DRUG DISTRIBUTION SYSTEM IN HOSPITAL

Drug distribution is defined as “ physical transfer of drugs from storage area in the
hospital to the patient’s bedside.”

Types of patient for drug dispensing

1) Inpatient (Admitted)

2) Outpatient (Ambulatory)
 Drug distribution system

Inpatients Outpatients

Individual patient Floor stock Combination of Unit dose dispensing

prescription filling systems individual and (automation through
floor stock system computers)

Charged floor stock drugs Charged non-floor stock drugs Non charged or free, floor stock
drugs

Labelling the floor 1. Charge plate system 1. Drug basket method

stock drugs with 2. Envelope system 2. Mobile dispensing unit
easily removable 3. Mechanical dispensing unit
labels
1) Individual prescription order system:

• It is a type of prescription system where the physician writes the prescription for individual
patient who obtains the drug prescribed from any medical or hospital dispensing by paying
own charges.

Advantages:

o Medication orders are directly received by pharmacist.

o Provides better interaction among pharmacist, doctor and patient.
o Maintenance of record is easy and paper work is minimized.

Disadvantages:

 Emergency medicines are not quickly supplied.

 Delay in receiving medicine.
 Prepackaging requires more man power.
2) Floor stock system:

i. It is the system where drugs are stored at each floor or near to the
ward at nursing station.

ii. Floor stock may include many bulk supplies of medications carried
out in hospital pharmacy.

iii. Floor stock list must be recorded and reviewed periodically to avoid
overstocking and misuse of medication.

iv. It is of two types

a) Charged floor stock system.
b) Non-charged floor stock system
a) Charged floor stock system:

Medication that are stocked on the nursing station at all the times are
charged to the patient’s account after they are administered.

Example: includes costs medicines such as pencillin, quinidine, streptomycin etc.

b) Non-charged floor stock system:

These medications are stocked on nursing stations at all times but they are
not directly charged to an account of patient.

Example: saline solutions, dextrose solutions are non-charged drugs.

It includes
i) Drug basket method:

 Nurse checks the medicine cabinet.

 The nurse fills the requisition form for the delivery of drugs at their floor stock supplies.
 When there is an empty container, nurse places it in the drug basket, then it is sent to the
pharmacy.
 Pharmacy staff fills each container and dispensed requested required ampoules and vials.
 Once the basket is completed, it is delivered to the floor via messanger service.

ii) Mobile dispensary unit:

 Utilizes a specially constructed stainless steel trucks with appropriate dimension to hold
all sort of drugs and is equipped swivel wheels.
 The interior of the unit consists of shelves which allow for the transport of container of
all sizes.
Advantages of floor stock system:
1. Waiting period is less. Medicine can be received immediately.
2. It avoids exercise of patient’s relative to bring the medications.
3. Emergency medicines are easily available for quick distribution.

Disadvantages of floor stock system:

1) It increases work load to nurses.
2) Maintenance cost and wastage of medicines is increased.
3) More space is required at nursing station for stocking of medicines.
4) Counselling of patients by pharmacist is not possible.

Application:
i. Useful in large hospitals.
ii. Helps to check the efficacy of nursing unit.
iii. It provides emergency supply of medicines to patients.
3) Combined individual drug order and floor stock system:

 This system utilizes simultaneously on individual drug order system as the primary
means of dispensing along with a limited floor stock system.
 This system of drug dispensing is probably the most commonly used in hospitals today.

Advantages:

 Better financial control.

 Reduced chances of medication errors.
 Improved overall drug control and drug monitoring.
4) Unit dose dispensing system:

a) It is the system which of dispensing unit doses to the patients containing a

predetermined amount of drugs.
b) Unit doses are prepared as per the requirement.
c) It is useful to inpatients and also outpatients.
d) Two methods of dispensing unit doses are

i. Centralized unit-dose drug dispensing system.

ii. Decentralized unit-dose drug dispensing system.
a) Centralized unit-dose drug dispensing system:

All inpatient drugs are dispensed in unit doses and all the drugs are stored in the
central area of the pharmacy and dispensed at the time dose is to be given to the patient.
Drugs retransferred from the pharmacy to the indoor patient by medication cards.

b) Decentralized unit-dose drug dispensing system:

The operator through small satellite pharmacies located on each floor of hospital

i. Patient profile card containing full date, disease and diagnosis is prepared.
ii. Prescriptions are sent directly to the pharmacist which are then entered in the patient
profile card.
iii. Pharmacist checks medication orders.
iv. Patient profile card and prescription order is filled by pharmacy technicians.
v. The nurses administer the drugs and make the entry in their records.
Advantages:

1. Easy for administration staff.

2. Accounting became easier in certain cases.
3. Better stability of the products.

Disadvantages:

1) High cost.
2) Consumes more time and doubtful.
3) Will occupy more space for storing.
Suggested method of distribution of drugs in general hospital

For inpatients Physician examines For outpatients

diagnosis

Writes on the case sheet Writes on the outpatient card

Separate prescription is written
Separate prescription is written
Nurse collectively sends prescription to pharmacy Patient comes to the pharmacy with the prescription

Pharmacist a) Pharmacist processes drug

a) Procures drugs Issued on prescription
b) Dispenses with directions
b) Checks and fills prescription
Pharmacist is incharge of the
c) Outpatient takes away the drug
drugs received from the drug store
c) Transfers the filled prescription to the
nursing station
Nurse sorts out into patient boxes Central store pharmacist incharge. Drugs
issued are stocked at the sub-store
Administered or ordered
Inpatient Central pharmacy
DISPENSING OF DRUG TO OUTPATIENT/AMBULATORY PATIENT

It is also called ambulatory services or refers to those patients who are not
occupying beds in hospitals or in clinics, health centers and other places when they came
for consultation and diagnosis, treatment.

Categories of ambulatory services:

1) Emergency outpatients.
2) Referred outpatients.
3) Special outpatients.
4) General outpatients.
1. Emergency outpatients: The outpatients if receiving emergency treatment or an
accident case are called emergency outpatients.

2. Referred outpatients: If outpatients are referred for receiving specific treatment then
those are called referred outpatients.

3. Special outpatients: If outpatients are referred for accurate diagnosis by clinical,

pathological or radiological examination then those are called special outpatients.

4. General outpatients: These patients come for general checkup and medicines as
prescribed to him. They may either undertake minor surgery, superficial surgery or
dressing at hospital.
Location of outpatient pharmacy:

1) It should be located at the ground floor of the building.

2) There should be separate independent outpatient pharmacy.

3) There should be two prescription windows, one for men and other for women.

4) Waiting area should be provided for outpatient to wait for their turn.

5) The outpatient department should be located in such a way that, it should not cause
disturbance to the inpatients.
Layout of outpatient pharmacy:
1. Layout of OPD creates an image of the hospital.
2. In the layout there should be adequate number of windows for receiving and filling up
prescription.
3. Waiting room should be pleasantly furnished with sufficient educative posters hanged on the
walls.
4. To avoid over crowding, more windows and manpower should be provided.
Classification of case in outpatient department:

1. Emergency care
2. Referral or tertiary care
3. Primary care

Provision of pharmaceutical services in outpatient care:

1) Patient medication histories.

2) Safety and efficacy of drug therapy.
3) Providing drug information.
4) Educating and counselling patients
i. Detecting and reporting adverse drug reaction.
ii. Education of health care provider.
iii. Assisting prescriber.
iv. Supervising the storage, preparing, dispensing of medicine.
Minimum standard for outpatient care:

1. Be a qualified pharmacist.
2. Maintenance of medication profiles for patients.
3. All medications dispensed to the patients completely and correctly labelled and
packaged.
4. Drug and its dosage, route of administration and amount must be verified by the
pharmacist.

Drug distribution to outpatient:

1) No medicament should be issued without the prescription.

2) After the issue quantities supplied must be recorded.
3) Medicines are given to the outpatient block.
 Charging policy

Charging of pharmaceutical services includes the cost of drug products, dispensing

fees for intravenous drug admixtures, per day fees for basic dispensing and clinical services,
and fees for basic dispensing and clinical services, and fees for special clinical services.

The basic per day charge covers:

1. Drug purchasing and inventory control

2. Department management
3. Drug information services
4. Dose preparation
5. Drug order interpretation
6. Drug therapy monitoring
7. Pharmacists require to answer the query of physician and nurses
Clinical services for which special fees are charged:
Example: haemogram drug report, drug liver function report, heparin i.v infusion,
pharmacokinetic drug level interpretations and consultations etc.

Implementation of the system varies in relation to:

Calculation of fees, comparison with alternate charging methods, approval of special
clinical service charges, computer billing, information about pharmacy charges for patients
and third party payers.

These policies can be categorized under several systems like:

i. Drug charge or all inclusive or no special rates
ii. A part-inclusive rate
iii. The professional fee concept
iv. Break – Even point pricing
v. A cost-plus rate system
vi. The profit aspect
vii. Computerized pricing
 Labeling

1) A drug label refers to all the printed information included with any dietary supplement,
over-the-counter medicine, or prescription drug.

2) According to the FDA, all drug labels should remain in place and be read in different
environments through distribution, storage, and use.
Each label on outer cartons provide further details if desired by the manufacturer. The pattern
of label is as under

• Name (proprietary Name, Approved Name, etc.): The name of the drug should be typed/
written in such a manner that it should be legible or prominent.
• Dosage form: for products other than oral use, type of dosage form and route of
administration should appear on label like (Injection – Intramascular route)
• Strength: strength of a drug should be given in metric system and whole number
• Batch Number: batch number is an important parameter, which should be written along
with manufacturers name and address.
• Expiry date: expiry date of a drug with limited shelf life should always be mentioned on
the label.
• Special direction: special directions like, “ shake the bottle well before use”, “ for external
use only”, “ Not to be chewed”, etc should be written as special notes on the label.
 Dispensing of controlled drugs

o Controlled drugs are substances are drugs that have some potential for abuse or
dependence.
o To exercise control on the use of these drugs, Narcotics and psychotropic substances Act,
1985 was passed and such substance are entered in schedule “X” of drug and cosmetic
Act,1940.

Schedules
Schedule 1: the drug under this schedule have high potential for abuse and have not
accepted medical use in treatment (eg. Marijuang raw opium)
Schedule 2: the drugs under this schedule have potentials for abuse but accepted for
medicinal use (eg. Cocaine, morphine)
Schedule 3 – 5: the drugs under these schedules have less as compared to above potentials
for abuse, accepted for medical treatment and have low physical dependence and
psychological dependence (eg. Benzodiazepine, phenobarbitone, low strength codeine,
steroids, etc)
 While maintaining stock of these drugs they should be kept under lock and key and
must be accurately received and issued.
A separate register should be maintained to record them and a controlled procedure
is used to issue or receive these drugs. The various steps are:
1. Medical superintendent is overall responsible for handling of controlled drugs.
2. Chief pharmacist procures and he is responsible for proper dispensing of drugs within
the hospital.
3. Prescription for Narcotic drugs under “Narcotics and psychotropic substances Act”,
1985 must include the following information
i. Patient’s full name
ii. Address
iii. Date
iv. Name and strength of the drug
v. Quantity of drug
vi. Signature of prescriber
vii. Dose and route of administration
4) If the required drug is not in stock in the ward, the complete controlled drug prescription
must be written on a hospital prescription blank form by registered medical practitioner and
then it is signed and send to pharmacy.
5) The prescription signed by RMP will also permit the patient to purchase drug from
outside pharmacy.
6) The delivery of narcotic drugs from the pharmacy to the wards and nursing stations must
be carried out through some reliable persons.
7) Charges for Narcotics and psycotrophic substances depends upon the policy of hospitals.
8) After the dispensing of narcotics by the pharmacy, nurses resume the responsibility for
administration, control and auditing of the inventory.
9) While administering a dose, if patient refuses or doctor cancels any dose it is the duty of
the nurse to destroy the drug into sink and record “ Refused by patient” or “ order cancelled
by doctor”
10) Nurses should always maintain a proper record in care of
wastage/destruction/contamination.