Drug Dispensing During Off-Hours and Drug Distribution to In-Patients

PART 1: Methods of Dispensing Medication During Off-Hours

1. Traditional On-Call Pharmacist Service

• A pharmacist is available by telephone or in person after pharmacy hours.
• Nursing and medical staff contact the on-call pharmacist for emergencies, urgent drug queries, or medication needs.
• The pharmacist can authorize retrieval of a drug from a secure location or physically return to the pharmacy.
• This is the most widely used model in hospitals lacking 24-hour pharmacy services.
• Limitation: Response time may be delayed; the pharmacist may not be physically present to review complex orders.

2. Emergency Drug Box (Night Locker / Emergency Cabinet)

• A pre-stocked, locked cabinet or box is maintained on the ward or nursing station.
• It contains a limited supply of essential and frequently required drugs (e.g., emergency cardiac drugs, analgesics, antibiotics).
• Access is given to a designated nursing supervisor or on-duty nurse.
• Stock is replenished and audited by the pharmacy the following day.
• Advantage: Immediate access to critical drugs without delay.
• Disadvantage: Limited drug range; increased risk of medication errors without pharmacist review.

3. Nurse Supervisor / Ward Stock Access (Modified Floor Stock)

• Drug distribution during off-hours is carried out primarily by nursing supervisors.
• Modified drug distribution systems give nurse supervisors access to additional and more complex medication supplies.
• Standard order sets and medication protocols may be altered or underused in this model.
• Limitation: Higher medication error rates; limited clinical pharmacist oversight.

4. Purchasing an Off-Hours Service from Another Pharmacy (Remote / Outsourced Service)

• The hospital contracts with an external pharmacy (another hospital or a community 24-hour pharmacy) to provide after-hours dispensing and pharmacist consultation.
• This may involve telepharmacy - a remote pharmacist reviews orders electronically and communicates with on-site nurses.
• Advantage: Pharmacist oversight is maintained; cost-effective for smaller hospitals.
• Disadvantage: Logistical challenges; delay in physical drug delivery.

5. Automated Dispensing Devices (ADDs) / Automated Dispensing Cabinets (ADCs)

• Technology-based solution (e.g., Pyxis MedStation, Omnicell) installed at ward level.
• These cabinets store pre-loaded, commonly required medications.
• Access is controlled through a computer interface linked to the patient's electronic medication profile.
• A nurse can only access medications displayed on the computerized profile, providing an inherent safety check.
• The cabinet logs all transactions for pharmacist review during regular hours.
• Advantage: 24/7 access to medications with electronic accountability; reduces medication errors; eliminates the need to call an on-call pharmacist for routine doses.
• Disadvantage: High initial cost; requires regular replenishment and maintenance by pharmacy.

6. 24-Hour Satellite Pharmacy

• In larger hospitals, a satellite pharmacy operates 24/7 in a high-dependency area (e.g., ICU, emergency department).
• This provides full pharmacist services and dispensing capability at all hours.
• Considered the gold standard but is resource-intensive.

Summary of Off-Hours Models

PART 2: Methods of Drug Distribution to In-Patients

System 1: Individual Prescription Order System

• Each patient's medication is dispensed individually against a written prescription by the physician.
• Used primarily in small and private hospitals due to economic considerations and reduced manpower requirements.
• The pharmacist directly reviews every medication order, checks for allergies, contraindications, and interactions.
• Drugs are dispensed patient-by-patient from the central pharmacy.

• All medication orders are reviewed by the pharmacist.
• Reduces drug wastage and inventory at wards.
• Better drug charge accuracy per patient.
• Controlled use of drugs - no surplus accumulates at the nursing station.

• Time-consuming for pharmacy staff.
• Delays in drug delivery, especially for urgent doses.
• High workload on pharmacy personnel.
• Not suitable for large hospitals with high patient volumes.

System 2: Complete Floor Stock System

• Envelope Method (for charge floor stock): Medications are placed in envelopes labeled per patient and charged accordingly.
• Drug Basket Method (for non-charge floor stock): Medications are kept in a basket on the ward for common, low-cost drugs.
• Mobile Dispensing Unit: A mobile cart carrying floor stock is moved between wards by pharmacy personnel.

• Minimum return of drugs.
• Reduces the volume of individual in-patient prescription orders sent to pharmacy.
• Reduced pharmacy personnel requirements.
• Easy and prompt delivery of required drugs.
• Suitable for emergency situations.

• Higher chance of medication errors (no pharmacist review per dose).
• Increased drug inventory on wards.
• Greater risk of drug deterioration due to improper storage and unnoticed drug degradation.
• Increased workload on nurses.
• Less accurate patient-specific drug charging.

System 3: Combination of Individual Prescription Order and Floor Stock System

• The most commonly used system in hospitals today.
• The individual prescription order system serves as the primary method of dispensing.
• A limited floor stock of selected drugs (usually essential, emergency, or frequently used items) is also maintained at the nursing station.
• Hospitals where patients pay for hospitalisation typically use this hybrid approach.

• High frequency of use.
• Low cost.
• Drugs required urgently (e.g., antihypertensives, analgesics, antiemetics).
• Stable under ward storage conditions.

System 4: Unit Dose Dispensing System (UDDS)

• Better financial control.
• Prevents loss of partially used medications.
• Does not require drug storage facilities at the nursing station.
• Eliminates labeling errors.
• Accurate medication charging per patient.
• Reduces medication errors significantly.

a) Centralised Unit Dose Dispensing (CUDD)

• All in-patient drugs are dispensed in unit doses from a central pharmacy.
• All drugs are stored in the central pharmacy and dispensed when each dose is due.
• A pharmacist or technician prepares and delivers dose carts or trays to the ward - typically a 24-hour supply per patient.
• Robotic systems may package, store, and pick patient-specific doses automatically.

• Maximum pharmacist control and review.
• Highly accurate and safe.
• Reduced ward inventory.

• High setup and operational cost.
• Requires efficient transport logistics between pharmacy and wards.

b) Decentralised Unit Dose Dispensing (DUDD)

• Medication in unit-dose packages is stocked in Automated Dispensing Cabinets (ADCs) located at the ward or nursing station level.
• Access is controlled by a computer linked to each patient's medication profile (entered by pharmacy into the system, e.g., Meditech, EPIC-based).
• A nurse may only access medications displayed on the computerized profile, guided by the system to pick the correct medication.
• Preferred in most acute care locations.

• Immediate bedside availability.
• Electronic accountability and audit trail.
• Pharmacist oversight via electronic medication profiles.

• High initial cost for cabinet infrastructure.
• Regular replenishment required by pharmacy staff.

Summary of Inpatient Drug Distribution Systems