Unit dose drug distribution (UDD) systems were introduced into hospitals in the US in the early 1960s in order to achieve a number of objectives. These included prevention of theft or “diversion”, provision of clear audit trails, identification of accurate costs for third party charging purposes and reduction in drug administration errors. American authors have put forward the view that UDD systems should be adopted in all secondary healthcare systems worldwide. These recommendations have not taken into account local circumstances. Although the way in which hospital pharmacies operate in Europe is usually very different from their counterparts in the US, some have decided to follow the unit dose route. The European Association of Hospital Pharmacists (EAHP) has also repeatedly stated its requirement for the introduction of barcoded unit dose medicines across the EU by 2015.
This has given rise to a dilemma. In the US, hospitals can purchase medicines packaged in unit doses by the manufacturer. Thus, for example, a pack of 1000 tablets would consist of 1000 individually packed, labelled and bar-coded tablets.
Furthermore, these tablets will have been subject to stringent stability testing by the manufacturer. In Europe, the pharmaceutical industry is not supplying unit doses. Automated technologies have been introduced at the hospital level to assist with the implementation of UDD, but there is no clear consensus regarding the current limitations of these systems, such as the need to de-blister or re-blister medicines which have been separated from original multi-dose blister packs, and the associated issue of product stability. Additionally, up to 50% of medicines presented in unit-dose format lack barcodes, with this 50% mainly representing medicines in high-risk categories, such as parenterally-administered drugs and cytotoxics.
Hospital Pharmacy Europe took a recent survey of its readership, and the key findings are reported below.
Respondees representing a pan-European Hospital Pharmacy Europe readership were based in primarily university teaching (42%) or general (39%) hospitals. The number of beds served by pharmacy ranged from 101-350 (22%) to more than 1000 (15%), with, in some cases, thousands of individual items listed on hospital formularies. Eighty-three percent of responders provide a seven-day-a-week pharmaceutical service, and 67% of responders provide a unit dose service.
In those hospitals represented, 75% of unit-dose medicines were supplied to patients as opposed to wards, and, of these, 43% were in-patients. Where unit dosing was not being used, a striking 75% stated that the reason was cost, and 65% cited time as the reason. Where unit dosing was not being used, some readers expanded on the reasons, including ‘lack of time to properly evaluate potential benefit’, ‘is not UK Department of Health policy’, ‘the management does not know the benefits of unit dosing’, ‘not being used for patients as cost is too high’, ‘tried in the 1990s but equipment was not GMP compliant’ and ‘barcoding difficulties’.
Where pharmaceutical products were being supplied as unit doses, 84% were for solid oral doses (Fig. 1).
The majority of medication that cannot be purchased directly from the manufacturer in unit dose form are kept in bulk and repackaged on site (Fig. 2) manually (Fig. 3).
Almost 60% of responders prepare unit doses in their pharmacies and there is an equal split between deblistering and cutting blisters.
When a machine is used for repackaging, it is for an average of five hours per day, requiring three-four man hours per day to support it in the task of repackaging as many as thousands of oral doses.
Where issue packaging is done for patients, the majority is for single dose in sachet, not several doses in sachet. Whether single or several, the prevalent reason refers to the method ‘serving the pharmacist goal of the right medicine to the right patient’.
When de-blistering or over-wrapping were being used, the method was selected ‘to create a uniform packaging model’, ‘because with this method we can buy medicines with the lowest price’ and ‘because it is safer than others’.
Barcoding technology is currently at point-of-care in only 21% of the facilities represented in this survey.
Almost 55% of responders issue unit doses on a daily basis (Fig. 4). Twenty-one percent of responders destroy unit doses that are returned unused, 28% recycle them and the remainder do a mixture of both.
In the patient areas, unit doses are stored in medicine carts/trolleys in the majority of cases (Fig. 5), and replenished by pharmacy staff (Fig. 6).
Electronic storage cabinets are not widely used yet either on the ward or in the pharmacy and purchasing plans sit within the next two-three years. The most important drivers for faster adoption of unit-dose distribution include ‘international standards on single-dose packaging and barcoding’, ‘better articles in the literature on how other hospitals have adopted’, ‘the level of resource involved’, ‘identify a need that justifies the cost and time’, ‘patient safety issues’ and ‘a culture shift’.
One respondee issued an excellent challenge at the end of his questionnaire: “These systems seem good in principle but any paper I have seen identifying benefit seem to show benefit relative to very inefficient process before. Staff hours spent on supply, waste at ward level and missed doses reported seem astonishing in some cases. We need to see benefit demonstrated where these rates are low.”
- Most of Europe is moving toward unit dose distribution.
- The period of in-patient supply is, in general, one or two days.
- There is an equal split between deblistering and cutting blisters.
- More hospitals would move to unit dose if there were no cost constraints.
- Approximately 20% of responders intend to buy cabinets, for either the pharmacy or the wards, in the next two-three years.