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Chapter 7 MEDICATION DISTRIBUTION SYSTEMS

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Page 1: Hospi Phar Reporting

Chapter 7MEDICATION

DISTRIBUTION SYSTEMS

Page 2: Hospi Phar Reporting

KEY TERMS AND DEFINITIONS:

ADC – medication storage devices located in patient care areas designed to allow nurses to have quick but accountable access to medications

Centralized Pharmacy Services- distribution of medication from a centralized pharmacy location

Decentralized Pharmacy Services – distribution of medication from a decentralized satellite pharmacy located in or near a patient care area.

Page 3: Hospi Phar Reporting

KEY TERMS AND DEFINITIONS:

Floor Stock System – consisting of an individual storage area on each nursing unit where drugs are stored prior to preparation and administration by the nurse.

MAR – record of all current medications prescribed for each patient.

Medication profile – primary record used by pharmacist

Page 4: Hospi Phar Reporting

KEY TERMS AND DEFINITIONS:

Patient prescription system – anti-quated system of medication distribution that consists of patient specific containers with 2 or 5-day supply of drugs.

Unit dose system – characterized by medications contained in unit dose packages, dispensed in ready-to-administer form and no more than a 24-hour supply available/delivered.

Unit of use package – exact dose in a ready-to-administer form

Page 5: Hospi Phar Reporting

History of Medication Distribution

systems leading to the unit Dose

Concept

Page 6: Hospi Phar Reporting

Role of the Hospital Pharmacist 50 years ago

Confined to the basement Purchase and prepare

medications to be used on the nursing unit

Repackaging and compounding of Medication except IV admixtures

Page 7: Hospi Phar Reporting

2 distinct distribution methods:a. Floor Stock System

Consists of an individual storage area on each nursing unit

the nurse was the professional responsible for preparing the patient-specific medications for both oral and intravenous use.

this system was utilized because it required minimal pharmacy resources and it was assumed that this distribution system was safe.

Page 8: Hospi Phar Reporting

2 distinct distribution methods:

b. Patient Prescription System involved the pharmacist to a greater

extent than the floor stock system by requiring a review of the patient order.

the pharmacist would place only limited judgment on whether it was correct or appropriate for the patient.

Page 9: Hospi Phar Reporting

Unit Dose System A pharmacy coordinated method of

dispensing and controlling medications in health care institutions

Pharmacist dispenses drugs to be administered (not prepared) by the nurse

Page 10: Hospi Phar Reporting

It is the most cost-effective of any distribution system.

Studies have shown the reduction in medication errors when transitioning from floor stock to be 2% to 11% of all orders studied.

Page 11: Hospi Phar Reporting

In this system medications are:

contained in unit dose packages dispensed in ready-to-administer

form not more than 24-hour supply

being delivered on the patient care unit at any time

Page 12: Hospi Phar Reporting

Advantages of the Unit Dosedistribution method:

Reduction in medical errors

Decrease in total cost of medication-related activities

More efficient use of pharmacy and nursing personnel

Page 13: Hospi Phar Reporting

Improved drug control and drug use monitoring

More accurate patient billing for medications

Minimization of credits for drugsGreater control by pharmacist over work

patterns and schedulingReduction of inventories maintained on

nursing units

Page 14: Hospi Phar Reporting

Floor Stock

Patient Prescription

Unit Dose

-Bulk containers stored on unit indefinitely

-Patient-specific containers with 2-day to 5-daysupply of drug stored on unit

-Medications contained in unit dose packagesand dispensed in ready-to-administer form

Page 15: Hospi Phar Reporting

Floor Stock

Patient Prescription

Unit Dose

-Containers not patient-specific

-Drug order transcribed by the nurse andreviewed by the pharmacist

-No more than a 24-hour patient-specific supplyon unit at any time

Page 16: Hospi Phar Reporting

Floor Stock

Patient Prescription

Unit Dose

-No review of drug order by pharmacist

-No patient information available to pharmacist

-Pharmacist reviews every order and checksagainst patient records

Page 17: Hospi Phar Reporting

Role of Unit Dose onDrug use control

Unit dose placed pharmacists front and center in the medication cycle

Pharmacists are required to review every medication order prior to dispensing

Page 18: Hospi Phar Reporting

Duplicate carbon copies of the original orders were provided to pharmacists

Pharmacies are required to maintain a patient medication profile

Page 19: Hospi Phar Reporting

Patient medication profiles allowed pharmaciststo gain access to the following patient-specific

information:

Patients name and locationGeneric name of medicationDosage in metric systemFrequency of administrationSignature of the PhysicianDate and hour the orders were written

Page 20: Hospi Phar Reporting

UNIT DOSE PROCESS The process of unit dose varies with each institution

Orders are written on the patient care area and sent to the pharmacy through various methods.

Couriers that routinely go to nursing unitsPneumatic tube systems (pressurized tubes that

move small containers throughout institutions)

Some orders are delivered to decentralized pharmacy satellites located near or within nursing units

Page 21: Hospi Phar Reporting

Increasingly, physician orders are sent through CPOE

Advantages

Pharmacists can review orders any place they have computer access

likely become the primary form of order delivery

Page 22: Hospi Phar Reporting

Medication orders written and sent to pharmacy

Pharmacist receives and reviews order-clarifies any discrepancies with the

prescriber

Order is entered into the drug profile (medication profile in the pharmacy

information system)

Page 23: Hospi Phar Reporting

Order is filled by tech and checked by pharmacist

a label is generated and filled by technician for enough doses until the next cart fill

the technician sends the medication to the unit after the pharmacist has checked it for accuracy and

appropriateness

Medication is sent to floor by courier, by pneumonium tube or with a nurse

Page 24: Hospi Phar Reporting

New order is recorded onto the MAR After each physician order, the nurse updates

the MAR on the nursing unit

On the unit, nurse checks the medication against patient’s MAR

this is prior to giving the medication to the patient

to ensure that the medication is appropriate

Page 25: Hospi Phar Reporting

Nurse administers the medication to the patient

Nurse records when and how the drug was administered on the patient’s MAR

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Pharmacy medication profiles and the nursing MARs are linked within each institution’s computerized medication system

Any changes in the patient medications are updated manually on the nursing unit until the next computerized MAR is delivered

Page 27: Hospi Phar Reporting

UNIT USE PACKAGE/UNIT DOSE PACKAGE

reduce the cognitive burden on nurses in administration process

The majority of drugs in institution can be purchased from manufacturers in this kind of package

Medications from bulk bottles can also be repackaged into unit dose

Page 28: Hospi Phar Reporting

On the nursing unit, medications are typically stored as automated dispensing cabinets or locked medication carts

Common area (bulk medications and floor stock)

Individual patient medication bins

2 major sections of medication carts:

Page 29: Hospi Phar Reporting

Carts have wheels but usually kept stationary

Carts have flat surface

Medications in the carts are exchanged each day with new ones

Page 30: Hospi Phar Reporting

The cart replenishment process medications are placed in the cart the carts are filled by the pharmacy

technician and checked by pharmacist before being exchanged

If receives a new medication order or a dose request from the nurse, the pharmacist provides the medication on the floor before the next cart exchange.

Page 31: Hospi Phar Reporting
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Prior to giving controlled medication doses, the nurse takes an inventory of the medication and documents removed

Discrepancies are reported immediately

Nursing also takes an inventory at each shift change to reconcile the number of orders against the number of medications given

Page 33: Hospi Phar Reporting

Although time intensive, this process efficiently reduces diversion

PRN Medications• Handled according to different institution-

specific methods:

a. Keep them in the pharmacy and dispense upon request Provides the most control over medication

distribution Rarely used because of the time burden and

delays

Page 34: Hospi Phar Reporting

b. Send up a small amount of PRN medications for each patient in their medication drawer If the patient requests a dose, the

nurse retrieves the medication from the medication cart

Many doses are sent daily to the nursing unit and returned unused

Inefficient

Page 35: Hospi Phar Reporting

Most hospitals now use a limited floor stock system where medications with low potential for misuse and patient harm are stored in small quantities in the medication cart.

Medications with greater risk potential may be kept in individual patient bins or locked in ADC

Page 36: Hospi Phar Reporting

Emergency Medications

Select number of drugs needed to be kept on-site to respond immediately to patients who deteriorate quickly

Must be available instantlyMade available throughout the hospital in

tamper-evident boxes or carts (sometimes called “crash or code carts”)

Page 37: Hospi Phar Reporting

typically contain nondrug items, intravenous solutions, and medications.

medications are in ready-to-administer form and located on nursing units

checked periodically

Page 38: Hospi Phar Reporting

Models of Unit Dose Delivery

Two main models:a. Centralized modelb. Decentralized model

Centralized Model Emanates from the main pharmacy

(a centralized location)

Page 39: Hospi Phar Reporting

Medication orders are received in the central pharmacy

All of the processing for patients occur there: order processing drug packaging cart fill medication dispensing

Page 40: Hospi Phar Reporting

Centralized ModelAdvantages: Disadvantages:

All sources can be localized into one area

Drug inventory can be minimized

Pharmacist is not able to directly interact with the physician and nurse

Clinical services are limited

Page 41: Hospi Phar Reporting

Decentralized ModelCharacterized by having pharmacy satellites

located throughout the institutionA physician order is routed to a satellite where

the pharmacist there processes the order and dispenses the first dose of the medication directly to the nursing station

It is very easy for physicians and nurses to stop by to ask a question

Page 42: Hospi Phar Reporting

Decentralized ModelPharmacists can also go into the patient care

areas

Still needs to be supported by a centralized pharmacy

Can provide services in pediatrics, oncology, critical care, the emergency room, and the operating room

Page 43: Hospi Phar Reporting

Decentralized Model

Faster order fillingIncreased physician and nursing satisfactionBetter professional relationships between

pharmacy and other departmentsExpansion of clinical servicesFewer dispensing errorsDecreased need for floor stock medications

Advantages:

Page 44: Hospi Phar Reporting

Robotic fill technology centralized automated dispensing device

Benefit replaces tedious manual cart fill

accuracy time and overall inventory costs are reduced

Disadvantage special preparation needed

medications need to be placed on unit dose packages read and handled by robots

robotic breakdowns and routine maintenance

RISE OF TECHNOLOGY TO ASSIST DRUG DISTRIBUTION

Page 45: Hospi Phar Reporting

ADC (Automated Dispensing cabinets) located on patient care areas designed to

replace traditional floor stock systems and unit dose cart exchange systems

useful in controlling narcotic usecan provide tracking by the DEA and

store narcotics in safe locations where distribution is limited

Page 46: Hospi Phar Reporting

Benefit permits quick order

filling while still maintaining control of the medication uses

system waste is reduced

more accurate patient charges and minimizes the number of credits

processed

Disadvantage similar to floor stock

system ( increase medication

errors though evidence is not clear)

increases drug inventory on patient

care areas

Page 47: Hospi Phar Reporting

Minimized disadvantages by linking ADC systems with pharmacy information

systems

controlled at computer terminals with up-to-date patient specific profiles

allows accurate patient billing and maintenance of a perpetual drug inventory

Page 48: Hospi Phar Reporting

Future of the Medication Use

System Automation will further decrease the

number of people involved in medication dispensing

Mix of centralized, decentralized and automated dispensing

Page 49: Hospi Phar Reporting

Future of the Medication Use

System Outsourcing may become more

widespread

Bar-code technology

Pharmacist’s value lies in using professional judgment

Page 50: Hospi Phar Reporting

Requirements of any good Medication

Distribution system

Always maintain quality control System must be efficient in how it

achieves drug use control Medication distribution system must

always attend to the needs of its users