MEDICATION DISTRIBUTION SYSTEMS

History

• 50 years ago:– Space was small– Few personnel– Pharmacist’s role - purchase and prepare medications– Two distribution methods:

1. Floor stock system2. Patient prescription system

Distribution Methods: Floor Stock System

• Consisted of individual storage area on each nursing unit called “drug room”• Pharmacist – responsible for stocking

- never sees the physician’s order• Nurse – reads the physician’s order

- selects the drug- prepares medication- administer to the patient

• Required minimal pharmacy resources• Assumed safe• Patients – charged for drugs administered to them/billed per diem

Distribution Methods: Patient Prescription System

• Nurse – prepares the medication• Pharmacist – reviews patient order

- dispenses and charges the patient a 2 to 5-day supply of medications

- do not have the access to patient information

Unit Dose System

• Pharmacy-coordinated method of dispensing and controlling medications in health care institutions

• Pharmacist - dispenses medications contained in unit dose packages, ready to administer, not more than 24-hour supply

• Nurses – administer medications, not prepare• Safe• Offer more opportunities for pharmacists to help improve the medication

use cycle• Most cost-effective (U.S. General Accounting Office, 1971)– Floor stock and individual prescription system were error-prone

Floor Stock • Bulk containers stored on unit indefinitely• Containers not patient-specific• No review of drug order by pharmacist

Patient Prescription

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

• Drug order transcribed by the nurse and reviewed by pharmacist• No patient information available to pharmacist

Unit Dose • Medications contained in unit dose packages and dispensed to ready-to-administer form

• No more than a 24-hour patient-specific supply on unit at any time

• Pharmacist reviews every order and checks against patient records

Role of Unit Dose on Drug Use Control

Advantages of Unit Dose System

1. Reduction of Medication Errors2. Efficient use of pharmacy and nursing personnel3. Decrease in total cost of medication-related activities4. Minimization of credits for drugs5. Improved drug control and drug use monitoring6. More accurate patient billing 7. Greater control by pharmacist over work patterns and scheduling8. Reduction of inventories maintained on nursing units

What did Unit Dose System Do?• Duplicate Carbon Copies of Original Orders: prevented transcription

errors • Patient Medication Profile: provided the pharmacists an access to

patient-specific information:Patient’s name and locationGeneric name of the drugDosage in metric systemFrequency of administrationRoute of administrationSignature of PrescriberDate and hour the order was written

Unit Dose System

Developed the credibility of pharmacists to provide clinical pharmacy services by

demonstrating reliable and responsive distribution of medication for patients

upon the foundation of excellent medication distribution system

Unit Dose Process

Medication is written and sent to

pharmacy

Pharmacist receives the order and

reviews it

Order is entered to the patient’s

medication profile

Technician fills the order and checked

by pharmacist

Medication is delivered to the unit

by courier, pneumatic tube, or

by a nurse

Nurse administers the medication to

the patient

New order is entered to MAR by the nurse:

Medication Administration

Record

On the unit, nurse checks the

medication against the patient’s MAR

Nurse records the when and how the

drug was administered to the

patient’s MAR

Order Delivery

• Courier• Pneumatic Tube System: pressurized tubes that move small

containers throughout institutions• Decentralized pharmacy satellites• Computerized Prescription Order Entry (CPOE): Pharmacists can review order any place they have computer

access to patient specific informationWill most likely become the primary form of order delivery

Medication Administration Record

• Updated on the nursing unit• Linked with the patient’s medication profile• In completely computerized record keeping system: MAR is

instantaneously updated with each new order entered in the pharmacy medication profile

• Some cases: a hard copy of MAR is printed every 24 hours with each new order

Unit of Use Package

• Aka Unit dose packages • Reduces the burden of nurses in the administration process• Contains:Correct doseReady-to-administer formLabel: Name of the drug Strength Expiration Date Bar code identifier

On the nursing unit

Medications are stored in:1. Automated dispensing cabinetsAccess is restricted2. Locked medication cartsTwo sections: common area where bulk medications and floor

stock can be stored, and individual patient medication bins

Unit Dose Cart Exchange System

• Patient medication bins are filled by the pharmacy technicians and checked by a pharmacist before being exchanged

• Each day, medications in this cart are exchanged with new ones for the day

• Any unused medication from the cart is evaluated: credited to the patient since many systems charge upon dispensing

• Cart replenishment process starts again, where medications are placed in the cart for the next day

For new medication order

• Pharmacist receives the new medication order from the patient or nurse

• Pharmacist provides medication to the floor before the next cart exchange

• Drugs will be delivered either through a courier or pneumatic tube system

Pnuematic Tube System

- reduce manual labor- staff can focus more on patient-care activities

Other Drug Delivery Methods and Storage

• For PRN (as needed) medications- Kept in pharmacy and dispensed upon request- Send small amount to each patient’s medication drawer

• Emergency drugs- available throughout the hospital- placed in tamper-evident boxes or carts – “crash or code carts”- are in ready-to-administer form

• Locked cabinets - Limited access (nurse-in-charge)- Prior to giving controlled medication doses, the nurse takes an inventory

of the medication and documents the doses removed- Discrepancies are reported immediately- Inventory at each shift change is done to ensure that no diversion takes

place

• Automated Dispensing cabinet- Located on patient care areas to replace traditional floor stock systems

and unit dose cart exchange systems- Allow nurses to have quick drug access

Models of Unit Dose Delivery

• Centralized Main pharmacy- Medication

orders, drug packaging, cart fill, and dispensing.

• DecentralizedPharmacy satellites- physician’s

orders and dispensing of first dose of the medication

Can offer clinical servicesSpecialized services in pediatrics,

oncology, critical care, emergency room and operating room

Needs to be supported by a central pharmacy

Centralized ModelAdvantages• All resources can be localized into one

area• Drug inventory can be minimized

Disadvantages• Pharmacist is not able to interact with

physician and nurse• Clinical services are limited

DecentralizedAdvantages• Faster order filling• Drugs are immediately available for

administration to the patient• Increased physician and nursing satisfactory• Expansion of clinical services• Fewer dispensing errors• Decreased need for floor stock medications• Drug control and accountability are greater

Disadvantages• Drug inventory control within the

department is more complex because of multiple pharmacy location for the same drug, particularity infrequently prescribed drugs

• More equipment is required• Use of technology to automate and

mechanize the drug distribution system component of pharmacy service will require more hardware and software

Rise of Technology to Assist Drug Distribution

• Pharmacy robot• Centralized• Bar-code• packaging

Pharmacy robot

Pharmacy patient profile system transferred to the robot

Bar code is generated for the patient

Robot scans barcode

Robot recognizes patient’s medication

needs

Places medication in the bin and puts it on a

conveyor belt

Next patient

Pharmacy Robot

Advantages• Replaces manual cart fill• Accurate because of the bar-coding• Frees up time for pharmacist and

technicians• Inventory cost is reduced

Disadvantages• Special preparations are needed

before it can be loaded into the filling system

• All medications should be in unit dose packages that can be held by the robot

• Maintenance

ADCs (automated dispensing cabinets)

• Decentralized• Patient care areas • Allows nurses to have quick

access to the drugs but may have full accountability for audit trail

ADC’sAdvantages• Fast order filling while maintains control

of medication use• When linked to a pharmacy drug profile,

pharmacist can control first doses of new drug orders

• Drug waste reduction• Control narcotic drugs by providing

drawer types with restrictions

Disadvantages• Reduced pharmacy oversight of

medication use that could lead to medication errors

• Increase of drug inventory in patient care areas

Future of the medication use system

As technology progresses many Manual tasks involved with the medication distribution system like:

• Fill the medication cart(manually)• Replenish the robotic dispensing device• Refill the ADC

Automation will further decrease the number of people involved with the dispensing of medication.

Who would provide the drugs to nursing units?

In the future, drugs may be provided to nursing units from pharmacy within the institution or it can be outsourced to wholesalers or another providers.

Most pharmacies will likely maintain a mix of centralized, decentralized, and ADC.

Sources of medication for nursing units

Nursing Unit

wholesaler

Decentralized Pharmacy

Central Pharmacy

Automated Dispensing

Cabinet

OUT SOURCING

IN SOURCING

Pharmacist’s value

The pharmacists' value lies in using professional judgment in the: • Profiling of medication order• Monitoring the medication use process• Taking medication histories• Conduction discharge counseling and the like

Technician’s value

• The technician’s value lies in the distribution process.

Requirements of any Good Medication Distribution System

1. Pharmacists must always maintain quality control over drug use in institution where patients are assured of receiving the right drug at the right time in the right way.

Pharamcists need to be involved:• Efforts to prevent the diversion of drugs• Reduce medication errors and waste• Minimize adverse drug events• Ensure that drugs maintain potency through proper storage and

handling

2. Any system must be efficient in how it achieves drug use control.

Trade-offs may need to be made in some tradtional practices that may not be cost-effective.

3. Current and future medication distribution systems must always attend to the needs of those served by these systems:

• Patients• Physicians• Nurses

The systems need to reduce the effort and inconvenience associated with the medication use process and enhance patient outcomes.