Hospital Pharmacy: Medication Distribution Systems

Medication Distribution Systems in Hospital Pharmacy

• Hospital pharmacy is the department dealing with procurement, storage, compounding, dispensing, manufacturing, testing, packing, and drug distribution
• The pharmacy department is responsible for safe and effective medication use throughout the hospital
• Medication distribution systems can be traditional or unit dose systems for in-patients

Traditional Systems

• Traditional systems include individual prescription order systems and floor stock systems as well as a combination of the two

Individual Prescription Order System

• A physician writes the prescription for the individual patient
• The patient then obtains the prescribed drug from any medical store or hospital dispensary by paying their own charges
• All medication orders are directly reviewed by the pharmacist
• Interaction between pharmacist, doctor, nurse, and patient is possible
• Provides closer control of inventory
• Possible delays in obtaining medication
• Increased cost to the patient

Complete Floor Stock System (FSS)

• A duplication of a small pharmacy on the nursing unit
• Drugs stored for the nurse to prepare for patient administration
• The pharmacist stocks the nursing unit
• The pharmacist places bulk medication containers in the medication room
• The nurse is responsible for preparing patient specific medications for both oral and intravenous use
• Medications are not labeled for a specific patient and can be used for several doses for numerous patients
• It was common for 150-200 medications to be stored in a minipharmacy on each PCU
• The pharmacist would see only transcribed drug requisitions sent by nursing personnel.
• Drugs on the nursing station or ward are divided into charge and non-charge floor stock drugs
• Medicines available at nursing site
• Reduction in pharmacy personnel
• Reduction in the number of orders received in the pharmacy
• Minimized return of medications
• Increased medication errors
• Increased drug inventory on the pavilions
• Greater opportunity for pilferage
• Increased hazards associated with drug deterioration
• Lack of proper storage facilities
• Greater nurses time spent on drug dispensing
• Minimal pharmacy-doctors contact
• Pharmacist cannot make drug monitoring

Combination System

• Some hospitals use the individual prescription or medication order system as their primary dispensing means but also utilize a limited floor stock
• Combination systems are commonly used and modified in hospitals today via the inclusion of unit dose medications

Unit Dose System (UDS)

• Both the Floor stock system and the individual prescription system were found to be error prone from a medication use perspective
• Some hospitals began experimenting with UDS
• Appeared as a safer system
• Placed the pharmacist in a position to begin affecting a patients medication therapy
• Orders, packages, handles, administers, and charges medications in multiples of single dose units
• Units contain a predetermined amount of drugs or supply sufficient for one regular dose application or use

Elements of Unit Dose Distribution

• The pharmacist receives the physician's original order
• The pharmacist reviews the medication order
• Medications are in single-unit packaging
• Medications are in ready-to-administered form
• Not more than a 24 hour supply
• The patient's medication profile is maintained
• A single-unit package contains one discrete pharmaceutical dosage form

Unit Dose Advantages

• Reduction of medication errors
• Reduction in total medication cost
• More efficient usage of pharmacy and nursing personnel
• Improved overall drug control and drug use monitoring
• More accurate patient billing for drugs
• Great control over pharmacy workload pattern and staff scheduling
• Reduction in the size of drug inventories located in patient care areas
• Greater adaptability to computerized and automated procedures

Unit Dose Disadvantages

• Increased cost
• Time consuming
• Increased staff
• Frequent ordering

Unit Dose Dispensing Methods

• Centralized unit dose drug distribution system (CUDD)
• Decentralized unit dose drug distribution system (DUDD)

Centralized Model

• Emanates from the main pharmacy, a centralized location
• The medication order is received in the central pharmacy
• All of the processing for patients occurs there including: order processing, drug packaging, cart fill, and medication dispensing
• All resources localized in one area
• Drug inventory can be minimized
• The pharmacist cannot directly interact with the physician and nurse

Decentralized Model

• Characterized by pharmacy satellites distributed evenly throughout the institution
• A physician order is routed to a satellite
• The pharmacist processes the order and dispenses the first dose of the medication directly to the nurse unit
• Easy for a health care professional to stop by to ask a question since satellite pharmacies are closely located to patient care areas
• The pharmacist can go into the patient care areas to speak with a patient or provide clinical services
• The centralized pharmacy still exists to provide cart fill and serve the decentralized satellites
• The pharmacy remains open all the time, providing services for satellites when they close
• Satellites can focus on pediatrics, oncology, critical care, the emergency room, and the operating room
• Fewer dispensing errors as well as an increase nurse and physician satisfaction
• The pharmacist-physician interactive role began to emerge
• A more active role in the medication cycle exists for the pharmacist
• Expansion of clinical services
• Decrease floor stock

Decentralized Unit-Dose System Procedure

• Upon admission to the hospital the patient is entered into the system, diagnosis, allergies and other relevant data are entered on to the Patient Profile card
• Direct copies of medication orders are sent to the pharmacist
• The medications ordered are entered data the Patient Profile card
• The Pharmacist checks the medication order for allergies, drug interactions, drug-laboratory test effects and rationale of therapy.
• Dosage scheduled is coordinated with the nursing station
• Pharmacy technician picks medication orders and places drugs in bins of transfer cart per dosage schedule
• The medication cart is filled for particular dosage schedule delivery
• Pharmacist checks cart prior to release
• The nurse administers the medication and makes appropriate entry on her medication record
• The cart is rechecked upon returns to the pharmacy
• The pharmacist is available for consultation by the doctors and nurses throughout the sequence and maintains surveillance for discontinued orders

Out-patients

• Out-patients refers to patients not occupying beds in a hospital or in clinics, health centers and other places.
• Out-patient load can be divided into three categories: emergency, tertiary care and primary care

Emergency Out-Patients

• Requires immediate medical attention due to an emergency or accidental care

Tertiary Care Out-Patients

• Are directly sent to the outpatient department by his attending medical practitioner for specific treatment other than an emergency treatment

Primary Care Out-Patients

• Describes a range of services adequate for meeting the needs of patients who are ambulatory i.e are able to move about freely

Drug Distribution to Out-Patients

• No medicaments should be issued without a prescription
• After the issue has been made the quantities supplied must be recorded
• Medicines are given to the out- patients from the pharmacy situated in the out patient block
• The location of out-patient dispensing should be on the ground floor of the building with a proper seating arrangement
• The pharmacy receives its supplies from medical stores weekly but emergency supplies can be obtained at any time.

Ward drug storage areas

• Controlled drugs cupboard
• Cupboard for medicines intended for internal use
• Cupboard for medicines intended for external use
• Area to store disinfectants
• Refrigerator to store drugs
• Temperature controlled with thermometer being used
• Must be calibrated, clean and lockable
• Clean area for intravenous fluids

Clinical Role Enhancement

• The unit dose system has led to greater use of the pharmacist’s drug therapy expertise and, in turn, has improved patient care
• With this system, the pharmacist assumes responsibilities
• This involves delivering a carefully prepared drug product to the patient in a safe, accurate, and timely manner
• Includes monitoring all prescribed drug therapy to assess appropriateness of dose
• Includes evaluating suitability of therapy in light of the patient’s condition, the cost effectiveness of therapy, and the potential for drug interactions
• These combined activities form the foundation of clinical pharmacy practice

Summary

• The unit dose system and the development of automation for medication distribution has significantly improved hospital pharmacy
• The system reduced medication errors and aided in the introduction of the concept of clinical pharmacy
• Technology has further enhanced the distribution of medications, allowing pharmacists to become more involved with patient care
• The future of technology should further reduce medication errors while maintaining the pharmacist oversight of the process and better care of patients