Chapter 10. Unit-Dose Drug Distribution Systems

Medication errors are especially likely when health professionals engage in multiple tasks within a short time span. This situation occurs repeatedly in hospitals when pharmacists and technicians load unit-dose carts, and when nurses administer medications. Unit-dose carts are prepared daily, often manually, by technicians and then checked by pharmacists. These carts, containing thousands of patient-specific dosages of drugs, are sent to the wards daily, for nurses to administer medications to patients. Dosing frequencies vary widely, ranging from regular intervals around the clock to “stat” doses given to control acute pain or other symptoms. Medication administration alone is an enormous task for nurses, and one in which they are repeatedly interrupted. It is not surprising that the administration phase of medication use is particularly vulnerable to error. Unit-dose dispensing of medication was developed in the 1960s to support nurses in medication administration and reduce the waste of increasingly expensive medications. Most of the investigations of medication errors and unit-dose dispensing took place from 1970 to 1976. Now, unit-dose dispensing of medications is a standard of practice at hospitals in the United States. This chapter reviews the evidence supporting this practice.