Manual Unit Dose Repackaging

November 2015 - Vol.12 No. 11 - Page #86

The recent report that nearly half of all surgeries at Massachusetts General Hospital experienced a medication error or drug-related incident was greeted in the press with great surprise given the frequency of the error rates.1 But for pharmacists, these data come as less of a surprise. Over the past 2 decades, hospital pharmacists have expended great efforts to provide medications in bar coded unit of use. The risks inherent in unlabeled products were among the initial drivers behind this effort, and while vast improvements have been realized across hospitals nationwide, procedural areas retain a higher risk given the need for timely medication preparation often under emergent conditions, which lowers the rates of prospective review and verification.

In response, many facilities have begun to focus on providing inservices for nurse anesthetists and other perioperative staff, standardizing commonly used doses, establishing satellite pharmacies, or assigning dedicated OR pharmacists to serve the perioperative area.

Purchasing Roadblocks
The inherent risk from products that are unlabeled or available only in bulk is not limited to procedural areas. With the advent of bar coded medication administration—the first system was launched at the Topeka, Kansas VA in 1995—many in pharmacy expected a sea change in medication availability to ensue. A common prediction at that time was that all medications would soon be available in unit of use directly from the manufacturer, making distribution, tracking, and billing a much simpler process. Two decades on, the reality of the situation is much more complex. Drug shortages and rapid changes in product availability have become normalized within pharmacy operations, and, as noted in PP&P’s State of Pharmacy Automation, 98% of US hospitals are unable to purchase all of their medications in bar coded unit dose.2 While there are many options for automating repackaging, from outsourcing to high-volume or tabletop repackagers, there will always be medications that require manual packaging. Many oddly shaped items require repackaging in the pharmacy, manufacturer’s bar codes do not always scan accurately, and labels are often required for non-bar-coded products, meaning the role of repackaging remains key to any hospital pharmacy’s medication distribution system.

System Features
Fortunately, there are many solutions available to address the challenge of managing manual repackaging in an effective and cost-efficient manner. In order to choose the system that best fits your operation, there are a number of features to consider. To ensure staff acceptance and limit the amount of time dedicated to training, review the system’s ease of use. Likewise, a variety of customization options will avert staff frustration and allow for improved safety.

Look for a system that provides warning symbols to designate hazardous drugs or controlled substances, for example. Determine if templates can be modified to display alerts. Label flexibility is important, so ensure that the system can accommodate multiple label types, including butterfly labels. Even if the pharmacy currently uses 1D labels exclusively, consider a system that can also provide 2D labels in order to ensure its longevity. The ability to deliver accurate and consistent labels will be appreciated by nursing, while also ensuring patient safety. Labels should permit customization of data fields, bar code sizes and locations, as well as color and font sizes.

In addition to label customization, the system must be able to handle all of your repackaging needs, including unit dose cups, liquid medications, and syringes. Safety features, such as tamper evidence, UV protection, cold sealing, and moisture resistance, should be standard.

Because recalls are a reality for every hospital pharmacy, it is important that the system include an effective audit trail, including the names of the technician and pharmacist that produced and checked any given batch. Date and time should be captured on the labels and be traceable within system. Ultimately, the reporting tool must allow for easy retrieval of medications in the event of a recall.

Once the desired features have been identified and evaluated, cost effectiveness will come into play. Does the system include expensive components? Consider how many licenses need to be purchased, and whether additional hardware is required. In addition, the quality of the vendor’s customer service is a strong reflection of their commitment to quality. Talk to other facilities that use the system to learn about their experiences with tech support, and ask if the vendor provides tutorials.

Ultimately, it is pharmacy’s responsibility to ensure that every medication leaving the pharmacy is correctly bar coded and in unit of use. While this process is becoming more complex, there are excellent, cost-effective systems available to bring safety and efficacy to manual repackaging. n

Deanne Halvorsen is the editorial director for Pharmacy Purchasing & Products and can be reached at



  1. Nanji KC, Patel A, Shaikh Sk, Seger D, Bates DW. Evaluation of perioperative medication errors and adverse drug events. Anesthesiology. 2015 Oct 24.
  2. State of Pharmacy Automation. Pharm Purch Prod. 2015;8:32.


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