The patient prescription system and unit dose system

Let’s move to another distribution system. Patient Prescription System started before 1960. It is different from Floor Stock System. In Patient Prescription System, pharmacists play more roles in reviewing the patient order. In addition, unlike the Floor Stock System, in Patient Prescription System, most medications are stored in pharmacies rather than at the nursing unit. In the past, if hospitals applied Patient Prescription System, the nurse would transcribe the medication order after physicians prescribed the order, and send it to pharmacy for preparation. Nowadays, in hospitals which apply computerized order entry system, as known as CPOE system, the computer would send the prescription to the pharmacy without transcription via nurses.

Then pharmacists prepare a 2 to 5 day medications into a patient-specific containers according to the prescriptions. Then the nurse would store these patient-specific medications on the nursing unit. In Patient Prescription System, nurses still need to prepare every single dose for patients before administration, and contact pharmacists for medication refill.

In Patient Prescription System, patient-specific drug containers are applied. So when the drug is discontinued, or the patient is discharged, the prescription containers would be returned to the pharmacy. This system is suitable for small hospitals because the limited manpower requirement.

Compared to Floor Stock System, Patient Prescription System needs a smaller storage space on the nursing unit because nurses only store about 2 to 5 days medication on the nursing unit. And it needs patient-specific containers because pharmacists would prepare medication for each inpatients. So the working process is nurses read physicians prescription and transcribe the prescription, or physicians prescribe orders through CPOE system and computer send the orders to the pharmacy directly. After pharmacist prepare the medications for 2 to 5 day period and send to the nursing unit, nurses need to prepare each single dose of medication for patient administration. Pharmacists are responsible for review transcribed prescriptions because the prescription is transcribed, it may only have limited patient information.

But nowadays, this disadvantage can be overcome by a well-designed order form, or by using a CPOE system. Even the pharmacist has the opportunity to review the patient order, in the Patient Prescription System used in the past, the pharmacist would place only limited judgment because they could not access patients’ medical records. So pharmacists could not verify whether it is correct, or appropriate for the patient. And then pharmacists prepare patient-specific medications at admission and refill patient-specific containers if therapy is continued. The advantages of Patient Prescription System include that pharmacists have opportunities to review orders and provide service between other healthcare members, mainly are doctors and nurses. In Patient Prescription System, the patient-specific container also provide a clear control of inventory.

Disadvantages of Patient Prescription System are similar to Floor Stock System. It has potential for unsecured medications or expired medications. And it need proper storage environment on the nursing unit. And for new order, nurses need pharmacists to prepare new medication, so they cannot get medication immediately.

In our pharmacy in Taipei Veterans General Hospital, we apply Patient Prescription System in our emergency department. Physicians prescribe a 3 day order for each patient. Because we use a computerized order system, so prescription include essential patient information on it. We receive original prescriptions from doctors through CPOE system, and dispense medications to nurses. Then the medication keep at the nurse station, and nurse prepare medication for each administration.

After the Floor Stock System and Patient Prescription System, the Unit Dose System started in mid-1960s. Why this change happened? Because several studies had shown that the Floor Stock System and Patient Prescription System may lead to more medication errors. So Unit Dose System become a popular system in hospitals. More importantly, Unit Dose System led the pharmacists playing a more important role. And pharmacists began to influence a patient’s medication therapy. The Unit Dose System is a pharmacy-coordinated method regarding to the practice of dispensing and controlling medications in hospitals. The Unit Dose means the individual dose of medication is prepared into a separate package. So in the Unit Dose distribution, the pharmacists dispense the number of doses for each patient.

Each dose is prepared in a separate package. And the drug supply period is usually not more than 24 hrs. In previous studies, they have shown that the Unit Dose System could reduce medication errors by 2% to 11% when transitioning from the Floor Stock System to the Unit Dose System. Therefore, in 1971, the United States General Accounting Office concluded that the Unit Dose System was the most cost-effective of any distribution system. Unit Dose System has been adopted by hospital pharmacies in Taiwan since 1983.

So the working process in Unit Dose System is usually like this: Physicians prescribe an order, and send a copy to pharmacy in various methods. Because pharmacists receive a copy of original prescription, so it reduce transcription errors. Pharmacists receive and review prescriptions before dispensing. Based on the prescription, pharmacists should check and discuss any drug related considerations with physicians. After reviewing prescription, pharmacists confirm it as an appropriate prescription for the patient, pharmacists can document patient-specific drug profile. The patient drug profile is the primary record used by pharmacists. Pharmacists can record allergy history, lab data, and patient’s response to treatment and so on. Then pharmacists dispense and check the medications. Reviewing prescriptions before dispensing let pharmacists have a chance to intervene if needed.

So the Unit Dose System let pharmacists start to have a role in the medication use cycle. It means that pharmacists are given a new role which did not exist in the Floor Stock System and Patient Prescription System. And they can utilize their professional knowledge and training to ensure patients safely using medications. In addition, the Unit Dose System also provide another change for pharmacist, pharmacists can maintain a patient drug profile in the pharmacy. Therefore, pharmacists are allowed to approach patient-specific information. In Unit Dose System, nurses’ work become more simple, they are only responsible for administering the unit-dose medication to patients, and they can get more time to do direct nursing care.

So, the advantages of Unit Dose System include: Reduce the medication errors. Decrease in total cost of medication waste. A more efficient utilization of pharmacists and nurses, provide opportunity for pharmacists and nurses to do more direct patient-care. Improved overall drug control and drug use monitoring. More accurate patient billings for drugs. Greater control in pharmacy workload patterns and staff scheduling. Reduce the space of drug storing areas located in patient-care areas. Regarding to the disadvantages of the Unit Dose System, it also delays in new orders or doses missed. And it needs more pharmacists, so the labor costs is higher.