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Improve Core Processes for Dispensing Medications:
Increase Frequency of Medication Delivery

Medication deliveries from the pharmacy to nursing units should be frequent so medications are always available when they are needed. When deliveries are infrequent or unreliable, staff members may "borrow" medications from doses intended for other patients or may create stashes from discontinued medications. Both of these practices create an enormous opportunity for errors that can lead to adverse drug events. If the pharmacy dispenses a large supply of doses, e.g., enough for a 24-hour period, it introduces other opportunities for error, especially if the unit lacks a good system for immediately removing discontinued medications. Frequent delivery means the pharmacy must dispense fewer doses each time, and it can easily update the list of drugs to be delivered to fulfill the most current orders. Most important, the more frequent the deliveries, the fewer the opportunities for error.


Tips
  • Review medication orders from a 24-hour period in your organization and note the peak medication administration times (i.e., when the most patients get their morning, afternoon, evening, etc. doses); schedule deliveries for shortly before those peak times.
  • Include a process for immediate removal of discontinued medications.
  • Consider hourly rounds during peak hours, during which pharmacy staff can deliver new medication doses and retrieve paper orders.
  • Integrate into the delivery process any orders placed via computer so each delivery fills all current orders.