Key conclusions and recommendations of the studies on centralised, decentralised and hybrid medication distribution systems in hospitals
| Centralised medication distribution system | Hybrid medication distribution system and others | Decentralised medication distribution system | |
| Medication errors | Unit-dose DDS seems safer than the traditional ward-stock DDS41
Medication carts alone did not reduce the risk of MEs1 Unit-dose distribution using CDT with BC scanning seems to improve accuracy of dispensing and may be even less costly and equally effective without carts40 More attention should be paid to reduce MEs in centralised DDS41 No change was identified in the incidence of technical (selection) errors in UDS in comparison to pharmacy-based ADCs34 | Automated dispensing technology reduces MEs3 17 26
All error types reduced in the unit-dose drug distribution system26 Hybrid system reduces MAEs compared with WSS. The system does not affect prescribing errors26 Hybrid system does not prevent errors caused by missing medications26 Strategies to prevent MEs must be based on changes to the systems rather than individuals3 BC scanning was found to prevent errors17 | Decentralised medication distribution system reduces MEs: prescribing, administration, picking/selection, preparation, missing medications and wrong dose errors13 14 16 24 25 27 29 30 35 39
ADCs and CPOE reduces prescription and dispensing errors8 ADCs improve the efficiency of medicines administration but have little effect on the rate of MEs2 An increase in MAEs and decrease in ADEs was found27 Decentralised dispensing system could not prevent all MEs, for example, wrong-technique errors and picking errors still remain for non-ADDS medicines13 29 36 Risks are found in subprocesses other than administration itself8 |
| Clinical pharmacy | Gives pharmacists a better chance of performing clinical pharmacy activities41
Automation has a positive impact on medication management process21 More visits to the wards are needed to stregthen clinical pharmacy-related activities41 | Not reported | Pharmacists have a better chance to review prescriptions and control the usage of medicines. More errors are avoided and safety is improved16 24 30 |
| Patient safety | Unit-dose DDS improves patient safety41
Improved quality management enables better patient safety28 Nursing staff were satisfied with the use of technology and believed it facilitated their work and contributed to safe healthcare1 | Technology improves the quality of patient care itself by controls and alerts and by freeing up healthcare professionals to perform tasks that improve patient care in other ways3 17
Medications are ready to dispense after pharmacist's verification17 The risk of an unnecessary medication being administered was reduced due to redesigned cartfill process33 | Decentralised system may improve safety and quality of care13 16 27
Electronic systems can have benefits in drug administration and safety aspects31 BCs increased confirmation of patient identity before administration30 31 39 Nurses believed that safety improved and system helped to reduce medication incidents35 Collaboration is essential to ensure safe patient experiences32 New technologies may compromise patient safety or create a false sense of security23 35 System increased documentation discrepancies31 |
| Time | Cart-fill process was faster before implementation40 | Hybrid system saves time compared with decentralised system18
The cart-fill redesign had positive impact on lead times33 | Time spent on medication-related tasks inrceased after implementation24 30
Technican spent more time managing the stocks with ADDS25 30 32 Pharmacists’ time spent performing technical distribution activities was decreased while time spent on clinical work appeared to increase14 Nusing time dedicated to medications reduced2 25 30 Faster medication process: the automated medication dispensing systems outside patient rooms resulted in fewer episodes waiting to access the system and allowed nurses more time at the bedside. ADCs enabled fast ADE reports, improved timelines and security of administration16 31 32 38 The time taken to retrieve narcotics and other controlled drugs improved14 16 37 Pharmacists and nurses spend less time dispensing drugs. Pharmacists have more time to collaborate with their nursing colleagues, check physicians’ orders against patients’ drug profiles, reconcile patient medication, participate in patient care rounds and provide patient education. Nurses have more time to observe patients16 25 31 With ADM the medication retrieval process was slower than before37 |
| Work/workload | Centralised dispensing systems create additional workload in pharmacies, especially for pharmacy technicians28 40
Reduction in labour required to perform first-dose dispensing enabled reallocation of technician staff to other areas40 | Automation eases pharmacists’ distributive responsibilities. It also frees up technicians to do other duties17 33
Transition from hybrid system to decentralised system would result in decreased technician labour requirements and greater increase in nursing staff workload, which inreases costs18 | Technology implementations need additional work compared with traditional system23
The automated dispensing systems improved the productivity of pharmacists and nurses.25 27 ADCs reduced pharmacists’ dispensing time16 Nurses believed that the system made their work easier35 To improve nurses’ working conditions and knowledge about medications will reduce MEs13 16 |
| Cost | Carousels seem to reduce inventory costs and increase the inventory turn rate40 | Has best total human resource utilisation and employee skill mix. Decentralised is more expensive compared with hybrid system18 | With ADDS, costs are easier to control or are even reduced14 25 27 |
| Stocking | Better tools would be needed to manage medication inventories, generate usage reports and monitor workflow in the future40 | Gives better tools to manage medication inventories, evaluate charging, decrease returns to pharmacy, reduce waste and enable just-in-time delivery17 33
Better stocking enables improved safety: system stores and controls medications, fewer unnecessary medicines are stored in the ward17 33 | Automation improved storage, stock control and security22 27 29 31 37
Less time is spent searching for medicines37 ADDS decreased storage errors13 14 Narcotics management has been improved with ADC. It eliminates the manual count and provides secure medication storage supported by electronic tracking16 35 Automated dispensing increases the accuracy of inventory levels and decreases time spent on billing14 |
| Technology | Healthcare leaders must understand the impact a technology solution has at individual group and organisational levels to achieve maximum benefit and to minimise unnecessary consequences40
Some individual problems are found in centralised systems concerning technology: no alerts combined with BC scanning, computers’ touch-screen selection enables look-alike, sound-alike medication-related mistakes, problems passing the information on stat medications34 40 | Complementary solutions are needed in technology to prevent MEs and optimise medication management26
Some individual problems are found in hybrid systems concerning technology: robots do not handle all the medications (large bottles and cold storage) and errors are still observed, labelling and preparing processes are also prone to errors17 26 | Nurses were satisfied with the decentralised dispensing system13 16 22 24 32 35 37
Proper integration into an institution’s distribution process is needed to achieve positive results14 Technical systems will require time and effort to improve safety24 Some individual problems are found in decentralised systems concerning technology: Manufacturers do not provide medication in unit-dose packages and repackaging is needed, which is costly. Formulation and allergy alerts are needed8 29 35 Decentralised medication distribution system cannot prevent all ME types. Additional solutions and new technological enhancements are needed to reduce errors and improve safety: electronic prescribing, CPOE, BCed patient identification (with photographs), user identification, eMAR, pop-up alerts, clinical warnings, clinical decision support tool2 8 13 16 25 29 30 36 39 |
| Education, information and general guidelines | Individual and general group trainings for healthcare staff are needed to minimise change resistance towards the new technologies and to improve accuracy in medication administration21 34
Patient infomation and communication between healthcare professionals must be intensified to improve patient safety in a centralised medication distribution process28 Common guidelines on the optimal use of the carts, reducing the interruptions and reviewing the filling policies are needed to improve processes1 | Education on the new system helped personnel overcome initial resistance to the changes33
Despite the use of various methods for communication and education, it was not as successful as desired33 With the thrice-daily cart-fill process, nurses had fewer opportunities than before to contact pharmacists or pharmacy technicans directly33 Drug information about brand names and availability is needed to prevent errors caused by missing medications26 | Good planning and communication is needed to ensure successful implementation2 23
Nurses’ better knowledge about drugs is needed to reduce errors36 System improved communication between nurses and pharmaceutical staff25 Employees were satisfied with training and felt system easy to use22 |
ADC, automated dispensing cabinet; ADDS, automated drug dispensing system; ADE, adverse drug event; BC, barcode; CDT, carousel dispensing technology; CPOE, computerised physician order entry;DDS, drug dispensing system; MAE, medication administration error; ME, medication error; UDS, unit-dose system; WSS, ward-stock system; eMAR, electronic medication administration record.