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DD-006 Unit dose drug distribution system. How to improve the process in a tertiary hospital
  1. EG Fernández López,
  2. MA Ocaña Gomez,
  3. I Plasencia Garcia,
  4. M Suarez Gonzalez,
  5. JA de Leon Gil,
  6. E Marques Guell,
  7. M Navarro Davila,
  8. A Morales Barrios,
  9. E Tevar Alfonso,
  10. J Merino Alonso
  1. Hospital Nuestra Señora de Candelaria, Santa Cruz de Tenerife, Spain


Background The unit dose system of medication distribution (UDDS) is a pharmacy coordinated method of dispensing and controlling medications in organised healthcare settings. In our hospital, medications contained in single unit packages are delivered during the morning for a 24 h period.

However, after delivery, many drugs are requested throughout the day for different reasons. Medication dispensed in this way is more susceptible to medication errors than those included at UDDS.

Purpose To assess drug requests (out of UDDS) from clinical units, identify the reason for the same and try to improve the process to reduce their numbers.

Material and methods Retrospective descriptive study over a 2 month period in which request forms from various clinical units (traumatology, rheumatology and pneumology) were analysed, quantified and classified into 7 subgroups.

Results During the study period, 605 requests for drugs were analysed and we observed the following distribution:

28%: drugs not prescribed.

21%: drugs that theoretically were distributed at UDDS.

18%: changes in treatment and new hospitalised patients.

15%: drugs not included in the hospital pharmacotherapeutic guide.

12%: drugs that are not distributed at UDDS for different reasons (multidose vials, drugs that must be given only in some situations like pain or insomnia).

3%: drugs for an erroneous route of administration.

3%: drugs that were not distributed at UDSS for different errors (human error, computer error).

Conclusion 55% of drug requests were not justified, with a high percentage of drugs that were notprescribed, which is often caused by verbal orders from doctors.

45% of drug requests were justified, with a high percentage of new hospitalised patients and changes in treatment.

To improve the drug distribution chain and patient safety, we have decided to implement electronic medication request forms through electronic medical order. In this way, we can reduce dispensations of drugs not prescribed and ensure safe and correct distribution for new hospitalised patients and changes in treatment.

According to this study, this would reduce by approximately 55% the number of dispensations out of UDDS.

References and/or Acknowledgements We would like to thank all members of the Department of Pharmacy for their effort and patience during the implementation of this study.

No conflict of interest.

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