What does the future hold for the UK regarding the development of medicine supply methods in hospitals?
B Pharm MSc MBA MProf MRPharmS
City Hospitals Sunderland
Unlike the USA or some other countries in Europe, the UK has so far shown little interest in unit dose dispensing. In part, the lack of enthusiasm today stems from the 1990s when the requirement for provision of patient information leaflets drove the move towards original pack dispensing (OPD). OPD reduced the availability of bulk packs of tablets or capsules in the UK.
In many European countries such as Sweden or Holland, unit dose blister packing of tablets is seen as a safer option for compliance aids. The use of unit doses dispensing methods in the USA stems from the financial requirements of their method of insurance-based payments. Much of the earlier literature on unit dose dispensing originates from the USA, and the works of Barker et al.1 are worthy of reading when medication systems for patient safety are being considered.
However, there is a case for using automated systems for dispensing in pouches in the UK. The Alzheimer’s Research Trust2 estimates that the number of patients with dementia in the UK will double in the next 10 years, from around 700,000 in 2010 to over 1.5 million in 2020 (around 160,000 new cases are diagnosed each year). This is a staggering increase. Patients with Alzheimer-like dementias require a lot of support from carers, or eventually some form of nursing or social care support. Compliance aids can form an important part of the care package, helping the patient, carers, community workers or community nurses to administer medication in an appropriate way. Patients with other psychiatric illness such as schizophrenia also have compliance aid requirements. Although provision of compliance aids is a contractual obligation for pharmacies, receiving a compliance aid in the UK is occasionally a problem because of the shortage of capacity within the health care service to provide them.
The origins of compliance aids in the UK began with simple boxes divided into compartments to reflect the main parts of the day when medication should be given. Early prototypes were developed by companies such as Manrex and Nomad into the compliance aids now so familiar in the UK. The problem with supplying these devices is that the process is labour-intensive, and for pharmacies providing them on any scale, the job is very repetitive, and therefore boring, making it prone to errors. General estimates of dispensing errors in community pharmacies suggest a level of around 1.6%.3 Packing into pouches provides an opportunity to increase the efficiency of this process. Organisations such as Apoteket in Sweden have significant amounts of safety data for the blister packing of medicines.
Companies such as HD MEDI also have plenty of safety information regarding the use of blister packing into pouches. They estimate that, if the correct procedures are followed, their equipment would make an error of 1 in 20,000 for the packaging machine and 1 in 6,000,000 if the process is linked to automatic checking devices.
For those less familiar with the operation of unit-dose dispensing equipment, it may be worth a few moments to explain how reductions in dispensing errors can be achieved using these methods.
The basic unit of the machinery is a cassette that is designed to hold a specific capsule or tablet. The machine can hold many of these cassettes, each for a different product. The aperture that releases the tablet in the required sequence is specifically made for each brand of tablet. There is no interchangeability between brands in a cassette. The cassettes are electronically ‘chipped’ for the specific product. The information contained includes the EAN barcode, name, strength, drug form and other details such as the colour, shape and tablet markings.
The cassette is filled and to permit filling, the EAN
barcode has to be scanned each time within the control software. The control software checks the details scanned, and requests the batch number and expiry date of the product. This is checked to ensure a licensed product is being used (products that do not have a product licence cannot be entered onto the database). The cassette is filled on a special cradle, to ensure correct cassette content which allows planning of the work schedule. The cassette can then be put in the machine. The control software has had the patient’s prescription details entered, and when authorised, dispenses items into pouches in the sequence required. The pouches can contain one item or several, as the patient requires at that time. The pouches are produced in a sequential string, and are therefore presented to the patient in the prescribed manner. There can be as many pouches per day as required, and it is not limited to four dosing times. Times to take doses can be mapped to patient requirements. For example, patients with medicine for Parkinson’s disease may require more frequent doses of medicine.
Moreover, each and every pouch has the details of the contents specified, alongside the patient’s name, date and other prescription details. This means that looking at a pouch, anyone can see and check that the contents are correct, because all the tablet details are printed on the pouch (colour, shape, identifying marks). When complete, a medication administration sheet is printed to accompany the medicine. Some readers unfamiliar with these systems may ponder on some of the operational implications of the above description. This is not the place to explain how all the requirements are managed. The key points to remember are that:
- The systems are flexible for dose times.
- The information on the pouches allows checks to confirm the medication is what is required at that time of day by the patient, carer or nurse.
- In the event of a product recall, the complete traceability means products can be recalled down to the level of an individual pouch, if required.
- By following appropriate procedures, dispensing errors are virtually eliminated. Additional safety can be included by the use of post-dispensing screening though an optical scanner. These devices are linked to the control software and scan and record each pouch, and check to see if any error has occurred. Potential errors are identified for the pharmacist to check. The optical record can be archived.
- Optical records mean that once dispensed, if there is a concern about diversion of products, the photograph of the pouch in question can be recalled.
- The process is significantly more efficient than hand dispensing into Dosette boxes.
One or two psychiatric hospitals in the UK have bought this type of machinery for dispensing of compliance aids for patients. There are also commercial companies that provide this service for community pharmacies.
But what of the needs within the hospital pharmacy? Is there any potential for unit dose in this setting? Lupo et al4 suggested there might be a business case for this method of dispensing based on reducing nursing time to administer medicines. Missed doses are a sensitive issue for any hospital, as they might reflect potential failures in the medication system, and reliable data are not easy to obtain. Reasons for missed doses vary, and include patient absence (in theatre or radiology), patient refusing medication, patient unable to take medication, adverse reactions and medication not available. Some hospitals have procedures for patient self-administration to mitigate the above problems, but the use is variable. Many UK hospitals have patient medication lockers near the bedside, but do not always consider self-medication appropriate for a variety of reasons.
So, is there a case to consider unit dose dispensing in British hospitals? The answer is possibly. With electronic prescribing comes the possibility of recording details of administration by barcoding, and providing an extra safety step in checking prescription, medicine and the patient’s barcode. In the USA, ‘vending’ machines for some medicines are used, and strips of medication in blisters lend themselves readily to use in these machines. The medicine cupboards found on most wards stem from a 1950s design, and are not ideal for the requirements of the twenty-first century. ‘Smart’ medicine cupboards are commercially available, and these will be increasingly utilised by hospitals. Unit dose dispensing can improve some of the features of the smart cupboards or vending machines.
The difficult bit is in predicting when this might happen. Let us go back to the growth of the number of patients with dementia. As the numbers of patients with dementia rise, and the national capacity to supply compliance aids comes under increasing strain, then the automation of dispensing of compliance aids will occur out of commercial necessity. As this process accelerates, there will be a demand to avoid ‘de-blistering’, and manufacturers will increasingly be asked to provide bulk packs in the UK wherever possible. This point might come in around five years’ time.
Once the use of unit dose dispensing machines becomes more commonplace, it will be easier for hospitals to assess these as options for alternative ways to provide safer medication systems. The original pack robotic dispensing machines currently being used in the UK will be ageing by 2017, and along with these emerging technologies, hospitals will look at all options for meeting their medication needs, particularly as electronic prescribing systems become more frequently used. By 2017, I anticipate that the UK will be seeing more business cases for unit dose dispensing along the lines Lupo and colleagues mention.4
By 2020, I would expect to see the current OPD method of supply to be regarded as not the only option available, and installation of unit dose systems in acute hospitals to be increasing. I would suggest the drivers for this to be the increasing use of electronic prescribing in hospitals, increased usage of unit dose dispensing in the community (familiarity) and a drive to capture as much medicine administration information as possible. Allied to these are the potential efficiencies that may accrue from reductions in staff costs associated with administration, smart cupboard developments, a perception of the processes as being less wasteful and the benefits of optical audit trails. The next 10 years will be interesting times in the UK for developments of medicine supply methods in hospitals.
1. Barker KN et al. Am J Hosp Pharm 1964;21:609−25.
2. Alzheimer’s Research Trust: www.alzheimers-research.org.uk
3. Dean FB, O’Grady K. Int J Pharm Pract 2007;15:273−81.
4. Lupo C et al. Impact of automated centralised dispensing system on nurses’ work time. ESCP-GSAS symposium Geneva, Switzerland 3−6 November 2009.