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43
Chapter
Drug Distribution
System in Hospitals
Drug distribution process can be explicated as “delivery of drugs from storage area to
the patient’s bedside in a hospital”. Usually, two types of drug distribution process as
illustrated here, are followed in a hospital.
I.DistributionininpatientdepartmentandII.Distributioninoutpatientdepartment
I.Distribution in inpatient department: Theinpatientsarethose,whoareadmitted
inhospitalforgeneralorspecifictreatment.
Forexample, patients in wards, operation theatres, X-ray,and other specific
departments.Requireddrugsupplymaybedoneintheinpatientdepartmentby
theoutpatientdispensingdepartmentorthepharmacistsassociatedindispensing
thedrugs for outpatient can also dispense drugsfor inpatients. Under each
circumstance,drugdistributionorsupplyofdrugstotheinpatientiscarriedout
underthesupervisionofwellskilledandqualifiedstaff.
II.Distribution in outpatient department: Outpatientdepartmentisabbreviatedas
OPD,whichisinitialintermediatorybetweenpatientandhealthcareprofessionalin
ahospital.Onvisittohospital,patientgetthetreatmentbutarenotallottedbedsin
hospitalorinclinics,healthcentresandotherplacesovernightstay.Thesetypesof
patientsgetthemedicinesfromthedesignatedcounteronshowingtheprescription.
Nameofpatientalongwithtypeandquantitiesofmedicinesgivenarerecordedin
theregister.
An outpatient department (OPD) is the part of a hospital, structured for the treatment
of outpatients, who come to the hospital for diagnosis or treatment.
There are three types of outpatients in a hospital:
a. General outpatient:Such types ofpatients aregiventreatmentfor a general
conditionoremergencyconditionbutnotreferredcase.Forexample,diarrhoea,
hypertension,diabetes,fever,etc.
b.Referred outpatient: Thesearereferredpatients,meansreferredtoOPDbythe
attendingmedicalpractitioner orprimaryhealthcentreforspecifictreatment
orexpertise.Patientsafterspecifictreatmentmayreturntothepractitionerto
continuethetreatment.
c. Emergency outpatient: These typesofpatients need immediateattentionfor
medicalorsurgicaltreatment.Emergencyoutpatientisthendischargedafter
emergencytreatmentormaybeadmittedifconditionisnotfavourable.
5
44
Textbook of Pharmacy Practice
CLASSIFICATION OF VARIOUS DRUG DISTRIBUTION SYSTEMS
Generally, there are four kinds of drug distribution methods in inpatient department.
These are as follows:
• Individualprescriptionordermethod
• Floorstockmethod
• Combinationofindividualprescriptionandfloorstockmethod
• Unitdosemethod
INDIVIDUAL PRESCRIPTION ORDER METHOD
Individual patient procures the medicines on showing the prescription, issued by
physician either from retail drugstore or hospital on payment basis in this method.
In government hospital, medicines may be free of cost.
This method is usually followed by the small and/or private hospitals due to lack
of manpower and advisability for individualised service. This method is considered
economical for hospital.
Advantages
• As prescriptionsare directlyreviewed by pharmacist, hence,chances of adverse
drugreactionsordruginteractionsareminimisedorprevented,ifany,duetoerrors.
• Professionalcollaboration is promoted for better healthcare due to interactionof
pharmacist,prescriber,nursingstaffandthepatientinthismethodofdrugdistribution.
• Managementofpharmaceuticalinventoryinthedispensingdepartmentbecomes
simplified,andefficient.
Disadvantages
• Illegiblehandwritingofphysicianmaymisleadthepharmacisttodelivertheright
medicines.Thus,objectiveofbetterpatienthealthcareishamperedduetoincreased
chancesoferrors.
• Physicianmayprescribethecostlydrugstoobligethemedicalrepresentativesor
pharmacompanies.
FLOOR STOCK METHOD
In this method, drugs are stocked at the floor or pharmacy store, from where supply
is done via nursing station.
The floor stock distribution method again subdivided into 2 types of methods.
These are:
i. Charged Floor Stock Method
Envelop method: In this method, pharmacist delivers the medicines prescribed by
physician in envelopes or pouches labelled with patient name or bed number to the
nursing ward. The nurse after getting the envelop, confirm the name and room or bed
number of patients administer the medicines to patient. At the same time, nursing
station send the list of medicines administered to patient along with their quantities to
pharmacy department for costing. Pharmacy department then forward the complete
information to billing section of accounts department.
45
Drug Distribution System in Hospitals
Advantages
• Requiredmedicinesarestockedatthenursingstationsandchargedtothepatients
accountafteradministeringtothem.
• Patientischargedonlyforthedose,administeredtothepatient.
• Oncethefloorstocklistofdrugsisprepared,itisthedutyofthehospitalpharmacist
toensuretheavailabilityofcompletedrugs.
ii. Noncharged Floor Stock Method
a.Drugbasketmethod
b.Mobiledispensingunit
This method comprised of the list of general medicaments placed at the nursing
station, which can be used by any admitted patients on the floor. Cost of these medicines
is not directly charged from the individual patient.
Drug Basket Methods
In a routine method, night nurse inspect the drug stock supplied by pharmacy
department in this method. In case of shortage or require any drug, nurse fill the
requisition form for supply of medicines at their floor. Nurse keeps this requisition form
in drug basket and send to pharmacy floor for filling/dispensing the basket. Finally,
basket with requested medicines is delivered at the concerned floor by the pharmacy
department.
Mobile Dispensing Unit
Itisstainlesssteeldesignedcupboardortrolleywithfacilitytocarrythedifferentsize
ofcontainer.Inthismethod,nightnursedoesnotcheckthedrugstockbutpharmacy
staffcheck the drug cabinet and refillthe empty container.Thecopy ofrequisition
formforfloorstocksuppliesiskeptatthenursingstationforrecord.Inthismethod,
pharmacistismadeavailableatnursingwardswhichincreasetheinteractionofnursing
andpharmacystaff.
Advantages
• Waitingperiodisless.
• Medicationcanbereceivedimmediately.
• Emergencymedicationsareeasilyavailable.
Disadvantages
• Medicationerrorsarenotminimised.
• Itincreasestheworkloadofnursing.
• Reviewofpreparationbypharmacistisnotpossible.
COMBINATION OF INDIVIDUAL PRESCRIPTION AND FLOOR STOCK METHOD
Government hospitals follow this combined method, which is also followed in private
hospitals, who run on the basis of no profit and no loss.
Patients generally purchase surgical items from the stores and deliver these items to
concern medical staff member in a hospital ward room. At the same time, patient uses
several drugs in the floor stock.
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Textbook of Pharmacy Practice
UNIT DOSE METHODS
Unit dose dispensing method supply the medication in single dose packages. This
method is followed generally in a well-organised hospital. Single dose packing is
prepared by pharmacist, who dispensed them in ready to administer form and in
quantity, not more than 24 hours supply. Dispensing is done on the prescription of the
physicians in a hospital.
The single unit package of medicines contains one complete pharmaceutical dosage
form. For example, 1 oral tablet or 1 capsule.
Thesearemainlytwotypes.
1. Centralized Unit Dose Dispensing Method
• The central supply department (CSD) in a hospitalprovides theessential
professionalsuppliesandequipment(drapes,syringes,tubing,intravenous,etc.).
• The central supplydepartment and procurement, storage, distribution and
manufacturingofvarioussterilesolutionswithinhospitalaremanagedbythe
pharmacist.
• Theunitdoseisdispensedfrompharmacydepartment.
2. Decentralized Unit Dose Dispensing Method
• Thisismanagedthroughnursingstation/smallsatellitepharmacieslocatedat
eachfloorofthehospital.
• The main pharmacy drugstoreis responsiblefor procurement,storage,
manufacturingandpackingofdrugs.
Advantages of Unit Dose Methods
• Thereisbetterfinancialcontrolinthismethod.Thereisanaccuratepatientbilling
fordrugs.Patientonlypaythecostofmedicine,whichisusedbyhim.
• Itchecksandstopsthelossofpartiallyusedmedications.
• Thereisnoneedforessentialstoragefacilitiesatnursingstations.
• Chancesofmedicationerrorsareminimised.
Disadvantages of Unit Dose Methods
• Manpowerisrequiredforpre-packagingofunitdosageform.
• Separatecontainermachineryandalsospaceisrequired.
• Properattentionofphysicianisrequiredforadministrationofdrug.
• Regularmonitoringofunitdosemethodisrequired.
NATIONAL POLICY FOR DISTRIBUTION OF NARCOTIC AND PSYCHOTROPIC SUBSTANCES
INCLUDING STORAGE CONDITION
Psychotropic agents have the ability to alter an individual’s consciousness, while narcotic
drugs relieve anxiety.
Characteristic Features
• TheNarcoticDrugsandPsychotropicSubstances(NDPS)Act,wasimplementedto
controladdictive drugsandillegalpossession,dispersion,sale,import,andtrade
inIndia.
• StorageofnarcoticdrugsandpsychotropicsubstancesisdoneasperthisAct.
47
Drug Distribution System in Hospitals
• NarcoticdrugsandpsychotropicsubstancesareprescribedorutilizedasperNarcotic
DrugsandPsychotropicSubstancesAct.
• Undermentionedinformationontheprescriptioncontainingnarcoticdrugsunder
NarcoticDrugsandPsychotropicSubstancesAct,1985mustberecorded:
a. Nameofpatientalongwithaddress
b.Dateofprescription
c. Nameandstrengthofprescribeddrug
d. Quantityofeachprescribeddrug
e. Batchnumber
f. Doseofprescribeddrugalongwithitsrouteofadministration
g. Specialdirection,ifneeded.
h. Signatureofprescriber
• Thecompleterecordofitsuses,administrationanddisposalregardingnarcoticand
psychotropicshouldbemaintainedasindicatedintheRules,foraperiodoftwoyears
fromthelastentry.TheyshouldbemadeavailableforinspectionfortheGovernment
officerauthorizedinthisregard
• Asperpolicymatter,onlyappropriatepersonnelshouldbeallowedtoenterinthe
roomwherethesedrugsstored.
• Fordispensingofnarcoticandpsychotropicmedicines,prescriptiondulysignedby
registeredmedicalpractitionerismandatory.
• Lockandkeyfacilityarerequiredtostorenarcoticsandpsychotropicinthehospital.
• Propersecurityalarmsystemshouldbeinstalledintheroomwherenarcoticdrugs
orpsychotropicsubstancesarestored.However,thisprovisionisnotapplicablein
shipsandaircraft.
• Nootheritemsshouldbestoredwithnarcoticandpsychotropicdrugsinthesame
cupboardincludingmoneyorothervaluableitem.
• Declininginventorysystemshouldbefollowedinissuesofnarcoticandpsychotropic,
whichshouldbedonestrictlyonprescriptionissuedbythemedicalpractitioner.The
prescribingpractitionerwillberesponsibleincasetheprescriptiondoesnotconform
tostatutoryregulationsasimplemented.Nursingstaffmembersareresponsiblefor
entryofdrugalongwithbatchnumberintheprescribedformwhileadministering
thenarcotic/psychotropicdrug.
• Security clause forstorage: Strict compliance of statutory requirements must be
followedaspertheNarcoticDrugsRules,1985,andDrugs&CosmeticsAct,1940,
Drugs& Cosmetics Rules, 1945. Narcoticand psychotropicdrugs are storedin
properlylabelledcontaineralongwithnecessaryinformation.Registersfornarcotic
drugsshouldbeproperlyindexedandmaintainedtohaverequiredinformationon
itsusage.
• Pharmacistshouldbeintimatedaboutlossormissingofnarcotic/psychotropicdrug
immediately.
• Recordofallreceivedandissuednarcotic/psychotropicdrugsmustbemaintained
inaregister.
• Narcoticdrugsregistermustbeahardboundedbookwithcontinuousnumbered
pages.
• Eachnarcoticdrugshouldberecordedonseparatepage.
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Textbook of Pharmacy Practice
• Properrecordofeachnarcoticrelevanttoitsuses,administrationanddisposalshould
bemaintainedatalltheplaceswherevernarcoticdrugsarestored.
• Weeklyauditsshouldbedonebymedicalsuperintendentandchiefpharmacist.
DRUGS SUPPLY IN EMERGENCY WARD
An emergency department or ward is a specialized area in a hospital, meant for giving
immediate attention to the patient requiring urgent treatment. The patients come to
this department in emergency without prior appointment, either by their own means
or brought in hospital in an ambulance. The emergency department in the hospitals
remain in providing the services round the clock, means 24 hours in a day.
Atropine, adrenaline, dexamethasone, naloxone, etc. are common examples of
emergency drugs likely to be available in hospital.
The hospital system generally uses a special cabinet/box, which is referred to as
emergency box. The emergency contains selected and limited quantities of emergency
medications packaged in single-unit containers.
The pharmacy personnel check the emergency drug supplies on a routine basis to
ensure the presence of adequate number of emergency medicines. Emergency kits should
have a seal, which visually indicates when they have been filled. The expiry date of the
kit medicines should be clearly indicated on the box.
The appropriate policy is implemented to supply emergency drugs, when the
pharmacist is off the premises or when there is insufficient time to get them from the
pharmacy department. Emergency drugs should be limited in number. These should
include only those, whose prompt use and immediate availability are generally
considered essential by physicians in the proper treatment of sudden and unforeseen
patient emergencies. The medications included should be primarily for the treatment of
cardiac arrest, circulatory collapse, allergic reactions, convulsions, and bronchospasm.
The P&T Committee should recommend the list of drugs and supplies to be included
in emergency box.
AUTOMATED MEDICATION DISPENSING METHOD
Large-sized hospital involves the dispensing of vast numbers of medications in a regular
manner. Medication errors, even at low rates, can have serious consequences in terms
of adverse drug reactions (ADRs). These ADRs may cause potential impacts on patient
morbidity and mortality. To prevent these errors, use of automated dispensing units
is recommended.
Automated Dispensing Cabinet
Automated dispensing cabinet (ADC) is a computerized medicine cabinet in a hospital
setting. ADCs store and carry out the dispensing of drugs at the point of care. Drug
supply of medicines can also be tracked. They are also referred to as unit-based cabinets
(UBCs), automated dispensing devices (ADDs), automated distribution cabinets or
automated dispensing machines.
Special Features of ADCs
• Facilitatestheproperstorage,inventorycontrolandsecurityforpharmaceuticalsat
thepoint-of-healthcare.
49
Drug Distribution System in Hospitals
• Authenticatedbypassword,whichonlyallowsthecompetentpersontousethem.
• Canbeusedinwards,ICUs,etc.
Advantages
• Commonlyrequiredpharmaceuticalsaredeliveredatthepoint-of-care
• Workloadofnursesisminimised
• ControlledsubstancesremaininADCsunderlockandkeyconditionuntilneeded,
whenthesearedispensedwithpasswordauthentication.
• ADCcangiveallergyalerts,andalsoguideforhigh-riskmedication,thusprovision
forpatientsafetyisenhanced.
• Withthehelpofbarcode,medicinesareidentified,whichdecreasetheerrorsinthe
drugdistributionsystem.
EXERCISE
Multiple ChoiCe Questions
Tick mark the appropriate choice
1. What is the advantage of unit dose drug distribution system?
(a) Simplified financial control system
(b) Economical
(c) Minimised storage facility at nursing station
(d) All of the above
2. Which system allows the medications to be stored and dispensed near the patient bed side in
hospital?
(a) ADCs (c) Computerized order system
(b) Unit dose drug method (d) Floor stock system
short Questions
3. What is National Policy for distribution of narcotic and psychotropic substances and their storage.
4. Write a note on drug supply in emergency ward.
long Questions
5. Classify and explain the different systems of drug distribution in hospital.
6. Explain various drug distribution methods inpatient department in hospital.
7. What is drug basket and mobile drug dispensing unit? Give the advantages of these methods.
Answer to MCQs
1. (d) 2. (a)
50
Chapter
Hospital Formulary System
Most of the pharmaceuticals although have the same active ingredient but marketed by
different names in the current scenario. Some are imitated or non-essential products.
Many drugs are marketed by bringing out minor variation in an original drug, which
are not even better than already existing prototype drug. Some drugs are therapeutically
effective but not safe in comparison to the existing drugs. In some cases, drugs appear
in the market with insufficient information on efficacy or toxicological data. Finally,
many new products are not promoted for particular therapeutic indication but these
do not meet to basic need of the community. Cost is generally high in comparison to
already existing drug, when new drug enters in market.
Under the above circumstances, it is very difficult to select the suitable drug. Hospital
formulary system is a mechanism to solve these problem and number of other problems,
which exist in most of the hospital systems. These problems are:
• Limitedfundsavailabilityinhospitals.
• Availabilityofmorenumbersoftherapeuticalternatives.
• Inappropriateprescribing.
• Non-rationaluseofmedications.
• Non-availabilityofsafeandeffectivedrugs.
• Absenceofunbiaseddruginformation.
• Handlingofmorenumbersofdrugsisnoteasyandeconomical.
• Availabilityofdoubtfulqualitydrugsinthemarket
On appropriate implementation of formulary system, positive results are expected
which are:
• Decreasedmorbidityandmortalityduetoexclusionofunsafeandineffectivedrugs.
• Procurementoflessernumberofdrugsresultsindecreasedexpenditures,thusmore
quantitiesofsafeandeffectivedrugscanbeprocuredfromlimitedfunds.
• Decreased periodof hospital staysof patient through elimination of unsafe and
ineffectivedrugsresultsinlowercostoftherapy.
• Havingamorenumberofdrugsinthelistofhospital,requireaneedforthedrug
informationcentreandcontinuingeducationprogramsforguidance.
DEFINITION
“The hospital formulary is a continually revised compilation of pharmaceuticals,
reflecting the current views of the medical staffs”. These pharmaceuticals are
6
51
Hospital Formulary System
considered most useful in the diagnosis, prophylaxis, or treatment of disease in
patient care.
ADVANTAGES AND DISADVANTAGES OF THE HOSPITAL FORMULARY SYSTEM
On selection of fewer safe and efficacious drugs, drug management process, including
procurement, storage, distribution and use becomes easier. The selection of fewer drugs
can bring out the following results:
1. Lower cost and enhanced provision for buying essential medicines: Purchasing
fewernumbersofmoreeffectiveandsafedrugsresultinlowercost,whichmay
give the chance toprocure more quantities. Thus, there will be improveddrug
availabilityforneedypersonsatlowercosts.
2. Better quality of patient care: Patientsiftreatedwithfewerbutmorecost-effective
safemedicines,willleadtobetterqualityofpatientcare.Informationcanbeprovided
inabetterwaytotheprescribersregardingthesafetyprofile,ADRs,interaction,
contraindicationsifsystemdealtwithfewerdrugs.
The formulary system only encourages the use of drugs, listed in formulary. Major
disadvantage of formulary system is its restriction on the use of drugs, especially
recently developed clinically indicated drugs. This restriction may potentially reduce the
quality of care. The hospital formulary system also put a restriction on the practitioner
to prescribe the brand of his choice.
TYPES OF HOSPITAL FORMULARIES
Open formulary encourages the physician to prescribe the drug listed in the formulary,
although he may prescribe any drug.
Closed formulary incontrastmayprovidelimiteddrugstospecialist,dependingonareas
ofexpertise(e.g.cardiology),patientcareareas(e.g.operatingroom),ordiseasestates
(e.g.acuterespiratoryinfection)viaformularyrestrictions.Hence,itisalsoreferredtoas
restrictedformulary.Thedrugslistedintherestrictedformularyarereimbursedbythe
healthcareprovider.Non-formularydrugsarereimbursedonlyincaseofpriorpermission.
Incentive-based formulary representsan amalgamationof the open and closed
formularies.Closedformularyincludesalimitednumberofdrugs,availableforcoverage
byhealthcareproviderineachclass.Incentive-basedformularygivesconsiderationto
selectionofpatientsaswellasphysiciansbyprovidingsomelevelofcoverageformost
ofdrugs.Atthesametime,patientsandtheirphysiciansareencouragedtoselectthe
cost-effectivedrugsforthetherapy.Inthiscase,patientmaypayahigherpricefora
drugnotlistedintheformulary.
Examples of formulary: WHOFormulary,BritishNationalFormulary,IndianNational
Formularyaresomeexamplesoftheformularies.Theseareusedasstandardreferences
inmostofthehospitals.SomehospitalsinIndialikeKasturbaHospitalatManipal,
ChristianMedicalCollegeandHospitalatVellore,KLEHospitalatBelgaum,etc.have
theirownformularies.
SALIENT FEATURES OF HOSPITAL FORMULARY
The hospital formulary system is usually managed by hospital administration through
P&T Committee or other equivalent body of the hospital. Hospital formulary consists
of the following features:
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Textbook of Pharmacy Practice
1.Formulary enlistedthedrugs,indicating their dosageforms,package sizes, and
drugstrengthsstockedinthehospitalpharmacystoretoprovidetheinformation
tophysicianandnursingstaffs.
The contents of formulary consist of four general sections: The introduction,
therapeutic index, the drug monographs, and general reference section. Drugs are
listed alphabetically by generic name as per their pharmacological or therapeutic
action in the therapeutic index section. It is most informative when drug is available
in more than one dosage forms. From this section, the physician can determine the
availability of the stock of the desired drug in any form.
After getting the information for its availability, physician proceed to the drug
monographs section for getting complete information.
In the drug monographs section, there is an alphabetical listing of drugs both
by trade names and generic names. The trade name is also cross referenced to the
generic name. Under generic name, the complete information regarding drug is
available. Each monograph has the:
a. Official, non-proprietary, or generic name.
b.Trade name: Listingofatradenamedoesnotnecessarilymeanthatitisstocked
assuchinthepharmacy.
c. Category: Itisrelatedtotherapeuticsection,whereinformationisprovided.
d. Dosage form: Allthedosageformsofparticulardrug,stockedinpharmacyarelisted.
Note: Specific information regardingparticular drug if any is indicated here.
However,the absence of a cautionary note here does not necessarily be understood
that a particular drug may be used without taking precaution.
General reference section is useful for patient care for getting the meaningful
information like conversion tables for weight, formula for calculating dose,
hospital approved abbreviations, as well as directions for use of certain drugs as
recommended by the Pharmacy and Therapeutics Committee.
2. Formularyconsistsofdrugitems,listedbygenericnames.Hence,requestorder
sentbyphysiciansfordrugsisinterpretedandfilledbyusinggenericnames.
Pharmacy and therapeutic (P&T) committee: It, established by the hospital
medical board, is the heart of the formulary system. List of members includes
representatives of the professional departments/services, house staff, nursing,
pharmacy, administration. The committee is generally responsible for framing of all
drug utilization policies and practices within the hospital in order to assure optimum
clinical outcomes. Committee shall also help in making professional strategies
regarding the evaluation, appraisal, selection, procurement, storage, distribution,
use, safety procedures and all other matters relating to drugs in the hospital.
Some specific functions as mentioned here is also performed by P&T committee:
i. Advicethehospitalmedicalstaffmembersonmatterspertainingtotheavailable
formularydrugs.
ii. Makesuggestionsregardingthedrugstobestockedatthenursingstationinthe
ward.
iii. Developandreviewthedrugs,listedinhospitalformularyforusage.
iv. Prevent unnecessary duplication in the stock havingthe similar therapeutic
ingredientsinthesamestrength.
v. Developandreviewprocedurestocontrolthenarcoticandpsychotropicdrugs.