Cite this article as Suryadinata HU. The benefits of automated dispensing machine for hospital pharmacy
in Indonesia: situation, implementation, and feasibility. 2017; 1(1): 15-22.

Global Health Management Journal
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Review

The benefits of automated dispensing machine for hospital pharmacy in Indonesia:

situation, implementation, and feasibility

Haryman Utama Suryadinata

Faculty of Public Health, Universitas Indonesia, Indonesia

*Corresponding author. Email: harymanutamasuryadinata@gmail.com

ARTICLE INFO ABSTRACT

Article history:

Submitted 17 April 2017

Accepted 17 June 2017

Background: Pharmacy as the main core of hospital is responsible for the quality

and safety of medicines. Yet the numbers of medication errors are still high.

Automated Dispensing Machine (ADM) is one of the solutions to reduce the

dispensing errors in pharmacy. Many countries had studied and proved that the use

of ADM gives more benefit than liability. However, ADM is considered as

something new, a “nice to have” product.

Aims: This study will explain the benefits of ADM especially in Indonesian hospital

pharmacy.

Methods: Systemic Review with PRISMA method uses 5 databases as Scopus,

Springerlink, Google Scholar, Science Direct and ProQuest, with keywords

Automated Dispensing Machine, Automated Dispensing Device, Automated

Dispensing System, Automated Drug Dispensing System, or Robotic Dispensing

System. The inclusion criteria are all the studies that showed any impact in minimum

of one aspect of ADM in hospital.

Results: There are 13 studies that explained ADM benefits such as increase staff

satisfaction for the nurse and pharmacist, reduce dispensing errors about 35% or up

to reducing all dispensing errors, time saving until 50% in peak hours and cost

analysis and effectiveness. The cost analysis such as inventory stock reduction,

increases the cost saving.

Conclusion: In Indonesia, it needs many considerations to implement ADM but it

had already installed in 1 Indonesia Hospital. This hospital had proved that ADM

can reduce dispensing errors and can solve some pharmacy problem such as the

human resources problems and the long waiting time. With the proven benefits of

ADM, it is justified for Indonesian hospital to implement ADM and information

system in their pharmacy. The effectiveness will perceive the pharmacy and

positively affect to all related departments in hospital.

Keywords:

Automated dispensing machine

Automated dispensing system

Automated dispensing device

Robotic dispensing system

Automated drug dispensing system

This article is an extension of a selected paper “The benefits of automated dispensing machine as solutions for hospital pharmacy in Indonesia: A systematic

review” published in Proceedings of the International Conference on Applied Science and Health (No. 1, February 2017).

This is an open access following Creative Commons License Deed – Attribution-NonCommercial-ShareAlike 4.0 International (CC BY-NC-SA 4.0)

INTRODUCTION

Pharmacy is a hospital's main core which products

are widely used, such as medicines, medical

devices, films and reagents. Thus pharmacy

becomes the revenue center in hospital [1]. In

Indonesia, most of hospitals pharmacies in

Indonesia are still using man-power to do their daily

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Global Health Management Journal, 2017, Vol. 1, No. 1 16

activities. According to Indonesia Ministry of

Health regulation (Undang-undang No. 35 Year

2014), the pharmacy is responsible for the quality

and safety of all medicines in hospital, this includes

inventory planning, purchasing, receiving,

distributing and evaluating the drug usage by the

patient. In the ideal workflow, the pharmacy must

get a prescription from the doctor, then continues to

verification process, dispensing to hand over or

administering the drug and educate the patient also

evaluates the drug usage. This processes are not

easy to do and error-prone, especially when using

only man power; the risk of errors might harm the

patient and it some cases it leads to death [2].

Presently, Pharmacy dispenses many drugs to the

patients, meaning that dispensing is one of the main

and most complex processes. Dispensing includes

picking and labelling the drugs. When it is manually

done, dispensing error can happen any time,

without anyone noticing until the patient is

experiencing the harmful effect [2, 3]. There were

134,431 dispensing errors cases annually in

England and Wales [3]. Another study showed there

were 24% dispensing errors in community

pharmacy and 12.5% in hospital outpatient

pharmacy [2]. According to Anacleto, Perini, Rosa,

& César, 2007 the dispensing errors are responsible

for 11% from 50% of medication errors. The most

common dispensing errors are wrong drug, wrong

dose, wrong label, and wrong quantity [3].

Hospitals are now focusing to improve patient

safety and dispensing errors is one of the main

concerns. There are some technologies to reduce the

dispensing errors such as software, barcoding,

automated dispensing machine (ADM). ADM is

one of the ultimate solutions for pharmacy to help

dispensing automatically and it will become the

long-term care solution. ADM uses barcode to

identify the drugs, hence, it greatly reduces

dispensing errors [5]. ADM use barcode as the

drugs identification and must integrated with

hospital software.

ADM is relatively new in Indonesia, even though

some hospitals have already used it. Many studies

said that ADM could give positive impacts to the

pharmacy even just make the pharmacy focus on

caring the patient. But there was study told that

ADM can reduce medication errors especially for

dispensing errors, reduce the number of staff and

make the services faster than before [6].

Most of countries have been used and proved that

ADM was their main solutions to give more

benefits for their pharmacy. So this study will

explain and give some images of the benefits of

ADM especially for Indonesia hospital pharmacy.

METHODS

There are many types of ADM such as the box

dispensing machine, cabinet dispensing machine,

and unit dose dispensing machine. Each machine

has its own function for example cabinet system

that can be used in emergency, or intensive care

unit. The types of machine will be chosen, depends

on where the place is pharmacy want to increase the

quality services (see figure 1 to understand the

pharmacy flow). This Systematic Review (SR) will

not analyse the difference of the machines

otherwise discuss the hall effect of the machine in

all departments with some types of machines.

Searching

This SR used PRISMA to make readers more

understand with the simplest methods of ADM. The

Figure 1. Indonesia pharmacy workflow

17 Global Health Management Journal, 2017, Vol. 1, No. 1

sources of the journals are searched via online from

Scopus, SpringerLink, ScienceDirect, Google

Scholar and ProQuest. The keywords are

Automated Dispensing Machine (ADM),

Automated Dispensing Device, Automated

Dispensing System, Automated Drug Dispensing

System (ADDS), or Robotic Dispensing System.

Others keywords used to find the local journal and

used the synonym to get more variation of the

journals. The limitation for this study is free

journals that published from 2010 - now. As the

result, all journals that fulfilled the criteria are used

even only the abstract is available. This study used

2 level filters are the title and abstract.

Inclusion and exclusion criteria

The eligible journals parameter is all the studies that

showed any impact of ADM in hospital minimum

one aspect such as the financial aspects, workflow

efficiency, investment, services speed, etc. All the

journals without any impact of the ADM in the

hospital explained had excluded. As the final, this

study reviewed 13 journals (see figure 2).

Figure 2. PRISMA methods of the study

Global Health Management Journal, 2017, Vol. 1, No. 1 18

RESULTS

There are 13 reviewed articles. There are 5 from 13

(2 abstract only) explained ADM for outpatient

pharmacy and 8 (2 abstract only) of 13 explained

about ADDS (Automated Drug Dispensing System)

for intensive care, emergency or wards. Most of

those studies, 11 of 13, used observational study

such as longitudinal (2 studies), case control (1

study), cross sectional (3 studies), 2 analysis study

such as financial perspective. One from 13 used

semi experimental study and another 1 study is a

systematic review. They compared between before

and after implementation of ADM for many

perspective in big hospitals (4 studies at more than

1000 beds hospitals, 4 studies at teaching hospital).

ADDS is types of ADM which mostly use for

automated dispensing in ward. It doesn't matter

about the name even ADDS and ADM used only to

represent the inpatient and outpatient department.

The result is ADM will give the efficient effect such

as the cost saving, reducing error, reduced time

services and smooth workflow for inpatient

(including intensive and emergency unit) and

outpatient department. Another positive impact is

especially for the nurse satisfaction and reduced

total inventory control cost. One of study showed

ADM didn't give any impacts to increase the time

for the service because their internal regulation put

limited access for only some staff and another staff

must wait those staff to use ADM. On the other side,

1 studies also showed that ADM need skilled staff

to operate and the pharmacy have to choose kinds

of medicines that ADM can dispensed (see

appendix). Therefore, to maximize ADM hospitals

need to integrate with hospital information system

and manage all the process including how to make

the accurate filling and preparation process and also

training the staff about the machine and how to

through access to the machine.

Staff satisfaction

From 2 journals which used ADDS as their

solutions, all the nurses had satisfied and want to

use ADDS as their dispensing system in wards.

Totally 91% nurses were very satisfied with ADDS.

One journal gives the result that ADM in outpatient,

the average of the Pharmacist satisfaction is 8.63±

0,744 and for the nurse satisfaction is 7.78 ± 0.667.

According to Gonzalez et al., 2016, his study

divided 3 kinds of satisfaction based on the process

and the results of ADM (see table 1). The greatest

result was in patient safety factor from pharmacy

(9.75 ± 0.463), it means the pharmacy was satisfied

with the ADM because ADM increase the safety

[7].

Table 1. The result of satisfaction types for the nurse and

pharmacist [7]

Satisfaction Pharmacist Nurse

Patient safety 9.75 ± 0.463 8.00 ± 0.7077

Ease of use 9.13 ± 0.641 8.2 ± 0.667

Dispensing speed 7.75 ±0.886 6.33 ± 0.50

Inventory control

and integration

> 8.5 7.75 ± 0.707

Average 8.63 ± 0.744 7.78 ± 0.667

Most of nurses and pharmacists actually aware, that

they need ADM as their solutions in their job. With

the good operational and ease to use, ADM can

increase the patient safety, increase the inventory

control quality and it had been approve by most

nurses and pharmacists.

Reducing incidents or errors

ADM can increase patient safety by reducing

dispensing errors and medication errors as final

impact. Five studies showed ADDS can reducing

the errors, the administration errors by 57% and

reduce dispensing errors by 6% [8–12]. For ADM,

there are 3 studies that showed ADM has the effect

to reduce errors. Even 1 journal only showed the

staff satisfaction about the patient safety, but it

means the staff approved the ADM reduced the

errors and it made them satisfy [7, 13, 14]. Sujatno

2016 showed that in his hospital, ADM could

reduce dispensing errors more than 35% (50.33 ±

34.77 to 15.67 ± 6.282). But Beard & Smith, 2013

and Ong et al., 2014 had showed that ADM can

make all the dispensing process without any

mistakes.

Time-saving

As the result from the staff satisfaction parameter,

they agree that ADM and ADDS help them to serve

faster. ADDS can reduce the time in emergency

case, peak hour and for preparation process. ADDS

also can increase the service-speed and can spare

more work-time about 2 hours a day [9, 16, 17]. But

Roman et al., 2016 has another opinion, in

19 Global Health Management Journal, 2017, Vol. 1, No. 1

emergency case ADM could service faster than the

normal situation. Beard & Smith, 2013 mention that

ADM can reduce 50% of the time with almost zero

errors. As the saving-time effect from ADM, the

pharmacist and the nurse have more time to spend

it with patients.

Cost analysis and effectiveness

There are 6 studies about the effectiveness of ADM

or ADDS which showed as saving the total number

of staff, space and total number of stock. ADM

compared by manual process, ADM can save up to

US$ 1,894,429 (for 10 years) if reach 75%

dispensed volumes from ADM[18].The more

medicines dispense from the ADM, the more

effective the pharmacy will be[14]. Beard & Smith,

2013 explained that ADM can reduced 4 staff,

reduced the inventory stock about £250,000,

increase the saving cost £500,000.

ADDS can save approximately US$ 148,229 for 5

years [19]. Another study showed also the cost-

effectiveness about US$ 80,000 annually. Mostly in

US, the ADDS are rented for the hospitals, with the

rent cost about US$27,000 annually [9].However

one study showed that ADDS can give the impact

for the patient cost. The patient cost reduced 20.3%

and can increase number of drugs for stocked about

11.4% with the less needed [16].

DISCUSSION

Situation in Indonesia

In Indonesia, there is only one hospital already

reported use ADM, outpatient pharmacy of

Bethesda Hospital Yogyakarta [13]. The ADM

need to integrated with the hospital software system

to maximize its potential as what Beard & Smith,

2013 results. The integration between ADM and

Hospital Information System (HIS) can make the

zero result of errors.

There are some challenges for Indonesia to

implement ADM: the low cost of labor with the big

population and the low economic rate. All the ADM

are made from foreign country such as Italy,

Germany, Japan, etc. so the prices usually

expensive.

Nowadays, it is very difficult to get the well-trained

staff even easier to recruit any new staff. As long as

pharmacy still using human power, the errors

incidents will be higher than use technology [14].

So the human resource problem for hospitals is still

high and ADM can solve the problem with its

benefits.

ADM can reduce the total staff needed in pharmacy,

increase the inventory control, reduce the errors,

increase the time service and increase the staff

satisfaction. All the benefits can calculate as the

money or cost savings or cost-effectiveness. With

those benefits, Indonesian hospitals must considere

to implement ADM as their solutions in their

pharmacy departments. Claire Chapuis et al., 2015

said that it is very profitable and improve efficiency

with the ADM. The only one barrier is the

resistance of staff to changing.

ADM implementation in Indonesia

Bethesda hospital has implemented ADM in

outpatient department since 2014. Bethesda faced

three main problems, the human resource problem,

medication errors and very long waiting time before

implemented ADM. They had tried many ways to

solve the errors problem such as human training,

organizing the stocks, using information system and

barcode system, but in reality, it just reduced some

errors while dispensing errors were still high and

the staff workload still very high. After ADM

installed, the staff were very satisfy and the

dispensing errors incidents had reduced drastically.

Bethesda hospital used 20% and 80% role, to make

the priority system for ADM stocked medicines.

Most of Indonesia medicines are finished as strips

(aluminum foil) or blisters and packaged into 1 box

with lot of number (e.g. 10 strips in 1 box), so

Bethesda Hospital need to repackaged and put into

the box and they called smart pack. Those smart

pack containing certain number of medicine. It will

be possible if there will be 3 smart packs with the

same medicine but different number.

They also promoted ADM to the physicians as the

prescriber. They put any options of the medicines

with different number that stocked in ADM in

electronic prescribing, so the physicians can choose

the kinds and number of medicines to prescribed,

which will be dispense with ADM. As the result

they got the dispensing errors reduction about 35%.

With the combination between ADM and electronic

prescribing, they got 69.78% reduction of

Global Health Management Journal, 2017, Vol. 1, No. 1 20

dispensing errors, but the reduction not as much as

the Beard & Smith, 2013; Ong et al., 2014 studies.

It because they still printed the label outside the

machine.

According to Bethesda Hospital experience, the

biggest issue for hospital pharmacy is the variation

of total medicines requested from the physician.

Sometimes, the patient also does not want to take

hall the total number of medicines in prescription,

they would like to buy half from the total amount of

medicines. From that reason, the pharmacist should

make priority, which medicines will be save inside

ADM. They can do a research to find the 3 top of

total number from each medicines that the

physicians often prescribed as the priority to keep

inside the machine. The more medicines are going

out from the ADM, the less error will be happen.

Another problem pharmacy faced is about the

software system and barcode system. Some

hospitals just have simple software just for logistic

system, but ADM need more complete software

such as electronic prescribing and barcode system

for each medicines. As the leaders who would like

to implement ADM, software and barcode is the

first preparation of hospital must have. The leader

also must to create the working climate into the

technology based to all staffs because some staff

could resists for the new technology and do not

want to exit from their comfort zone.

Type of data for feasibility study

The implementation of ADM need more

management consideration as the financial

prospective become the main part to take any

decision. The benefits of using ADM should be

calculated as the money, but it is not easy to convert

all aspects as money value for example the staff

satisfaction and the workflow efficient.

First of all the hospitals should think about the

standardization of the pharmacy procedure, to

keeps the process and the result in good quality and

safety as the requirement of accreditation. ADM

will record all the dispensing process by

computerize and it will make stream-lining the

processes. This benefit is the sample of the

intangible aspect. Another example is the nurse and

pharmacist satisfaction when using ADM.

According to the result, the average for both

satisfaction is more than eight, it means they are

happy when implementing ADM in their

department. It should give any positive impact to

their work when they are happy. The workload

might be reducing and could give impact to their job

quality for example incident errors less happen or

the service time is faster for their job.

Second, ADM could reduce the dispensing errors

incidents. It should become the first priority as

ADM implementation consideration. Reducing

errors will saving-cost to the hospitals. Hospitals

will spend much money to prevent the errors or to

solve the impact of errors. The amount of money

that they spend for errors can be used for the FS

calculation.

Third, the improvement of service time. ADM

could saving the time about 2 hours even in

inpatient or in peak hour time of outpatient

department. The time saving can be converted to the

cost-saving and can be used for FS calculation. The

converted time-saving become cost-saving can use

the human power or staff cost/hour.

The last one is the effectiveness of ADM. From the

human resource aspect, ADM can reduced 4 people

according to Beard & Smith, 2013. The reduction

can be calculated as the cost-saving by using the

total cost/month. For the stock efficiency, the

average of cost-saving from ADM is about US$

189,442/year (1 USD = 13,200 IDR,

2,500,634,400,- IDR), or from another study said

ADM increase the saving cost about £500,000(1

GBP = 16,800 IDR, 8,400,000,000,- IDR). ADM

can give any extra saving money if using ADM in

inpatient department, from the result ADM can save

US$ 29,645/year or IDR.391,314,000,- per year

(1USD = 13,200 IDR). Tsao et al., 2014 also said

its profitable when rent ADM while using manual

(US$ 80,000 saving vs US$ 27,000 cost). If the

hospitals use ADM for inpatient, they can save

about IDR.699,600,000 annually.

Now, all the benefits can be calculated and

accumulated and must be comparing with the ADM

selling price or another additional activity when

ADM had been implemented. ADM

implementation is also very depending on the leader

strategic plan. If the leader didn't put technology as

the strategic way to make any improvement for his

hospital, it's very difficult to push that hospital to

21 Global Health Management Journal, 2017, Vol. 1, No. 1

install the ADM otherwise the FS calculation is

ready for them, it might be change his mind.

Limitation and strength

It is very good news for Bethesda hospital that had

started to used ADM in Indonesia even just in

outpatient pharmacy. Indonesia need another ADM

for the inpatient pharmacy (ADDS) to become the

sample and as the evidence that ADDS improve the

pharmacy process. It's not just for the pharmacy, but

for all staff. It can help the nurse workload and their

service care to patient. With the ADDS the nurse

can safely administrate the medicine and as the

result, the total incidents of medication error will

reduce.

ADM as the solution is very depends on the

leadership, management skill and all the

departments support. ADM need some

consideration from the leader to make it as the

priority for the pharmacy. They need to calculate

some analysis to make the real Feasibility Study

(FS) of the ADM investment. In this study, the

benefits had written so it can help the leader for

their FS. In fact, there will be more benefits of

ADM rather than the listed in this study, such as the

saving space or the opportunities of revenue rising.

With the ADM benefit, increase the speed of

pharmacy services and reduce the waiting time, can

make the patients who do not like to wait, to buy the

medicines in hospital.

This study requires more the data such as

dispensing errors calculation as the money saving,

another improvement in cost calculation. To

maximize the function of ADM, it needs trained

staff, good managerial concept to review

periodically the consumption of medicines inside

ADM.

CONCLUSION

Some studies showed ADM could reduce

medication errors, increase the staff satisfaction,

increase the saving cost and reduce the inventory

stock, saving time and make some efficiency such

as the reduce the total number of staff and patient

cost. With the benefits of ADM, it's very feasible

for Indonesian hospital to implement ADM and

information system in their pharmacy. The

effectiveness not just for the pharmacy, but it would

positively change for all related departments in

hospital.

CONFLICT OF INTERESTS

None declared.

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