Medication Management Policy / Procedure Unit Dose Distribution System

Inpatient Care Areas

POLICY The IWK Health Centre shall use a decentralized automated unit dose system in combination with centralized, manual unit dose system as its medication delivery system for inpatients.

GUIDING PRINCIPLES AND VALUES The unit dose drug distribution system is endorsed by the Canadian Society of Hospital Pharmacists and Accreditation Canada as the drug distribution system of choice in organized health care settings. This system provides improvements in medication safety, overall system efficiency, job satisfaction, and effective use of human resources. It is designed to:  Promote tsafe and effective administration of medications at a reasonable cost 

Reduce medication errors

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Reduce medication-related activities of nursing staff

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Promote effective utilization of nursing and pharmacy personnel allowing for more direct patient care involvement by pharmacists and nurses.

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Minimize drug deterioration, pilferage and reduce health centre and patient care area and main pharmacy inventories

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Provide greater drug control and drug use monitoring

 Provide greater adaptability to computerized and automated systems and bar coding. This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and should be checked against the server version prior to use.

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PROCEDURE  Scan all medication orders to the Pharmacy Department via Pyxis Connect.  A Meditech profile is created for each patient admitted to the IWK via the Admitting Department. Other information entered upon admission and by the patient care area includes: patient name, unit number, room number, date of birth, age, gender, attending physician, diagnosis, allergies, height and weight. Pharmacists check written orders for allergy history and enter the patient’s medication related allergies into the Meditech profile.  All medications ordered for each patient are reviewed by a Pharmacist.  With each order entry, a Pharmacist reviews the patient’s entire medication profile for appropriateness, incompatibilities, potential hypersensitivity reactions, duplications in therapy or other potential risks.  A Pharmacist clarifies any order where there is question as to the appropriateness of drug therapy, dose, route, legibility etc. Should any discrepancies be discovered, the Pharmacist contacts the prescriber to resolve them prior to dispensing. If necessary, a Drug Order Clarification/Intervention Form IWK_DROR is completed, sent to the care area and placed in the patient’s chart. Alternatively, a new order may be written directly on the chart.  A Pharmacist may round doses of selected medications according to Medication Management 3.02 - Standardized Doses. A label comment referring to the policy will be included where medication doses are standardized.  A Pharmacist is responsible for notifying the care area or prescriber about potential food/drug interactions.  Only a Pharmacist, Pharmacy Practice Assistant or licensed personnel authorized by the Pharmacy Department may dispense medications, make label changes or transfer medications to different containers.  A 24-hour supply of medication in unit dose packaging is delivered by Pharmacy to the care area in a unit dose drawer designated for each inpatient labelled with patient name, room number and unit number (K#). The medications are delivered to the care areas in unit dose cassettes on a daily basis at a designated time. The content of all patient specific unit dose drawers is checked by a Pharmacy Practice Assistant or Pharmacist prior to delivery. Partial tablet doses will be supplied as whole tablets in unit of use package and will be identified with a label: “NOTE: STRENGTH OF TAB/CAP DIFFERENT FROM THAT OF DOSE ORDERED. GIVE APPROPRIATE AMOUNT.” This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and should be checked against the server version prior to use.

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 Medications stocked in Pyxis MedStations that are in unit dose or unit of use packaging will not be sent in patient specific unit dose drawers. Eg. tablets/capsules. Medications stocked in Pyxis MedStation in multiuse containers may be used for initial doses and as needed doses (PRN). Subsequent scheduled doses will be prepared in unit dose packaging in pharmacy and supplied in patient specific unit dose drawers. Eg. furosemide liquid will be sent in oral syringes.  Requests for missing doses or replacement doses will be written on Dose Request Form by the nurse and scanned to pharmacy.  A daily refill list is printed in pharmacy at 1400 hours. It is used to identify the latest patient transfers to ensure that medications are sent to the correct care area for each patient. Care areas must ensure that patient specific medications including unit dose drawer, intravenous drawer, and pharmacy prepared items are sent with the patient if transferred to another care area.  All reusable medication returned to the Pharmacy Department is credited and returned to stock. Reusable medication shall contain a lot number/pharmacy control number and expiry number for tracking purposes. Fill and Exchange Procedure: 

Two (2) sets of unit dose drawers are utilized. One (1) set is stored in the medication room on the patient care area for administration to patients. The second set is stored in the Pharmacy Department. Each set contains a 24-hour supply of medication per patient. Each unit dose drawer is labelled with the patient’s name and room number and stored in a unit dose cassette labelled with the patient care area.

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Between 0800 and 1400 hours each day “cart refill lists” are generated as patient medication orders are entered into Meditech.

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Narcotics, inhalers, creams, ointments, eye/ear preparations, insulin and medications not stable at room temperature for twenty-four hours will be stored in the care area med room. They are not supplied in unit dose drawers and should not be placed in the unit dose drawers by the nurse or they will inadvertently be returned to pharmacy when the drawers are exchanged at 1500h.

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A nurse must fill out a Refill Prescription Requisition (Form 8095R) to request refills of medications such as inhalers, creams, ointments and refrigerated items that are not in supplied in the Pyxis MedStation.

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During the filling process, the quantity of drug required for scheduled medications for a 24 hour supply, is placed in the patient’s unit dose drawer.

This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and should be checked against the server version prior to use.

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Unit dose drawers are filled by a Pharmacy Practice Assistant, Pharmacy Student , Technician Student or Pharmacist.

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The contents of each patient’s unit dose drawer are checked against the “cart refill list” for: correct medication, strength, dosage form, quantity, expiry date, labelling and packaging by a Pharmacy Practice Assistant or a Pharmacist.

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Unit dose cassettes are delivered to the patient care areas daily between 1500 and 1600 hour daily and the previous 24 hour unit dose cassettes are returned to pharmacy. This includes weekends and holidays. Medications due to be administered around these exchange times should be removed from the patient’s unit dose drawer by a nurse before 1500h.

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Unit dose drawers must remain in the unit dose cassettes in the medication rooms to facilitate exchange. Failure to do so will necessitate care area staff to return the previous day’s unit dose drawer to the main pharmacy to exchange for a new unit dose drawer.

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Medication orders scanned to pharmacy after 1400 hours will be reviewed and entered into Meditech. Medication doses due before the next unit dose cassette exchange the following day at 1500 hours, will be filled and either; delivered on the next pharmacy run, picked up by care area staff or sent through the pneumatic tube system. A nurse shall put the medications in the appropriate patient specific unit dose drawer.

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Discontinued medications shall be removed from the patient’s unit dose drawer by the nurse. The discontinued medications shall be placed in the pharmacy beige bin in the care area med room.

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Prior to the next filling of the medication drawers, the Pharmacy Practice Assistant will make note of all scheduled medications remaining in unit dose drawers on a Returned Medications Log (Pharmacy Form). The Pharmacist will prioritize investigation and follow up on doses which were not administered as ordered.

REFERENCES 1. Canadian Society of Hospital Pharmacists (CSHP). Background Paper: Medication Safety and Drug Use Management Enhanced by Drug Distribution , Ottawa, Ontario, June 2008, available at http://www.cshp.ca 2. Drug Distribution: Statement on Unit-Dose & Intravenous Admixture. Ottawa, Ontario: Canadian Society of Hospital Pharmacists; 2008, available at http://www.cshp.ca This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and should be checked against the server version prior to use.

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3. MacKinnon NJ, Safe and Effective, The Eight Essential Elements of an Optimal Medication-Use System, Canadian Pharmacists Association, 2007 4. 2016-2017 Targeted Medication Safety Best Practices for Hospitals www.ismp.org 5. Murray, MD Shojania, KG Chapter 10. Unit-Dose Drug Distribution Systems http://archive.ahrq.gov/clinic/ptsafety/chap10.htm

RELATED DOCUMENTS Policies  Policy 3.12 - Medication Orders: Turnaround Times  Policy 3.02 - Standardized Pediatric Oral Doses Forms  Returned Medication Log  Drug Order clarification/Intervention Form ID IWKDROR  Dose Request Form

Appendices 

Appendix A - Definitions

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Appendix A

DEFINITIONS  Cart refill list - a Meditech generated print out of scheduled inpatient medication orders which includes the quantity required to provide a 24-hour supply of drugs that are not contained in Pyxis Medstation in a unit dose format.  Unit dose package - one that contains the particular dose of the drug ordered for the patient.  Unit of use package - one that contains the drug ordered but may not be the exact dose ordered for the patient. Eg. Full tablet in package, but patient required one-half tablet. The nurse would split and discard the remaining half tablet.  Centralized manual unit dose drug distribution - a medication delivery system, where pharmacy provides individual patient care areas with a determined quantity of single dose packaged drugs that is sufficient to meet patient requirements over a given time frame (not to exceed twenty-four hours).  Decentralized automated unit dose drug distribution (Pyxis MedStation) - a medication delivery system consisting of automated medication dispensing cabinets located in patient care areas. At the IWK, inpatient dispensing cabinets are profiled, meaning that when pharmacy is open, new or initial orders must be verified by a pharmacist for the appropriateness of the medication, dose, and frequency before the drug may be removed.

 Patient specific unit dose drawer:

 Unit dose cassette:

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Version History

Major Revisions (e.g. Standard 4 year review)

Minor Revisions (e.g. spelling correction, wording changes, etc.)

This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and should be checked against the server version prior to use.