Pharmacy practice in hospital settings in GCC countries: Dispensing and administration

Abstract

Purpose

To outline dispensing and administration practices in hospital pharmacy across the Gulf Cooperation Councils (GCC) countries’ hospitals. Paucity of data in appraising hospital pharmacy practice in GCC regions motivated us to conduct this study.

Methods

A modified survey questionnaire was prepared from the American Society of Health-System Pharmacist (ASHP) survey questions. Three major domains of questions for general characteristics of the medication use process for dispensing and administration were identified. These were, (1) medication distribution system, and medication distribution technology, (2) technology used to compound sterile preparations, compounding I.V. medication and method of compounding nutrition support preparations, (3) medication administration practices, medication orders, medication administration records (MARs), and technician activities. A list of hospitals was obtained from the Ministry of Health of the targeted GCC countries. A secure invitation link containing a survey questionnaire was sent to the participants directly.

Results

Sixty-four hospitals responded to this survey. The overall response rate was 52%. Most surveyed hospitals have centralized inpatient medications distribution system (75.0%). About 37.5% of hospitals used automated dispensing cabinets (ADCs) in their patient care areas. Compounding sterile preparations in the pharmacy, barcode verification technology, workflow management technology, and robotic technology were used by 17.2%, 15.6%, and 4.7% of hospitals, respectively. In using safety technology for medication administration, almost all hospitals have partially or completely implemented an electronic health record (EHR). About 40.6% of hospitals used electronic medication administration records (e-MARs), 20.3% used bar-code-assisted medication administration (BCMA), and 35.9% used smart infusion pumps.

Conclusion

The results of this survey revealed an opportunity to improve the medication use management process on dispensing and administration practices in hospitals in GCC countries.

1. Introduction

A medication error is an unintended failure in the drug treatment process that leads to, or has the potential to lead to, harm to the patient. Medication errors are expected during the medication use process, leading to morbidity, mortality, and unnecessary strain on health budgets. (Tariq et al., 2021). In the United States of America alone, medication errors cause at least one death every day, injure approximately 1.3 million people, and cost nearly 42 billion dollars annually (WHO report 29 March 2017). These errors can occur at any stage of prescribing, dispensing, and administering the medication use process (Aronson 2009, Tariq et al., 2021). The possible reasons for these errors are poor work environment, worker dissatisfaction, staff shortages, poor training, lack of electronic administration records and technologies, and many other reasons. The medication use process is an integral part of any hospital; it must be done in the correct time interval, at the correct user, and with the right drug and dose (Aronson 2009). Therefore, the safe dispensing of medication to patients is a core function of a pharmacist. Pharmacists ensure that patients can get the correct medication and dosing. Hence, implementing safe, organized, and efficient drug-dispensing systems is essential for preventing or reducing medication errors and cost control.

The healthcare system in GCC countries is advancing rapidly in response to changing healthcare needs in a population suffering from increased prevalence of non-communicable disease. Published studies assessing hospital pharmacy practices in GCC countries are very limited. Although specific hospitals in GCC countries are known to practice at international standards, the overall current practices are uncertain.

In 2012, we published our first survey on hospital pharmacy practice on prescribing and transcribing in the Riyadh region, Saudi Arabia. We surveyed 29 hospitals on compliance with clinical practice guidelines, prior approval of non-formulary drugs, pharmacists' activities, medication consultation, electronic drug information resources, computerized prescriber order entry (CPOE) systems with clinical decision support systems (CDSSs), and availability of electronic medical record (EMR) system. Most hospitals reviewed compliance with clinical practice guidelines, and pharmacists were actively involved in providing consultations on drug information and had electronic drug information resources. However, only a third of hospitals had computerized prescriber order entry (CPOE) systems with clinical decision support systems (CDSSs), and half of the hospitals had electronic medical record (EMR) systems. Our new survey was intended to examine the current structure and future direction of the medication distribution system for inpatient pharmacies, including the technology being utilized and the methods used in the preparation and dispensing of medications. It also investigates the use of technology in medication distribution and administration, such as barcode technology, smart infusion pumps, and medication administration records (MARs); technology used by the pharmacy department during sterile product preparation; staff competency assessment to prepare compounded sterile preparations; and hazardous drug handling; pharmacist deployment in practice model (status and future direction), and activities of pharmacy technicians.

The current survey is a follow-up of a 2012 project to survey the current state of hospital pharmacy practice. Henceforth, in our current survey asking the same questions at different points in time allows us to report on changes in the overall practices of the hospital pharmacy in Gulf regions. This is the second article in the series, which focuses on the dispensing and administration steps of the medication use process in hospitals of the GCC countries.

2. Methods

To evaluate dispensing and administration practice in GCC countries, we prepared a modified survey questionnaire from the original ASHP survey questions in consultation with ASHP survey members (Pedersen et al., 2015, Schneider et al., 2018). Prior to finalization and distribution, we validated the questionnaire using the following approaches: (1) A research team in our group reviewed the questionnaire and provided feedback. Then, the questionnaire's content was revised or eliminated accordingly (2) We discussed the survey details for clarity and relevance with some pharmacy directors and sought their opinion and input in developing and improving the items to ensure that we measured what we intended to measure.

Three major domains of questions for general characteristics of the medication use process for dispensing and administration in GCC hospitals (Saudi Arabia, Kuwait, UAE, Oman, and Bahrain) were identified. (1) Medication distribution system, medication distribution technology, the primary method of medication distribution, machine-readable coding in pharmacy, and outpatient dispensing pharmacy operations. (2) Technology used to compound sterile preparations, compounding I.V. medication by non-pharmacy personnel, assessing staff competence to prepare compounded sterile products (CSPs), method of compounding nutrition support preparations, and hazardous drug handling. (3) Medication administration practices, pharmacist approval of medication orders, medication administration records (MARs), smart infusion pumps, pharmacy practice models, and technician activities.

Data collection was performed using a convenience sampling technique. Convenience sampling is a non-probability sampling technique in which the study subjects are selected based on specific criteria, such as availability at a given time, willingness to participate, convenient accessibility, and geographical proximity to the researchers (Martinez-Mesa et al., 2016). A list of hospitals from the Ministry of Health of the targeted GCC countries was obtained. A secure invitation link containing a survey questionnaire was sent to the participants directly. The study was conducted between November 2019 and April 2020. Three attempted to follow- ups were made within the study period to declare non-responders.

The survey was conducted using the online survey platform “Google Forms,” which was considered user-friendly and easily accessible with different web browsers (Rayhan et al., 2013) and was comparable to those of the ASHP survey method (Pedersen et al., 2015, Schneider et al., 2018, Pedersen et al., 2021). The hospitals were classified based on bed capacity (number of beds), location, type, ownership, and accreditation. The participating hospitals' responses were collected, cleansed, and analyzed using descriptive statistics before being tabulated as frequencies and percentages. Descriptive statistics with numbers and frequencies were used to describe the various study variables via the Statistical Package for Social Sciences (IBM SPSS Statistics, version 26).

3. Results

Overall, 123 hospital pharmacy directors were approached, and 64 responded to the survey. The overall response rate was 52 %. The characteristics of respondent hospitals are described in Table 1.

Table 1.

Bed capacity, location, type, ownership, and accreditation of survey respondents’ hospital.

Characteristics	Hospitals (n = 64)
	n	%
Number of Staffed beds
< 50	7	10.9
50–99	8	12.5
100–199	14	21.9
200–299	6	9.4
300–399	11	17.2
400–499	6	9.4
500–599	5	7.8
≥ 600	7	10.9
Country
Saudi Arabia	31	48.4
Kuwait	21	32.8
UAE	6	9.4
Oman	5	7.8
Bahrain	1	1.6
Type of hospital
General	25	39.1
Academic/Teaching	4	6.3
Secondary care	7	10.9
Tertiary care	12	18.7
Specialized	16	25.0
Ownership
Government hospital	64	100.0
Accreditation
Accredited*	47	73.4
Non-accredited	17	26.6

*Joint Commission International, JCI; Central Board of Accreditation for Healthcare Institution, CBAHI; Canadian Accreditation Body; United Arab Emirates, UAE.

3.1. Medication distribution system

Hospital pharmacy directors were asked about the basic philosophy of their current inpatient pharmacy’s distribution system (medication doses prepared and/or dispensed for patients). Over 75 % of hospitals currently have a centralized inpatient medications distribution system, and about 25 % of hospitals have decentralized systems (Table 2).

Table 2.

Current structure and future direction of pharmacy distribution system.

Characteristic	Hospitals (n = 64)
	n	%
Current structure
Centralized distribution system	48	75.0
Decentralized distribution system	16	25.0
Future direction
Centralized distribution system	34	53.1
Decentralized distribution system	30	46.9

Hospital pharmacy directors also provided information about their hospital's future direction of the inpatient medication distribution system. Almost half (47 %) of directors indicated that they prefer a decentralized model in the future (Table 2).

3.2. Medication distribution technology

The number (%) of hospital pharmacies that use technology as part of their drug distribution system is shown in Table 3. Automated dispensing cabinets (ADCs) are used by 37.5 % of hospitals in their patient care areas, whereas in 35.9 % of hospitals, ADC is linked to the pharmacy system (i.e., profile mode).

Table 3.

Medication distribution activities.

Characteristic	Hospitals (n = 64)
	n	%
Utilization of technology and automated solutions
Automated dispensing cabinets (ADC) in patient care areas	24	37.5
ADCs linked to pharmacy system	23	35.9
Primary method of medication distribution*
Centralized - manual (e.g., unit dose sent from pharmacy)	56	87.5
Decentralized - manual (e.g., satellite pharmacies)	6	9.6
Centralized - automated (e.g., robot)	3	4.7
Decentralized - automated (e.g., automated dispensing cabinets; ADC)	15	23.4
Centralized – semi-automated (e.g., carousel for unit doses)	6	9.4
Use of machine-readable coding (bar codes) in pharmacy
During dispensing	15	23.4
During restocking of ADCs	14	21.9

*Multiple responses; ADC; Automated Dispensing Cabinets.

3.2.1. Primary method of medication distribution

Most hospitals (87.5 %) used centralized manual unit dose systems as the primary method of medication distribution. In comparison, about a quarter of hospitals (23.4 %) used a decentralized automated system such as automated dispensing cabinets (ADCs) as the primary method for dispensing medication doses (Table 3).

Some hospitals used other primary methods of distribution. About 9.4 % of hospitals used carousel-type medication storage and retrieval system to automate medication dispensing. In contrast, merely 4.7 % of the responding hospitals used a robotic distribution system that automates the dispensing of unit doses of inpatient medications in a centralized distribution system (Table 3).

3.2.2. Machine-readable coding in pharmacy

The directors were also asked about the use of machine-readable coding (e.g., barcoding technology) in inpatient pharmacies to verify doses during the restocking of ADCs and to scan and verify doses during dispensing. Overall, 23.4 % of hospitals used some form of machine-readable coding to verify doses during dispensing in the pharmacy. Furthermore, 21.9 % of hospitals routinely used machine-readable coding (scan medication barcodes) during the restocking of ADCs (Table 3).

3.3. Outpatient dispensing pharmacy operations

Overall, 96.9 % of surveyed hospitals have an outpatient dispensing pharmacy (Table 4), and almost all of them were operated by the hospital pharmacy department except a few hospitals (3.2 %) outsourcing this service. In addition, about 73.4 % of hospitals frequently offer a discharge prescription service (e.g., a “meds to bed” service) through outpatient dispensing pharmacy (Table 4).

Table 4.

Outpatient dispensing pharmacy operations.

Characteristic	Hospitals (n = 64)
	n	%
Hospital has outpatient dispensing pharmacy
Yes	62	96.9
No	2	3.1
Who operates outpatient dispensing pharmacy?	(n = 62)
Hospital pharmacy department	60	96.8
Outsourced (e.g., chain, independent)	2	3.2
Hospital offers discharge prescription service
Yes	47	73.4
No	17	26.6

3.4. Technology used to compound sterile preparations

Several technologies were used to compound sterile preparations in surveyed hospitals (Table 5). The use of workflow management technology for intravenous (IV) compounding is used in 15.6 % of hospitals. Furthermore, barcode verification to verify ingredients during the IV medication compounding process was used by 17.2 % of hospitals. Moreover, about 45.3 % of hospital pharmacy departments reported having a United States Pharmacopeia (USP) chapter 797 compliant cleanroom (Table 5).

Table 5.

Technology used by pharmacy department during sterile product preparation.

Characteristic	Hospitals (n = 64)
	n	%
IV workflow management technologies used for sterile product preparation activities	10	15.6
Use bar-code verification during i.v. medication preparation	11	17.2
Pharmacy department has USP chapter 797 compliant cleanroom for compounding sterile preparations	29	45.3
Robotic IV compounding device used for compounding flushes or syringe-based small volume parenteral preparations, excluding chemotherapy	3	4.7
Robotic IV compounding device used for chemotherapy	1	1.6

IV; Intravenous.

Only 4.7 % of hospitals used a robotic intravenous compounding device (e.g., intelligent hospital systems RIVA, Baxter IntelliFill i.v., Aesynt/Health Robotics i.v. station) in the pharmacy department for compounding flushes, syringe-based small-volume parenteral or mini bags (excluding chemotherapy preparations). Moreover, robotic chemotherapy compounding devices were used in 1.6 % of hospitals (Table 5).

3.5. Method of compounding nutrition support preparations

For the nutrition support preparation, 29.7 % of hospitals used automated compounding devices as the predominant form, followed by 4.7 % used gravity methods, 4.7 % used commercially available two-in-one total parenteral nutrition (TPN) preparations, and 12.5 % of hospitals outsourced nutrition support preparation. Almost half (48.4 %) of hospitals did not provide parenteral nutrition support for the patient because it was not used in the hospital (Table 6).

Table 6.

Method of compounding nutrition support preparations.

Methods	Hospitals (n = 64)
	n	%
Automated compounding device (e.g. Baxa)	19	29.7
2-in-1 commercially available bags	3	4.7
Gravity	3	4.7
Outsourced	8	12.5
No nutrition support solution prepared at our hospital	31	48.4

3.6. Assessing staff competence to prepare compounded sterile products (CSPs)

More than half (54.7 %) of hospitals did not use any method to assess staff members’ (Pharmacy technicians) sterile compounding competency (Table 7). The rest used various techniques to assess their staff: 29.7 % used direct periodic observation of cleaning and disinfecting method, 25 % used media-fill challenge testing procedure, 23.4 % used direct periodic observation of garbing and gloving, 20.3 % used surface testing using contact plates, and 17.2 % used gloved fingertip sampling.

Table 7.

Methods used to assess staff competence to prepare compounded sterile preparations.

Methods*	Hospitals (n = 64)
	n	%
Media fill challenge testing	16	25.0
Gloved fingertip testing	11	17.2
Direct periodic observation and documentation of garbing and gloving competency	15	23.4
Direct periodic observation and documentation of cleaning and disinfecting competency	19	29.7
Surface testing using contact plate to assess cleaning effectiveness	13	20.3
None of the method is used	35	54.7

*Multiple responses.

3.7. Compounding I.V. medication by non-pharmacy personnel

Pharmacy directors were asked about situations in which nurses or non-pharmacy personnel compound intravenous (IV) medications in their hospitals. Almost half (48.4 %) of the hospitals allowed nurses to prepare IV medications in the following conditions: emergency (35.9 %), medications with short stability (29.7 %), operating theaters (21.9 %), and emergency room (18. 8 %). However, 7.8 % of hospital directors reported that nurses or non-pharmacy personnel were not permitted to prepare any IV medications in their hospitals (Table 8).

Table 8.

Compounding IV medication by non-pharmacy personnel.

Situations*	Hospitals (n = 64)
	n	%
Nurses routinely prepare most IV medications	31	48.4
In emergency	23	35.9
IV medications having short stability	19	29.7
IV medications used in the operating room	14	21.9
Interventional radiology / imaging procedure IV medications	12	18.8
Emergency department	12	18.8
Pharmacy department is closed	8	12.5
Nurse preference	6	9.4
Nurses or non-pharmacy personnel are not permitted to prepare IV medications	5	7.8
None	9	14.1

*Multiple responses.

3.8. Hazardous drug handling

Pharmacy directors were asked about their procedures for handling hazardous drugs (Table 9). Overall, 78.1 % of hospitals had developed a list of hazardous drugs with hospital-wide procedures for receiving, compounding, dispensing, administering, and disposing of these hazardous drugs. In addition, almost half (46.9 %) had a designated compounding supervisor responsible for implementing appropriate procedures to handle hazardous drugs, and 34.4 % had a segregated negative-pressure area specifically designed for receiving, unpacking, storing, and compounding hazardous drugs. Hospital directors reported various facility design methods to manage hazardous drugs as follows: 43.8 % had separate storage areas for hazardous drugs from nonhazardous drugs, 25 % had a negative-pressure room, 21.9 % used an externally vented class II biological-safety cabinet, 12.5 % had secondary engineering controls (anteroom and buffer areas), and 12.5 % used an externally vented compounding aseptic containment isolator (Table 9).

Table 9.

Handling and facility design for hazardous drugs.

Handling	Hospitals (n = 64)
	n	%
Developed list of hazardous drugs and hospital wide procedures for receiving, compounding, dispensing, administering, and disposing of them	50	78.1
Designated compounding supervisor responsible for developing and implementing appropriate procedures for handling hazardous drugs	30	46.9
Segregated negative pressure area specifically designed for receipt, unpacking, storage, and compounding of hazardous drugs	22	34.4
Facility design features*
Negative pressure room	16	25.0
Separate storage area for hazardous drugs	28	43.8
Class II Biologic Safety Cabinet (Vertical Airflow Hood) that is externally vented	14	21.9
Compounding Aseptic Containment Isolator (CACI) that is externally vented	8	12.5
Secondary Engineering Control (Ante-room and buffer areas)	8	12.5
None	30	46.9

*Multiple responses.

3.9. Closed-system transfer devices (CSTD)

Only 17.2 % of hospitals use closed-system drug transfer devices (CSTDs) for the safe handling of hazardous drugs.

3.10. Outsourcing medication preparations

Overall, 28.1 % of hospitals partially or completely outsource some medication preparation activities (Table 10). Of hospitals that outsource some part of preparation activities, the majority 83.3 % outsourced unit-dose repackaging (drug only), parenteral nutrition solutions (61 %); high-risk products from non-sterile sources (33.3 %); IV admixtures / piggybacks (27.8 %); syringe-based anesthesia medications and medications used for cardioplegia (16.7 %).

Table 10.

Outsourcing of medication preparation activities.

Outsourced activity *	Hospitals (n = 64)
	n	%
Outsourced some preparation activities	18	28.1
Types of preparations or activitiesa, * (n = 18)
Unit-dose repackaging (drug only)	15	83.3
Unit-dose repackaging (bar coding)	2	11.1
Total parenteral nutrition solutions	11	61.1
I.V. Admixtures / Piggybacks	5	27.8
Patient-controlled and/or epidural analgesia	1	5.5
Cardioplegic preparations	3	16.7
Oxytocin preparations	2	11.1
Syringe-based anesthesia medications	3	16.7
High risk compounded sterile products from non-sterile sources	6	33.3

*Multiple responses.

^aAmong respondents reporting outsourcing of preparation activities.

3.11. Medication administration practices

3.11.1. Pharmacist approval of medication orders

Almost in three-quarters (70.3 %) of hospitals, pharmacists reviewed and approved all medication orders before the first dose was administered, either onsite or by remote order view, except in procedure room areas and emergency situations.

3.11.2. Medication administration records (MARs)

Overall, 46.9 % of respondent hospitals used handwritten MARs, 40.6 % used an electronic MAR (e-MAR) and 12.5 % of hospitals used computer-generated paper MARs (Table 11).

Table 11.

Technology used to document medication administration.

Characteristics	Hospitals (n = 64)
	n	%
Medication Administration Records
Handwritten MAR	30	46.9
Computer generated paper MAR	8	12.5
e-MAR	26	40.6
Complete EHR	20	31.2
Partial EHR	44	68.8
CPOE system	27	42.2
BCMA	13	20.3
Use of smart infusion pumps
Smart infusion pumps	23	35.9
Capability of smart infusion pumps
Smart pumps auto populate dosing and patient information from CPOE/pharmacy information system	8	12.5
Documentation practices of infusion data
Nurses manually document infusion data into health record/EHR	32	50.0
Infusion data auto populate from smart pump to EHR	7	10.9

MARs; Medication administration records, e-MAR; Electronic medication administration record system, BCMA; Bar-code-assisted medication administration, CPOE; Computerized physician order entry, EHR; Electronic health record.

3.11.3. Electronic health record (EHR)

One third (31.2 %) hospitals had a complete EHR system without paper charts, 68.8 % had a partial EHR with some components still on paper charts (Table 11).

3.11.4. Computerized prescriber order entry (CPOE)

Forty-two percent of hospitals had computerized prescriber-order-entry (CPOE) systems for inpatient medication orders that incorporates with clinical decision support (CDS).

3.11.5. Bar-code-assisted medication administration (BCMA)

Majority, 79.7 % of pharmacy directors indicated that they do not use machine-readable coding (e.g., bar-code-assisted medication administration (BCMA) system) to verify the identity of the patient and the accuracy of medication administration at the point-of-care (before administering the medication by the nurse). However, 20.3 % of respondent hospitals are currently using BCMA (Table 11).

3.11.6. Smart infusion pumps

3.11.6.1. Use of smart infusion pumps

A total, 35.9 % of hospitals used smart infusion pumps that use extensive drug libraries (decision support software) that guide dose calculation, rates, and drug administration (Table 11).

3.11.6.2. Capability of smart infusion pumps

Only, 12.5 % of hospitals have a smart pump that auto populates from the computerized physician order entry (CPOE) and/or pharmacy information system, with dosing and patient information, eliminating the need to manually select the drug and infusion rate during setup (Table 11).

3.11.6.3. Documentation practices of infusion data

Only 10.9 % of hospitals have an interface through which smart-pump infusion data auto populate in the electronic health record (EHR) (eMAR and electronic nursing flow sheets), with 39.1 % of hospitals requiring the nurse to manually document infusion data into the EHR (Table 11).

3.11.7. Pharmacy practice model

Overall, 54.7 % of hospitals used a drug distribution centered model, 20.3 % used a comprehensive model, and 12.5 % used a clinical specialist centered model and a patient centered integrated model (Table 12). Hospital pharmacy directors also provided information on their future plans for pharmacists’ deployment to patient care areas. Most hospitals (59.4 %) anticipated having a comprehensive model (including pharmacists in distributive, generalist/integrated, and specialist roles) with only 10.9 % of them anticipating having a patient centered integrated model in the near future (Table 12).

Table 12.

Pharmacist deployment in practice model, current status and future direction.

Characteristics	Hospitals (n = 64)
	n	%
Pharmacists in practice model: current status
Drug distribution centered model	35	54.7
Patient centered integrated model	8	12.5
Clinical–specialist-centered model	8	12.5
Comprehensive model	13	20.3
Pharmacists in practice model: future direction
Drug distribution centered model	10	15.6
Patient centered integrated model	7	10.9
Clinical–specialist-centered model	9	14.1
Comprehensive model	38	59.4

3.11.8. Technician activities

The most common activities performed by pharmacy technicians in the pharmacy department include restocking of floor stock and/ or automated dispensing cabinets (71.9 %), packaging (67.2 %), replenishing unit dose carts (57.8 %), technician supervising other technicians (45.3 %), compounding sterile preparations (37.5 %), and order entry (35.9 %) (Table 13).

Table 13.

Activities of pharmacy technicians.

Activities	Hospitals (n = 64)
	n	%
Replenishing unit dose carts	37	57.8
Restocking of floor stock and/or automated dispensing cabinets	46	71.9
Compounding sterile preparations (excluding chemotherapy)	24	37.5
Compounding chemotherapy preparations	11	17.2
Order entry activities (for pharmacist verification)	23	35.9
Purchasing / inventory management related activities	19	29.7
Information technology system management	12	18.8
Controlled substance system management	11	17.2
Technician supervising other technicians	29	45.3
Checking dispensing by other technicians (tech-check-tech)	18	28.1
Billing	8	12.5
Criteria-based screening of medical records to identify medication-related problems for pharmacist follow-up	5	7.8
Preparation of clinical monitoring information for pharmacist review	6	9.4
Dispensing medications with remote video supervision	5	7.8
Medication assistance program management	6	9.4
Initiation of medication reconciliation (obtaining list)	2	3.1
Quality Assurance activities / unit inspections	16	25.0
Packaging activities	43	67.2
Facilitating transitions of care (e.g., discharge medications, medication history taking)	15	23.4

*Multiple responses.

4. Discussion

The survey is the first in the Gulf Cooperation Councils (GCC) countries. It provides descriptive data, and the results give baseline information for the first time on the current status of pharmacy practice in GCC countries' hospitals. However, a paucity of data in assessing hospital pharmacy practice in GCC regions motivated us to publish the outcomes of the survey in a stepwise manner. Hence, this will be the second report in the series and will focus on important domains of the medication use process, i.e., dispensing and administration practices in GCC countries' hospitals.

The survey had representation from all the GCC countries across various types of hospitals, with a favorable response rate of 52 % compared to the ASHP survey of 18.7 % (Pedersen et al., 2021), and other survey studies in Saudi Arabia of about 60 % (Alsultan et al., 2012, Altyar et al., 2020). Our survey indicated that 75 % of GCC countries’ hospitals had a centralized distribution system. The survey results revealed comparable figures to other survey studies where centralized medication distribution was the most commonly used model (Alsultan et al., 2012, Altyar et al., 2020). Remarkably, hospitals in the GCC countries are taking a more decentralized approach, as almost 47 % of the pharmacy directors have shown a desire to move towards a decentralized distribution system in the future compared to the current use of 25 %.

ADCs represent one of the most widely deployed technologies integrated with today's hospital medication use systems. Pharmacy practitioners have recommended ADCs as one possible mechanism to improve patient safety and efficiency (Fung and Leung 2009). In our survey, about 37.5 % of GCC countries’ hospitals used ADCs in their patient care areas while about a quarter of hospitals used ADCs in their decentralized distribution system as the primary method for dispensing medication doses. Whereas, in Saudi Arabia, 20.7 % of the hospitals reported usage of ADCs in 2012 (Alsultan et al., 2012) while 28.6 % in 2019 (Altyar et al., 2020). On the other hand, there has been a rapid increase in adopting ADCs in other countries. In the U.S., 22 % of hospitals used ADCs in patient care areas for drug dispensing in 2002, but this rose to 74.5 % by 2020 (Pedersen et al., 2021). This indicates that the use of technological solutions for distributing medication in hospital pharmacies in GCC countries' hospitals is in its early stages.

Hospitals worldwide have introduced scanning technologies in the medication management process to reduce medication errors and associated harm and improve the quality, safety, and efficiency of health services. (Bainbridge and Askew). Overall, 23.4 % of our survey hospitals reported routinely using machine-readable coding in the inpatient pharmacy to verify doses before dispensing. In addition, 21.9 % of hospitals also used this technology to verify the accuracy of restocking ADCs in patient care areas. Moreover, a similar survey in Saudi Arabia reported that about 20.6 % of hospitals routinely used machine-readable coding in the inpatient pharmacy to check medications before dispensing (Alsultan et al., 2012). Furthermore, Pedersen et al. also revealed that machine-readable coding was used in 66.3 % of U.S hospitals to verify the accuracy of drug dispensing. In comparison, about 81.4 % of hospitals used this technology during restocking ADCs. (Pedersen et al., 2021).

The process of compounding sterile preparations in hospital pharmacies comprises the preparation of medications that are not commercially available, and it is based on the medical need of individual patients. The survey revealed that about 45.3 % of hospital pharmacy departments reported having a USP (7 9 7) compliant cleanroom. This finding can be inferred as a good practice. We also found that too sterile compound preparations in the pharmacy, barcode verification technology, workflow management technology, and robotic technology were used by 17.2 %, 15.6 %, and 4.7 % of hospitals, respectively. Using automation and technology during sterile product preparation is rare in GCC countries' hospitals. This could be because of the motives that adopting these technologies is quite expensive and requires a large budget for equipment, licensing, training, and maintenance, as well as hospital commitment to redesign the way of practice.

The hospital pharmacists are an integral part of the nutrition support team and they are responsible for ensuring the appropriateness of the parenteral nutrition (P.N) supplied, not only in composition but also in quality. However, our survey found that almost half (48.4 %) of hospitals did not provide parenteral nutrition support for the patient because it was not used in the hospital. While 29.7 % of hospitals used automated compounding devices as the predominant form of nutrition support preparation, followed by 12.5 % of hospitals outsourced nutrition support preparation. Although, in many countries, P.N. formulations are still compounded in-house by pharmacy staff within the hospital pharmacies to cover patients' needs (Katoue et al., 2016).

Outsourcing medication preparation can provide substantial economic and patient care benefits for hospitals with limited pharmacy staff and compounding facilities. Our survey result showed that 28.1 % of hospitals partially or completely outsourced some medication preparation activities, which is lower than the finding of the ASHP study, where 79.6 % of hospitals outsource some drug preparation activities (Schneider et al., 2018).

5. Medication administration practices

Medication review is a multidisciplinary responsibility that ensures the ongoing safe and effective use of medicines at all stages of the medication management pathway. The result from our study indicated that pharmacists reviewed and approved all medication orders before the first dose was administered in 70.3 % of GCC countries' hospitals. Hospital pharmacies in our study show commitment to providing a review of medication orders that ensures safe medication use. (American Society of Health-System Pharmacists 2010). A review of prescription orders by a pharmacist is considered a safe medication practice and is one aspect of pharmacist patient care.

MARs is the report that serves as a record of drugs administered to a patient by a health care professional. MARs can be created by hand, generated on paper by the pharmacy computer system, or created electronically (e-MAR) on a screen on a computerized system. Our survey result indicates that most GCC hospitals used handwritten MARs (46.9 %) or e-MAR (40.6 %). Similarly, a survey in Saudi Arabia indicated that two-thirds of all respondent hospitals use handwritten MARs, and one-third use electronic MARs (Alsultan et al., 2012). Contrary to our findings, the ASHP survey reported that overall, 93.3 % of hospitals used an electronic MAR, and only 1.3 % used handwritten MARs in the U.S (Pedersen et al., 2015). Handwritten MAR can contribute to medication errors through illegible handwriting, incomplete or ambiguous orders, and transcription errors (Velo and Minuz 2009). On the other hand, an electronic MAR can minimize the risk of errors related to misinterpreted handwriting and transcription errors and improve medication chart legibility.

EHR is more than a digital version of a patient's paper chart. In our survey, almost all hospitals have partially or completely implemented an electronic health record (EHR). About one-third (31.2 %) of hospitals had a complete EHR system without paper charts, and 68.8 % had a partial EHR with some components still on paper charts. EHR helps provide better patient care, makes patients' medical information easier to read, enables physicians to exchange information with one another remotely and in real time, and automates various tasks for the practice.

CPOE systems allow providers to enter orders for drugs, laboratory tests, radiology, and physical therapy into a computer rather than doing so on paper. Using a CPOE system, especially when it is linked to a CDS, can result in improved efficiency and effectiveness of care. Our results showed that 42.0 % of hospitals had CPOE systems for inpatient medication orders incorporating CDS. This percentage is noticeably lower than the percentage found in the ASHP survey (80.9 %) (Pedersen et al., 2015).

BCMA systems reduce medication errors relating to incorrect patient identity, drug, or dose and promote patient safety when used accurately (Shah et al., 2016). On the other hand, BCMA can, if poorly implemented, cause disrupted workflow, increased workload, and cause medication errors (van der Veen et al., 2018). In our study, only 20.3 % of the hospitals used BCMA to verify the patient identity and accuracy of medication administration at the point of care. ASHP survey had shown that 88.4 % of hospitals had BCMA systems to verify patient identity and electronically check doses administered by nurses (Pedersen et al., 2015).

Smart infusion pumps containing preprogrammed drug libraries are vital in reducing medical errors. More than 80 % of U.S. hospitals utilize smart pumps to deliver medication and fluids to patients (Pedersen et al., 2015). Although, only 35.9 % of hospitals used smart infusion pumps in GCC countries.

There are variations in the type of pharmacy practice model implemented at hospitals in GCC countries. The survey included questions concerning four types of pharmacy models: a drug distribution-centered model (defined as “mostly distributive pharmacy with limited clinical services”), a patient-centered integrated model (defined as “clinical generalist model with limited differentiation of roles- nearly all pharmacists have distributive and clinical responsibility”), a clinical– specialist-centered model (defined as “separate distributive and clinical specialist roles”) and a comprehensive model (defined as “pharmacists in distributive, generalist/integrated, and specialist roles). In this survey, more than half (54.7 %) of the respondent hospitals used a drug distribution-centered model. Another study reported that the majority of hospitals (62.1 %) in Saudi Arabia also utilized a central drug distribution system (Alsultan et al., 2012). In addition, 59.4 % of hospital pharmacy directors anticipated that they have plans to deploy pharmacists in a comprehensive model (including pharmacists in distributive, generalist/integrated, and specialist roles).

An important pharmacy team member supporting the pharmacist in their day-to-day activities is the pharmacy technician, who usually performs critical activities in the pharmacy department supporting the pharmacy practice model. The present survey highlighted that pharmacy technicians majorly participated in restocking floor stock and/ or automated dispensing cabinets, followed by packaging and replenishing unit dose carts. The findings were in line with the previously published literature reporting the most common activities by the pharmacy technicians to be restocking of floor stock and/ or automated dispensing cabinets (98.8 %), packaging (95.7 %), and compounding sterile preparations (87.7 %) (Pedersen et al., 2017).

Our survey had some limitations. First, the study's small sample size is relative to the ASHP survey. Second, the part of the survey was restricted to government hospitals with no representation from the private sector of any GCC countries. Hence, the findings cannot be generalized. Despite our small sample size, we have included the most prominent small and large government hospitals in the region and government hospitals in the GCC countries.

6. Conclusion

The survey result revealed an opportunity to improve the medication use management process of dispensing and administration practices in hospitals in GCC countries. Numerous medication distribution and administration technologies have been adopted by hospitals globally; however, the adoption of change associated with implementing and using these new technologies in GCC countries' hospitals is slow. Understanding the current pharmacy practice culture across different health care systems is an essential step towards improving the profession. Recognizing gaps in practice can pave the path for future research aiming at furthering the pharmacy profession. Researchers in the field of hospital pharmacy practice are encouraged to publish their work.

Declaration of Competing Interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.