Journal of Palliative Care & Medicine
Open Access

Unit-dose dispensing systems; Krankenhauszukunftsgesetz; Nursing relief; Closed Loop medication management; Medication safety; Digitalization

UDDS: Unit-Dose Dispensing System; CLMM: Closed-Loop Medication Management; KHZG: Krankenhauszukunftsgesetz (hospital future act); ADC: Automated Dispensing Cabinets; CPOE: Computerized Physician Order Entry

In Germany, the need for modernizing hospital infrastructure and improving patient care has been recognized. The Krankenhauszukunftsgesetz (hospital future act, KHZG), which was enacted in September 2020, mandates the modernization and digitalization of hospital infrastructure to ensure better patient care and efficiency. A fundamental component of KHZG is the establishment of a Closed Loop Medication Management (CLMM). This system encompasses Computerized Physician Order Entry (CPOE), prescription validation by clinical pharmacists, patientoriented logistics, and electronic documentation of medication administration [1]. Unit-Dose Dispensing System (UDDS) is one way of implementing patient-orientated logistics. Each blister contains a barcode that should be scanned together with the patient’s wristband. This will simplify electronic documentation and help nurses administer the right medication at the right dose and the right time, to the right patient (last step of CLMM) [1,2]. By integrating UDDS into the hospital system, the CLMM is greatly enhanced and the final step, electronic documentation of administration, is strongly supported.

As an individual component of the CLMM, UDDS also contributes to an improvement in drug management, aiming to enhance patient safety and improve operational efficiency [3]. UDDS involves the centralized preparation and distribution of individually packaged doses of medication, tailored for each patient. The system minimises the occurrence of medication errors, optimises the management of pharmaceutical supplies, and alleviates the workload of nursing staff, in part due to the monitoring of medication by clinical pharmacists [4].

This mini-review evaluates the practical experiences and time savings associated with the introduction of UDDS in a large teaching hospital, with a particular focus on the system’s acceptance among nursing staff and its impact on medication-related processes. Additionally, the review discusses the implications of UDDS within the framework of KHZG and its role in achieving the CLMM.

The introduction of UDDS has been shown to streamline medication management processes significantly. In the study at Helios Kliniken GmbH, nurses reported a reduction in the time required for medication dispensing from 4.52 minutes to 1.67 minutes per day per patient, resulting in substantial time savings and a 50% reduction in overall medication process time. Notably, the time savings were not limited to medication dispensing alone. Nurses also experienced a reduction in the time needed for ordering medications. The streamlined process of UDDS led to a more efficient and accurate ordering system, reducing the time required for medication ordering tasks [4]. This comprehensive reduction in time required for both dispensing and ordering medications highlights the efficiency gains achieved through UDDS implementation. Similar outcomes were also presented by working groups from Cologne and Linz [5,6]. In these locations, time reductions of 46%-62% were observed in the medication process, with the extent of the reduction varying according to the specific sub-steps considered [5,6]. This indicates that UDDS can effectively alleviate the workload on nursing staff and improve efficiency in medication administration.

One of the key aspects of training for nursing staff is the implementation of physicians’ orders. This also encompasses the dispensation and administration of medication in accordance with the 6R rule.

This rule states that the right drug is administered to the right patient in the right dosage and at the right time in the right form, and that the drug administration is documented in the right way [2]. The statement “dispensing drugs=essential part” supports that nurses consider drug dispensing as an essential and important aspect of their work (Figure 1). As nursing staff sees the administration of medication as a fundamental and important part of their work, the introduction of an automated dispensing system could lead to a real or even perceived loss of these competences. Obviously, however, this is not perceived as such by colleagues in the care sector. Three quarters of those surveyed do not fear losing this core competence.

Figure 1: Satisfaction with UDDS from the perspective of the nursing staff. Note: The results are presented in percentages with the following scale levels: ( ) Do not agree at all; ( ) Agree rather less; ( ) Agree rather; ( ) Agree completely; UDDS: Unit-Dose Dispensing System.

The time saved by UDDS was objectively measurable. The question is whether this is also experienced as such by the nursing staff. Remarkably, this is not realised in this way. Three quarters of respondents do not perceive UDDS as making their work easier. The most likely explanation for this striking phenomenon is that we conducted the survey relatively soon after the introduction of UDDS, so that the new processes on the ward had not yet been translated into routines. A majority of nursing staff, on the other hand, agreed with the statement that ward stocks have been reduced following the introduction of unit dose.

The next two questions deal with practical aspects of working on the ward. Firstly, the question of whether the delivery times of the unit doses on the ward fit in with everyday ward life. Fortunately, two thirds of respondents said that yes, the delivery times fit in with their needs and routines. The cut-off times for entering the medication were determined in collaboration with the wards, taking into account the duration of the ward rounds. This resulted in two production rounds: The surgical wards from 11:00 a.m. and the internal medicine wards from 01:00 p.m. The blister packs are produced for the following day. Consequently, there is some time between the production of the blisters and the administration of the tablets to the patient. During this period, there may be changes to the medication e.g. as result of altered vital parameters. This then leads to the work being revised. Some colleagues find the work tolerable the other half does not.

The KHZG emphasizes the importance of digitalization and modernization in hospitals to improve patient care and operational efficiency. UDDS aligns perfectly with these objectives by leveraging technology to streamline medication processes [7]. In addition to the digitization and modernization of the healthcare system through the KHZG, the legislator has set itself the task of counteracting the nursing shortage. It is therefore possible to refinance measures that relieve the burden on nursing care in accordance with § 5 of the (care budget negotiations). Recognizing UDDS as a nursing relief measure would support hospitals in meeting requirements of KHZG and Pflegebudgetverhandlung.

Similar legislative initiatives have been seen or are in preparation in other key economic nations, reflecting a global trend towards digital transformation in healthcare. In the United States, the Hospital Inpatient Services Modernization Act introduced by Congress aims to extend the Acute Hospital Care at Home waiver initially implemented during the COVID-19 pandemic. This waiver allows acute-level care to be delivered in patients’ homes, promoting innovative healthcare delivery methods that reduce hospital stay risks and increase flexibility in patient care. This act highlights a significant shift towards homebased care, driven by the lessons learned during the pandemic [8]. The United Kingdom’s National Health Service (NHS) has also pursued similar modernization through various initiatives. Programs focusing on integrating digital technologies into healthcare provision, enhancing telemedicine, and improving data infrastructure have been key areas of investment. For example, the NHS long term plan emphasizes the need for digital-first primary care and the use of technology to streamline hospital operations and patient care [9]. Despite efforts to further digitize the healthcare system, the adoption of UDDS does not seem to be a priority. In 2014, UDDS was not used by any of the NHS hospitals, and to our knowledge this has not changed [10]. This illustrates the disparate approaches to digitizing the healthcare system. Germany is focusing its efforts on the inpatient sector, while the UK is prioritizing the digitalization of the outpatient sector, including patient responsibility. These international efforts align with the objectives of Germany’s KHZG, emphasizing the necessity for healthcare systems to adapt and modernize using digital solutions. The overarching goal across these legislations is to improve efficiency, patient outcomes, and the resilience of healthcare systems against future crises. This global movement underscores the critical need for policies that support healthcare digitalization, ensuring robust and efficient care delivery mechanisms worldwide.

The transition from outpatient to inpatient and vice versa is fraught with risk [11]. Further blister packaging of the medication for the patient’s home can be done by public pharmacies to prevent misuse. This has the advantage of ensuring care, especially for elderly patients with delirium or dementia.

In addition to the use of UDDS as a method for implementing CLMM, Automated Dispensing Cabinets (ADCs) should be mentioned. These are cabinets for storing drugs. By providing a patient-specific barcode, the individual steps can be electronically documented by nursing staff by scanning. The advantage of ADCs over UDDS is that they can also be used to cover all non-oral drugs as well as on-demand drugs [12]. It is important to note that the use of ADC alone requires additional work for nursing staff [13]. Research has demonstrated that medication errors are less frequent when both systems are combined with the scanning step [14]. By taking over the repetitive and timeconsuming task of medication dispensing, UDDS allows nursing staff to allocate more time to patient care activities [4]. This is a significant benefit, particularly in light of the increasing demand for healthcare services and the ongoing nursing shortage. Reducing the time spent on routine and administrative tasks enhances the work environment for nurses. Increased job satisfaction is critical for retaining skilled nursing staff, especially in the face of global nursing shortages.

Recent advancements in UDDS technology have focused on improving integration with other healthcare systems and enhancing user interfaces to facilitate smoother transitions for healthcare staff. Innovations such as real-time tracking of medication administration and advanced analytics for monitoring medication usage patterns are being developed to maximize the benefits of UDDS. Additionally, efforts are being made to lower the cost of UDDS implementation through scalable solutions and financial incentives for healthcare institutions.

In conclusion, the evidence strongly supports the recognition of UDDS as a nursing relief measure by healthcare payers. The substantial time savings, enhanced medication safety, alignment with the necessity for healthcare systems to adapt and modernize using digital solutions, support for closed loop medication management, cost-effectiveness, and improvement in nurse job satisfaction collectively make a compelling case.

To overcome the challenges and barriers to UDDS adoption, future research should focus on large-scale, multi-centre studies to gather comprehensive data on the economic and clinical impact of UDDS. Additionally, exploring the potential of UDDS in outpatient settings and its integration with telemedicine could expand its benefits beyond inpatient care. Collaboration between healthcare providers, technology developers, and policymakers is essential to drive innovation and support the widespread adoption of UDDS.

Conflicts of interest: The author reports no conflicts of interest in this work.

Availability of data and materials: The data that support the findings of this study are not openly available due to reasons of sensitivity and are available from the corresponding author upon reasonable request.

Ethical approval: The research conducted is a survey of clinic staff, with a focus on ensuring the quality of new processes. Participants were informed of the voluntary and anonymous nature of their participation through a declaration of consent, including information on data processing. Authorisation for this study was obtained from the Works Council with appropriate data protection measures in place. As this study does not involve diagnostic or therapeutic procedures on patients, no ethical approval is required.

Funding: The authors have no relevant financial or non-financial interests to disclose.

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