Chapter 7

MEDICATION
DISTRIBUTION
SYSTEMS

KEY TERMS AND

DEFINITIONS:
ADC medication storage devices
located in patient care areas
designed to allow nurses to have
quick but accountable access to
medications
Centralized Pharmacy Servicesdistribution of medication from a
centralized pharmacy location

KEY TERMS AND

DEFINITIONS:
Floor Stock System consisting of an
individual storage area on each
nursing unit where drugs are stored
prior to preparation and
administration by the nurse.
MAR record of all current
medications prescribed for each
patient.

KEY TERMS AND

DEFINITIONS:
Patient prescription system antiquated system of medication
distribution that consists of patient
specific containers with 2 or 5-day
supply of drugs.
Unit dose system characterized by
medications contained in unit dose
packages, dispensed in ready-toadminister form and no more than a

History of Medication
Distribution systems
leading to the unit Dose
Concept

Role of the Hospital

Pharmacist 50 years ago
Confined to the
basement
Purchase and prepare
medications to be used
on the nursing unit
Repackaging and
compounding of
Medication except IV

2 distinct distribution
methods:
a. Floor Stock System
.Consists of an individual storage
area on each nursing unit
.the nurse was the professional
responsible for preparing the
patient-specific medications for
both oral and intravenous use.
.this system was utilized because it
required minimal pharmacy
resources and it was assumed that
this distribution system was safe.

2 distinct distribution
methods:

b. Patient Prescription
System
involved the pharmacist to a
greater extent than the floor
stock system by requiring a
review of the patient order.
the pharmacist would place
only limited judgment on
whether it was correct or
appropriate for the patient.

Unit Dose System

A
pharmacy
coordinated
method of dispensing and
controlling
medications
in
health care institutions
Pharmacist dispenses drugs to
be administered (not prepared)
by the nurse

 It is the most cost-effective

of any
distribution system.
Studies have shown the
reduction
in
medication
errors when transitioning
from floor stock to be 2% to
11% of all orders studied.

In this system medications are:

contained
in
unit
dose
packages
dispensed
in
ready-toadminister form
not more than 24-hour
supply being delivered on
the patient care unit at any
time

Advantages of the Unit Dose

distribution method:
Reduction in medical errors
Decrease in total cost of
medication-related
activities
More
efficient
pharmacy
and

use
of
nursing

 Improved drug control and drug

use monitoring
More accurate patient billing
for medications
Minimization of credits for drugs
Greater control by pharmacist
over
work
patterns
and
scheduling
Reduction
of
inventories
maintained on nursing units

Floor Stock

ulk containers stored on unit indefinitely

Patient Prescription

tient-specific containers with 2-day to 5-d

supply of drug stored on unit

Unit Dose

edications contained in unit dose package

nd dispensed in ready-to-administer form

Floor Stock
-Containers not patient-specific

Patient Prescription

Drug order transcribed by the nurse and

reviewed by the pharmacist

Unit Dose

more than a 24-hour patient-specific sup

on unit at any time

Floor Stock

No review of drug order by pharmacist

Patient Prescription

o patient information available to pharma

Unit Dose

harmacist reviews every order and check

against patient records

Role of Unit Dose on

Drug use control
Unit dose placed pharmacists
front
and
center
in
the
medication cycle
Pharmacists are required to
review every
medication order prior to

 Duplicate carbon copies of the

original
orders were provided to
pharmacists
Pharmacies
are
required
maintain
a patient medication profile

to

atient medication profiles allowed pharmacist

o gain access to the following patient-specific
information:

Patients name and location

Generic name of medication
Dosage in metric system
Frequency of administration
Signature of the Physician
Date and hour the orders were written

UNIT DOSE PROCESS

The process of unit dose varies with each
institution
Orders are written on the patient care
area and sent to the pharmacy through
various methods.
Couriers that routinely go to nursing units
Pneumatic tube systems (pressurized
tubes that move small containers
throughout institutions)
Some

orders

are

delivered

to

Increasingly, physician orders are

sent through CPOE

Advantages
Pharmacists can review orders
any place they have computer
access
likely become the primary form
of order delivery

Medication orders written and

sent to pharmacy
Pharmacist receives and
reviews order
-clarifies any discrepancies with
the prescriber

Order is entered into the drug

profile
(medication profile in the

Order is filled by tech and checked

by pharmacist
a label is generated and filled by
technician for enough doses until the
next cart fill
the technician sends the medication to
the unit after the pharmacist has checked
it for accuracy and appropriateness

Medication is sent to floor by

courier, by pneumonium tube or
with a nurse

New order is recorded onto the

MAR
After each physician order, the
nurse updates the MAR on the
nursing unit

On the unit, nurse checks the

medication against patients MAR
this is prior to giving the medication
to the patient
to ensure that the medication is
appropriate

Nurse administers the medication

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

 Pharmacy medication profiles and

the nursing MARs are linked within
each
institutions
computerized
medication system
Any
changes
in
the
patient
medications are updated manually
on the nursing unit until the next
computerized MAR is delivered

UNIT USE PACKAGE/UNIT DOSE

PACKAGE
reduce the cognitive burden on
nurses in administration process
The majority of drugs in institution
can
be
purchased
from
manufacturers in this kind of
package
Medications from bulk bottles can

On the nursing unit, medications

are typically stored as automated
dispensing cabinets or locked
medication carts

2 major sections of medication carts

Common area (bulk
medications and floor stock)
Individual patient
medication bins

 Carts
have
wheels
but
usually
kept
stationary
Carts
have
flat surface
Medications in the
carts
are
exchanged
each
day with new ones

The
cart
process

replenishment

medications are placed in the cart

the carts are filled by the pharmacy
technician
and
checked
by
pharmacist before being exchanged
If receives a new medication order or
a dose request from the nurse, the
pharmacist provides the medication
on the floor before the next cart
exchange.

Prior to giving controlled medication

doses, the nurse takes an inventory of
the
medication
and
documents
removed
Discrepancies are reported immediately
Nursing also takes an inventory at each
shift change to reconcile the number of
orders
against
the
number
of
medications given

Although time intensive, this process

efficiently reduces diversion

PRN Medications
Handled according to different
institution-specific methods:
a. Keep them in the pharmacy and
dispense upon request
Provides the most control over
medication distribution
Rarely used because of the time
burden and delays

b. Send up a small amount of PRN

medications for each patient in
their medication drawer
If the patient requests a dose,
the
nurse
retrieves
the
medication from the medication
cart
Many doses are sent daily to the
nursing unit and returned unused
Inefficient

Most hospitals now use a limited

floor
stock
system
where
medications with low potential for
misuse and patient harm are stored
in small quantities in the medication
cart.
Medications
with
greater
risk
potential may be kept in individual
patient bins or locked in ADC

Emergency Medications
Select number of drugs needed to
be
kept
on-site
to
respond
immediately
to
patients
who
deteriorate quickly
Must be available instantly
Made available throughout the
hospital in tamper-evident boxes or
carts (sometimes called crash or
code carts)

typically
contain
nondrug
items,
intravenous solutions,
and medications.
medications are in
ready-to-administer
form and located on
nursing units
checked periodically

Models of Unit Dose Delivery

Two main models:
a. Centralized model
b. Decentralized model

Centralized Model
Emanates from the main
pharmacy (a centralized location)

Medication orders are received

in the central pharmacy
All of the processing for patients
occur there:
order processing
drug packaging
cart fill
medication dispensing

Centralized Model
Advantages:

Disadvantages:

All sources can

be localized into
one area
Drug inventory
can be
minimized

Pharmacist is
not able to
directly interact
with the
physician and
nurse
Clinical services
are limited

Decentralized Model
Characterized
by
having
pharmacy
satellites
located
throughout
the
institution
A physician order is routed to a satellite
where the pharmacist there processes the
order and dispenses the first dose of the
medication directly to the nursing station
It is very easy for physicians and nurses
to stop by to ask a question

Decentralized Model
Pharmacists can also go into the
patient care areas
Still needs to be supported by a
centralized pharmacy
Can provide services in pediatrics,
oncology, critical care, the emergency
room, and the operating room

Decentralized Model
Advantages
Faster :order filling
Increased physician and nursing
satisfaction
Better
professional
relationships
between
pharmacy
and
other
departments
Expansion of clinical services
Fewer dispensing errors
Decreased need for floor stock

RISE OF TECHNOLOGY TO
ASSIST DRUG
Robotic fill DISTRIBUTION
technology
centralized automated dispensing device
Benefit
replaces tedious manual cart fill
accuracy
time and overall inventory costs are
reduced
Disadvantage
special preparation needed
medications need to be placed on unit
dose packages read and handled by
robots

ADC (Automated Dispensing

cabinets)
located on patient care areas
designed to replace traditional
floor stock systems and unit
dose cart exchange systems
useful in controlling narcotic use
can provide tracking by the DEA
and store narcotics in safe
locations where distribution is

Benefit
permits quick order filling while still
maintaining control of the medication
uses system
waste is reduced
more accurate patient charges and
minimizes the number of credits
processed

Disadvantage
similar to floor stock system
( increase medication errors though
evidence is not clear)

Minimized disadvantages by
linking ADC systems with
pharmacy information systems
controlled at computer terminals with
up-to-date patient specific profiles
allows accurate patient billing and
maintenance of a perpetual drug
inventory

Future of the
Medication Use
System
Automation will further
decrease the number of
people involved in medication
dispensing
Mix of centralized,
decentralized and automated
dispensing

Future of the
Medication Use
System

Outsourcing may become

more widespread
Bar-code technology

Pharmacists value lies in

using professional judgment

Requirements of any
good Medication
Distribution system
Always maintain quality
control
System must be efficient in
how it achieves drug use
control
Medication distribution
system must always attend to