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Develop an Effective Unit Dose Packaging Strategy


March 2016 - Vol. 13 No. 3 - Page #12

Repackaging medications in the pharmacy demands accuracy and attention to detail every time the process is executed, as even a single mistake can result in a patient receiving the incorrect medication with potentially deadly consequences. Having the right equipment and training all staff on its use are crucial to ensuring a safe, efficient process.

Lakeland Regional Medical Center in Lakeland, Florida, is licensed for 851 beds and has one of the busiest emergency departments in the state. The pharmacy operates 24/7, and every shift is involved in bar coding medications. The hospital utilizes bar code medication administration (BCMA), so nurses receive an alert if the scanned medication is not in the system. Because scanning is linked to the billing system, medications cannot be charged to patients unless they scan correctly. Ensuring that patients receive the right medications is critically important, so accurate bar coding and an efficient repackaging process are high priorities at Lakeland. At the present time, about 94% of all medications administered in the facility are scannable.

The Bar Coding Process

All medications that arrive in the pharmacy are scanned into the CPOE system before they are stored to ensure that drugs will scan correctly at the patient’s bedside. This allows the technicians to add bar code labels as needed and ensures that inventory is correctly mapped within the system.

Similarly, every medication that leaves the pharmacy is required to have a bar code. If an item lacks a bar code and one must be created, a technician enters the information into the repackaging computer system and a pharmacist verifies that this information is correct. Information that must appear on the new label includes the institution’s name, brand and generic drug names, manufacturer, strength of the drug, technician’s initials, pharmacist’s initials, a bar code, and an expiration date. Our policy is to never place an expiration date on a product that is more than 1 year from the date the product was packaged. All repackaged items are recorded in a log, which details who prepared and checked the drug, and also includes a label of the final product.

The bar code on the label is then scanned for mapping into the CPOE system. A single drug may have multiple bar codes mapped to it denoting medications from different manufacturers or packages of different sizes. If the bar code on the package is unscannable, the nurse must contact the pharmacy for a replacement, which can cause a delay in patient care. Following the same process every time a drug is repackaged helps ensure that bar codes scan correctly and contributes to nursing’s confidence in the scanning process.

Repackaging Equipment

Creating a bar code for a medication that needs to be repackaged is a straightforward process when the right equipment is available. Lakeland uses three types of repackagers:

  • An oral solid repackaging machine
  • A tabletop unit dose repackaging machine
  • A liquid repackaging machine

The pharmacy’s primary repackaging machine repacks oral solids that arrive in bulk form. It can be used to auto-pack or manually repack items, holds up to 350 products, and interfaces with the carousel in our central pharmacy. This feature is particularly efficient as the carousel sends a message to the packager when a refill is required, be it for an ADC refill or for a patient-specific fill.

The tabletop unit repackages tablets and pills and also is used as a backup to the primary repackager. In addition, this unit serves to repackage medications that are light sensitive. One side of the packaging has the drug information printed on it, while the backside is tinted amber to block certain light waves and protect the medication. The tabletop unit also is used for oral medications that cannot be repackaged in the primary unit.

The liquid repackaging machine is used to repackage liquids that arrive in bulk form, such as oral prednisolone. The machine utilizes an external peristaltic repeater pump that allows the user to repackage liquids in multiple quantities, including 5 mL, 10 mL, 15 mL, 25 mL, and 35 mL cup amounts, with an information label and a bar code. This process is much easier than drawing up items individually in syringes.

For items that are too large to go through any repackaging machine, such as fish oil capsules, the pharmacy is still able to apply the safety of automatic bar code label production using the repackaging automation. The technician simply uses the primary packager to run the number of empty packages required (plus one for the log book). Staff then cuts the ends off the labels, fills the packages manually, and heat-seals the packages to close them. This is the most time-consuming part of the repackaging process, but it provides assurance that the nursing staff will be able to scan the bar codes accurately.

Staff Training

Effective staff training is critical to ensuring a seamless medication repackaging process. Thus, all pharmacy technicians are fully trained on how to use all of the repackaging machines. Hands-on training, using many different types of drugs (ie, liquids, oral solid tablets, and half– and quarter-tablets), with direct supervision from team leaders, is especially effective. A training checklist, which includes cleaning protocols for all the equipment in the pharmacy, should be part of new employee training, as well as yearly competency testing. The initial technician checklist must be completed within 90 days of hire.

Benefits Realized

A decade ago, the hospital operated with a single repackaging machine. One technician was designated solely to repackaging and accomplished little else over the course of an entire shift. Today, that same technician loads up to 350 drugs in our primary unit and the items are repacked in about a quarter of the time.

The repackaging machines used at our facility are simple to operate, require little more than general maintenance and cleaning, and significantly improve efficiency. Because Lakeland requires a high volume of repackaged products and must run batch fills day and night, were we to operate without in-house repackaging machines, a significant amount of time would be required for the staff to manually repackage all needed medications. Instead, the carousel batch fills are sourced directly from the primary packager, complete with an accurate bar code, thus eliminating the need for manual handpicking by the technician. Moreover, because medication scanning is linked to billing, an efficient repackaging process ensures equally efficient billing.

Conclusion

Appropriate staff training is key to a safe, efficient repackaging process. Proper education and training ensures that all pharmacy technicians are capable of using all repackaging technologies and that production will not be halted or stalled due to a lack of knowledge regarding the machines’ operation.

Because medication availability and the number of bar codes are constantly increasing, repackaging technology must keep up with demand. Embracing this technology helps ensure that medications are repackaged correctly, reduces the amount of time required to repackage medications, and improves pharmacy workflow.


Alison Kagel, CPhT, has been a pharmacy technician at Lakeland Regional Medical Center in Lakeland, Florida, for almost 14 years. She is a nationally registered pharmacy technician through the Pharmacy Technician Certification Board.

Gary Reckart, CPhT, is a nationally registered pharmacy technician and has worked at Lakeland Regional Medical Center for 5 years.


The Systems Scoop

Technologies and automation solutions used at Lakeland Regional Medical Center include:

  • Cerner’s CPOE System
  • Talyst’s AutoCarousel HD
  • ARxIUM’s MedSelect Flex ADCs
  • Talyst’s/JVM’s Autopack JV 350 Oral Solid Repackaging Machine
  • Medical Packaging Inc’s Pak-EDGE Tabletop Unit Dose Packaging Machine
  • Medical Packaging Inc’s Fluidose III Liquid Repackaging Machine with Baxter’s Peristaltic Repeater Pump

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