Jon Beard
Chief Pharmacist & Accountable Officer for controlled drugs
Taunton & Somerset NHS Foundation Trust, UK
I read the brief lead article (HPE74) with interest but find myself having difficulty accepting the rationale behind unit dose dispensing in hospitals.
Leaving aside the fact that dispensing for discharge and automation are UK Government policy at this time, my main concern would currently be the need for large-scale repacking (presumably under licence) of thousands of individual doses of medicines on a daily basis. This may well be the concern of other Governments, not only in the UK and Germany but also in Denmark, Sweden and Norway, for example, as they widely use calendar packs.
I recall with dismay the error-prone, pre-packing associated with bulk packs before the widescale introduction of calendar packs in the late 1980s. It represented a significant patient risk then and there is no reason to assume that with the skill mix reviews that have occurred in Britain over the last 20 years, that it will not represent a similar, or greater, risk if it were to return in the guise of unit dose dispensing without expensive electronic bins and time-consuming closed loop checking systems, which can easily be circumvented.
While unit dose dispensing may becoming widespread in Europe, the activities of ward-based clinical pharmacists is still developing, and in some EU countries exists in only small pockets. Employing pharmacists and technicians in the UK to pre-pack unit doses and additional assistants to load ‘electronic bins’ methodically using closed loop checking procedures would, in my opinion, be a retrograde and expensive step.
More specifically, if unit dose dispensing were to be introduced in the UK, my initial assumption is that discharged patients would still require calendar packs on discharge from hospital. Therefore unit dose dispensing would represent a new workstream and would require appropriate funding. Where would the money come from? Would it come from savings associated with reduced drug wastage in a hospital operating unit dose dispensing? In a hospital where the average length of stay was, say, four days, would the savings be sufficient to offset the increased use of medicines by that hospital as represented by four days of unit dose dispensing prior to discharge? Has anyone done a direct comparison of the cost of drugs per admission between this single (n=1) Spanish hospital and a hospital where one stop and drug returns were managed reasonably well and where staffing costs were also accounted for?
The leader also reads to me in such a way that it suggests that closed loop checking systems would only work with unit dose dispensing. The closed loop system is a very simple concept. The nurse identifies the patient via a barcode and using a barcode reader. This barcode is duplicated on the (electronic or paper) medicines administration record. He/she is then able to ensure that this is the correct patient, together with the correct medicines administration record. Each required drug on the record would be linked to a corresponding barcode, which would also be displayed on the outer packaging of the medicine. The nurse is then able to manually select a packaged drug and check that selection using the barcode reader and that the bar code on the packaging is correct. It does not, of course, prevent erroneous drug administration but simply tells the nurse that if drug A is on Patient A’s drug chart, scanning the package in their hand will indicate whether it is in fact a package with drug A’s barcode on it…think about it.
The article also contains some contentious statements my favourite being: “In the UK, many hospitals operate a one-stop dispensing system in which medicines labelled for out-patient use are used in readiness for discharge are dispensed to in-patients. If the prescription is changed, then relatively large quantities are returned to pharmacy for re-use or destruction (a succinct and accurate description followed by….) Such a system has no place in the electronic, paperless age.” This is a completely unsupported statement that does not withstand objective scrutiny. Electronic prescribing supports one-stop dispensing well. Equally evaluating the reusability of returned drugs does not require a paper trail, but the reliable application of approved procedures. Unit dose dispensing is supported by paper or electronic ordering and one can return calendar packs to stock as easily (if not more so) than unit dose preparations.
It is worth reflecting that unit dose dispensing is not uncommon in the US, where it is argued that it reduces diversion and therefore is a financially favourable option. In the UK, commonly used medicines that have no abuse potential have little or no street value and the US financial argument falls down immediately. My recollection is that manually filled, ward-based automated drug cupboards in the US were found to have a 1% filling error rate. That is no better than normal human error, and therefore closed loop checking would be absolutely essential because filling these machines is a highly repetitive task. Presumably, filling electronic bins is equally repetitive and it would not be difficult to circumvent the closed loop checking process if one were so inclined.
The introduction of commercially available unit dose medicines would no doubt increase overall costs of currently cheap generic medicines. Their use would still require much manual handling by pharmacy staff who are currently not employed. Extra staff and extra hardware and associated software would all have to be paid for.
My second favourite statement is, of course: “Pharmacists have a responsibility to patients to provide medicines safely, accurately and economically (again, one can only completely support this statement). The EAHP has taken the lead here and hospital pharmacists should now take up the banner and campaign collectively for the introduction of unit-dose dispensing across Europe.”
Maybe they should take up the banner against UK Government policy but only when it is proven that it is safer and cheaper than currently well-run systems.
I much prefer an evidence-based approach to innovative change. I operated under eminence rather than evidence-based guidance for the first part of my career and I strongly feel that abandoning evidence now would be the biggest retrograde step (see, anyone can couple up a reasonable statement and then slip in a far-less reasonable one straight after, therefore giving the impression that there is a rational link between the two when in fact there is none).
Show me robust unequivocal evidence and plenty of it (not n = Uno) or make it clear that this is an opinion piece.
Jon Beard
