Learning Objectives

• Differentiate Inpatient and Outpatient
• About different categories of drug distribution to outpatient and inpatient
• Able to describe dispensing steps to outpatient and inpatient
• Able to describe dispensing of drugs to ICCU/ICU/NICU/Emergency wards
• About Automated drug dispensing systems and devices
• About Distribution and storage of narcotic and psychotropic substances

Definition of Drug Distribution

Correctly and efficiently physical transfer of drug from storage area of hospital to the patient’s bedside.

Types of Drug Distribution System

1. Drug distribution to inpatients
2. Drug Distribution to outpatients

Drug Distribution to Outpatients Services

Outpatients are those patients who are not admitted in hospitals.

Types of Outpatients

1. Primary Care patient: Daily care patients (e.g., immunization, acute/chronic disease follow-up, health education).
2. Ambulatory patient: Receives diagnosis or treatment without hospital admission; may arrive walking or with mobility aids. Services include routine visits to same-day procedures (e.g., imaging, endoscopy, minor operations, urgent care, same-day surgery).
3. Referral/Tertiary care: Requires specialized, advanced services for complex conditions, typically after formal referral from primary or secondary care providers.
4. Emergency care patient: Presents with sudden serious illness or injury requiring immediate care to prevent serious harm or death.

Issue of Medicine in the OPD

1. Rx written by doctor
2. Rx received by pharmacist
3. Filling of prescription
4. Dispensing to patient (Selection, Pricing, Labelling)
5. Receipt of payment (Free/Charge/Cash)
6. Prescription filled

Records maintained in:

• Regular prescription file
• Narcotic prescription file

Typical Distribution System in Hospital (Inpatient)

1. Physician prescribes drug to inpatient.
2. Nurse prepares requisition of drug & sends it to pharmacy department.
3. Pharmacist distributes drug to nursing unit as per requisition slip.
4. Nurse brings these drugs to inpatient and administers them.
5. Record keeping for administered drug.

Different Drug Distribution Systems to Inpatients

1. Individual prescription order
2. Floor stock system
3. Combination of individual & floor stock system
4. Unit dose system

4.1.1 Individual Prescription Order

Physician writes prescription → Sent to Hospital Pharmacy (electronically or manually) → Pharmacist prepares medication → Delivered to nursing station or patient’s ward → Administered by nurse/ward staff (via hospital messenger/attendant).

Advantages

• Close control on stock of medicine is possible.
• Medication error can be easily traced.
• All medication orders are directly received by the pharmacist.
• Provides better interaction among pharmacist, doctor, nurse, and patient.
• Reduced manpower requirement.

Disadvantages

• Not suitable for big hospitals.
• Possibility of delay in obtaining medication.
• High cost may be passed on to patients.

4.1.2 Floor Stock System

Physicians prescribe drugs directly → Nurses dispense from floor stock based on prescription → Document administration in patient chart.

Floor stock stored at wards/nursing units under supervision of nursing incharge.

Nursing Station Types

• Free floor stock drugs
• Charge floor stock drugs
• When both are present → Complete floor stock system

Free Floor Stock Drugs / Non-Charge Floor Stock Method

• Routinely used medications from a predetermined list.
• Patient not charged separately.
• Examples: Saline solution, Dextrose injection, Absorbent cotton, Paracetamol, Aspirin, Dettol, etc.

Free Floor Stock Subtypes

• Drug basket
• Mobile dispensing unit (MDU)

Stock Management: Medications stored in bulk on the ward (e.g., analgesics, IV fluids, antiseptics, first-line antibiotics).

Usage: Nurses administer as needed without specific patient charges; recorded for inventory.

Costs: Hospital absorbs cost (funded via general budgets or government programs).

Drug Basket Method

1. Night shift nurse checks inventory against master checklist (medicine cabinet, utility room, refrigerator).
2. Nurse ticks required quantities on requisition.
3. Empty containers + requisition placed in basket → sent to pharmacy.
4. Pharmacist fills containers and returns basket to nursing station.

Mobile Dispensing Unit (MDU)

1. Physicians enter orders electronically or send prescriptions.
2. Pharmacists verify for allergies, interactions, dosage.
3. Technicians prepare unit-dose meds into patient-specific drawers.
4. Pharmacist performs final check before releasing cart.
5. Cart transported to nursing station.
6. Nurses administer from cart; pharmacists handle restocking & documentation.

Charge Floor Stock

• Expensive drugs directly charged to patient’s account.
• Includes injections and other single-dose preparations.
• Broad range including specialized drugs.
• Usage recorded per patient for billing.

Dispensing of Charge Floor Stock Drug: Envelope Method

1. Pharmacy prepares pre-labeled envelopes with drug name/strength.
2. Nurses administer from envelopes per physician order.
3. Nurses record patient name and room number on envelope.
4. Used envelope placed in out-basket or returned to pharmacy as charge ticket.
5. Pharmacy prices and charges drug to patient account.
6. Pharmacy restocks new envelopes continuously.

4.1.5 Combination of Individual Drug Order and Floor Stock System

• Primary dispensing via individual prescription order + limited floor stock.
• Frequently used drugs supplied as ward stock; others dispensed individually.
• Most common system in hospitals today; often modified to include unit-dose medication.

4.1.6 Unit Dose Dispensing

Definition: Medications ordered, packaged, handled, and charged in multiples of single-dose units containing a pre-determined amount of drug.

Process: Physician writes prescription → Sent to pharmacy → Pharmacist packages into unit doses (blister packs, syringes, ampoules) → Delivered to nursing station → Administered by nurse.

• Patient charged only for administered doses.
• Reduces medication errors (pharmacist receives copy of prescription).
• Avoids drug losses.
• Less space & inventory vs. floor stock.
• Minimizes nurse involvement and paper work (no duplicated orders).
• Solids: prepacked; Liquids: premeasured in bottles; Parenterals: premeasured in sterile syringes.
• Strip-packed tablets are common examples.

Unit Dose Dispensing Models

4.1.7 Satellite Pharmacy (Mini-Pharmacies)

Process Flow for Stock Management:

• Located near patient care areas (e.g., ICU, wards).
• Stores limited supply of frequently used medications.
• Restocked regularly by central pharmacy.

Prescription Writing: Physicians write prescriptions → sent electronically or manually to satellite pharmacy.

Dispensing: Satellite pharmacists prepare meds → delivered to patient care area by nurses or pharmacists.

Record Keeping: Dispensing records maintained at satellite; usage logged in patient charts; data shared with central pharmacy.

Advantages

• Efficient drug distribution.
• Reduced dispensing time.
• Reduced drug distribution errors.
• Pharmacist availability for patient/nurse counseling.
• Pharmacist takes drug history and monitors reactions.

Disadvantages

• May affect overall hospital budget.
• Requires additional manpower.

4.1.8 Bedside Pharmacy

Process Flow for Stock Management:

• Individualized meds stored in secure cabinets/lockers at bedside.
• Replenished as needed by central or decentralized pharmacy.

Prescription Writing: Physician writes Rx → documented in patient’s medical record.

Dispensing: Nurses/pharmacists access bedside cabinet → prepare and administer meds directly.

Record Keeping: Administration details documented in medical chart.

Importance of Bedside Pharmacy

• Pharmacist as part of inter-professional team (physician, pharmacist, nurse).
• Pharmacist visits wards and bedside for each patient.
• Provides drug information (storage, administration), patient counseling on food habits and administration methods.
• Guides on post-discharge treatment and home drug storage to avoid degradation.
• Takes medication history during visits.
• Acts as drug therapy advisor, sharing healthcare responsibility.

Automated Drug Dispensing System

Explanation

An Automated Drug Dispensing System is a secure, computerized cabinet or robotic device that stores and dispenses medications directly at the point of care.

• Replaces traditional manual methods.
• Nurses access patient-specific meds using biometric or password authentication.
• Tightly controls high-value/high-risk drugs with real-time tracking.
• Reduces cost of expired drugs and missing medicines.
• Ensures “right drug, right dose, right patient” → enhances safety and reduces errors.
• Streamlines nursing workflow by minimizing trips to central pharmacy.
• Increases efficiency, security, and accountability.

Demerits

• Remote dispensing → pharmacist not in same room → may miss visual cues.
• Harder to spot dangerous drug interactions for high-risk meds without in-person interaction.
• System stops working if internet/phone lines fail.
• Smaller selection of medicines vs. regular pharmacies.

Drug Distribution in Specialized Units

ICCU (Intensive Coronary Care Unit)

Specializes in severe cardiac conditions (heart attacks, arrhythmias, acute heart failure). Continuous monitoring (ECG, BP, O₂ saturation).

Common Drugs:

• Vasodilators: Nitroglycerin
• Antiarrhythmics: Amiodarone
• Anticoagulants: Heparin
• Thrombolytics: Alteplase (for acute MI)

ICU (Intensive Care Unit)

Manages critically ill patients (respiratory failure, sepsis, multi-organ dysfunction) requiring life support.

Common Drugs:

• Vasopressors: Dopamine, Norepinephrine
• Sedatives: Midazolam, Propofol
• Broad-spectrum antibiotics: Meropenem
• Inotropes: Dobutamine

NICU (Neonatal Intensive Care Unit)

Cares for newborns needing specialized attention (preterm, congenital abnormalities, infections).

Common Drugs:

• Surfactants: Beractant
• Antibiotics: Ampicillin, Gentamicin
• Analgesics: Fentanyl

Emergency Ward

Handles acute/life-threatening conditions (trauma, poisoning, cardiac arrest, anaphylaxis).

Common Drugs:

• Epinephrine (anaphylaxis, cardiac arrest)
• Naloxone (opioid overdose reversal)
• Rapid-acting sedatives: Diazepam (seizures, agitation)

General Practices for ICCU/ICU/NICU/Emergency Wards

• Drugs stocked in Automated Dispensing Systems (ADS) or crash carts → immediate access.
• Restocked daily by pharmacy teams integrated with EMR.
• Unit-dose systems ensure precise, single-dose dispensing → minimize errors, track usage.
• Pharmacists verify orders, monitor high-risk meds, respond to codes 24/7.
• Emphasis on rapid response to prevent complications.
• Frequent audits for expiration and security.
• Integration with Electronic Medical Records (EMR) for real-time tracking.

Unit-Specific Variations

• ICU/ICCU: Prioritize therapeutic monitoring (e.g., vancomycin levels) and cardiac agents; fast restocking for sustained crises.
• NICU: Use pre-diluted meds, strict sterility protocols, neonate-specific dosing precision to avoid infections.
• Emergency: Crash carts immediately restocked after use; maintain extra capacity during high-demand periods.

Distribution and Storage of Narcotic and Psychotropic Substances

Refer to Supply Chain and Inventory Control sections 16, 17, and 18.