The medicine cabinet is a computer: securing automated dispensing cabinets
A week into the May 2024 ransomware attack on Ascension, a nurse advocate relaying what staff were telling her said they were "having to override all the medications from their Pyxis or their automatic dispensing cabinet" and had been "handed a packet of downtime forms, paper forms, and that's it" (WKRN, 15 May 2024). A union president put it more plainly: "There's no second safety check from the pharmacy" (CNN, 29 May 2024).
The cabinet did not fail. It did what it is built to do when the network goes: it opened. That is the point of this post. An automated dispensing cabinet is a networked Windows computer wrapped around locked drawers, and it deserves the same attention as any other piece of operational technology on the ward.
Three in four hospitals
In the United States 74.5% of hospitals use automated dispensing cabinets as their primary method for drug distribution (ASHP national survey 2020). Europe is behind: in a 2022 survey by an EAHP special interest group, manual ward stock was "by far the most used" model, reported by 65% of respondents for general medicine and surgery wards (Hospital Pharmacy Europe, 23 October 2023). But new hospitals are built around them: Midland Metropolitan University Hospital opened in October 2024 with 45 Omnicell cabinets, 44 of them on the wards (Hospital Times, 3 December 2024).
Each cabinet talks to the pharmacy system, the patient record and sometimes the hospital directory. A US government privacy assessment of one Pyxis estate describes it exactly: it uses the hospital's Active Directory for authentication, receives patient data from the records system, and "may include biometric fingerprint verification" (Indian Health Service, 23 May 2025).
What the advisories say
The public record on cabinet security is mostly one vendor's, because BD publishes detailed bulletins and its competitors publish far less. In 2016 researchers found 1,418 known vulnerabilities in one tested version of the Pyxis SupplyStation, the supply-cabinet sibling of the MedStation, running on Windows XP and Server 2003; the versions were end of life, so the advice was to "Isolate affected products from the Internet and untrusted systems" (ICSMA-16-089-01). In 2019 a domain-joined Pyxis ES let a user whose directory account had expired keep their old permissions; the mitigation included the sentence "Pyxis ES systems are not recommended to be placed on the hospital domain" (ICSMA-19-248-01). In 2022 came hard-coded credentials across 24 product lines (ICSMA-22-062-01) and, that May, default credentials that "may presently still operate" on installed cabinets, scored 8.8 (BD bulletin, 31 May 2022).
Apart from the 2016 XP-era flaws, which were remotely exploitable with public exploits, none of these is reachable from the internet: the later three need someone on the same network segment or in front of the machine, and for the hard-coded credentials BD reported "no reports of this vulnerability being exploited in a clinical setting". That is the realistic threat: an insider, a stale account, a credential that was never changed.
Identity is the control that matters
The pharmacy safety bodies reached the same conclusion from the other direction. ISMP's cabinet guidelines say "Use biometric identification for ADC access whenever possible", "Prohibit staff from sharing usernames/passwords for ADC access" and remove access "immediately upon employee separation" (ISMP, 2019). ASHP goes further: "Staff should be required to use biometrics", the access-management system "must allow for immediate suspension of access", and a second nurse's biometric signature should witness every wasted dose (ASHP, 2022).
The diversion cases show why. A Colorado intensive-care nurse removed fentanyl "under a different nurse's login credentials" (US Attorney's Office, 28 August 2021). A Boise nurse whose access "required the use of a unique username and her fingerprint" still diverted fentanyl on at least 28 occasions by falsifying transactions (DEA, 17 April 2019). What caught a nurse at a hospital outside Denver was the routine audit report flagging her high use and repeated "remove-cancel" transactions (US Attorney's Office, 13 November 2019). Strong identity stops the borrowed login; the audit trail catches the authorised insider.
When the cabinet goes dark
Cabinets are designed to fail open. One Canadian health authority's procedure states that Pyxis "will automatically place itself on critical override after a maximum of two hours of interface disruption", that controlled drugs then move to a locked cupboard tracked on paper, and that "disaster keys" may be used only after consulting the on-call pharmacist (Health PEI). Every one of those steps is a window in which the second check, the witness and the log are weaker than usual. A cyberattack that lasts weeks, as Ascension's did, holds that window open.
Five things to check
Is the cabinet on its own segment, with the vendor's isolation advice actually applied? Are its accounts managed centrally, so that leaving the organisation ends access the same hour, and do you test that? Is biometric or two-factor login enforced rather than offered? Who reviews the override and remove-cancel reports, and how often? And has the downtime procedure been rehearsed with the keys, the paper log and the pharmacist on call, rather than discovered mid-incident?
The cabinet on the ward is a computer with a lock on it. The lock is good. The computer needs the same care as the rest of the estate.
