Improving Patient Safety with Unit Dosing
The role of the hospital pharmacy in inpatient care is broader in scope and more complex than that of the average neighborhood pharmacy. Inpatients are generally sicker and frequently require more serious kinds of medications to treat their illnesses. Diagnosis and intervention strategies must sometimes be modified rapidly to accommodate the diverse and emergent needs of unstable patients whose diagnostic changes necessitate treatment protocols that require a different medication.
According to studies done by the American Psychological Association, deaths due to medication mismanagement have historically been viewed as unfortunate instances of collateral damage in the hospital inpatient setting. Within the last few years, however, a much greater emphasis has been placed on monitoring of hospital pharmacy unit dosing to produce improved outcomes. Quality assurance measures in the pharmacy setting have become the focus of raising the standards of inpatient care. With the help of agencies like The Institute for Safe Medication Practices, in cooperation with the FDA, practitioners are learning how to improve pharmaceutical protocols and safety measures with respect to the packaging, labeling, and administering of bedside medications.
In 1999 the Institute of Medicine released findings that suggested that errors in medication management could be responsible for as many as 7,000 deaths per year in the hospital setting.  Studies like these have highlighted the need for raising the standard of medication management of inpatient care. According to the Food and Drug Administration, the use of bar-codes on unit dose medication has decreased pharmaceutically-related hospital errors by as much as 85% in some cases. In light of growing trends toward improving procedures to greatly reduce medication errors, pharmacy unit dosing is emerging as a leading technological advance in preventing unnecessary accidents and deaths related to lax pharmaceutical practices in the healthcare setting. Manufacturers of healthcare technology like Cerner, McKesson and Omnicell offer fully automated systems that provide the means to inventory, store, barcode, and deliver secure point- of-care patient medication services.
Pharmacy unit dosing provides a system of checks and balances for tracking prescription medications from the time of documentation in a patient’s chart until the moment they are administered. Standardized protocols for labeling and bar-coding help to ensure that proper dosing occurs in a timely manner for every patient. When medications arrive at the bedside they are carefully checked against patient wristbands to confirm that the dispensed drug is given to the correct patient. This is accomplished by checking the full name and birth date on the wrist band against the patient’s medical record.
A single dose of medication in pill or capsule form is usually dispensed in a bubble or blister pack. Liquid medication is prepackaged according to a specified volume for each dosing unit. The Federal Food and Drug Administration mandates that certain information must be clearly labeled including the patient’s name, the name and dosing amount of each medication, the expiration date, its lot or control number, and any specific instructions needed to assure that the medication remains stable and does not lose its efficacy prior to being administered.
The FDA also requires that all manufacturers provide bar-coding on unit dosing medications. This means that before a medication is administered at the bedside, its packaging is equipped with a computer readable strip that is scanned to verify the patient’s identity and to ensure that the unit dose matches prescribed orders contained in his medical record.
In the hospital setting, some pharmacies repackage and label their own unit doses from medications that been shipped in bulk from manufacturers. To do this, they must have computerized equipment that is capable of packaging and applying scannable labels. Smaller pharmacies often outsource production of bar-code labels that meet FDA standards. Hospitals that do not currently have in-house bar-code label printers can opt for new technology such as the thermal printer that interfaces with already existing pieces of equipment to produce bar-coded labels.
When a patient enters the hospital he is given a scannable identification wristband that connects him to his medical record. When a physician writes a drug prescription, a national drug code assigned to that specific medication is scanned onto the unit dose through the use of bar-coding. Prior to bedside administration, the label on the medication is also scanned and compared to the patient’s identification wristband to confirm proper patient and dosage. The medication label is then cross-checked to be certain that the dosing unit is identical to the written prescription. Any inconsistency must be identified and resolved before the medication can be administered.
In more progressive hospital facilities, the latest technology is being used to ensure that medication errors are reduced and patient care delivered in keeping with the “Five Rights Check.” Before administering a medication to a patient, his wristband is checked to make certain that it is the right medication, right dosage, right patient, right method of dispensing, and right time. This is possible because of the use of bar-coding that allows for all necessary documentation to be scanned, connecting patient to patient record.
The use of bar-codes and labels in the hospital pharmacy is not restricted to processes related directly to patient care. Pharmacy technicians use scanner technology to track the inventory of all medications that have either been prepackaged by the manufacturer or repackaged in the pharmacy to meet unit dosing requirements. While some smaller pharmacies may prefer to outsource production of bar-codes and labels, many inpatient pharmacies are moving toward the use of automated systems that will perform cart fills, first doses, and bar-code scanning with only minimal technician and/or hands-on involvement.
Whether outsourced or produced inside the hospital pharmacy, preparation, labeling, and bar- coding of unit doses is the emerging standard of care necessary to meet FDA guidelines and to substantially decrease medication error. In the future, this method should standardize and vastly improve reporting data used to measure quality assurance in the hospital setting as well as reduce the need for ancillary reporting of medication error by hospital administrations.
- Cohen, Michael Richard, medication Errors, APA, 2006
- http//www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/2004/ucm108250.htm 4. FDA (CPG Section 430.100 Unit Dose labeling for Solid and Liquid Oral Dose Forms).
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