

Contribution to Patient Safety

A before-and-after comparison between two intensive care units in a 2,000-bed university hospital showed that, following the implementation of an automatic dispensing system on one ICU ward, the percentage of total opportunities for error was reduced significantly from 20.4% to 13.5% (Chapuis et al. 2010).

A deeper analysis showed a significant impact of SCs on preparation errors reduction. Medication errors related to drug picking and administration were also reduced. Overall, a decline in medical errors from 3.5 to 0.5 per 1,000 patients can be achieved (von Eiff W 2021a).

Efficiency, Cost Containment Effects and Return on Investment

Smart cabinets contribute significantly to reducing adverse drug events, helping to avoid opportunity costs caused by an extended length of stay—on average, 2.9 additional days (Rottenkolber et al. 2012). The additional costs of a patient suffering from an adverse drug event are tremendous and not reimbursed by the sickness funds (medical aid funds).

Direct treatment costs for such patients range between €1,500 and €2,700 per case. In addition, opportunity costs have to be mentioned: a 2.9-days stay extension means that 2 to 3 ADE patients cause a loss of revenue for at least one surgical procedure, such as total hip replacement, total knee arthroscopy or transapical valve intervention, which typically involves a 6- to 9-day length of stay. This results in a loss of contribution margins estimated between €7,500 and €20,000 (von Eiff MC et al. 2019).

Furthermore, SCs reduce drug storage costs, mainly by preventing expiration (Bourcier et al. 2016). A comparison of drug stock and consumption across various internal medicine wards over a one-year period showed a reduction of 61% when an SC was in operation (Bourcier et al. 2016; Monzón Moreno et al. 2016). The same sources report that the costs of implementing one SC (€61,000 over five years) can be recouped in 4.4 years.

Bonnabry & Francois (2020) report annual savings of 0.2 full-time equivalents (€21,000) per smart cabinet located in a 33-bed ward. Moreover, drug usage was reduced by 5% of the total medication budget, and a further 1% of the budget could be saved by avoiding shortages. Compared with traditional warehousing management approaches such as the KANBAN principle ("split supply") (Kenney 2011) or the use of supply chain assistants, SC technology leads to 30% lower storage and inventory costs.

Finally, using electronic cabinets to provide the wards with controlled substances contributed to substantial time savings. For an average 24-patient ward, time spent on ordering and inventory activities was reduced by 80 to 120 minutes per day (von Eiff W 2020).

Evaluation of SCs from the Viewpoint of Hospital Managers and Pharmaceutical Decision-Makers

Despite these convincing results reported by different hospitals from various countries, German hospital managers (including CEOs, procurement officers and pharmacists) have not so far been willing to implement smart cabinets in their institutions. Therefore, no smart cabinet-based medication processes are currently in place in German hospitals.

In order to determine the reasons behind this persistent refusal to adopt electronic cabinets, despite their successful implementation in hospitals outside Germany, 59 decision-makers of German hospitals were surveyed (von Eiff W 2020). The findings revealed several surprising insights:

• 56% of the decision-makers in German hospitals stated they refused to consider the potential of cabinet solutions due to being satisfied with their current systems.
• This attitude stands in conflict with the fact that in 57% of German hospitals, the matching of patient and medication is operated via sight control by the nurse, without any digital support. Furthermore, only 33% of hospitals use medication testing software to enable early detection of drug interactions.
• 84% of the decision-makers criticised a lack of reliable cost-benefit analyses for the SC system, despite the availability of studies demonstrating the benefits of smart cabinets for patient safety and staff workload reduction.
• Not a single respondent (0%) reported having a clear understanding of how smart cabinets function or being adequately informed about the various smart cabinet solutions available on the market.
• Interestingly, a significant number expressed fear of not being able to manage the transition from traditional medication logistics to a digitally based system using smart cabinets.

Discussion

The generic process blueprint, combined with best-in-class reports, was expected to convince decision-makers of the positive effects of electronic cabinets—namely, increased patient safety, reduced nursing workload and higher cost-effectiveness.

However, experience shows that innovative technologies bring changes to workflow organisation and disrupt established interprofessional routines. As a result, many employees fear being unable to fulfil the requirements of the new work environment and anticipate being overburdened by additional tasks and responsibilities.

Keeping this in mind, the successful implementation of electronic cabinets requires several elements:

• an effective change management organisation in order to support employees during the implementation process,
• a convincing and reliable cost-benefit analysis,
• a detailed description of the reorganised workflow based on smart cabinets and
• a summary of the advantages employees can expect for themselves from the new workflow.

Thus, an effective change management organisation can be recognised as a dominant success factor when implementing an ADC-based closed-loop medication administration system (Hänninen et al. 2021).

From the field of workplace engineering, it is established that work efficiency, measured in terms of therapy effectiveness, economic performance and patient safety, is mainly determined by staff acceptance of new technologies and reengineered workflows (von Eiff MC et al. 2019).

Significant investments—especially those with substantial effects on working behaviour, interprofessional cooperation and changes in workflows, responsibilities and tasks—often encounter financial barriers. The demonstration of a positive return on investment (ROI) is often necessary to secure board-level approval.

SC technology seems to be most effective and efficient in intensive care units, emergency departments, internal medicine wards, operating theatres and oncological departments—settings known for the rapidity of changes in medication schemes.

Moreover, SCs are ideally suited to support the realisation of a closed-loop medication administration system that includes all dosage forms. They address a key limitation of traditional unit dose systems, which focus almost exclusively on oral medications.

Against this background, it becomes evident why SC technology also plays a major role in the leadership concept of Magnet Nursing (von Eiff AKS et al. 2020). The Magnet Nursing model implies a cause-and-effect correlation between working conditions and nurse staffing on one hand, and defined outcome indicators on the other. In Magnet hospitals, SCs help avoid medication errors by reducing work pressure and lowering stress levels of nursing staff.

Last but not least, it is essential to consider that the efficiency and effectiveness of SC-based medication logistics depend on the precision and quality of drug therapy. Studies show that medication decisions can be significantly improved by involving clinical pharmacists in a collaborative approach with physicians and nurses. For instance, interventions by clinical pharmacists have contributed to reducing polypharmacy rates from 42.2% to 12.2% (Ságiné et al. 2022). In another study reviewing 1,329 prescriptions, 9.6% of prescription errors, 9.8% of dispensing and administrative errors, and 9.9% of dosage errors were identified (Berger et al. 2022). Hence, SCs and clinical pharmacists are important success factors when establishing a fail-safe medication management environment.

It must also be acknowledged that digitalised work processes are increasingly vulnerable to cyberattacks and IT failures. Therefore, when implementing SC technology, it is recommended to integrate SCs in a cyber-secure and fail-proof IT environment.

Conflict of Interest

None