The Need for Automated Drug Dispensing Systems (ADDS) at In-Patient Pharmacy Departments in Malaysia: A Brief Overview

Pharmaceutical care services in hospitals strengthen health services delivery and are vital to the health care system. Indeed, hospital pharmacy services have seen a significant transformation in recent times, where there is a trend to move toward patient-centered services. ¹ In Malaysia, public hospital pharmacy services are funded through centralized government taxes, whereby all medications are subsidized and pharmaceutical care services are provided by the pharmacists and assistant pharmacists at the point of care. Public hospital pharmacy services cater both outpatients and inpatients, with approximately 21 million outpatient visits and 2.6 million inpatient admissions in 2019. ²

The majority of patients who visit hospitals require medication as part of their treatment process. Most commonly, the inpatient pharmacy supplies medication through the unit dose system to the wards, clinics, and other departments in the hospital. The supply of medication involves organized steps that include screening prescriptions/orders, preparation, delivery/dispensing, administration of medications, and monitoring of safety and therapeutic effects.^3,4 Nevertheless, all these mentioned steps are prone to human errors. ⁵ Therefore, automation in medication supply procedures has been a viable strategy for hospital pharmacies. There has been technological advancement in medication supply in the hospitals which are increasingly being accepted, especially in developed countries. ⁶ In addition, the timeliness of the preparation of medications contributes to the satisfaction of patients and nursing staff, thus, automation in drug dispensing procedures could reduce the time spent to prepare the medication supplies as well as patients’ waiting time which commonly is a major setback in a hospital pharmacy.

Automated Drug Dispensing Systems (ADDS) have been introduced in medication supply systems to address the concerns of manual dispensing and delivery. ⁷ The role and impact of these automated systems have been widely explored in multiple regions of Europe, Middle East and North America.^{8 -10} With automated methods, the drug dispensing process in the medical wards can either be centralized or decentralized. The centralized medication distribution model relies on the pharmacy to process orders for each medication and deliver the medications to the patient care areas, which includes the Carousel Dispensing Technology (CDT) and robotic medication picking systems. ¹¹ Meanwhile, with the decentralized approach, medications are kept within the patient care areas, to be dispensed upon physicians’ orders. Several types of decentralized ADDS such as automated dispensing cabinets (ADCs) have been utilized to assist pharmacists and nurses during medication dispensing. Most inpatient pharmacies have adopted a hybrid system that combines both centralized and decentralized elements. ¹² With centralizing logistic elements of medicine distribution to hospital pharmacies, hybrid automated dispensing systems appear to reduce the time to supply medications, where an average of 14.7 hours were saved per day among nurses and pharmacists at in-patient departments.^12,13

Typically, ADDS enable computer-controlled medication storage, dispensing, and tracking. ¹⁴ Nevertheless, only trained personnel, primarily pharmacists and pharmacy technicians were able to manage the inventory and supply of medications using the ADDS.^12,15 Therefore, there are requirements for pharmacists and pharmacy technicians to be equipped with basic knowledge on machine handling. Generally, patients are vulnerable to medication errors and adverse events due to narrow therapeutic window drug administration, pharmacokinetic changes of drugs, and significant medication turnover. As of date, this has been the issue among patients in Malaysia^{16 -18} It is a constant challenge for hospital pharmacies to ensure the treatment process is both safe and effective for their patients while minimizing medication errors. ¹⁹ According to the evidence, the ADDS increased the quality of patient care by diverting pharmacists’ attention away from technical distribution operations and toward clinical activities.^12,13,15 ADDS were also found to reduce errors in drug dispensing and storage, despite the fact that it does not affect other sources of error which occur before the dispensing phase such as prescribing errors. ²⁰ With an automation in the drug dispensing system, there is a subsequent reduction in pharmacists’ time on medication handling which has enabled pharmacists to dedicate more time to review prescriptions more thoroughly. Therefore, this has improved the ability to detect medication errors before medications are administered to patients. ¹¹

From an economic point of view, ADDS enabled easier medication management and lowered drug expenses. ²¹ According to a Canadian study, the cost of stock inventory was reduced by $152 000, while medication error rates were reduced by more than 25% using ADDS. With regards to the costs of pharmaceutical care as well as medicine safety and time spent, the decentralized drug delivery system is by far the most studied medication distribution method compared to the centralized system. Many healthcare facilities are transitioning to a decentralized approach to provide optimal care for their patients due to the limitations of centralized systems. This explains the research attention toward the impact and effectiveness of newer developments such as automated drug dispensing systems and decentralized medication distribution in the healthcare setting.^8,22 According to the Pharmacy Automation System Market Overview (2020-2030), the global market size was valued at $5001 million in 2020 and is estimated to reach $11 211 million by 2030, growing at a CAGR of 8.3% from 2021 to 2030. North America has the greatest market share in the pharmacy automation market, followed by the European countries. The pharmacy automation systems market in Malaysia has been growing at a quicker rate in recent years, with considerable growth rates, and it is likely to grow significantly in the forecast period, that is, 2020 to 2027.^23,24

There was no conclusive evidence that the different ADDS studied differed in their influence on health care expenses. This could imply that medicine dispensing automation, rather than a specific type of automated system (centralized versus decentralized versus hybrid), is the primary source of cost savings. It was discovered that a hybrid system with ADCs might have a positive impact on cost effectiveness among staffs in hospital. ²¹ Decentralized ADDS have also been found to save costs due to lower drug storage costs and lower medication use in intensive care and hemodialysis units. ²⁵ All of these published researches demonstrate that automated system has yielded good effects, which should motivate hospitals to invest in automation as part of a comprehensive plan to increase the accuracy and effectiveness of the medication administration process.

The workload of health care personnel has become significant attention for hospitals in Malaysia, especially during the COVID-19 pandemic, and that includes the pharmacists. As a result, the pressure to reduce the time and workload associated with manual distribution, while reallocating pharmacists to more clinical tasks should be the major driver of drug distribution automation, ensuring that the right patient gets the right medication. Furthermore, automated drug dispensing systems improve medication safety while offering a cost-effective solution, besides being an essential technical skill for Malaysian pharmacists as they have shown significant interest and knowledge of telepharmacy. ²⁶ The topic of financial savings of ADDS have received the least attention, and thus it should be the key focus for future research. Therefore, the reliance on technology and automation is crucial to minimize the chance of human-related medication errors, and public hospital pharmacies should gradually transition toward automated drug dispensing in the near future.