Dosette Boxes Research Articles

Ordering medication for hospital inpatients in England: pharmacy staff decision on the type and duration of supply

Abstract Introduction In the last few decades, hospital pharmacies have introduced new medication supply systems to increase safety and cost-efficiency1. Hospitals currently use a mixture of inpatient supply types, including ward stock, “one-stop” dispensing (OSD) and non-OSD patient labelled dispensing. A mixed supply model has become the dominant system in the UK1 despite some criticism2 and has been introduced in other countries3. There is no current guidance for deciding the type and duration of inpatient supply, and little known about how pharmacy staff make this decision. Aim To explore how pharmacy staff decide on type and duration of medication supply for hospital inpatients in an English teaching hospital organisation. Methods A list of 19 factors was developed through discussions with pharmacy staff. These were arranged into four categories: medication, patient, treatment, and miscellaneous. An online survey was designed using Qualtrics. This explored staff perceptions of the importance of each factor when making decisions, separately for type and duration of supply, using a 5 point Likert scale ranging from 1 (”not at all”) to 5 (“a great deal”). A free-text box was available to add any additional factors. All pharmacy staff responsible for ordering patient-specific medication were invited to take part. Demographics were collected, participation was voluntary and all response data anonymous. Responses were subjected to descriptive statistical analysis using Microsoft Excel. A pre-selected subset of factors were compared using Mann-Whitney U tests. The study was approved as a service evaluation in the organisation concerned; therefore ethical approval was not necessary. Results There were 47 pharmacist and 10 medicines management pharmacy technician (MMPT) responses (response rate 32% for each group). For decisions both about supply type and duration, 14 factors were considered important (median score 4 or 5) with “patient on dosette box” and “duration of treatment” rated 5. Others with a median of 4 included “high risk patient”, “medication route/formulation”, “day of the week” and “drug history completed”. Only one factor, “nurse skill set on ward”, was considered unimportant (median score 2). The remainder were considered moderately important (median score 3). Statistical analysis suggested that some factors were significantly more important in certain groups. The factor “medication screened by a pharmacist” appeared less important to pharmacists versus MMPTs (p=0.0002) and less important to staff employed at the trust for longer than 10 years versus those employed less than this (p=0.0011). Discussion/Conclusion Results of this study provide valuable insight into the factors pharmacy staff consider when deciding on the type and duration of inpatient medication supply. To our knowledge, no previous studies have explored the factors influencing this kind of decision-making. Limitations include a small sample size, and that we focussed on which factors were more or less important rather than how they were used to guide decisions. We conducted some sub-group analysis, but the project was not powered to demonstrate statistical significance. This could now be addressed with the results of this survey enabling a power calculation. Further work using semi-structured interviews is currently underway to further explore how the factors influence decision making.

Dosing practices made mundane: Enacting HIV pre-exposure prophylaxis adherence in domestic routines.

Maintaining routines of medication dosing requires effort amidst the variabilities of everyday life. This article offers a sociomaterial analysis of how the oral HIV prevention regimen, pre-exposure prophylaxis (PrEP), is put to use and made to work, including in situations which disrupt or complicate dosing regimes. Other than a daily pill, PrEP can be taken less frequently based on anticipated sexual activity and HIV risk, including 'on-demand' and 'periodic' dosing. Drawing on 40 interviews with PrEP users in Australia in 2022, we explore PrEP and its dosing as features of assemblages in which bodies, routines, desires, material objects and the home environment interact. Dosing emerges as a practice of coordination involving dosette boxes, blister packs, alarms, partners, pets, planning sex, routines and domestic space, and as an effect of experimentations with timing to suit life circumstances and manage side effects. Dosing is materialised in the mundane; a practice that is made to work, as well as domesticated, in its situations. Although there are no 'simple' solutions to adherence, our analysis offers practical insights into how routine, planning and experimentation come together to capacitate PrEP to work in people's lives, in sometimes unexpected ways, including through adaptations of PrEP dosing.

Yonder: Drunkorexia, dosette boxes, doctor shopping, and slums.

Yonder: Drunkorexia, dosette boxes, doctor shopping, and slums.

Dispensing care?: The dosette box and the status of low-fi technologies within older people's end-of-life caregiving practices.

Technology has been lauded as a solution to range of challenges presented by ageing population internationally. While the lion‐share of scholarship has focussed on high‐fi, digital technologies, there has been a recent shift to exploring the contributions mundane, low‐fi technologies make to older people's daily lives and our understandings of health, illness and care more broadly. Drawing from serial narrative interview data collected with 19 married couples aged 70 and over living in the U.K., this article explores the way one medical technology—the dosette box—was taken‐up and deployed in their end‐of‐life caring process. Informed by actor–network theory and critical feminist scholarship, this article considers how the dosette box played an active role in structuring relationships, scheduling daily care activities and enforcing medical compliance. In doing so, we suggest that the dosette box provided an unexpected companion and ‘weapon of the weak’ for older partner's attempting to assert their expertise and power while caring. We also explore how the dosette box demanded an even higher level of regular, vital care from older partner's once introduced into the home, thus entrenching the physical and emotional demands of dispensing care.

Organising polypharmacy: unpacking medicines, unpacking meanings—an ethnographic study

ObjectivesWe explore how older patients affected by polypharmacy manage the ‘hidden work’ of organising their medicines, how they make sense of this work and integrate it into their lives.Design and...

SP9 The KidzMed project part 1: pill popping heroes

BackgroundThere are large groups of children where families have problems obtaining ongoing supplies of their children’s medicines in primary care due to them being high risk and complex, unlicensed, off label or expensive. The KidzMeds project was established ‘For all children to get the right medicine at the right dose at the right time with the right monitoring with minimum fuss wherever they live.’Tablets are safer, more convenient and cheaper than liquid medications. Children often remain on liquid due to habit, reluctance and parental and staff not knowing how to convert. The idea of converting came from initial HIV medications which were only available in tablets1; children as young as 3 years could be taught.2 3AimQuality improvement project to teach children and young people (CYP) on long term medication how to take tablet medication in an out-patient setting.MethodWorking with families and our teams we created an interactive training package with video (http://northernpaediatrics.com/kidzmed/) and comic poster. We ran interactive hour-long training sessions for staff. Using positive reinforcement and play, the trainer sat facing the learner with sweets or dummy filled capsules of increasing sizes, from size 3 (15 mm) to size 00 (23 mm).Over the next 12 weeks in one team we embedded a process for children ≥5 years attending complex renal clinics to be converted from liquid to tablet medication unless contraindicated (e.g. swallowing or cognitive impairment).Outcome measures included successful conversion rate, patient and staff feedback and cost savings.We overcame practical barriers by placing easily accessible ‘switching kits’ in clinic filled with the necessary dummy pills, awards and certificates. To increase confidence, we created a sealed dosette box with common medications so children could see the size of tablets they needed to swallow. Working with the clinical team we standardised processes (e.g. how to round doses, pre-screening clinic lists and creating prompts).ResultsOver three months, 90 CYP were seen in 13 multi-disciplinary renal clinics, 25 were suitable for conversion to tablet medication. 21 CYP (median age 8.4 years range 5.1 to 15.5) were successfully converted (only one patient required two sessions). 36 medicines were switched, generating £46,500 per year recurrent savings.Feedback was good. Staff liked the opportunity for positive interaction with children and families appreciated the ease of obtaining tablet medications versus liquids. We subsequently trained other teams, including our research team who were recruiting for a study in which swallowing tablets is an inclusion criteria.ConclusionsIn a short timeframe it is possible to embed a system to convert children to tablet medication, improving patient experience and realising considerable cost savings. It requires staff training and cultural change. Pill swallowing is an easy skill to teach and learn and children as young as five can successfully swallow pills. We automatically teach inhaler technique so equally we should teach CYP how to swallow tablets as a skill for life. We would encourage all units to set up pill swallowing training.ReferencesFischl MA, et al. The efficacy of azidothymidine (AZT) in the treatment of patients with AIDS and AIDS-related complex. NEJM 1987;317:185–91Garvie PA. Efficacy of a pill-swallowing training intervention to improve antiretroviral medication adherence in pediatric patients With HIV/AIDS. Pediatrics 2007;119:e893–e899Patel A, et al. Effectiveness of pediatric pill swallowing interventions: a systematic review. Pediatrics 2015;135:883–889

Understanding Visual Impairment and Its Impact on Patients: A Simulation-Based Training in Undergraduate Medical Education.

Introduction:Simulation activities are valuable teaching aids for understanding about living with visual impairment (VI). Our medical students used low-vision simulation spectacles (Sim-specs) to enable learning about VI.Methods:Students made tea and filled dosette boxes using Sim-specs simulating central visual loss (age-related macular degeneration) and navigated using Sim-specs simulating peripheral visual loss (glaucoma). Facilitators recorded errors made for each task. Students completed questionnaires to grade the tasks’ difficulty on a 4-point Likert-type scale. The students also participated in focus groups to discuss how their approach to working with patients may change following this training.Results:In total, 252 out of 254 students participated. Central visual loss provided the greatest challenge when undertaking fine motor skilled activity (dosette box). Highest average number of errors made was for dosette box task (0.70 error), followed by navigation (0.59), then making tea task (0.34). Students scored the most difficult task on average as the dosette box task (3.23 Likert-type points), followed by navigation (2.97), then making tea task (2.63). Our students have shown learning in recognising the challenges of VI and have adapted their approach to patients.Conclusions:Simulation activities are valuable additions to the undergraduate curriculum. Such activities can potentially enable greater empathy for our visually impaired patients.

Viewpoint: A taste of my own medicine.

I was recently asked to speak at our local trust induction for the new Foundation Year 1 doctors. The thrilling subject matter I was entrusted to cover was discharge summaries. When I arrived, there was an action-packed schedule essentially telling the new doctors what not to do, how not to get in trouble, and one talk (I wish I could have stayed) aptly entitled ‘how not to kill people’. The new recruits looked pale and clammy, and there was a definite sense of impending doom. Perhaps they were hungover, but, sadly, I’m pretty sure they weren’t. I was tasked with imparting the importance of timely, concise discharge summaries, ensuring they avoid the dreaded phrase ‘GP to chase’ and know how to write a fit note. I’m not sure how helpful it all was — talk of dosette boxes as their minds swum with more pressing …

‘Has she seen me?’: a multiple methods study of the pharmaceutical care needs of older people with sensory impairment in Scotland

ObjectivesTo explore the pharmaceutical care needs of, and service provision to, older people with sensory impairment (visual, hearing and dual impairment) on prescribed polypharmacy (≥4 medicines) in Scotland.DesignInterviews were conducted...

Impact of a Universal Medication Schedule on rationalising and understanding of medication; a randomised controlled trial.

Patients frequently encounter difficulty understanding their prescription drug labels. This problem is more common in patients with limited health literacy (HL). Patients are not always counselled on their medicines by their doctor or pharmacist, therefore this label can be an important source of information. To assess the impact of a Universal Medication Schedule (UMS) on the knowledge and consolidation of a prescription drug regimen compared to standard pharmacy labelling. Seventy-six in-patients at a specialised rehabilitation hospital in Dublin, Ireland, were randomised into control (usual care) or intervention (UMS) groups. Adult in-patients, receiving oral medicines, who spoke English fluently were included. Patients with dexterity issues documented, or those unable to provide written informed consent were excluded. The Newest Vital Sign (NVS) and validated HL screening questions measured HL. A five medication regimen was presented to each participant, and they were asked questions to assess their understanding of the medication regimen and were asked to dose out the medications into a 24 h dosette box. Data analysis was conducted using SPSS® (IBM Corp.), V23. The majority of participants (n = 76) were Irish (89.5%), male (63.2%) and the median age of participants was 49 years. 46% of participants had a third level qualification, however 14.4% of participants had not completed any formal school examinations. Those in the UMS group displayed better understanding of the prescription regimen than those in the usual care group, but this was not statistically significant. (Mean score 9.28 vs 8.81, p = 0.135). Subgroup analysis did not find any additional benefit of UMS in those with limited health literacy (Mean score 8.56 vs 9.06, p = 0.514) but rather in those who said that they found instructions on tablets hard to understand (Mean score 10.00 vs 8.43, p = 0.019). A UMS approach may improve patients understanding and use of their medicines.

The e-multidose is better for patients’ safety than dosette boxes and faxes

The e-multidose is better for patients’ safety than dosette boxes and faxes

Pharmaceutical care services to people living with dementia in care homes: A qualitative study of community pharmacists' perceptions.

There is a paucity of information on the perceptions of community pharmacists about the nature and effectiveness of pharmaceutical care services they provide to people living with dementia in care homes. This paper explores pharmacists’ perceptions of the nature and effectiveness of pharmacy services provided, and their experiences when providing these services. Community pharmacists delivering services to care homes with dementia in Thurrock, Essex and in Medway, Kent, England were invited to participate in the study involving face-to-face interviews. Analysis of semi-structured interviews with 15 community pharmacists revealed that the main pharmaceutical service provided by the pharmacists was prescription processing, normally involving the clinical review and supply of medication into monitored dosage systems (dosette boxes) and delivery to the homes. This was coupled with advice to care homes on the appropriate storage and administration of drugs and appliances supplied, which was in line with the NHS Community Pharmacy Contractual Framework Enhanced Service for care homes. A majority of the community pharmacists interviewed acknowledged that the services they were currently commissioned to provide did not meet the pharmaceutical care needs of dementia patients in care homes, including the monitoring of the appropriateness, safety and effectiveness of drug therapy.

AN AUDIT TO ASSESS THE TIMINGS OF TTAS AND INPATIENT ORDERS IN PAEDIATRICS; FROM WRITING, TO SCREENING, TO DISPENSING, AND TO LEAVING DISPENSARY

AimTo assess the time it takes for paediatric TTA and inpatient orders to be dispensed and sent to ward. This is to establish if the Trust is meeting an operational...

How complete are our clerkings? A project aimed at improving the quality of medical records by using a standardised proforma.

Clerking a patient is the first and most important contact that any medical team has with the patient. It provides information that may not be available later in the admission if recorded improperly, such as referral letters, collateral history, dosette boxes or prescription sheets. The quality of data recorded from this encounter was examined at a busy district general hospital surgical department. Initial measurement demonstrated that less than half of certain key parameters like dosages of medication were being recorded by clerking doctors. A clerking proforma was therefore designed to combat this problem. Over three audit cycles (n = 170, 150, 174) the proforma showed statistically significant improvements in the proportion of data that was captured at initial contact with the patient. We conclude that the introduction of proformas for clerking significantly improves the collection of data that impacts patient care during their hospital stay.

Advice on dosette boxes highlights lack of evidence

Advice on dosette boxes highlights lack of evidence

Stability of Dispersible Aspirin Tablets Repacked into Dosette Boxes

ABSTRACTBackgroundAlthough guidelines indicate that dispersible aspirin tablets should not be repacked into dose administration aids, it is common practice especially among older people.AimTo determine the stability of acetylsalicylic acid (ASA) in aspirin tablets repacked into Dosette boxes.MethodDispersible aspirin 300 mg tablets were removed from their primary (foil) packaging, and repacked as whole and split (halved) tablets into Dosette boxes under 4 storage conditions: refrigeration (2–8 °C), controlled room temperature (25 °C; 60% relative humidity [RH]), accelerated (40 °C; 75% RH), and ‘in‐use’ with natural variations in daylight exposure and internal temperature fluctuations (23–26 °C; 45–60% RH) for 1 week. The high performance liquid chromatography method developed was validated for accuracy, precision, linearity and range, sensitivity, robustness and specificity, and the suitability of extraction media evaluated.ResultsLinearity (r2 > 0.999), precision (relative standard deviation < 2%) accuracy (recovery: 95–102%) and selectivity for the high performance liquid chromatography method were confirmed. The ASA content remained within specifications (95–105% of labelled amount) for all except the accelerated storage condition, with 93% of the ASA remaining. The split tablets did not display any additional ASA degradation when compared to the whole tablets under the same conditions.ConclusionWhile the ASA content of the dispersible aspirin tablets remained within specifications at room temperature, there were changes in the physical appearance under accelerated storage conditions.

Retrospective analysis of DATIX dispensing error reports from Scottish NHS hospitals

The primary objective was to analyse reported dispensing errors, and contributing factors, in Scottish National Health Service hospitals by coding and quantifying error reports from the DATIX patient-safety software. The secondary objective was to gather managerial responses to dispensing error in order to gain a perspective on interventions already in place. Incident reports collected from 23 Scottish hospitals over a 5-year period were analysed retrospectively. Reported incident types, contributory factors and managerial responses were categorised according to the event description, and the frequency of such factors calculated. Dispensing errors (n = 573), from both pharmacies and wards, were analysed. The main incident types were incorrect drug (19.2%, n = 110) and incorrect strength of drug (16.8%, n = 96). The main contributory factors were reported as drug name similarity (15.5%, n = 30) and busy wards/pharmacies (14.9%, n = 29). Patient-centred issues (6.1%, n = 12) also featured. Managerial responses to these errors took the form of meetings (16.7%, n = 42), increasing staff awareness (14.7%, n = 37) or staff reminders on the importance of checking procedures (17.9%, n = 45). The pattern of incidents reported is similar to previous research on the subject, but with a few key differences, such as, reports of errors associated with filling dosette boxes, and patient-centred issues. These differences indicate a potentially changing pattern of errors in response to new techniques in medicine management. Continued assessment of dispensing errors is required in order to develop practical interventions to improve medication safety.

Dose administration aids: Pharmacists’ role in improving patient care

Dose administration aid (DAA) usage has become increasingly prevalent among populations worldwide and as such has become an important part of pharmacy practice. The evidence for the use of these aids has been favourable in Australia resulting in 2006 in a community based DAA program being considered by the Australian Government Department of Health and Ageing PPSAC (Professional Programs and Services Advisory Committee) and the first phase of this program implemented in October 2007. The program was established under the Better Community Health Initiative of the 4(th) Community Pharmacy Agreement between the Pharmacy Guild of Australia and the Commonwealth Government. The aim of this program is to reduce medication-related hospitalisations and adverse events through improved medication management and adherence by people in the community. The most common patient groups that access this service include the elderly, who are often on several different medications, and patients with cognitive disabilities who may have trouble understanding or remembering their dosage regimes.Repackaging of a medication, involving removal from its primary packaging invalidates the stability guarantee of the manufacturer. It is in fact the role of the healthcare team to ensure optimal patient care by making an informed judgment as to the effect on the quality and safety of this repackaging process. Drug manufacturers, on the whole, tend to discourage repackaging of medications and there is little quality data available to support this process. Indeed, only a small number of medications have been investigated for their stability following repackaging into DAAs, namely atenolol, paracetamol, frusemide, prochlorperazine, sodium valproate, aspirin (dosette boxes) and clozapine. This paper will review the repackaging of medications into DAAs and the role that the pharmacist plays in this process to improve patient care, in addition to presenting the Australian research that has contributed substantially to the body of information available internationally on the quality implications, relating to the stability of medicines repackaged into DAAs.

Dose administration aids: Pharmacists' role in improving patient care.

Dose administration aid (DAA) usage has become increasingly prevalent among populations worldwide and as such has become an important part of pharmacy practice. The evidence for the use of these aids has been favourable in Australia resulting in 2006 in a community based DAA program being considered by the Australian Government Department of Health and Ageing PPSAC (Professional Programs and Services Advisory Committee) and the first phase of this program implemented in October 2007. The program was established under the Better Community Health Initiative of the 4(th) Community Pharmacy Agreement between the Pharmacy Guild of Australia and the Commonwealth Government. The aim of this program is to reduce medication-related hospitalisations and adverse events through improved medication management and adherence by people in the community. The most common patient groups that access this service include the elderly, who are often on several different medications, and patients with cognitive disabilities who may have trouble understanding or remembering their dosage regimes.Repackaging of a medication, involving removal from its primary packaging invalidates the stability guarantee of the manufacturer. It is in fact the role of the healthcare team to ensure optimal patient care by making an informed judgment as to the effect on the quality and safety of this repackaging process. Drug manufacturers, on the whole, tend to discourage repackaging of medications and there is little quality data available to support this process. Indeed, only a small number of medications have been investigated for their stability following repackaging into DAAs, namely atenolol, paracetamol, frusemide, prochlorperazine, sodium valproate, aspirin (dosette boxes) and clozapine. This paper will review the repackaging of medications into DAAs and the role that the pharmacist plays in this process to improve patient care, in addition to presenting the Australian research that has contributed substantially to the body of information available internationally on the quality implications, relating to the stability of medicines repackaged into DAAs.

Partial Compliance With Antipsychotic Medication is Common in Patients With Schizophrenia

Partial compliance with antipsychotic medication increases relapse and rehospitalization rates in patients with schizophrenia. The aim of the present study was to assess the frequency of and factors contributing to partial compliance. During a 10 day period in June 2004 psychiatrists working in hospitals or in private practices in Germany were asked to participate in a compliance survey. Physicians were requested to evaluate the compliance in 10 patients with schizophrenia using a questionnaire consisting of 10 questions. The frequency of unintentional and intentional partial compliance as well as patient-related contributing factors were assessed. Unintentional partial compliance was defined as the lack of drug intake on any day during the past month. Demographic data of participants were collected. Responses were analysed using descriptive statistics and generalized estimation equation models. The psychiatrists (n=699) regarded 68% of the evaluated patients (n=5729) as unintentionally partially compliant within the last month. Sixty-nine per cent of the patients were considered intentionally partially compliant in the past. The most frequently assessed patient-related factors contributing to the partial compliance were lack of insight into the need for prophylactic medication (68%), lack of insight/denial of illness (66%/63%), feeling embarrassed at taking medication every day (62%), needing someone to remind them to take their medication (62%), cognitive problems (55%), and living conditions inappropriate for compliance (46%). Partial compliance is a common problem in schizophrenia. Strategies to improve partial compliance derived from the contributing factors identified in the present study may include regular telephone reminders by case managers or families, adequate support in the patients' environment, use of dosette boxes, rationalizing drug regimens (e.g. once-daily dosage, monotherapy, depot medication), and psychoeducation.