Regardless of the size of a health care institution, enabling a safe, efficient, and traceable method for the provision of individually dosed medications is of great importance. However, size indicators such as the number of patients visiting the emergency department, being admitted, or utilizing outpatient services can have an effect on what methods are employed and how they are managed. 

Susan B. Allen Memorial Hospital in El Dorado, Kansas, is a 52-bed acute care, general medical and surgical hospital that handles approximately 13,000 ED visits, 2,000 admissions, and 3,000 total surgeries per year. Given these numbers, running a unit dose packaging program using a tabletop packaging machine offers the greatest operational and financial return for our needs while also providing the necessary safety features we require. For a facility of our size, there were basic operational elements that influenced our decision to use tabletop automation; we determined that a larger, high-volume unit dose packager was unnecessary to fill our workload and would take up valuable physical space. On the other hand, our medication packaging workload is sufficient enough such that manually packaging all our unit dose medications would be too time consuming, prone to error, and would not offer the automated information capture and documentation we wanted to ensure safety and accountability. 

Packaging on Demand
As a smaller facility that does not package a large volume of medications, a compact tabletop machine is the perfect fit for us. On a daily basis, we perform one or two packaging runs of about 30 oral solid medications at a time; if the order is for a higher volume, we package 100 medications per run. We do try to purchase most liquid medications in unit dose cups or syringes. However, any liquid medications we are unable to purchase this way are drawn up into oral syringes and a technician manually bar codes them with labels generated through our pharmacy information system (PIS).

Tabletop packaging automation has now evolved to the point that we are able to fill medication orders on demand and include all the required information on the package label of each dose. All of our medications come out of the packager with labels that list generic and brand names, bar code, lot number, expiration date, and manufacturer. The only extra step we have to take is to make sure the bar code is linked with the proper drug in our PIS drug library. To do this, a technician will access the PIS drug library and scan the bar code on the packaged drug. If the scan brings up the correct drug, the product is sent to the floor. If it does not link to the proper drug, the technician will double check that the right drug was packaged and then will go into that drug’s profile and add the bar code.

Furthermore, the device’s software keeps track of everything we have packaged. For example, if we are faced with a recall situation, we can review our logs to determine if the affected lot was repackaged. As all content and patient information is recorded, we would know exactly how many recalled tablets were packaged and what patients, if any, received the medication. This greatly influences the speed and efficiency of any necessary remediation actions.



How the System Works
As soon as a medication order is received by the pharmacy, a technician retrieves the drug from the storage shelves, takes it directly to the packager, performs the run, and sends it out to the appropriate nursing unit. All received orders indicate the medication, dosing schedule, route of administration, any lab values that the physician wants during the use of the medication, and the start/stop dates, if necessary; all of our medication packaging orders are verified by a pharmacist before being sent out of the pharmacy. We rarely have issues with our packager, but perhaps the most common involves packaging very small tablets. These have a tendency to get caught under the pill slots in the packaging disk, which can result in the production of several empty packages followed by several packages containing multiple pills. Accordingly, we monitor the packaging of very small tablets more closely to avoid mispackaging.

For our facility, the largest single factor in deciding what to package is price. Typically, most unit dose medications are equal in price to the bulk package. However, there are some drugs that cost $150 for a package of 100 tablets packaged in unit dose, whereas a bulk bottle of the same quantity is only $10. When disparate medication pricing presents a clear choice, as in this case, we purchase the bulk medication and repackage in house to garner the savings. The reliability of the tabletop packager gives us the flexibility to make money saving decisions with the confidence that we can do so without any risk to the quality of our final product. 

Handling Demand Fluctuations and Maintenance
Our packaging volume does fluctuate depending on the season and we tend to package more in the winter and spring when our patient census is higher. Packaging volume also can increase when a new medication is added to formulary that our physicians want to explore, thereby leading to an increase in the number of orders for that medication. Fortunately, it takes less than ten minutes to perform a packaging run, so such fluctuations have minimal impact on our workflow in the pharmacy.

The packager typically requires only minor maintenance and most of our pharmacy staff are trained to resolve any problems that arise. Maintaining a close relationship with your vendor representative is also wise and ensures any needed maintenance visits are just a phone call away. For general quality control, we clean the device before every packaging run, primarily to remove any pill residue from the pill slots on the packager’s sorting wheel. We also make sure that the sealing mechanism is clean and there are no loose pills obstructing the machine. Back-up supplies are minimal and consist of extra rolls of packaging materials and ink cartridges for the label printer. We have been able to determine a proper schedule for purchasing replacement materials so that we only need to place those orders every 9-12 months.



When it comes to reporting, we do not usually run regular usage reports unless there is a specific reason that calls for it, as in the case of a recall or if we find a discrepancy between the packaging and administration of a narcotic. Currently, our packager does not interface directly with our PIS, but such functionality would be advantageous as it would eliminate the need to confirm bar code accuracy and the bar code and NDC could instantly match up with our drug library. 

When reviewing your own current or potential use of tabletop packaging automation, there are a few safety concerns that should be accounted for. The use of tall man lettering is highly recommended, especially for look alike/sound alike medications. While we do not typically process hazardous drugs through our packager, the ability to indicate on the medication label whether the drug is high risk or can be harmful if handled by certain individuals is important. Just as the safety of our patients is paramount, we establish a high standard of safety for our employees as well. To date, we have had no problem incorporating the tabletop packager into our program. Knowing that we have a product that will come out safely packaged with a bar code and all relevant information on the label is well worth the minimal time, expense, and maintenance required to support our packaging activities. 

Justin Douglas, CPhT, is a pharmacy technician and pharmacy buyer at Susan B. Allen Memorial Hospital in El Dorado, Kansas. He is also working with anesthesia providers to integrate automated dispensing cabinets into the surgery department. Justin is currently pursuing a degree in microbiology.