A qualitative systemic analysis of drug dispensing in Swiss hospital wards

The traditional floor stock drug distribution system entails that, in most Swiss hospitals, drugs are prepared in a pillbox for each patient by nurses before administration. The aim of this study was to analyse and evaluate the process of inpatient pillbox dispensing in Switzerland.

Internal medicine wards in three regional hospitals (32-39 beds).

A qualitative exploratory study with 4 days of participant observation and three semi-structured interviews on each of the three wards.

Thematic content analysis of observations, casual conversations and semi-structured interviews.

Pillboxes are prepared in a somewhat tumultuous context. The space for preparation is not isolated from health carers' other activities which makes it prone to numerous interruptions. Drug blisters and tablets often lack the necessary inscriptions to identify them as unit doses. Storage places are small and unstructured. Nurses have to translate medical orders into the name and dosage of the hospital formulary drugs. Use of patients' own drugs hampers both storage and preparation. Nurses take easily a task over one from another, which affects continuity. Practices vary and few standard rules have been set. The position of nurses in the medication process makes them routinely compensate for failures and gaps from healthcare workers involved in the upper stream of their tasks, without any opportunity of giving some feedback.

The preparation of a pillbox is error prone not only because single doses of oral drugs are not identifiable in a safe way, but also because of various context-related factors. The latter can be grouped into four categories that are linked in a dynamic relationship: tools, practices, organization and information transmission. Improvement strategies should consider all four categories as well as the specific position of nurses in the medication process which makes them fundamental guarantors of the system resilience.