By Michael C. Cotugno, RPh

At Brigham and Women’s Hospital in Boston—a 750-bed tertiary academic medical center with 170 intensive care beds including a neonatal intensive care unit—we have 45,000 admissions and 57,000 visits to the emergency department per year. In 2007, our pharmacists reviewed over four million orders and prepared over 500,000 sterile products. More than 2,500 nurses currently use our electronic bar code medication administration (BCMA) system.

When we first rolled out BCMA in 2003, there were many manufacturers that did not provide bar coded products. Prior to implementing the system, we decided that all medications dispensed from our pharmacy would require scannable barcodes. Our concern was that if nurses did not expect every medication to be scannable, they would override the system too readily when a bar code did not scan immediately.

To meet this need initially, we implemented an in-house, comprehensive repackaging center that included a unit-dose tablet repackager, a vial and ampoule labeler, an over-bagger machine, and a unit-dose liquid cup repackager. However, as more manufacturers met the Federal Drug Administration’s (FDA) requirement for having bar codes on all medications, we began repackaging fewer of our own medications and started purchasing bar coded products from the manufacturers as they became available. Currently we purchase 95% of our bar coded unit dose medications from the manufacturer, as opposed to 60% when we first enacted BCMA.

Deciding on Repackaging Options
Although we decided to purchase as much bar coded unit dose medication from the manufacturer as possible, there still were medications that needed to be repackaged, and we had to decide how to address this need. Our health care network consists of two tertiary medical centers and three community hospitals, and while we had already implemented bedside bar code scanning, the other institutions in our network were still in the process of doing so, so we examined our repackaging choices from a network perspective. We considered three paths:

1. Have each institution install its own repackaging center with the necessary equipment

2. Open a central repacking center to meet the needs of all the institutions

3. Outsource to a licensed repackaging company

For each of our hospitals to open their own repackaging center, it would require finding the necessary space at each institution, buying and maintaining equipment, as well as hiring and training new staff—all investments that would not be cost effective. To open a central repacking center we faced similar challenges. While we already had the equipment, the cost per dose for us to repackage was the same as the cost per dose being charged by the repacking company. Once we included the potential liability from a repackaging error, it made sense for our institution to use a repackaging company when a unit dose product is not available from the manufacturer.
We met with and considered multiple repackaging companies, and the most competitive bid was accepted. The cost per dose of using a licensed repackager worked out to be cost neutral when compared to doing our own repackaging.

Currently we outsource to a single company; they provide unit-dose tablets/capsules, oral syringes for our neonatal intensive care unit, liquid cups, and split-dose packaging of tablets. Using a repackaging company has significantly increased the amount of product that is available to the nurses in patient-ready bar
coded form.

We continue to maintain our unit dose tablet/capsule repackager and over-
bagger machine as there are times when we need to repackage a product immediately and cannot accommodate the two- to three-day turn-around time from the outsourcer. There also are some medications that the outsourced repackager cannot package, such as certain antibiotics. We also repackage a few low-volume items that are ordered sporadically.

Impact on Staffing
The move to purchasing the majority of our bar coded unit dose medication from manufacturers allowed us to reassign our repackaging staff to other tasks within the department. In 2005, our repackaging center—comprising two full-time technicians and one full-time pharmacist—repackaged upwards of 5,700 doses per day, Monday through Friday, or about 120,000 doses per month. By making this transition, we were able to reassign the pharmacist to our patient care areas. In our experience, having pharmacists in the patient care areas results in increased patient safety and better quality of care. We also were able to improve the management of our distribution systems by reassigning the two technicians. We had just installed two new carousels to improve inventory storage and automated dispensing cabinet filling, so we decided to move one technician into the role of carousel coordinator. This allowed us to better manage the dispensing of first doses and the batch filling of our automated dispensing cabinets. The second technician moved to our sterile products area. We had embarked on a program of providing intravenous preparations for the nursing units whenever possible and additional technical staff was required to manage the increasing volume of sterile product compounding.

Pros and Cons
The move to purchasing unit dose products from the manufacturer required us to make one significant concession: we have to accept the manufacturers’ choice of bar code type. Most manufacturers use a linear bar code that includes only the national drug code (NDC) on the product. We would prefer all of our medications use a two-dimensional bar code, which allows for the inclusion of additional information such as the lot number and expiration date. With this information, the user will know if the medication is expired, and in the event of a recall, we can track which patients received the medication from a specific lot number. We use a two-dimensional bar code when we do in-house repackaging.

As the technology has become more sophisticated, we have seen improvements in the size and shape of the unit dose packages that come from the manufacturers and the repackager. Pre­viously, our repackaging machine created a bulky product, which made stocking the automated dispensing cabinets challenging. Because of the unwieldy size of the package, we could only stock a limited amount of the product in the cabinets and could not take advantage of the OmniDispenser compartment.

Conclusion
To determine whether to purchase bulk or unit dose medications, it is important to evaluate available space for equipment and inventory, equipment contracts, staffing needs, drug volume, and liability issues. Then review your medication use system, considering both medication administration and pharmacy system processes, to determine how these products will fit into your system currently, and in the future as your system evolves. A thorough
evaluation of these factors will help you make the right decision for your
institution.

Michael C. Cotugno, RPh, has worked at Brigham and Women’s Hospital in Boston, Massachusetts for 17 years as a clinical pharmacist and pharmacy supervisor before assuming his current role as the assistant director of pharmacy. He served on the Brigham and Women’s Hospital decision and implementation teams that have directed the execution of computerized physician order entry, automated dispensing cabinets, bar code scanning technology, the electronic medication administration record, and medication reconciliation. Michael received his BS degree in pharmacy from North­eastern University in 1991 and is a member of ASHP and Massachusetts Society of Health-System Pharmacists (MSHP). Michael’s current practice interests include automation of the medication-use-system, medication safety initiatives, and emergency preparedness.

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