Lecture 6 Dispensinginpatients_71a21ebdb94bd84362d81422d1a10457.pdf

dispensing of drugs to inpatient

1. DISPENSING TO
INPATIENTS

2. Dispensing, Distribution and Administration
•Dispensing is a pharmacy act and consists of the removal of two or more doses from a bulk drug
container and placing them in another (dispensing) container/envelop subsequent use by a patient.
•The supply, delivery and transitory storage of drugs at patient-care areas (nursing stations) other than
main hospital pharmacy for subsequent patients' utilization is called distribution.
•The administration is a nursing act consisting of removal/withdrawal of a single dose. The drug
container and its administration to a patient on the order of a prescriber. A nurse may administer drugs
after the prescription has been dispensed by a licensed person (pharmacist).

3. •Start
↳Prescription of Drugs
•Physicians prescribe drugs for respective patients.
•Medication Order
↳Inpatients
•Prescription for inpatients is referred to as a "medication order."
•Nurse's Role
↳Carry Out Medication Orders
•Nurses obtain the required drugs from the pharmacy.
•Pharmacy Process
↳Preparation of Drugs
•Drugs may need to be:
•Prepackaged for future use.
•Compounded or manufactured.
•Properly labeled.
•Assayed and checked for accuracy.
•Distribution to Nursing Unit
↳Drugs Delivered to the Nursing Station
•Storage and Continuous Use
↳Storage at Nursing Station
•Drugs are stored for continuous patient use per physicians' orders.
•Drug Administration
↳Administration by Nurse
•Nurse prepares drugs for administration.
•Administers drugs to patients.
•Records the administration in the patient's records.

4. Guidelines for drug distribution:
1. Pharmacist must review the prescriber's original order before the initial medication dose is administered.
2. Drugs dispensed should be as ready for administration to the patient as the pharmaceutical technology
permits.
3. Drug dispensed must bear adequate identification.
4. drugs must be stored so as to be accessible only to the pharmacist or his nominee for dispensing and by
nurses for their administration.
5. When automated system is in use as pharmaceutical tools provisions must be made to provide the same in
event of failure of the device.
6. The in-house packaging must permit and facilitate drug use, ensure its stability and meet the standards of
good pharmacy practice.

5. Methods of drug distribution
INDIVIDUAL DRUG
ORDER SYSTEM
FLOOR STOCK
SYSTEM
Charge floor stock
drugs
Non-charge floor
stock drugs
Drug basket method
Mobile dispensing
unit
Complete floor
stock system
Combined
individual drug
order-floor stock
system
Unit dose
distribution system
CUDD DUDD
Combine CUDD-
DUDD system
Automated
dispensing system

6. Individual drug order system
•This is also termed as individual prescription order system and is used generally by the small and or private
hospitals due to desirability of an individualized service and for availability of a reduced manpower.
•Benefits
•1. Possibility of a direct review of medication orders by the pharmacist.
•2. Provides a better interaction among pharmacist, doctor and the patients.
•3. Provides a closer control of inventory.
•Drawbacks
•1. Results in a delay in obtaining the required medication.
•2. Increased cost to patients.

7. Floor stock system
•The floor stock drug distribution is a traditional drug distribution system and involves a separate storage
facility in a secured area on each patient care floor. Generally, each nursing area has limited (10 to 100)
dosage forms on hand for patient dispensing by nursing staff. The floor stock may include many bulk
supplies of the medications carried out in hospital pharmacy. However, a limited selection of drugs is
approved by the pharmacy and therapeutics committee.

8. Charge floor system
•The medications that are stocked on the nursing station at all the times are charged to the patient's
account after they are administered. Since each of these agents is chargeable to the patient's account, all
the decisions of the pharmacy committee regarding the storage and other matters of such medication
must be honored.
•Selection of charge floor stock drug
•The selection of the floor-stocked medication is the responsibility of pharmacy and therapeutics
committee with the consultation of the representatives of nursing service, pharmacy and the hospital
administration.

9. •The responsibilities of pharmacist, after determination of a list of floor stock drag include: (a) availability of drug, (b) enforcement of
decision of therapeutic committee and c periodically submission of list to the committee for reevaluation in light of later experience
and therapeutic trends.
•The charge floor stock drugs are supplied to nursing station on requisition submitted on a prescribed requisition form. the paperwork
for such activity must be streamlined to save the time. The paper already have printed information to see of drug the time. Manydrug
order formstrationrequiring only a minisuallythe d dosage form and route of administration chussaving time. Usually used for the dr
with demand.
•The drug order forms may be prepared on duplicate or triplicate snap out forms. T original is then forwarded to the pharmacy while
the duplicate is retained on the ward original is perforasesdrug administration record. On receiving of the original copy the pharmacists
then prepare charges to the patient's account and re-stock the inpaarea with the items consumed. At the same time, the pharmacist is
also required complete the form for the number of units dispersed and the cost price. This information
•is required for internal auditing purpose. A drug order prepared in triplicate can be used in which original is forwarded to pharmacy,
second copy is utilized in the billing procedure whereas the third copy is in the accounting department for internal audit purposes.
•Another system for charging is the envelope system whereby pharmacist fills pre-labeleenvelops with the specific drugs and places
a predetermined quantity on the nursing untAfter administration of the drugs to the patient, the nurse places the patient's name and
room number on the envelope and places in her out-basket". This is later picked up by the messenger service and is delivered to the
pharmacy where it is priced and forwarded to the accounting office.

10. Non charge floor system
•These drugs represent group of medications that are placed at the nursing station for use in inpatient-
care area without direct charging to the patients' account but costing in the per day cost of the hospital
room. The single doses of drugs with less cost and administered frequently to patients if billed to
patient may generate a bad public relation for the hospital. On the other hand if not billed to patients,
the total of several such charges for each dose is usually much heavy and must not be lost. To guard-
against whenever possible under this system the cost of such drugs is calculated and included in the
per day charges of the hospital stay.
•Selection of the non charge floor stocked drugs
•The selection of non-charge floor stock drugs is usually based on the cost of the preparation, frequency
of use, the quantity used and effect of the hospital budget and reimbursement from the third part payers.
Usually this list is exceptionally small.

11. Dispensing
•Under this system, night nurse checks medicine cabinet, utility drugs:
•room and drug refrigerator inventory of supplies against a master list provided by pomacy. The checking
nurse mark on the number required for each phatherequisition for Door stopketiuppliesprocetethere
is an empty container, she parugdrug basket. On of procedure, the drug basket containing empty
itoitainersand requisition for floor stock supplies, is then sent to pharmacy. Immediately upon opening
in the morning, the pharmacy staff fills each container and dispenses upquestedampules and vials as
ordered. Once the basket is complete, it is delivered to the floor via a messenger service.

12. •Mobile Dispensing Unit: A mobile dispensing system, also called medication cart system
•utilizes a specially constructed stainless steel truck with appropriate dimensions to hold all sort of the drugs and is equippedwith
swiveling wheels. The main compartment of the cart is provided with two locking sliding doors, a handle for steering and pushing, a
heavy duty..steeland rubber protective bumper and a 2-inch rim on the top to permit carrying empty containers being returned to the
pharmacy. The interior of the unit consists of shelves, which allow for the transport of containers of all sizes.
•One mobile unit is in use while the second is being serviced. The frequency and delivery time can be selected in cooperation with the
nursing service. In this system of distribution, it is not necessary for the night nurse, as in basket method to check the pharmacy
inventory or have the empty containers transported to the pharmacy. It is the duty of a pharmacist or of his nominee to checkthe
inventory of the cabinets in all inpatient care areas and check off items and quantity of supplies left. A requisition form in duplicate is
filled for floor stock supplies and the original is delivered to the pharmacy while the duplicate is left on the area as a record of delivery.
In pharmacy, the requisition
•form for floor stock supply will serve the following purposes: Restocking of the mobile units.
•Determination of rate of use/consumption.
•Charging for internal allocation of costs.

13. •Benefits
•This method provides the following benefits:
•Conserves the nurse time.
•Pharmacist has better supervision and control over drugs and nursing station drug cabinets.
•Availability of a pharmacist for the on spot consultation by clinical and nursing staffs.
•Due to routine checking of drugs by the pharmacist, the deteriorated and out-dateddrugs may quickly
be removed.

14. •COMPLETE FLOOR STOCK SYSTEM
•In a complete floor stock system the nursing station pharmacy/cabinet carries both the charge and
non-charge patient medications. For this system, the following two ways are currently in use:
•Floor stock system under supervision of nurse
•The supply. delivery and transitory storage of drugs at nursing station are requisitioned

15. •by nursing service and are distributed by pharmacy personnel. The rarely used or expensive drugs are omitted from floor stockthough, can be
dispensed upon the receipt of a prescription or medication order for an individual patient. This method is mostly used in governmental hospitals
and general hospitals.
•Merits
•Ready availability of required drugs at nursing station.
•Reduction in nursing time consumed by frequent trips to pharmacy to obtain medications/ancillary supplies.
•No drug returns to the main pharmacy.
•Reduction in the number of drug order for the pharmacy.
•Reduction in pharmacy workload and in number of pharmacy personnel required
•Demerits
•1. Increased chances of medication errors due to the elimination of a pharmacist review on medication orders.
•2. Increased drug inventory on the patient-care area.
•3. Increased chances of drug pilferage (theft).
•4. Increased chances for drug deterioration due to lack of proper storage facilities.
•5. Requires excessive nursing time.

16. •The indiscriminate stocking of drugs on nursing station in bulk quantities eliminates the pharmacist's
control because of dispensing by nurse on physician's prescription. situation, which is not appreciable
because dispensing is not a nurse's function. Now some of the disadvantages inherent with this system
has been resolved by use a unit dose system whereby floor stock drugs are supplied as urit-of-use
packaging rather than a preslabeled multiple dose units. This system ensures a better control and
identity of the medications and will be discussed in the next section.

17. •Floor stock system under supervision of Pharmacist-Satellite pharmacy
•In some hospitals, the floor stock system is successfully operated as a decentralized pharmacy under
the direct supervision of a pharmacist. The various demerits associated with floor stocking under nurse's
supervision can be eliminated.
•In summary, the floor stock system does not give pharmacist the opportunity to review physician's
order for accuracy of dosage and scheduling or potential drug interactions The medication nurse makes
the choice of medications from floor stock without the involvement of dispensing pharmacist.
Pharmacists have no chance to review the patient's medication profile to monitor drug therapy. They must
guess, based on nurses requests for a re-supply, when a particular drug is being used. Modified floor sod
systems were developed in an attempt to address the issue of pharmacist review of medication profile;
however, these systems do not deal with the issue of nus dispensing drugs.

18. •COMBINED INDIVIDUAL DRUG ORDER-FLOOR STOCK SYSTEM dihissystem utilizes simultaneously a
DER FLOOR STOCK SYSTE Primary measdispensing along with a limited floor individual drug order
system drug dipeningprobably the most commonly used in hospitals today and is modified to include
the use of unit dose medications.

19. •UNIT DOSE DISTRIBUTION SYSTEM
•dosed controlling medication supply is a pharmacy-Therdinatedmethod and controlling medications.
Under this system medicatiomacycoored, packaged, handled, administered, and charged in multiples of
single dionsare orderininga predetermined amount of drug sufficient for one regular dose. The unit dose
concept was derived the pharmaceutical manufactures preparing and be unit dose coned, single-dose
disposable syringes, single-dose vials and single-unit foil or cellophane frapped capsules and tablets.
Though this method is a responsibility of a hospital pharmacy yet it cannot be implemented without the
cooperation of nursing, administrative and medical staffs. Thus a hospital pharmacist has to educate
them about this concept.

20. •The unit dose distribution system has been developed to reduce medication errors and this system
guarantees pharmacist medication review and individual patient dispensing. It has largely replaced the floor
stock system. The unit dose system has two main components:
•a. A pharmacist reviews all physicians' medication orders before they are dispensed. The pharmacist may
review orders directly in the patient care area or may review copies of orders sent to the pharmacy.
•b. Medications are dispensed as unit-doses or units-of-use, in an individually labeled box or drawer for each
patient. Typically, a 24-hour medication supply is sent. For instance, for a patient who is to receive 250 mg of an
antibiotic orally three times daily, the pharmacy sends three individually packaged 250-mg capsules of that
antibiotic.
•c. The packages are dispensed in as ready-to-administer form as possible.
•d. Not more than 24-hours supply or not available at patient care area at any time for most of the drugs.
•e. Concurrently maintenance of a patient medication profiles in pharmacy for each patient.

21. •Advantages of unit dose dispensing
•Safer for patients
•1. Improved overall drug control and drug-use monitoring.
•2. Reduced chances of medication errors.
•Efficient and economical for Institution
•1. Helps cut pharmacy costs by eliminating floor stock medication supplies and reusing certain doses and decreased total
cost of medication-related activities.
•2. Reduction in the size of drug inventories located in patient-care areas as floor stocks of drugs are minimized and limited
to drugs for emergency use and routinely used safe items such as mouthwash and antiseptic solution.
•3. Greater adaptability to computerized and automated procedures.

22. •Optimum utilization of professional resources
•1. Greater pharmacist control over pharmacy workload patterns and staff scheduling. 2. Efficient usage
of the time of pharmacy and nursing personnel, allowing a time to
•Perform their respective tasks i.c., dispensing by pharmacist and administration by nurse and thereby a
direct patient care involvement by both professionals.
•The benefits of the UDD make it an essential part of drug distribution and control in hospitals. However
though it is superior to the floor stock system it is not totally free of drawback. It has the following
demerits: (a) delays may occur in initiating new medication orders, (b) pharmacy labor costs are higher.

23. •Accomplishment of unit-dose dispensing
•The implementation of unit-dose dispensing in a hospital requires a great deal of planning both within
pharmacy and within the nursing service. It can be initiated by distribution of the as many injectables as
possible in individual disposable syringes and distribution of tablets and capsules in strip-packages and
ultimately is entered into the concept of the
•full-fledged unit dose system. The unit-dose dispensing of medication can be accomplished by the
following four ways:

24. •Use of marketed single dose drugs.
•One way used to accomplish unit dose system in hospital is use of the commercial drugs available as
multiples of single units. Most of drugs are currently on market are prepared in multiples of single dose.
•In-house unit packaging
•The other drugs can be packed by use of strip packaging, vial and syringe filling equipmentsin hospital
pharmacy along with a manual bench caper. The injectable drugs -may also be prepared for the unit dose
system within the hospital but this will requires personnel and additional budget. Disposable glass syrir
gesin 0.5, 1.0, 2.5, and 10-ml sizes are commercially available and can be filled in the hospital using a
syringe filling stand and transfer needle. Once filled, the syringes are placed in a plastic tray and labeled.

25. •Purchasing of unit-dose packages of all drugs: The purchase of all drugs in unit dose packages is the
third method for accomplishment of unit dose dispensing. This can be arranged by making contract with
pharmaceutical industry to provide combination of single packaged and labeled tablets and capsules
and pre-filled, or injectables in ready-to-use plastic syringes.
•Use of packaging service: A packaging service from an outside contractor or by the joint purchase and
sharing of equipment with a neighboring hospital can be another method for unit dose dispensing. This
method is not yet tried in Pakistan.

26. •Methods of Unit-dose dispensing.
•The unit-dose dispensing concept may be introduced intethe hospital either of the three methods,
namely centralized unit-dose distribution, decentralized unit dose distribution or combination of these
both.
•Centralized unit-dose distribution (CUDD) system this system, all drugs stored
•I in central pharmacy and are dispensed service on receiving me in unit-doses. Under at the time the
dose is due to be given to patients.

27. •Decentralized unit-dose distribution (DUDD) system: The decentralized unit-dose Distribution system, unlike bercontralizedsystem, operates through smalunit-dose
istimacieslocated on each floor of the hospital. The main pharmacy in this system is pharm responsible for the pig delivery's storage, manufacturing and packaging centre
system is accomplished by the use of medication carts.
•the satellites. The drug system is typical sequence of the drug dispensing to the patient is as:
•Sending of the medication orders to the pharmacist.
•Entering of the medication order on to the patient profile card.
•Checking of the medication order for allergies, drug-interaction, drug laboratory test effects and rationale of therapy.
•Coordination of dosage schedules with the nursing station.
•Picking of medication order by the pharmacy technician and placing drugs in bins of the transfer cart per dosage schedule.
•Checking of the cars by the pharmacist before release for transfer to the inpatient care area.
•Administration of the medication by the nurse and making of the appropriate entry on the nurse medicatioifrecord.
•Rechecking of the cart on returning to the pharmacy.
•Throughout the entire sequence, the pharmacist is available for consultation by the doctors and nurses.
•Combined CUDD-DUDD systems
•Under this system, some hospital operate the dispensing of drugs 'from the main pharmacy as well as from the satellite pharmacy simultaneously.

28. •The unit doses/drugs not dispensed to the patients must be accounted for the purpose of preventing
medication error. For this purpose, hospitals with unit-dose dispensing have developed communication
forms for use by nurses to inform pharmacists. The communication forms contain the patient
identification, drug identity and dose, reason for the drug not being given, comments of the prescriber and
any new time for administration if so. These are usually placed in the bin with the returned medication and
sent to
•pharmacy. The dispensing of total parenteralsand cytotoxic drugs has been mentioned in Chapter on
Manufacturing Bulk and Sterile while dispensing of radiopharmaceutical has been dealt in Chapter on
Nuclear Pharmacy.

29. •OTHER CONCEPTS OF DRUG DISTRIBUTION/DISPENSING
•Patient servers concept
•In the patient serves method, specially designed supply closets are built into a wall at
•entrance to each patient's room, which can be opened from another room ww means that each drawer
has two-way access, from the patient room a another room under the use of a pharmacist: This allow the
pharmacist reach leaving his room and nurse access to the patient's medications and chart without the
patient's room. However, this concept is costly and impractical that is whaccepted. and as well

30. AUTOMATIC DISPENSING SYSTEM
This process of drug dispensing is initiated with medication order. Nurses or some messengers carry these
medication orders and obtain required drugs from pharmacy. On receiving of orders in the pharmacy, the
required drugs may have to be prepackaged (for future use), compounded or manufactured. Then labeled
appropriately, checked accuracy and eventually distributed to the nursing unit.
•Time is consumed for carrying of medication orders from nursing unit to pharm department. The checking of
the medication order in pharmacy also requires time. This combines with waiting time needed for messenger or
nurse till the mediation order filled or compounded in pharmacy.
•The time of all personnel can be saved by use of a computerized dispensing system known as computer
aided dispensing (CAD). This system utilizes computer network among physician, pharmacist and nursing.
Under this system, the computers of physician, pharmacist and of the nursing station are networked with
each other. The prescribe enters a medication order in computer and by pressing of a button of keyboard,
entire series of events take place. The order is displayed at pharmacy's computer. A pharmacist checks this
medication order and by using appropriate computer software, evaluates drug drug interaction. After
assurance of correctness of the order, just by pressing a button, the required labels will be printed out from
the printer connected with his computer and pharmacy inventory will be adjusted. Simultaneously, due to the
presence of computer a nursing station, a nurse is altered to administer he medication.

31. •Another press of button by nurse after drug administration enters this fact on patient's medical record. If 1
computer of accounts branch is also linked with this network, a charge is also possible to enter on patient's
account. The Figure 1 depicts these events. The computer can also notify the doctor if the drug is not in
inventory, not prescribed according to the dose/route of administration recommended in the hospital formulary
and will. alert the nurse if she has failed to administer the drug within a predetermined period of time.
•The use of automated system saves time of nurse's and that of messenger service and minimizes delays in
distribution. It also reduces the chances of medication error. Moreover, its use can generate a body of useful
statistical data governing drugs and their use. The functions of CAD do not end here, the drugs dispensed from
the pharmacy are deducted from the inventory. If inventory for that particular drug reaches at the point set for
ordering (order point) then, the system informs or automatically e-mail the order to the suppliers. Advance
information of the expiry dating of the drugs is also a possibility of CAD.
•It is necessary to mention that when this system is in use, an alternative system-for the provision of
pharmaceutical service must also be there to work in failure of the device or mechanism.