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10-lipowski(577-581)

RESEARCH
Time Savings Associated WithDispensing Unit-of-UsePackages Earlene E. Lipowski, DeArcy E. Campbell, David B. Brushwood, and
Debbie Wilson

Objectives: To determine how much time can be saved with the use of unit-of-use packaging in a community pharmacy, the distribu-
tion of work between the pharmacist and the pharmacy technician when unit-of-use packaging is used, and the number of errors that occur when either unit-of-use or bulk packaging is used in dispensing prescriptions. Design: A simulation comparing count-and-pour
dispensing with unit-of-use package dispensing. Setting: An independent community pharmacy. Participants: Two teams, each com-
posed of one pharmacist and one pharmacy technician. Intervention: Each team prepared 50 typical prescription orders, once using
unit-of-use packaging and once by transferring medication from a bulk container. Main Outcome Measures: Time needed to dispense
50 prescriptions, dispensing activities performed by technicians and pharmacists, and number of dispensing errors. Results: The time
saved with unit-of-use packaging compared with count-and-pour dispensing was 46.5 minutes per 100 prescriptions, which represents an average time savings of more than 27 seconds per prescrition. In the bulk package dispensing simulation, the pharmacists assisted in retrieving and counting medication for 26% of the prescriptions. This percentage dropped to 4% when unit-of-use packaging was used because the technicians dispensed prescriptions at a rate that occupied the pharmacist with verifying the prescription orders and dis- pensed products. Each team committed two counting errors when executing the bulk package trial and no errors when using unit-of- use packaging. Conclusion: Unit-of-use packaging can reduce the time needed for and increase the efficiency of pharmacists’ dispens-
ing activities. Unit-of-use packaging may also reduce the number of counting errors.
J Am Pharm Assoc. 2002;42:577–81. Pharmacists’ workload is a matter of increasing concern for the Industry statistics reveal that the number of outpatient prescrip- pharmacy profession and the public. Numerous groups have eval- tions processed in the United States increased from 2 billion in uated pharmacy workload issues, including the American Phar- 1992 to more than 3 billion in 1999; this number is projected to maceutical Association (APhA), the National Association of exceed 4 billion by 2005.4 Yet the population of pharmacists Boards of Pharmacy (NABP), the National Association of Chain remains relatively constant.1,3,4 This imbalance warrants giving Drug Stores (NACDS), and the National Community Pharmacists serious consideration to changes in practice that could improve Association (NCPA).1−4 The growing concern over a pharmacy the efficiency of prescription order processing.
manpower shortage has attracted the attention of the U.S.
Recently, the NABP Task Force on Pharmacy Manpower Congress. In December 2000 the Health Resources and Services Shortage recommended standardized unit-of-use packaging as an Administration (HRSA) delivered a report requested by Congress option for decreasing work at the point of dispensing.1 A unit-of- documenting the problem.5 All of the assessments conclude that a use package contains prescription medication in a quantity manpower shortage exists in pharmacy and that it will not be a “designed and intended to be dispensed directly to a patient with- short-term problem. One way to alleviate the manpower shortage out modification except for the addition of a prescription label by is to manage the workload more effectively.
a dispensing pharmacist.”6 Blister packs, compliance packs,course-of-therapy packs, and vials containing 1 month’s supply ofmedication are examples of unit-of-use packaging. In contrast to a Received September 21, 2001, and in revised form December 4, 2001.
Accepted for publication December 21, 2001.
unit dose package that contains enough medication for one dose, Earlene E. Lipowski, RPh, PhD, is associate professor; DeArcy E. Camp- unit-of-use packaging contains multiple doses sufficient for a typ- bell is PharmD/MBA degree candidate; David B. Brushwood, JD, is pro- ical course of therapy.7 Adoption of unit-of-use packaging could fessor; Debbie Wilson, MA, CPhT, is PhD student, College of Pharmacy, reduce pharmacy workload by eliminating at least three time-con- suming tasks from the dispensing process: measuring and count- Correspondence: Earlene E. Lipowski, RPh, PhD, College of Pharmacy, ing dosage units, selecting and retrieving dispensing vials, and University of Florida, Box 100496, Gainesville, FL 32610. Fax: 352-392-7782. E-mail: lipowski@cop.ufl.edu.
returning stock bottles to the storage shelves.
Vol. 42, No. 4 July/August 2002
Journal of the American Pharmaceutical Association
RESEARCH Unit-of-Use
This alternative to counting and pouring from bulk packages The dispensing simulation was conducted in an independent has been considered from time to time for more than 50 years.6 pharmacy in a large city in northern Florida with the cooperation The last time that the adoption of unit-of-use packaging was giv- of the pharmacy owner and staff. It took place on a Saturday en serious consideration as a standard in the United States was in afternoon in July 2000 after the pharmacy had closed for the day.
1992, when the United States Pharmacopoeial Convention spon- All participants in the simulation were familiar with the pharmacy sored a national conference on packaging. At that conference, as well as its equipment, layout, and inventory, and they had there was general agreement that unit-of-use packaging was tech- worked with one another before. The four participants were nically feasible and offered a number of advantages over stock assigned to two teams consisting of one pharmacist and one tech- bottles. Although a time savings was among the benefits cited, nician. The observer read instructions to each team, directing none of the presenters offered any specific data about the amount them to prepare the prescriptions in the order they were presented of time that could be saved or any evidence that unit-of-use could while taking the typical time and care needed for prescription pro- reduce the time pharmacists spend on dispensing relative to other cessing. The pharmacists were asked to perform the same check- activities.6 The adoption of unit-of-use packaging in the United ing procedures that they routinely apply to any prescription.
States has advanced little in the interim.
The prescription orders were computer printed and presented to the dispensing teams along with a prescription label. The labelshad been prepared in advance because this step is common to dis- pensing both bulk and unit-of-use prescriptions. Using preprintedlabels permitted us to measure the time intervals of interest with- The primary objective of this study was to measure the time out disrupting the computer record-keeping system at the pharma- that could be saved with unit-of-use packaging in a typical com- cy. Each preprinted label included the pharmacy’s name and munity pharmacy setting. The second objective was to note the phone number, the patient’s name, the drug and strength, the quan- distribution of work between the pharmacist and technician when tity prescribed, the directions for use, and the physician’s name.
unit-of-use packaging is used in place of bulk packaging. The We used 20-dram prescription vials with childproof caps to third objective was to compare the number of errors that occur simulate unit-of-use packaging. Each vial had a label (1 inch by 2 when using the two different package types.
5/8 inches) with the drug name, strength, package size, lot num-ber, and expiration date. There was enough room at the bottom ofthe vial for a prescription label to be placed below the “manufac- Bulk packaging for the simulation consisted of empty stock We conducted a simulation study to capture a credible estimate bottles collected from a local pharmacy. Appropriately sized and of the time that could be saved by using unit-of-use packaging in shaped candies were substituted for active medications and load- a typical community pharmacy. As a first step, members of the ed into the bulk bottles. This approach required the teams to select research team observed the dispensing process in several pharma- the proper package from among the bottles in the existing inven- cies. These preliminary observations were made at local pharma- tory while eliminating the need to handle and discard expensive cies representative of chain, independent, grocery store, and clinic products or assume the risk of returning medications to their orig- practice. The results of these initial observations showed that the inal containers. The simulated stock bottles were given labels number of prescriptions requiring transfer from one package to measuring 2 inches by 4 inches with the drug name and strength, another varied from site to site. However, the proportion of cap- the bulk package size, the lot number, and expiration date. Both sules, tablets, and liquids being transferred from bulk containers the unit-of-use and bulk packages were placed in the appropriate to prescription vials and bottles76%, 20%, and 4%, respective- location along with the regular pharmacy stock.
ly—was remarkably consistent. These proportions were adopted Team 1 first prepared the set of 50 prescriptions using the bulk for the mix of dosage forms used in the simulation study.
packages and then filled the set of 50 prescriptions using the unit- For the simulation, we selected a set of 50 prescription prod- of-use packages. Team 2 performed the same tasks in the reverse ucts (see Table 1) from among those ranked by Drug Topics as order; that is, they dispensed the 50 prescriptions using unit-of- the top 200 drugs by prescription in 1999.8,9 The selection includ- use packages first, followed by the 50 prescriptions using bulk ed an equal number of brand-name and generic drug products and packaging. The prescription set was presented in a different order a variety of manufacturers, so that during the simulation the par- each time to offset any learning effects on total dispensing time.
ticipants would traverse all the areas where prescription products The observer started timing when a team member picked up were stored in the pharmacy. We excluded topical medications the first prescription in the set. The time when each prescription and drugs that are almost always dispensed in unit-of-use pack- was deposited into the “completed” bin was recorded on the data ages, such as inhaled and injectable drugs, because the purpose of collection sheet along with the name of the team member who the simulation was to compare dispensing using bulk packaging retrieved and counted the medication. Timing was stopped after with dispensing using unit-of-use packaging.
the last prescription in the set was finished and the stock bottles Journal of the American Pharmaceutical Association
July/August 2002 Vol. 42, No. 4
Unit-of-Use RESEARCH
Table 1. Prescription Orders Used in the Simulationa
aPrescriptions were presented in a different order for each simulation trial.
Source: References 8, 9.
were returned to the pharmacy shelves. The entire simulation was unit-of-use packages, plus the time needed to open the container, recorded with a video camera that imprinted the elapsed time, and pour the contents onto the counting tray, count the correct number the videotape was used to verify the direct observation record.
of dosage units, return any excess to the stock bottle, locate an The times required for bulk and unit-of-use dispensing were appropriately sized dispensing vial, pour the “medicine” into the computed for both teams. All of the prescriptions were examined to prescription vial, and replace the bulk container to the proper shelf.
verify that they contained the proper content and correct quantity.
The total time the two teams needed to prepare 100 prescrip- tions using unit-of-use packaging was 40 minutes. These sametwo teams needed 86.5 minutes to dispense those 100 prescrip- tions when they were required to count or measure the varioustablets, capsules, and liquids that were ordered. The time saved The times recorded for preparing the set of 50 prescription was 46.5 minutes, an average of more than 27 seconds per pre- orders with unit-of-use packages were 19.5 minutes for team 1 scription. This represents a reduction of more than one-half of the and 20.5 minutes for team 2. These results account for the times needed to read the label, walk to the shelf, retrieve the package, When bulk packaging was used in the simulation, the pharma- return to the counter, label the package, have it checked by the cist member of team 1 retrieved the stock bottle and counted the pharmacist, cover the label with tape, place the vial in a bag, and medication for 14 of the 50 prescriptions in the set and performed put the bag in a bin designated for completed prescriptions. the final check for all 50 finished prescriptions. Likewise, the Using bulk packaging, team 1 needed 45 minutes to prepare the pharmacist from team 2 retrieved and counted the medication for same set of 50 prescription orders, whereas team 2 completed the 12 of the 50 prescriptions and checked all the finished products identical task in 41.5 minutes. The timed activities for this part of when bulk packaging was used. However, the pharmacists were the simulation included the steps required for dispensing using primarily occupied with checking the prescriptions when the team Vol. 42, No. 4 July/August 2002
Journal of the American Pharmaceutical Association
RESEARCH Unit-of-Use
prepared them using unit-of-use packaging. The pharmacist However, the relative time savings may be more important than assigned to team 1 retrieved the unit-of-use package from the a precise estimate of the number of minutes that can be saved per storage area for only 1 of the 50 prescription orders; the pharma- prescription or per day. The overall time that could be saved in any cist in team 2 retrieved the package from the storage area for 3 of given pharmacy will depend on the prescription volume and the the 50 orders. Overall, the pharmacists were involved in the actual proportion of prescriptions that require the drug product to be trans- prescription assembly process for 26% of the orders dispensed ferred from the manufacturer’s package to a container for the from bulk stock and 4% of the prescriptions using unit-of-use patient. Another factor that may affect total time is the use of auto- packaging. When dispensing in unit-of-use packaging, the techni- mated counting devices. Irrespective of these differences across cians assembled most of the prescriptions. The pharmacists con- pharmacy practice sites, the results of this study support the conclu- ducted the final check for accuracy of every prescription in both sion that unit-of-use packages save a significant amount of time.
Furthermore, our results suggest that technicians can handle a There were no errors in which the wrong product was used to greater share of the prescription assembly tasks with a unit-of-use fill any prescription order during the simulation. However, four system, while pharmacists may shift their efforts during the time counting errors were found when the bulk-packaged prescriptions gained to activities other than manual order processing. According were examined—two errors by each team. Team 1 prepared one to an NACDS−Arthur Andersen study on pharmacist productivity, prescription with 5 fewer dosage units than ordered and filled a the average pharmacist spends only 31% of his or her time on cog- second with 5 units more than the order specified. Team 2 dis- nitive activities, such as reviewing and interpreting the prescription pensed 10 extra dosage units in one instance and included 1 extra order, assessing patients’ drug therapy, resolving clinical conflicts, contacting physicians, and counseling patients about their prescrip-tions. Based on these results, the study consultants concluded that“a significant opportunity exists to transfer pharmacist time to ancillary personnel.”3 Our results confirm this conclusion. Unit-of-use packaging is one approach that may permit pharmacists to A search of the pharmacy literature yielded one article report- transfer certain work activities to ancillary personnel.
ing detailed information about the time required for preparing Pharmacists often identify cost considerations as the primary unit-of-use sized prescription packages from bulk packaging.
obstacle to adopting unit-of-use packaging. In national surveys of Campbell et al.10 recorded the time required for prepackaging pre- pharmacists conducted by NCPA in 200012 and by APhA in scription drugs as part of their effort to assess the cost-effective- 1985,13 the most frequently cited obstacle to unit-of-use was the ness of prepackaging activities in outpatient pharmacies operated assumption that drug products purchased in smaller package sizes by Kaiser Permanente. They separately measured the average are much more expensive per dosage unit than those supplied in manual packaging time for tablets, capsules, and liquids. Using bulk packages. We tested this assertion in the study pharmacy by their figures, we estimated that unit-of-use packaging would elim- consulting the wholesale price schedule for the prescription prod- inate approximately 45 minutes of time for every 100 products ucts used in the simulation. When we calculated the actual acqui- transferred in a set of prescriptions, given the mix of tablets, cap- sition cost (AAC) of bulk packages and compared it with the sules, and liquids selected for testing in our simulation.
AAC for an equivalent quantity of the same products purchased We found that unit-of-use packaging cut the amount of time in smaller package sizes, the net price difference was $6.31. In required for prescription assembly by a total of 46.5 minutes for our case, this increase in cost would be offset by eliminating the every 100 prescriptions prepared with unit-of-use packaging. This need for a separate prescription vial as well as by the time saved.
represents an average time savings of mose than 27 seconds per Other reports have suggested that unit-of-use packaging can prescription. Heaton et al.11 estimated that unit-of-use containers actually reduce total inventory cost. By requiring fewer units in would generate a savings of 50 seconds per prescription. Their esti- stock at any given time, adoption of unit-of-use packaging mate was derived from videotapes of the dispensing process record- increases inventory turnover and cash flow.6,11 The extent to ed in a busy chain pharmacy during normal business hours. The which unit-of-use packaging would require additional space and videotape was used to document the time needed to perform steps reconfiguration of existing storage space is open to debate.11 that could be eliminated with a unit-of-use package for a random The results of our study also suggest that unit-of-use packag- sample of prescriptions captured on tape; that is, the researchers ing could eliminate counting errors. Overages and shortages have measured the time needed to open the bulk container, count and implications for customer relations, inventory management, and place tablets in a prescription vial, and then cap and label the vial.
therapeutic outcomes. An inadvertent shortage of dosage units in They added time to their results to account for the reduction in trav- an expensive prescription may make a patient distrustful of his or el time between storage areas as an opportunity for further efficien- her pharmacist. Units dispensed in excess of the intended quanti- cies. In comparison with the results reported by Heaton et al.,11 it ty adversely affect profits, and perhaps, lead to overuse of the appears that our simulation represents a conservative estimate of medication. In addition to ensuring accurate quantities, unit-of- the time savings possible with unit-of-use packaging.
use packaging increases patient safety by maintaining Journal of the American Pharmaceutical Association
July/August 2002 Vol. 42, No. 4
Unit-of-Use RESEARCH
product integrity, allowing for a bar-coded label to be attached and new opportunities for patient-oriented pharmacy practice from the point of manufacture through delivery to the patient, emerge. Unit-of-use packaging is one way to help pharmacists and by giving the patient access to the manufacturer’s expiration reduce the time they devote to dispensing. The time saved could date and lot number in the event of a product recall.
permit pharmacists to oversee the processing of an increased vol- Most developed nations use unit-of-use packaging for pharma- ume of prescriptions and to provide cognitive services such as ceutical products, including Canada, Australia, New Zealand, and drug therapy management. Adoption of unit-of-use packaging most countries in Europe and South America.7 Undoubtedly, the may also help to clarify the complementary roles of pharmacists widespread adoption of unit-of-use packaging in the United States and pharmacy technicians. Unit-of-use packaging may offer addi- would require substantial changes in manufacturing and storage tional benefits in terms of reducing dispensing errors.
throughout the channel of distribution. It might also require a This study was funded by a grant from the Institute for the Advancement change in prescribing practices and, possibly, changes in the regu- of Community Pharmacy. The authors declare no conflicts of interest or lations governing pharmacy. Furthermore, the adoption of unit-of- financial interests in any product or service mentioned in this article, use could not occur without the consensus and cooperation of including grants, employment, gifts, stock holdings, or honoraria.
pharmaceutical manufacturers, medicine, pharmacy, nursing, The authors acknowledge the advice and assistance of Barbara F. Brice,PhD, in conducting this research.
government agencies, and consumer groups.6 In 1992 APhA adopted a policy opposing the exclusive use of A portion of this study was presented in a poster session at the AnnualMeeting of the American Pharmaceutical Association in San Francisco, unit-of-use packaging, and the National Wholesale Druggists Calif., March 18–9, 2001, and at a seminar titled Unit-of-Use: Pros and Association (now the Healthcare Distribution Management Asso- Cons for Community Pharmacy in Washington, D.C., May 9, 2001.
ciation) took the position that the demands of the competitivemarketplace would be the best way to establish whether unit-of-use packaging is useful and cost-effective.7 References
1. National Association of Boards of Pharmacy. Task Force on Pharmacy Manpower Shortage. Chicago, Ill: National Association of Boards of Pharmacy; 2000. 1999–2000 Committee and Task Force Reports.
2. Arthur Andersen, LLP. Pharmacy Activity Cost and Productivity Study. Arlington, Va: National Association of Chain Drugstores; 1999. Avail- It is possible that the precision of the estimated time savings able at: www.nacds.org/wmspage.cfm?parm1=609. Accessed May 10,2002.
was limited by interruptions. Although the simulation took place 3. Report to the APhA House of Delegates Strategic and Tactical Analysis after normal business hours, unexpected distractions occurred, Team (STAT) on Practice Environment and Quality of Worklife. Wash-ington, DC: American Pharmaceutical Association; 2000.
including the noise of telephone messages being recorded on the 4. Implementing Effective Change in Meeting the Demands of Communi- answering machine and the appearance of a patient who needed ty Pharmacy Practice in the United States [white paper]. Washington, an emergency prescription. Time was also lost in locating a mis- DC: American Pharmaceutical Association, National Association ofChain Drug Stores, National Community Pharmacists Association; placed stock bottle and replenishing office supplies. Although 1999. Available at: www.aphanet.org/stat/whitepaper.pdf. AccessedMay 10, 2002.
timing was suspended when there was an interruption, these dis- 5. The Pharmacist Workforce: A Study of the Supply and Demand for tractions could have interrupted the workflow and affected the Pharmacists. Rockville, Md: Bureau of Health Professions, Health precision of our time estimates. Nevertheless, both teams experi- Resources and Services Administration. U.S. Department of Healthand Human Services; 2000. Available at: http://bhpr.hrsa.gov/health- enced a similar number of interruptions, and their times were workforce/pharmacist.html. Accessed May 10, 2002.
6. Unit-of-Use Packaging: Contemporary Issues [conference workbook].
Rockville, Md: United States Pharmacopeial Convention, Inc; 1993.
Two factors support the reliability and validity of the time esti- 7. A Review of Unit-of-Use Packaging. Washington, DC: American Phar- mates. First, the times for the two teams were similar in both parts of the simulation. When using bulk packaging, the two teams fin- 8. Top 200 brand-name drugs by prescriptions in 1999. Drug Topics. ished within 3 minutes and 32 seconds of one another. In the unit- 9. Top 200 generic drugs by prescriptions in 1999. Drug Topics. March 6, of-use packaging simulation, the times differed by 58 seconds.
The total time difference for entire exercise was 2 minutes and 30 10. Campbell WH, Christensen DB, Johnson RE, Booker SF. Identifying seconds. Second, the total time savings of 46.5 minutes was con- economic efficiencies resulting from a drug prepackaging program.
Am J Hosp Pharm. 1974;31:954–60.
sistent with the predicted time savings of 45 minutes that was 11. Heaton PC, Lin AC, Jang R, et al. Time and cost analysis of repackaging based on data reported by Campbell et al.10 medications in unit-of-use containers. J Am Pharm Assoc.
2000;40:631–6.
12. Unit-of-use survey results. Presented at: National Association of Chain Drug Stores/National Community Pharmacists Association Seminar on Unit-of-Use; May 9, 2001; Washington, DC.
13. APhA Policy Committee on Scientific Affairs. Background Paper on Unit-of-Use Packaging. Washington, DC: American Pharmaceutical The pharmacy manpower shortages that exist today are predict- ed to worsen in the near future as prescription volume increases Vol. 42, No. 4 July/August 2002
Journal of the American Pharmaceutical Association

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