Time Savings Associated WithDispensing Unit-of-UsePackages
Earlene E. Lipowski, DeArcy E. Campbell, David B. Brushwood, and Debbie Wilson Objectives: To determine how much time can be saved with the use of unit-of-use packaging in a community pharmacy, the distribu-
tion of work between the pharmacist and the pharmacy technician when unit-of-use packaging is used, and the number of errors that
occur when either unit-of-use or bulk packaging is used in dispensing prescriptions. Design: A simulation comparing count-and-pour
dispensing with unit-of-use package dispensing. Setting: An independent community pharmacy. Participants: Two teams, each com-
posed of one pharmacist and one pharmacy technician. Intervention: Each team prepared 50 typical prescription orders, once using
unit-of-use packaging and once by transferring medication from a bulk container. Main Outcome Measures: Time needed to dispense
50 prescriptions, dispensing activities performed by technicians and pharmacists, and number of dispensing errors. Results: The time
saved with unit-of-use packaging compared with count-and-pour dispensing was 46.5 minutes per 100 prescriptions, which represents
an average time savings of more than 27 seconds per prescrition. In the bulk package dispensing simulation, the pharmacists assisted in
retrieving and counting medication for 26% of the prescriptions. This percentage dropped to 4% when unit-of-use packaging was used
because the technicians dispensed prescriptions at a rate that occupied the pharmacist with verifying the prescription orders and dis-
pensed products. Each team committed two counting errors when executing the bulk package trial and no errors when using unit-of-
use packaging. Conclusion: Unit-of-use packaging can reduce the time needed for and increase the efficiency of pharmacists’ dispens-
ing activities. Unit-of-use packaging may also reduce the number of counting errors. J Am Pharm Assoc. 2002;42:577–81.
Pharmacists’ workload is a matter of increasing concern for the
Industry statistics reveal that the number of outpatient prescrip-
pharmacy profession and the public. Numerous groups have eval-
tions processed in the United States increased from 2 billion in
uated pharmacy workload issues, including the American Phar-
1992 to more than 3 billion in 1999; this number is projected to
maceutical Association (APhA), the National Association of
exceed 4 billion by 2005.4 Yet the population of pharmacists
Boards of Pharmacy (NABP), the National Association of Chain
remains relatively constant.1,3,4 This imbalance warrants giving
Drug Stores (NACDS), and the National Community Pharmacists
serious consideration to changes in practice that could improve
Association (NCPA).1−4 The growing concern over a pharmacy
the efficiency of prescription order processing.
manpower shortage has attracted the attention of the U.S.
Recently, the NABP Task Force on Pharmacy Manpower
Congress. In December 2000 the Health Resources and Services
Shortage recommended standardized unit-of-use packaging as an
Administration (HRSA) delivered a report requested by Congress
option for decreasing work at the point of dispensing.1 A unit-of-
documenting the problem.5 All of the assessments conclude that a
use package contains prescription medication in a quantity
manpower shortage exists in pharmacy and that it will not be a
“designed and intended to be dispensed directly to a patient with-
short-term problem. One way to alleviate the manpower shortage
out modification except for the addition of a prescription label by
is to manage the workload more effectively.
a dispensing pharmacist.”6 Blister packs, compliance packs,course-of-therapy packs, and vials containing 1 month’s supply ofmedication are examples of unit-of-use packaging. In contrast to a
Received September 21, 2001, and in revised form December 4, 2001. Accepted for publication December 21, 2001.
unit dose package that contains enough medication for one dose,
Earlene E. Lipowski, RPh, PhD, is associate professor; DeArcy E. Camp-
unit-of-use packaging contains multiple doses sufficient for a typ-
bell is PharmD/MBA degree candidate; David B. Brushwood, JD, is pro-
ical course of therapy.7 Adoption of unit-of-use packaging could
fessor; Debbie Wilson, MA, CPhT, is PhD student, College of Pharmacy,
reduce pharmacy workload by eliminating at least three time-con-
suming tasks from the dispensing process: measuring and count-
Correspondence: Earlene E. Lipowski, RPh, PhD, College of Pharmacy,
ing dosage units, selecting and retrieving dispensing vials, and
University of Florida, Box 100496, Gainesville, FL 32610. Fax: 352-392-7782. E-mail: email@example.com.
returning stock bottles to the storage shelves. Vol. 42, No. 4 July/August 2002 Journal of the American Pharmaceutical Association RESEARCH Unit-of-Use
This alternative to counting and pouring from bulk packages
The dispensing simulation was conducted in an independent
has been considered from time to time for more than 50 years.6
pharmacy in a large city in northern Florida with the cooperation
The last time that the adoption of unit-of-use packaging was giv-
of the pharmacy owner and staff. It took place on a Saturday
en serious consideration as a standard in the United States was in
afternoon in July 2000 after the pharmacy had closed for the day.
1992, when the United States Pharmacopoeial Convention spon-
All participants in the simulation were familiar with the pharmacy
sored a national conference on packaging. At that conference,
as well as its equipment, layout, and inventory, and they had
there was general agreement that unit-of-use packaging was tech-
worked with one another before. The four participants were
nically feasible and offered a number of advantages over stock
assigned to two teams consisting of one pharmacist and one tech-
bottles. Although a time savings was among the benefits cited,
nician. The observer read instructions to each team, directing
none of the presenters offered any specific data about the amount
them to prepare the prescriptions in the order they were presented
of time that could be saved or any evidence that unit-of-use could
while taking the typical time and care needed for prescription pro-
reduce the time pharmacists spend on dispensing relative to other
cessing. The pharmacists were asked to perform the same check-
activities.6 The adoption of unit-of-use packaging in the United
ing procedures that they routinely apply to any prescription.
States has advanced little in the interim.
The prescription orders were computer printed and presented to
the dispensing teams along with a prescription label. The labelshad been prepared in advance because this step is common to dis-
pensing both bulk and unit-of-use prescriptions. Using preprintedlabels permitted us to measure the time intervals of interest with-
The primary objective of this study was to measure the time
out disrupting the computer record-keeping system at the pharma-
that could be saved with unit-of-use packaging in a typical com-
cy. Each preprinted label included the pharmacy’s name and
munity pharmacy setting. The second objective was to note the
phone number, the patient’s name, the drug and strength, the quan-
distribution of work between the pharmacist and technician when
tity prescribed, the directions for use, and the physician’s name.
unit-of-use packaging is used in place of bulk packaging. The
We used 20-dram prescription vials with childproof caps to
third objective was to compare the number of errors that occur
simulate unit-of-use packaging. Each vial had a label (1 inch by 2
when using the two different package types.
5/8 inches) with the drug name, strength, package size, lot num-ber, and expiration date. There was enough room at the bottom ofthe vial for a prescription label to be placed below the “manufac-
Bulk packaging for the simulation consisted of empty stock
We conducted a simulation study to capture a credible estimate
bottles collected from a local pharmacy. Appropriately sized and
of the time that could be saved by using unit-of-use packaging in
shaped candies were substituted for active medications and load-
a typical community pharmacy. As a first step, members of the
ed into the bulk bottles. This approach required the teams to select
research team observed the dispensing process in several pharma-
the proper package from among the bottles in the existing inven-
cies. These preliminary observations were made at local pharma-
tory while eliminating the need to handle and discard expensive
cies representative of chain, independent, grocery store, and clinic
products or assume the risk of returning medications to their orig-
practice. The results of these initial observations showed that the
inal containers. The simulated stock bottles were given labels
number of prescriptions requiring transfer from one package to
measuring 2 inches by 4 inches with the drug name and strength,
another varied from site to site. However, the proportion of cap-
the bulk package size, the lot number, and expiration date. Both
sules, tablets, and liquids being transferred from bulk containers
the unit-of-use and bulk packages were placed in the appropriate
to prescription vials and bottles76%, 20%, and 4%, respective-
location along with the regular pharmacy stock.
ly—was remarkably consistent. These proportions were adopted
Team 1 first prepared the set of 50 prescriptions using the bulk
for the mix of dosage forms used in the simulation study.
packages and then filled the set of 50 prescriptions using the unit-
For the simulation, we selected a set of 50 prescription prod-
of-use packages. Team 2 performed the same tasks in the reverse
ucts (see Table 1) from among those ranked by Drug Topics as
order; that is, they dispensed the 50 prescriptions using unit-of-
the top 200 drugs by prescription in 1999.8,9 The selection includ-
use packages first, followed by the 50 prescriptions using bulk
ed an equal number of brand-name and generic drug products and
packaging. The prescription set was presented in a different order
a variety of manufacturers, so that during the simulation the par-
each time to offset any learning effects on total dispensing time.
ticipants would traverse all the areas where prescription products
The observer started timing when a team member picked up
were stored in the pharmacy. We excluded topical medications
the first prescription in the set. The time when each prescription
and drugs that are almost always dispensed in unit-of-use pack-
was deposited into the “completed” bin was recorded on the data
ages, such as inhaled and injectable drugs, because the purpose of
collection sheet along with the name of the team member who
the simulation was to compare dispensing using bulk packaging
retrieved and counted the medication. Timing was stopped after
with dispensing using unit-of-use packaging.
the last prescription in the set was finished and the stock bottles
Journal of the American Pharmaceutical Association July/August 2002 Vol. 42, No. 4
Unit-of-Use RESEARCH Table 1. Prescription Orders Used in the Simulationa
aPrescriptions were presented in a different order for each simulation trial. Source: References 8, 9.
were returned to the pharmacy shelves. The entire simulation was
unit-of-use packages, plus the time needed to open the container,
recorded with a video camera that imprinted the elapsed time, and
pour the contents onto the counting tray, count the correct number
the videotape was used to verify the direct observation record.
of dosage units, return any excess to the stock bottle, locate an
The times required for bulk and unit-of-use dispensing were
appropriately sized dispensing vial, pour the “medicine” into the
computed for both teams. All of the prescriptions were examined to
prescription vial, and replace the bulk container to the proper shelf.
verify that they contained the proper content and correct quantity.
The total time the two teams needed to prepare 100 prescrip-
tions using unit-of-use packaging was 40 minutes. These sametwo teams needed 86.5 minutes to dispense those 100 prescrip-
tions when they were required to count or measure the varioustablets, capsules, and liquids that were ordered. The time saved
The times recorded for preparing the set of 50 prescription
was 46.5 minutes, an average of more than 27 seconds per pre-
orders with unit-of-use packages were 19.5 minutes for team 1
scription. This represents a reduction of more than one-half of the
and 20.5 minutes for team 2. These results account for the times
needed to read the label, walk to the shelf, retrieve the package,
When bulk packaging was used in the simulation, the pharma-
return to the counter, label the package, have it checked by the
cist member of team 1 retrieved the stock bottle and counted the
pharmacist, cover the label with tape, place the vial in a bag, and
medication for 14 of the 50 prescriptions in the set and performed
put the bag in a bin designated for completed prescriptions.
the final check for all 50 finished prescriptions. Likewise, the
Using bulk packaging, team 1 needed 45 minutes to prepare the
pharmacist from team 2 retrieved and counted the medication for
same set of 50 prescription orders, whereas team 2 completed the
12 of the 50 prescriptions and checked all the finished products
identical task in 41.5 minutes. The timed activities for this part of
when bulk packaging was used. However, the pharmacists were
the simulation included the steps required for dispensing using
primarily occupied with checking the prescriptions when the team
Vol. 42, No. 4 July/August 2002 Journal of the American Pharmaceutical Association RESEARCH Unit-of-Use
prepared them using unit-of-use packaging. The pharmacist
However, the relative time savings may be more important than
assigned to team 1 retrieved the unit-of-use package from the
a precise estimate of the number of minutes that can be saved per
storage area for only 1 of the 50 prescription orders; the pharma-
prescription or per day. The overall time that could be saved in any
cist in team 2 retrieved the package from the storage area for 3 of
given pharmacy will depend on the prescription volume and the
the 50 orders. Overall, the pharmacists were involved in the actual
proportion of prescriptions that require the drug product to be trans-
prescription assembly process for 26% of the orders dispensed
ferred from the manufacturer’s package to a container for the
from bulk stock and 4% of the prescriptions using unit-of-use
patient. Another factor that may affect total time is the use of auto-
packaging. When dispensing in unit-of-use packaging, the techni-
mated counting devices. Irrespective of these differences across
cians assembled most of the prescriptions. The pharmacists con-
pharmacy practice sites, the results of this study support the conclu-
ducted the final check for accuracy of every prescription in both
sion that unit-of-use packages save a significant amount of time.
Furthermore, our results suggest that technicians can handle a
There were no errors in which the wrong product was used to
greater share of the prescription assembly tasks with a unit-of-use
fill any prescription order during the simulation. However, four
system, while pharmacists may shift their efforts during the time
counting errors were found when the bulk-packaged prescriptions
gained to activities other than manual order processing. According
were examined—two errors by each team. Team 1 prepared one
to an NACDS−Arthur Andersen study on pharmacist productivity,
prescription with 5 fewer dosage units than ordered and filled a
the average pharmacist spends only 31% of his or her time on cog-
second with 5 units more than the order specified. Team 2 dis-
nitive activities, such as reviewing and interpreting the prescription
pensed 10 extra dosage units in one instance and included 1 extra
order, assessing patients’ drug therapy, resolving clinical conflicts,
contacting physicians, and counseling patients about their prescrip-tions. Based on these results, the study consultants concluded that“a significant opportunity exists to transfer pharmacist time to
ancillary personnel.”3 Our results confirm this conclusion. Unit-of-use packaging is one approach that may permit pharmacists to
A search of the pharmacy literature yielded one article report-
transfer certain work activities to ancillary personnel.
ing detailed information about the time required for preparing
Pharmacists often identify cost considerations as the primary
unit-of-use sized prescription packages from bulk packaging.
obstacle to adopting unit-of-use packaging. In national surveys of
Campbell et al.10 recorded the time required for prepackaging pre-
pharmacists conducted by NCPA in 200012 and by APhA in
scription drugs as part of their effort to assess the cost-effective-
1985,13 the most frequently cited obstacle to unit-of-use was the
ness of prepackaging activities in outpatient pharmacies operated
assumption that drug products purchased in smaller package sizes
by Kaiser Permanente. They separately measured the average
are much more expensive per dosage unit than those supplied in
manual packaging time for tablets, capsules, and liquids. Using
bulk packages. We tested this assertion in the study pharmacy by
their figures, we estimated that unit-of-use packaging would elim-
consulting the wholesale price schedule for the prescription prod-
inate approximately 45 minutes of time for every 100 products
ucts used in the simulation. When we calculated the actual acqui-
transferred in a set of prescriptions, given the mix of tablets, cap-
sition cost (AAC) of bulk packages and compared it with the
sules, and liquids selected for testing in our simulation.
AAC for an equivalent quantity of the same products purchased
We found that unit-of-use packaging cut the amount of time
in smaller package sizes, the net price difference was $6.31. In
required for prescription assembly by a total of 46.5 minutes for
our case, this increase in cost would be offset by eliminating the
every 100 prescriptions prepared with unit-of-use packaging. This
need for a separate prescription vial as well as by the time saved.
represents an average time savings of mose than 27 seconds per
Other reports have suggested that unit-of-use packaging can
prescription. Heaton et al.11 estimated that unit-of-use containers
actually reduce total inventory cost. By requiring fewer units in
would generate a savings of 50 seconds per prescription. Their esti-
stock at any given time, adoption of unit-of-use packaging
mate was derived from videotapes of the dispensing process record-
increases inventory turnover and cash flow.6,11 The extent to
ed in a busy chain pharmacy during normal business hours. The
which unit-of-use packaging would require additional space and
videotape was used to document the time needed to perform steps
reconfiguration of existing storage space is open to debate.11
that could be eliminated with a unit-of-use package for a random
The results of our study also suggest that unit-of-use packag-
sample of prescriptions captured on tape; that is, the researchers
ing could eliminate counting errors. Overages and shortages have
measured the time needed to open the bulk container, count and
implications for customer relations, inventory management, and
place tablets in a prescription vial, and then cap and label the vial.
therapeutic outcomes. An inadvertent shortage of dosage units in
They added time to their results to account for the reduction in trav-
an expensive prescription may make a patient distrustful of his or
el time between storage areas as an opportunity for further efficien-
her pharmacist. Units dispensed in excess of the intended quanti-
cies. In comparison with the results reported by Heaton et al.,11 it
ty adversely affect profits, and perhaps, lead to overuse of the
appears that our simulation represents a conservative estimate of
medication. In addition to ensuring accurate quantities, unit-of-
the time savings possible with unit-of-use packaging.
use packaging increases patient safety by maintaining
Journal of the American Pharmaceutical Association July/August 2002 Vol. 42, No. 4
product integrity, allowing for a bar-coded label to be attached
and new opportunities for patient-oriented pharmacy practice
from the point of manufacture through delivery to the patient,
emerge. Unit-of-use packaging is one way to help pharmacists
and by giving the patient access to the manufacturer’s expiration
reduce the time they devote to dispensing. The time saved could
date and lot number in the event of a product recall.
permit pharmacists to oversee the processing of an increased vol-
Most developed nations use unit-of-use packaging for pharma-
ume of prescriptions and to provide cognitive services such as
ceutical products, including Canada, Australia, New Zealand, and
drug therapy management. Adoption of unit-of-use packaging
most countries in Europe and South America.7 Undoubtedly, the
may also help to clarify the complementary roles of pharmacists
widespread adoption of unit-of-use packaging in the United States
and pharmacy technicians. Unit-of-use packaging may offer addi-
would require substantial changes in manufacturing and storage
tional benefits in terms of reducing dispensing errors.
throughout the channel of distribution. It might also require a
This study was funded by a grant from the Institute for the Advancement
change in prescribing practices and, possibly, changes in the regu-
of Community Pharmacy. The authors declare no conflicts of interest or
lations governing pharmacy. Furthermore, the adoption of unit-of-
financial interests in any product or service mentioned in this article,
use could not occur without the consensus and cooperation of
including grants, employment, gifts, stock holdings, or honoraria.
pharmaceutical manufacturers, medicine, pharmacy, nursing,
The authors acknowledge the advice and assistance of Barbara F. Brice,PhD, in conducting this research.
government agencies, and consumer groups.6
In 1992 APhA adopted a policy opposing the exclusive use of
A portion of this study was presented in a poster session at the AnnualMeeting of the American Pharmaceutical Association in San Francisco,
unit-of-use packaging, and the National Wholesale Druggists
Calif., March 18–9, 2001, and at a seminar titled Unit-of-Use: Pros and
Association (now the Healthcare Distribution Management Asso-
Cons for Community Pharmacy in Washington, D.C., May 9, 2001.
ciation) took the position that the demands of the competitivemarketplace would be the best way to establish whether unit-of-use packaging is useful and cost-effective.7
1. National Association of Boards of Pharmacy. Task Force on PharmacyManpower Shortage. Chicago, Ill: National Association of Boards of
Pharmacy; 2000. 1999–2000 Committee and Task Force Reports.
2. Arthur Andersen, LLP. Pharmacy Activity Cost and Productivity Study.
Arlington, Va: National Association of Chain Drugstores; 1999. Avail-
It is possible that the precision of the estimated time savings
able at: www.nacds.org/wmspage.cfm?parm1=609. Accessed May 10,2002.
was limited by interruptions. Although the simulation took place
3. Report to the APhA House of Delegates Strategic and Tactical Analysis
after normal business hours, unexpected distractions occurred,
Team (STAT) on Practice Environment and Quality of Worklife. Wash-ington, DC: American Pharmaceutical Association; 2000.
including the noise of telephone messages being recorded on the
4. Implementing Effective Change in Meeting the Demands of Communi-
answering machine and the appearance of a patient who needed
ty Pharmacy Practice in the United States [white paper]. Washington,
an emergency prescription. Time was also lost in locating a mis-
DC: American Pharmaceutical Association, National Association ofChain Drug Stores, National Community Pharmacists Association;
placed stock bottle and replenishing office supplies. Although
1999. Available at: www.aphanet.org/stat/whitepaper.pdf. AccessedMay 10, 2002.
timing was suspended when there was an interruption, these dis-
5. The Pharmacist Workforce: A Study of the Supply and Demand for
tractions could have interrupted the workflow and affected the
Pharmacists. Rockville, Md: Bureau of Health Professions, Health
precision of our time estimates. Nevertheless, both teams experi-
Resources and Services Administration. U.S. Department of Healthand Human Services; 2000. Available at: http://bhpr.hrsa.gov/health-
enced a similar number of interruptions, and their times were
workforce/pharmacist.html. Accessed May 10, 2002.
6. Unit-of-Use Packaging: Contemporary Issues [conference workbook].
Rockville, Md: United States Pharmacopeial Convention, Inc; 1993.
Two factors support the reliability and validity of the time esti-
7. A Review of Unit-of-Use Packaging. Washington, DC: American Phar-
mates. First, the times for the two teams were similar in both parts
of the simulation. When using bulk packaging, the two teams fin-
8. Top 200 brand-name drugs by prescriptions in 1999. Drug Topics.
ished within 3 minutes and 32 seconds of one another. In the unit-
9. Top 200 generic drugs by prescriptions in 1999. Drug Topics. March 6,
of-use packaging simulation, the times differed by 58 seconds.
The total time difference for entire exercise was 2 minutes and 30
10. Campbell WH, Christensen DB, Johnson RE, Booker SF. Identifying
seconds. Second, the total time savings of 46.5 minutes was con-
economic efficiencies resulting from a drug prepackaging program. Am J Hosp Pharm. 1974;31:954–60.
sistent with the predicted time savings of 45 minutes that was
11. Heaton PC, Lin AC, Jang R, et al. Time and cost analysis of repackaging
based on data reported by Campbell et al.10
medications in unit-of-use containers. J Am Pharm Assoc. 2000;40:631–6.
12. Unit-of-use survey results. Presented at: National Association of Chain
Drug Stores/National Community Pharmacists Association Seminar on
Unit-of-Use; May 9, 2001; Washington, DC.
13. APhA Policy Committee on Scientific Affairs. Background Paper onUnit-of-Use Packaging. Washington, DC: American Pharmaceutical
The pharmacy manpower shortages that exist today are predict-
ed to worsen in the near future as prescription volume increases
Vol. 42, No. 4 July/August 2002 Journal of the American Pharmaceutical Association
Divisão de Ensino de Química da Sociedade Brasileira de Química (ED/SBQ) Instituto de Química da Universidade de Brasília (IQ/UnB) Um pouco da história dos explosivos: da pólvora ao Prêmio Flávia Cristina Gomes Catunda de Vasconcelos (PG), Ladjane P. da Silva (PG), Maria Angela Vasconcelos de Almeida (PQ) firstname.lastname@example.org 1,2Universidade Federal Ru