Pharmacy Management for Off-Hour Dispensing

Off-Hour Dispensing

• Emergency Box (also known as "STAT BOX") is an essential part of 24-hour pharmacies, especially in small hospitals, and can be placed on each floor/ward by expanding the inventory of necessary supplies.
• The box should be placed in an accessible location known to all ward personnel.
• The nurse withdraws medicine and medical items, charges them on the patient's file, and sends them to the pharmacy for record purposes.

Night Drug-Supply Cabinets

• Night supply cabinets are an adjunct to charging floor stock medications on each floor.
• They can be a simple cabinet or a large installation with a narcotic vault and refrigerated compartments.
• The cabinet should be constructed along the pharmacy wall, accessible from inside and outside the pharmacy.
• The pharmacy must maintain the cabinet's inventory periodically.

Use of Physician

• More drawbacks are associated with this system, which is discouraged.
• Factors include the burden and shortage of physicians, and unfamiliar surroundings for physicians in the pharmacy.

Pharmacist-On-Call

• Organizations contract with pharmacists to serve them round the clock, if required, by visiting the pharmacy on call.
• This may be supported by bonus or extra payment plans or allowances.
• The pharmacy record should include information such as date, time of issue, patient care area, drug name, strength, and dosage form, quantity delivered or returned, and names and signatures of pharmacy and patient care area staff involved.

Distribution of Controlled Substances

• For each medication movement, the pharmacy record should include date, time of issue, patient care area, drug name, strength, and dosage form, quantity delivered or returned, and names and signatures of pharmacy and patient care area staff involved.
• For each medication movement, the record in the patient care area should include date, time of receipt, "Issued by Pharmacy" or "Returned to Pharmacy", drug name, strength, and dosage form, quantity added or subtracted from inventory, new balance, and names and signatures of pharmacy and patient care area staff involved.

Responsibility for Controlled Drug Substances in Hospital

• The administrator is responsible for the proper safeguarding and handling of controlled substances in the hospital.
• The pharmacist in chief is responsible for purchasing, storing, accountability, and proper dispensing of controlled substances.
• Registers must be maintained for dispensing of controlled substances.

Ward Stock for Controlled Substances

• Stock is replaced by a duly signed sheet and provision of empty vials.
• Each request for a new supply is accompanied by a controlled drug administration form.
• For any drug that is lost or wasted, the nurse in charge must prepare an incident form.

Doctor's Order for Administration of Controlled Drug

• Orders should be duly signed by a physician in non-edible ink.
• Prescriptions can only be written by licensed and authorized physicians or registered residents.

PRN or SOS Orders

• Should be discouraged and not entertained.
• Telephone or verbal orders are only allowed during necessity, and the nurse should write the order, which should be signed by a physician within 24 hours.

Miscellaneous Regulations

• Ward supplies of controlled medicines should only be used for patients on the ward.
• Narcotic prescriptions are not refilled.
• Prescriptions are retained for records.
• Physicians may not prescribe narcotics for personal use.

Control of Narcotics by Nurses

• Narcotics are audited for count and use in every shift change.
• Each shift has a designated nurse for narcotics control.
• Both the nursing staff from the new and old shifts sign the records.
• If a discrepancy is found, it should be reported to the pharmacy.

Research Use

• Personnel involved in research should be registered under DRAP rules.
• If there are multiple locations, each location should be registered separately.
• Each personnel should keep records of research and controlled substance use, including receipt records, dispensing records, and administration records.

Inpatient Dispensing

• Pharmacist reviews all medication orders directly.
• Provides for interaction between pharmacist, doctor, nurse, and patient.
• Provides closer control of inventory.

Complete Floor Stock System

• A supply of drugs is stored in the medicine cabinet of the nursing unit, serviced by a unit dose system.
• Drugs stored in the nursing station depend on the specialty of care and are termed floor stock drugs.
• It should be in minimum quantity.

Advantages of Complete Floor Stock System

• Ready availability of required drugs.
• Elimination of drug returns.
• Reduction in the number of drug order transcriptions for the pharmacy.
• Reduction in the number of pharmacy personnel required.

Disadvantages of Complete Floor Stock System

• Medication errors may increase due to the elimination of medication order review.
• Increased drug inventory on the pavilions.
• Greater opportunity for pilferage.
• Increased hazards associated with drug deterioration.
• Lack of proper storage facilities on the ward may require capital layout.
• Greater inroads are made upon the nurses' time.

Envelope Method

• Medication errors may result from the failure to review a prescribed regimen for appropriateness or the failure to use appropriate clinical or laboratory data for adequate assessment of patient response to prescribed therapy.

Classification of Medication Errors

• Monitoring errors result from the failure to review a prescribed regimen for appropriateness or the failure to use appropriate clinical or laboratory data for adequate assessment of patient response to prescribed therapy.
• Transcription and/or interpretation errors are made during the transcribing or interpreting of prescriptions due to causes including misinterpretation of abbreviations, illegible handwritten prescriptions, and misinterpretation of spoken prescriptions.
• Omission errors occur when a dose is not administered to a patient before the next scheduled dose or failure to prescribe a drug product indicated for the patient.
• Wrong time errors occur when medication is administered outside a predefined time interval from its scheduled administration time.
• Unauthorized drug errors occur when medication is dispensed or administered to a patient without a legitimate prescriber's authorization.
• Dose errors occur when medication is dispensed or administered to a patient in a dose that is greater than or less than the amount ordered by the prescriber.
• Dosage form errors occur when medication is dispensed or administered to a patient in a different dosage form than that ordered by the prescriber.
• Drug preparation errors occur when a drug product is incorrectly formulated or manipulated before dispensing or administration.
• Route of administration errors occur when medication is administered through the wrong route.
• Administration technique errors occur when an inappropriate procedure or improper technique is used in the administration of a drug.
• Deteriorated drug errors occur when medication is dispensed or administered that has expired or has compromised physical or chemical dosage-form integrity.

Factors Contributing to Medication Errors

• Hospital administration-related factors:
  • Inadequate policies regarding safe use of medication
  • Inadequate policies governing reporting of incidents in the institution
  • Inadequate policies concerning performance of tasks for supportive personnel
• Personnel-related factors:
  • Lack of hospital pharmacist
  • Lack of administration nurse
  • Overburdened personnel
• Technique-related factors:
  • Use of non-professional personnel in areas requiring professional judgment
  • Inadequate labeling of drugs and allied items for the nursing station
• Facility-related factors:
  • Inadequate storage and equipment facilities
  • Inadequate drug station on patient care areas

Learn about the importance of emergency boxes and night drug-supply cabinets in 24-hour pharmacies, and how to manage them effectively. Understand the role of nurses and pharmacists in off-hour dispensing.