Current systems

Current systems

In recognising that many processes had changed little since the 1970s and 1980s, a number of factors have influenced the systems and processes for the supply of medicines in UK hospitals over the past decade. Hospitals have a much higher occupancy rate, with reduced lengths of stay. There has been an increased emphasis on clinical governance and growing awareness of medication errors. Patients have more chronic illnesses and complex medication regimens. The European Community Directive 92/27 was incorporated into UK law on 1 January 1999. It required, amongst other things, that all medicines supplied to patients should include a patient information leaflet (PIL) and be labelled with the product batch number and expiry date. The directive was one of the key drivers behind the introduction of original pack dispensing into hospital practice. Traditional practice of limiting discharge supplies and split-ting packs risked non-compliance with the law and possible prosecution.

Along with individual patient dispensing and the more recent models of supply, the use of patient bedside medicine cabinets is now widely adopted as an established practice across the NHS. The benefits of the cabinets are that individual patients’ medicines are kept at their bedside, reducing the risk of selection errors and errors of omission and, in addition, the traditional nursing drug trolley, which was traditionally crammed with a huge array of medicines, is now a much more streamlined operation which also has the benefit of reducing selection error.

It is perhaps helpful to mention the arrangements under which hospital pharmacies operate at this point. Unlike community pharmacies, hospital pharmacy departments do not require premises registration with the General Pharmaceutical Council to provide services to their wards and out-patients. Whilst at the time of writing the Medicines Act is under review, the current exemption is based on section 10 of the Act and relates to a ‘hospital’s normal business’. Hospital pharmacies do have quality systems and detailed standard operating procedures for dispensing and supply just as required for registered pharmacies. However, many hospital pharmacies do register: this became common when Crown immunity was removed over 20 years ago. This permits them to undertake other activities not ‘normal business of a hospital’ and where this is the case the responsible pharmacist requirements apply. A detailed discussion of this is beyond the remit of this chapter. Details about responsible pharmacist can be found on the General Pharmaceutical Council website at

http://www.pharmacyregulation.org/regulatingpharmacy/thepharmacyregister/responsiblepharmacist/index.aspx.

Non-stock dispensing

The choice of inpatient supply system for a hospital lies anywhere on a spectrum between total stock and almost complete individual dispensing. Whilst the former was the traditional Scottish system and the latter is favoured in private hospitals because it facilitates charging, the choice in NHS hospitals throughout the UK should now be based on a careful risk appraisal of the options and resources (principally staff) available.

'One-stop dispensing'

Original pack dispensing has now been widely adopted across most hospitals in the UK and is referred to as ‘one-stop dispensing’ or ‘dispensing for discharge’. The concept is to combine inpatient and discharge dispensing into a single supply, labelled with directions for use. In this system, patients’ medicines are supplied as soon as they are needed, and labelled for discharge so that only one supply is made during the patient’s stay. Manufacturers’ original packs are usually dispensed and the patient is discharged with what remains after use in hospital. If this is less than a minimum quantity agreed with local general practitioners (GPs), usually 2 weeks’ supply, an additional pack is issued. Large numbers of individually dispensed items cannot be handled in a conven-tional medicines trolley, so each patient normally has a bedside medicines cabinet, which can also be used for the patient’s own drugs (PODs: see later in chapter) or in a self-administration scheme. To operate efficiently, a judge-ment needs to be made about which medicines can be relabelled for discharge early in the patient’s admission, and which cannot. For example, aspirin 75 mg tablets for cardiovascular disease are almost universally prescribed and taken by patients as a once-daily dose and, similarly, statins are also taken once at night. Therefore it would be reasonably safe to make the assumption that, provided the patient continues to take the medicine after discharge, the directions will probably not change. However, in the case of warfarin, corti-costeroids or antibiotics, for example, it is likely that doses or duration of treatment will change before or at the point of discharge, such that labelling them before this point is somewhat risky. These also reduce the risk of medi-cation error by limiting the choices for selection at administration times and allow nurses to give more individualised patient care. There is a need to keep the contents of cabinets up to date with prescription changes and, at discharge, to check that the pack quantity and label are still appropriate and that the cabinet is empty, all of which may be undertaken by a pharmacist or technician.

Patients benefit by having PILs provided and by avoiding the wait for discharge medicines to be dispensed, provided that the prescription is written in good time, and also by having more time before ordering repeat prescrip-tions. The hospital can meet its legal obligation on PILs and also benefits from speedier discharges.

The Royal Pharmaceutical Society’s Hospital Pharmacists Group has pro-duced useful guidance on the introduction of one-stop dispensing, use of PODs and self-administration schemes. Using patient packs at the time of discharge, a possible intermediate step to one-stop dispensing, has also been successful.

The review of medicines management in NHS hospitals undertaken by the Audit Commission in 2001 and the recommendations made have had a pro-found impact on the modernisation of the dispensing process. Many NHS hospitals have installed automated dispensing systems in the past decade as a consequence of the recommendations. A number of commercial systems are now available that accurately pick original patient packs to support the one-stop dispensing process and support re-engineering of services. Figure 4.1 provides an example of such a system the ARX Rowa from the Countess of Chester NHS Foundation Trust.

Scanning of bar codes is also used in loading such machines, enabling the robot to identify different products, strengths or pack sizes. Products can be packed very compactly because any gaps can be filled without regard to any human need for selection, as positions are memorised by the system’s com-puter. The machines can also occupy less floor space than an equivalent amount of conventional shelving. A number of studies have shown the bene-ficial impact on dispensing errors, reduced dispensary turnaround times, simplified ordering systems, improved reliability of service and more efficient use of staff.

Patients' own drugs

Patients admitted to hospital are usually asked to bring their medicines with them to facilitate the recording of their drug history and some trusts run publicity campaigns on bus adverts and in GP practices to promote this. Traditionally, PODs were routinely returned to pharmacy for destruction once a hospital supply was obtained. However, the move to dispensing of prescriptions in primary care using manufacturers’ original packs has given much greater confidence in their continued usefulness, but only for the patient to whom they were originally supplied. Before use their suitability must be assessed, with this being variously undertaken by pharmacists, technicians, doctors or nurses at different hospitals. Most hospitals will have a policy or set of procedures covering this. Reuse of patients’ own medicines has a number of benefits, including the reduced risk of medication errors, since PODs can be used a reference to patients’ medicines consumption prior to admission.

When the directions are inappropriate, relabelling by pharmacy staff may be permissible. As with one-stop dispensing, further checks on directions and quantities are required on discharge. The importance of these, including the check that the locker has been emptied, has been shown by reported errors, which also highlight the need for thorough training of those involved. Guidance on implementation includes the need for publicity to encourage patients to bring in their medicines.

Unit dose systems

Unit dose systems have been adopted quite widely in North America and many European countries but have only been tried to a limited extent in the UK. The concept is that pharmacy provides medicines to wards in single-unit packages, either just prior to the time of administration or on a daily or (for long-stay) weekly basis, placing them in the patient’s individually labelled drawer in a medicine cabinet, trolley or cassette. Because of the labour-intensive nature of this work, and the advent of original pack dispensing, it has not been widely adopted in the UK.