EDICATION DISTRIBUTION SYSTEMS

History

50 years ago:
Space was small
Few personnel
Pharmacists role - purchase and prepare
medications
Two distribution methods:
1. Floor stock system
2. 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 physicians order
Nurse reads the physicians 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
Patient
Prescription

Unit Dose

Bulk containers stored on unit indefinitely

Containers not patient-specific
No review of drug order by pharmacist
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
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

ole of Unit Dose on Drug Use Control

Advantages of Unit Dose System

1.
2.
3.
4.
5.
6.
7.

Reduction of Medication Errors

Efficient use of pharmacy and nursing personnel
Decrease in total cost of medication-related activities
Minimization of credits for drugs
Improved drug control and drug use monitoring
More accurate patient billing
Greater control by pharmacist over work patterns and
scheduling
8. 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:
Patients name and location
Generic name of the drug
Dosage in metric system
Frequency of administration
Route of administration
Signature of Prescriber
Date 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

New order is
entered to MAR
by the nurse:
Medication
Administration
Record

On the unit,
nurse checks the
medication
against the
patients MAR

Pharmacist
receives the
order and
reviews it

Medication is
delivered to the
unit by courier,
pneumatic tube,
or by a nurse

Nurse
administers the
medication to
the patient

Technician fills
the order and
checked by
pharmacist

Nurse records
the when and
how the drug
was
administered to
the patients
MAR

Order is entered
to the patients
medication
profile

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 information
Will most likely become the primary form of order
delivery

Medication Administration Record

Updated on the nursing unit

Linked with the patients 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 dose
Ready-to-administer form
Label:
Name of the drug
Strength
Expiration Date
Bar code identifier

On the nursing unit

Medications are stored in:

1. Automated dispensing cabinets
.Access is restricted
2. Locked medication carts
.Two 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 patients
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 pharmacyMedication orders, drug
packaging, cart fill, and
dispensing.

Decentralized
Pharmacy satellites- physicians
orders and dispensing of first
dose of the medication
Can offer clinical services
Specialized services in
pediatrics, oncology, critical
care, emergency room and
operating room
Needs to be supported by a
central pharmacy

Centralized Model
Advantages

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

Decentralized
Advantages
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

Next patient

Places medication in
the bin and puts it on
a conveyor belt

Robot recognizes
patients
medication needs

Pharmacy Robot
Advantages

Disadvantages

Replaces manual cart fill

Accurate because of the barcoding
Frees up time for pharmacist
and technicians
Inventory cost is reduced

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

ADCs
Advantages

Disadvantages

Fast order filling while maintains

Reduced pharmacy oversight of
control of medication use
medication use that could lead
When linked to a pharmacy drug
to medication errors
profile, pharmacist can control first
doses of new drug orders
Increase of drug inventory in
Drug waste reduction
patient care areas
Control narcotic drugs by providing
drawer types with restrictions

uture 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

OUT SOURCING

Automate
d
Dispensin
g Cabinet

IN SOURCING

wholesal
er

Nursin
g Unit

Central
Pharmacy

Decentrali
zed
Pharmacy

Pharmacists 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

Technicians value

The technicians 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.