Currently I am working in a nearby hospital pharmacy for my IPPE site. Unlike retail pharmacies (CVS, Walgreens, etc.), most hospitals, including mine, dispense medication by unit dosing. Unit dosing is a technique that enables efficient and accurate dispensing of a single dose to the patient, in a non-reusable container. Before I started working at this hospital that I will call ‘HIPPE,’ I thought that these unit dose packages came from the manufacturer. In all actuality, HIPPE has a machine called a ‘MPI’ that packages individual pills itself. To operate the MPI, a technician finds a medication that needs more unit dose packages, grabs the bottle of that medication, types the information in the computer, inserts each pill individually in a little slot, turns on the machine, logs what they filled, and then it is the pharmacists job to check over the medication and make sure all the data lines up. The packaging of the unit dose medications at HIPPE has one side that says the strength, NDC, medication, etc., while the other side is a ‘see threw’ orange plastic. Since you probably have not had the experience of seeing what the unit dose medications look like at HIPPE, it personally reminds me of going to Costco and getting a gummy vitamin sample that was packaged all alone with a tiny paper of information on inside.
("opack 150/6 automated," )
The invention of the MPI is absolutely AWESOME! It allows for a huge decrease in medical errors because each individual pill contains all the information on it that traces it back to the very single bottle it came from. Personally, I have noticed some possible errors this machine could cause. Just imagine if a technician typed up the correct information for one medication, but accidently filled it with another ‘look alike’ pill. When the pharmacist receives the pills to verify, hopefully he/she would catch this mistake. I say hopefully, because if the pill looks similar to the other medication, it may be difficult to notice any differences because the orange plastic is very difficult to see the medications detail (unless it is opened). I’m not sure because I never thought about this, but hopefully the pharmacist opens up at least 1 unit dose container to make sure it is the right pill; if it was a different medication, could you imagine all the possible medical errors? Or on the other hand, what if only one of the unit dose containers got filled with the wrong medication? Will the pharmacist catch it then, or will they notice when it goes out to the patient? (This is all just hypothetical FYI)
("The changing faces," 2006)
In my previous blog I told you that I’m not great with technology. I didn’t mention that I happen to define Murphy’s Law as well. For some reason, if it can happen, it just will! Anyways, my second day at HIPPE one of the student technicians introduced me to the MPI and she demonstrated how to use it. I was extremely fascinated and thought of all the fun things that could be done with this machine (like individually wrapping candy, or making funny labels like the ones they have at Spencers; FYI, I wouldn’t really do this, I just like to think about doing it). Next thing I know, the machine stopped working correctly. It ran out of the orange plastic film, so a technician had to come over and change it for us. The student technician continued to fill several more pills of medication ‘Z.’ As the pills went through the machine, some of the labels were cut off in the wrong area, multiple Zs were put in one package or the packages had no Zs at all, and some Zs were even crushed. In the end, the MPI wasted probably about 10 pills and probably about 30 potential labels and orange film backings. If this happens often (which I don’t believe it does), is unit dosing really more efficient?? When it comes down to filling the actual medication within the pharmacy, the technician grabs a unit dosed package, scans it, puts however many the order needs in a bag, and sends it off to the pharmacist. If the end product is going straight to the patient, does all the extra sequences in filling this medication make it worth it? YES, it does! If all goes right, each pill is INDIVIDUALLY AND CORRECTLY LABELED. With all the errors this decreases, including patient compliance errors, just think of the decrease in costs due to medication errors alone.
Images from:
opack 150/6 automated blister packaging machine. (n.d.). Retrieved from
The changing faces of unit-dose. (2006, March 3). Retrieved from
