With the increased use of bar code medication administration (BCMA), bar coded unit dose packaging plays a key role in improving patient safety. Due to the wide-ranging dosing requirements of pediatric patients, however, manufacturers offer few standard unit dose products for these patients, creating the need for pharmacists to manipulate adult dosage strengths to serve our vulnerable patient population, which subsequently increases the risk of medication error. 

Primary Children’s Medical Center, a 289-bed, level I trauma center, is a nonprofit facility in Salt Lake City that treats children with complex illnesses and injuries. As a pediatric facility, we require a broad range of doses in bar coded, identifiable packaging. For example, Primary Children’s stocks 10 different dosage strengths of oral furosemide (eight oral liquid doses and two tablet doses) instead of the three strengths typically available in an adult facility. To meet this need, Primary Children’s implemented in-house automated unit dose repackaging in 2004 with the goal of improving medication safety for our patients as well as enhancing pharmacy workflow.



The Packaging Process
The pharmacy dispenses first orders and batch fills via a dispensing robot, thus requiring every product be packaged in bar coded unit of use form. The robot contains 1,000 line items, which is typical for a children’s hospital given the number of drugs that require multiple dosage strengths. Approximately 30% of oral liquid drugs on formulary are standardized high-volume medications. Standardizing doses helps reduce waste because they are reusable, whereas patient-specific doses must be disposed of if they go unused. 

When considering packaging automation, we reviewed both high-volume and tabletop packagers, ultimately choosing a high-speed tabletop packager over the larger high-volume packager. The bins in high-volume packagers can be stocked with up to 50 drug cassettes, making them best suited for packaging large volumes of medication. We chose the smaller and less expensive tabletop machine, which allows our facility to package oral medications in any amount, providing us greater packaging flexibility. It also permits a quicker turnaround and requires less technician labor than manual repackaging. The tabletop machine repackages almost all of our bulk capsules and tablets, the latter of which can be packaged as full, half, or quarter tablets. We rely on an overwrapping machine to bar code inhalers, vials, ointments, eye drops, oral cups such as liquid Tylenol, and oral syringes, which are prepared by inpatient pharmacy technicians. Standard doses of oral liquids are prepared by pharmacy based on an algorithm [see SIDEBAR on page 34]. They are drawn in oral syringes and then overwrapped. 

All repackaged medications are stocked in the robot room prior to dispensing to nursing units. We find bar code-driven dispensing safer and more efficient than manual processes. When an order is received, the robot selects the item from the appropriate peg based on the bar code and it is sent to the appropriate unit. Larger medications too heavy to hang on pegs are housed in bins. Medications are also dispensed from the robot to the automated dispensing cabinets (ADCs) on the unit. 

Error Prevention
Packaging is performed in a separate room adjacent to the main pharmacy under the direction of the operations manager. The packaging technicians—outsourced employees of our vendor—operate the packager and overwrapping machines. The vendor is responsible for training the packaging technicians. A pharmacist is assigned to check the packaged drugs; a duty that is rotated to avoid burnout and complacency. 

Repackaging mistakes are rare with automated systems. We package approximately 40,000 doses per month and yet we have encountered just four errors since implementation in 2004. In each case the packager allowed more than one tablet or a broken tablet to be packaged. Of note, we have never had a packaging error that involved an incorrect drug. This is important, because once a product is packaged and stocked in the robot, the system relies on the bar code to select the drug, assess its beyond-use date, or to find a lot number in the event of a recall. 

We have developed two policies in order to prevent errors from occurring. First, to avoid any potential mixing of drug strengths, we do not allow more than one drug strength in the packaging room at any time. If we need to package two different strengths in a particular day, for example, one milligram then two milligrams, the technician will package one strength, have that batch checked by a pharmacist, put the product on the stock wall, and remove the remaining drug from the packaging room before bringing in the next strength of that drug for packaging. 

Second, no products can leave the room until the batch has been checked and approved by a pharmacist who tags the lot, which is then recorded in a log. The first and last doses of each batch are checked to ensure there is no drug left over from the previous batch in the transition from one medication to another. 

Bar Codes Drive Safety
Each bar code label includes the drug name, dosage strength, drug form, lot number, hospital name, expiration and/or beyond-use date, and where applicable, RX only. To support BCMA, every medication receives a bar code, which is scanned from the stock bottle into the packaging equipment before packaging begins. This initial step is key to ensure that the correct drug is packaged with the appropriate label. 

First doses are scanned on their way to the patient via our homegrown tracking system and then scanned again at the bedside prior to administration. Our tracking system verifies that the bar code is operational, and that the medication passes various checkpoints. For other medications, once the robot dispenses an item, it is scanned again at the bedside by a nurse prior to administration. However, if a medication is dispensed from the robot to be stocked on the unit in an ADC, it is scanned again at the ADC for stocking verification. When it is removed from the ADC to be administered, it is scanned once again before administration to a patient. No matter the pathway, the system has fail-safes along the entire route, with each dose scanned and checked at least twice prior to administration to any patient.

Conclusion
The implementation of a repackaging machine provides cost savings by allowing the purchase of bulk rather than unit dose medications. More importantly, it plays a role in updating error-prone manual packaging practices. In conjunction with a dispensing robot, ADCs, and BCMA, medication repackaging enables us to improve pharmacy workflow and enhance safety for our pediatric patients by providing unit dose medications that may not otherwise be available. 

Kevin Jones, RPh, MBA, is the director of pharmacy at Primary Children’s Medical Center, part of the Intermountain Healthcare network, in Salt Lake City, Utah. He received his bachelor of pharmacy and MBA degrees from the University of Wyoming. Kevin is a member of Intermountain Healthcare’s pharmacy executive team, system-wide P&T committee, and pharmacy directors’ committee.

Standardizing Liquid Oral Doses and IVs for Pediatrics 
Many medications are only available in limited dosage strengths not suited for the pediatric population, thus requiring significant pharmacy effort to create appropriate doses in-house. While the adoption of automated packaging systems and bar-coding technology can reduce the risk inherent in this process, another important safety step is the adoption of standardized doses where possible. 

Because most pediatric doses are calculated as milligrams per kilogram, each dose differs based on the patient’s weight. Quite often in pediatrics, dose standardization is an arbitrary process—pharmacy simply assesses the doses available for said product and then creates a range of doses between two available strengths. After the patient’s required dose is calculated, the closest of the standard doses is chosen for administration. 

At Primary Children’s, we wanted a more empirical system. Our department created algorithms in order to assign standard doses for medications on our formulary that have a wide therapeutic index; we avoid standardizing any medication with a narrow therapeutic index. We designed our algorithm by assessing the history of dosages prescribed for each item over the past five to six years, and identifying the necessary ranges based on the projected range of children’s weight and indications. The algorithm identifies the most commonly used doses consistent with therapeutic indication and the formula is different for each drug. A number of medications have been selected to create standard doses; the P&T committee and formulary committee approve each product and its assigned doses (see Table 1).

Once created, these items are packaged in the overwrapping machine, labeled with a bar code, and stocked within the robot. Using this approach, pharmacy can provide safe dosage strengths for each patient while also reducing both the waste and handling costs for these medications. 

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