The importance of pharmacist surveillance in a unit dose drug distribution system

A study was conducted at a Public Health Service Hospital to determine if the pharmacist could provide important services to patient care while simultaneously performing the repetitious acts involved in unit dose drug distribution. During two five-week periods, the pharmacist actively questioned requests by the nursing staff for additional doses of medication to determine why these additional doses were needed. Also, during these periods the pharmacy actively questioned all doses returned in the dose medication carts which, according to doctor's orders, should have been administered to the patient. Results of these studies included the detection of some potentially dangerous deviations from accepted medication administration times (i.e., "twice" a day order given only four hours apart) as well as other problems, such as missed orders, medication "borrowing" which sometimes magnified errors, and underdosing. The conclusions from the studies are that the pharmacist can provide essential services while simultaneously performing the repetitious tasks of filling, checking, and exchanging unit dose medication cassettes.