Drug Distribution Services for Long Term Care

Facilities

Susan L. Lakey, PharmD1/11/06

Drug distributionThe process:

Receipt / transcription of orderInterpretation / evaluation of orderFilling and packaging order and checking itDeliveryAdministration

New ordersCan be verbal or written, electronic, fax, or via phoneInvolves communication between

PhysiciansNursing staffPharmacistsPatient

Evaluation of ordersProspective reviewEnsure appropriate:

IndicationDosage and dosage formRoute of administrationDosing interval

Check allergy profile, concomitant disease states, other medicationsAssess interactions – drug, disease, food

Filling and packagingManual and semi manual systems

VialsUnit dose and cassettesModified unit doseMedisets

Automated systems

Traditonal vialsAdvantages

Time effective for pharmacyLess costly

DisadvantagesTime consuming for facilityIncreased chances for errorsMore medication waste

Unit Dose SystemsFirst used in the 1960s in the hospital setting Used to decrease errors, support nursing in medication administration, and reduce medication wasteStandard of practice in hospital settings today

Unit Dose and Modified Unit Dose Systems

AdvantagesLess waste Easy to track usageDecreased errors of commission and omissionDecreased nursing time

DisadvantagesIncreased pharmacy timeMore storage spaceIncreased cost

Unit Dose / Modified Unit Dose examples

Manufacturer unit dose Blister packs / bingo cardsMedication cassettes

Manufacturer unit dose

Medication cassettes

Blister / Bingo cards

MedisetsAdvantages

Less wasteFlexibilityLess nursing timeEase of use for patients

DisadvantagesCost of medisetsIncreased pharmacy timeDifficult for nursing to check for accuracyIncreased errors

Mediset examples

AutomationAdvantages:

Decreased pharmacy assimilation timeReduce medication errors by decreasing dispensing errorsAuthorized access only enhances securityAvailability of medications where neededImproved pharmacy inventory

Disadvantages:Does not effect decrease nurse administration timeTraining considerationsSystem downtimeExpensive!

Automation considerationsDispensing rateFlexibility and dose capabilitiesLabeling capabilitiesAccuracy and quality assurance safeguardsReporting and documentation capabiltiesTraining requirementsCost

Automation examplesSmall systems

Baxter ATCScript-pro 200Pyxis medstation

Larger systemsBaker cellsBaxter international bottle filler

Baxter ATCUsually installed in the pharmacyMedications stored in calibrated canisters.An order is sent to the system and the medication is dispensed from the correct canister.Packages unit dose tablets and capsules into labeled and sealed strip packsFound to be 99.98% accurate (vs. 92.62% for manual filling) – Kratz K. Hosp Pharm 1992.

Baxter ATC

Script-pro 200Usually installed in the pharmacyFills vials directly from dispensing cellsCan print prescription and auxillary labels

Pyxis medstationKept on nursing unitNurses can access medications out of drawersPharmacy responsible filling unit with medications

Baker cellsIn pharmacy systemCounts a 30 count vial in 3-5 secondsOption to use software that dispenses medication after prescription is scanned

Drug delivery and administrationDrug delivery

On time delivery to correct facilityCorrect nursing area / staffEnsure emergency back-up

Medication administrationCorrect:

• Patient, Dose, Dosage form, Route, and Time

Documentation of drug administration

The medication administration record (MAR)Monthly record of dispensed medications for each patientList of medications and administration timesList of PRNs to chart usageNursing/facility staff sign/initial when med dispensedTracks missed doses and changes in medications

Emergency KitSupply of short term emergency meds tailored to specific nursing facility needsGives dispensing services to facility to be used when pharmacy services not availableContents determined by nursing facility and pharmacy. Guided by state regulations.Box is sealed and locked when delivered to NFBroken seal indicates usageNurse documents usage and returns records inside emergency kit to pharmacy for refill

Medication distribution errorsHuman Error

Medication orders• Omissions, incorrect transcription

Interpretation/evaluation• Dose appropriateness, concurrent meds and diseases, drug

interactions

Filling and checkingMedication administration

• Wrong person, dose, dosage form, route, frequency• Missed doses or missed documentation

Medication distribution errorsSystem errors

Inadequate staffing or untrained staffPoor communication between providers, facility, pharmacyPoor coordination between pharmacy and nursing facility for drug ordering and delivery

Consultant pharmacist roleOrder processing

Review patient health and medication profilePerform prospective review Consider economic issuesCommunicate with prescribers and other health care workers

Consultant pharmacist roleDispensing and delivery

Ensure accurate packaging, labeling, and timely deliveryTrack usage and monitor medication returnsEnsure accuracy of MARMonitor reconciliation of controlled substances

Consultant pharmacist roleOther

Determine contents of emergency kits Ensure proper documentation and refills for emergency kitsDetermine house supply stockProvide drug information to staff, residents, and family membersEnsure compliance with applicable laws and regulations governing drug distribution