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Guide Mat er ials

f or
Medical St or es Managem ent Tr aining

Developed by :

Com m unit y Developm ent Medicinal Unit


97, Forest Park, Bhubaneswar-751009, Odisha - India.
Phone No: 0674-259 5013, 657 4302
Fax No: 0674 -259 5405
Email: cdmuorissa@satyam.net.in, cdmuodisha@gmail.com
Web Page: cdmuodisha.org
Guide Mat er ials for Medical St or es Managem ent Tr aining 1

Contents
1 Preface
2 A word about CDMU-Odisha.
3 Why this Medical Store Management Training.
4 Why CDMU-Odisha has taken up initiatives to do the
“Medical Stores Management Training”.
5 What the participants will learn from the “Medical Stores
Management Training”.
6 From whom the training was designed.
7 Routine Warehouse or storeroom management tasks.
8 Receiving and arranging commodities.
9 Keeping track of products in your storeroom.
10 Maintaining the quality of your products at your Disposal.
11 Setting up your medical store.
12 How to Manage a Drug Store in Peripheral Level
13 Storage of vaccines & monitoring with special emphasis on
Immunization.
14 What are the books available in CDMU on “Medical Stores
Management”
15 Case Study.
Guide Mat er ials for Medical St or es Managem ent Tr aining 2

Preface
This manual was developed by CDMU- Odisha, having obtained technical
inputs from the manuals of UNICEF, WHO, DELIVER, DSPRUD and
Government of Odisha. We hereby acknowledged the contribution of all of
them to help CDMU to develop this manual.
Drugs and medical supplies are dispensed at the cutting edge level of the
interface between the public health system and the people. Availability or lack
of it brings either credit or discredit to the public health system. The primary
reason for holding stocks of medicines and medical supplies in a proper
scientific manner is to ensure continuous and uninterrupted availability to
prevent stock-outs, especially of critical items of supply while at the same time
ensuring that stocks of medicines do not get expired. An efficient inventory
management is a pre-requisite for optimal stock management. It enables the
management of health facilities to know the current pattern of consumption of
drug trends over a period of time and also variances. The environmental
control of the drugs and other medical supplies play an important role to keep
the products' efficacy intact. Some medicines and vaccines need special
storage temperature, otherwise, there may be wastage. The quality of the
medicines can be adversely affected by poor storage, transportation and
distribution. Thus, maintaining proper storage condition for health
commodities is vital for ensuring their quality. So, by this training, CDMU wants
to educate different people dealing with medicines and equip them for the
roles they have to perform efficiently so that the wastage does not take place
or can be minimized.
The Rational Use of Medicines and supply of essential generic medicines is an
important area to make any health program successful and economical with
quality. This training on “Medical Stores Management” will help the
participants to understand the issue better so that they can maintain their
respective medical stores better. Hope, this manual will help the participants
and the readers will find it useful.
With hope, for and on behalf of the CDMU E.C. & RUM Board:
Prof. Dr. Mrs. T. R. Swain, Associate Prof., SCB Medical College, Cuttack
Prof. Dr S. N. Pandey, VSS Medical College, Burla
Prof. Dr. Tapas Bhattacharyya, NRS Medical College, Kolkata
Mr. Tarak Banerjee, Administrative Officer, CDMU-Odisha
Email: - cdmuorissa@satyam.net.in , cdmuodisha@gmail.com
Phone N0:- 0674-2595013 Fax: 0674-2595405, Mobile No:- 7205001797
Guide Mat er ials for Medical St or es Managem ent Tr aining 3

A WORD ABOUT C.D.M.U, ODISHA

BUILDING TRUSTFUL RELATIONSHIP:-


Community Development Medicinal Unit, Odisha (C.D.M.U) is a non-profit making organization,
working in the field of community health care for more than twenty six years. The constitution of
C.D.M.U, Odisha is secular. C.D.M.U, Odisha is the pioneer in promoting Rational Use of
Medicine (RUM) in Odisha.

In this era of modern Medicines, where every day lots of medicines (there has been a
proliferation of number of medicines) and subsequent phenomenal increase in data about
medicines and therapeutics emerge, there has remained a serious lacunae of organizations
those are meant exclusively for disseminating unbiased and accurate information on Medicines
and their prescribing information. The major activity of C.D.M.U, Odisha is to provide reliable and
qualitative Essential Medicines to the health programmers of NGOs and charitable institutions
working for the benefit of the poor at affordable cost. Besides that, for safe, effective and better
use of Essential Medicines, C.D.M.U, Odisha makes available relevant and reliable unbiased
information to the member partners. C.D.M.U believes in the concept of Co-operation and
mutual understanding among the partners covering whole of Odisha and thus develop a trustful
relation with the members to fulfill the concept of Rational Use of Medicines.

PARTNERS OF CDMU, ODISHA:-


Presently, the member organizations of C.D.M.U., Odisha availing support for health care
activities are around 421. All members work for social development. They can be categorised as
follows:
1. Hospital services run by Non Government Organizations (NGO) including their outreach
programmes.
2. Primary Health centers run by charitable institutions and NGOs.
3. Primary Healthcare programmes /services of NGOs working in the backward pockets of
Odisha.
4. Government programmes for T.B, Leprosy, Blindness eradication and HIV-AIDS.
5. Community Based Organizations recently formed in partnerships at the panchayat level
with medicinal units as a developmental concept.
6. Self Help group members who developed medical clinics at user point for the benefit of
the people.

VISION:-
“To make available the right drugs that is administered in right dose, at right time, for right
duration at an affordable cost to the common people of Rural Odisha” in normal as well as in
emergencies.
Guide Mat er ials for Medical St or es Managem ent Tr aining 4

MISSION:-
1. C.D.M.U, Odisha would create direct access to the rural consumers, especially the
vulnerable sections such as women, tribal and the people living below poverty line.
CDMU, Odisha would act as the collective agency of these sections to accelerate
leverage of their bargaining capacity.
2. C.D.M.U, Odisha would develop gender sensitive approaches to enable women for
taking decisions regarding their own health.
3. C.D.M.U, Odisha would use demand – based approach in distribution of drugs and
medicines by generic name to keep prices to the minimum. It is especially important
when this segment accounts for 25% of the market share that people may choose to
procure medicines in the generic name in place of the branded medicines.

GOALS:-
1. Building capacities of communities by promoting community-based organisation (CBO)
to manage the distribution and sale of medicines at user end. There would be emphasis
on gender equity and linkage to prevalent referral system of the locality.
2. Institutional Development and involvement of its partner's organisation, viz. (CBOs,
NGOs, private hospitals and Associations) through networking processes.
3. To provide trained manpower such as health service providers to work in rural areas.
4. Reduction of transaction costs in the distribution chain of medicines and drugs to provide
an enabling environment for sustainable supply.
5. Development of decision support system to foster trust among members of its
distribution network as well as improve their process capacity.
6. Policy advocacy in Rational Use of Medicines (RUM) in line with and concomitant to, its
Vision, Mission and Goal.
7. Provide emergency services during medical emergencies and promoting the concept of
emergency medical management.

OBJECTIVES OF CDMU:-
? Collect and disseminate medicine related information to the member organizations and
the Community people.
? Advise member organizations on different aspects of Rational Use of Medicines.
? Make available essential, generic quality medicines on time at economic rate.
? Maintain central store for members.
? Ensure quality by different means.
? Capacity building on medical store management.

Give emergency services during disaster and emergencies.


Guide Mat er ials for Medical St or es Managem ent Tr aining 5

Why this Medical Store Management Training


Community Development Medicinal Unit- Odisha is a low cost initiative that ensures access to
life saving medicines as a right to health. It was started as a positive response to many requests
of the health care NGOs in West Bengal and Odisha to help voluntary sectors to procure quality
medicines in time even in the remotest villages at economic prices. This initiative was to meant to
serve our fellow countrymen in maintaining their good health through the good times and the
bad. The activity of CDMU-Odisha was initiated in the year 1987 with the kind support and
involvement of noble minded personalities of Odisha. Without such support and sincere
cooperation, CDMU- Odisha could not have survived and prospered over the past twenty six
years to achieve these heights of dedicated services for the people of Odisha.
Presently, more than 421 member organizations receive support from our extensive supply
system which reach large segment of the rural/urban population. A large section of population
receive educational support services on Rational Use of Medicines Promotional activities and
other. It is very difficult to quantify the exact number of direct beneficiaries of our medical and
educational services. The “Rational Use of Medicine” concept is a worldwide phenomenon and
warrants proper attention so that more and more people be benefited from the exercise. Several
rural based associations get actively involved in Rational Use of Medicines promotional
activities. But, the need is much more. We need to venture out further in this journey in a more
strategically planned manner with active involvement of health care organizations, participation
of people and communities and the cooperation of the Odisha Government.
CDMU has taken up initiatives to involve more and more people, health care institutions,
hospitals, doctors, community leaders and Government of Odisha especially the Department of
Health and Family Welfare. CDMU supplies the life saving generic medicines to its 421 member
organizations covering whole of Odisha. It is a self sustaining effort initiated by CDMU-Odisha.
Some members are requesting CDMU to get back the expired medicines, which expires at the
members' store. Some times due to the faulty storing system at the MOs of the medicines, those
get damaged at different level. Some time efficacy of the medicines gets reduced due to lack of
scientific storing of medicines. Some time the patients are not able to keep the medicines
properly. Through this training program, CDMU has taken up initiatives to impart training to the
member organisations' persons to handle medicines correctly and properly at different levels -
so that wastage can be minimized. Environment management is an important issue for safe-
keeping of medicines. This training will provide fair knowledge to the participants on these
aspects so that losses can be minimized at different levels. This training will also provide
guidance needed in storing and environmental management of medicine stores. We hope that
the training will be beneficial to CDMU's members to deal with medicines better with their
optimum utilization.
Guide Mat er ials for Medical St or es Managem ent Tr aining 6

Why CDMU-Odisha has taken up initiatives to do the


“ Medical Stores Management Training”
30% of Indian health care services is being undertaken by Voluntary Organizations. Most of the
voluntary organizations are of non-profit motive and charitable in nature. They run on donations
from well wishers or donor agencies. They face scarcity of finance every time. Need of medicines
is increasing but fund is decreasing inversely. Since the first report on the selection of Essential
Medicines was published in 1977, the concept of essential medicines and its management has
become widely recognized as vitally useful. Many developing countries have already selected
Essential Medicine according to their needs.
Success of Essential Medicine supply system depends on the efficient management and
administration of supply, storage and distributions at every point from the manufacturers to the
end user. The training will provide detailed guidelines to the participants on Medical Stores
Management and effective use of medical stock. Thus, to eliminate wastage and to ensure
scientific continuity of supplies; procurement, storing, dispensing and appropriate
administration of medicine are to be handled properly with utmost care.

What the Participants will learn from the “ Medical


Stores Management Training”
After the training, the participants will learn the following things:-
1 What is “Medical Stores Management” & How?
2 The importance of Medical Store Management
3 What are the basic approaches and responsibilities for safe keeping of medicines?
4 The scientific Medical Store Management and Need based Medical Store
Management.
5 Different recording systems ( hard copy and soft copy)
6 Fundamental knowledge on generic and branded medicines.
7 Proper Storage Vs Economic Impact.
8 Purchase and utilization of medicines and its recording.

For whom the Training was Designed


1 Pharmacists & other persons working in Hospitals, Dispensaries and NGOs.
2 Medical Store In-charge
3 Experienced persons working in the field and dealing with the medicines.
4 Representatives from Commercial establishments & others.
Guide Mat er ials for Medical St or es Managem ent Tr aining 7

Routine Warehouse or Storeroom


Management Tasks
Any Hospital, dispensary and clinic should have a large number of medicines in its store room to
give better services to the people. The store keepers and pharmacists need to take care to safe
keep their medicines at the store. Following tasks at regular intervals are recommended to safe
keep the medicines at their respective stores.

(A) DAILY/WEEKLY:-
o Monitor storage conditions.
o Clean receiving, storage, packing and dispatching areas.
o Sweep or scrub floors.
o Remove garbage.
o Clean bins, shelves, and cupboards, if needed.
o Ensure adequate ventilation, environmental control and cooling.
o Ensure that products are protected from direct sunlight, rain water and moisture.
o Monitor store security and safety.
o Check the store roof for leaks, especially during the rainy season and during or after a
storm.
o Monitor product quality (visually inspect commodities and check expiry dates).
o Ensure that products are stacked correctly (Are the cartons below being crushed?)

(B) DAILY/WEEKLY:-
o Update stock records and maintain files.
o If rotational counting, conduct physical inventory and update stock keeping records.
o Monitor stock levels, stock quantities and safety of stocks.
o Place emergency order (as needed, using local guidelines).
o Update back-up file for computerized inventory control records.
o Update bin cards.
o Separate expired stocks and move to secure area.

© MONTHLY:-
o Conduct physical inventory or cycle count and update stock keeping records.
o Run generator to ensure the system is working correctly; check the level of fuel, if
needed.
o Check for signs of rodents, insects or roof leaks.
o Inspect the structure of the storage facility for damage, including the walls, floors, roofs,
windows and doors.
Guide Mat er ials for Medical St or es Managem ent Tr aining 8

(D) QUARTERLY (EVERY 3 MONTHS):-

o Conduct physical inventory or cycle count and update stock keeping records.
o Use established procedures to dispose of expired or damaged products.
o Visually inspect fire extinguishers to ensure that pressures are maintained and
extinguishers are ready for use.

TASKS ACCORDING TO REORDER INTERVAL AND REPORTING SCHEDULE


(USUALLY MONTHLY OR QUARTERLY)
o Assess stock situation.
o Complete and submit requisition form (indent or “pull” system).
o Determine issue quantity and issue products (“push” systems)
o Receive products.
o Store products using correct procedures: rearrange commodities to facilitate the first-
to–expire, first –out (FEFO) policy.
o Complete required reporting and documentation.

Every 6 months; -
o Conduct fire drills and fire safety procedures.
o Inspect trees near the medical store and cut down trees with weak branches.

Every 12 months: -
o Service fire extinguishers and smoke detectors.
o Conduct complete physical inventory and update stock keeping records.
o Reassess maximum/minimum stock levels and adjust if needed.

Pharmaceutical Procurement
Acquiring of supplies from Public suppliers or aid agencies or purchase from manufacturers, retailers or
specialized Government and Non Government approved distribution agencies is known as
pharmaceutical procurement.

I) Efficient Management:-
Efficient management of drugs supply ensures sustainable access to and availability of essential
medicines in public.

Efficient management saves money and improves performance in following ways:


Guide Mat er ials for Medical St or es Managem ent Tr aining 9

(1) Avoiding purchasing of unnecessary medicines:-


It is most important that each health care unit should carefully select those medicines that are
required in their own unit to treat maximum priority diseases. It acts as a check point to a large
extent & facilitates purchasing only those medicines that are needed.

(2) Reducing stock-out days:-


Every health care unit should order the required quantity of medicines by using scientific &
reliable estimation. It leads to the availability of medicines in accurate time interval. It has been
seen that many health care units fail in accurate estimation of the medicines as a result of which
“shortage of medicines occurs”.

(3) Reducing irregular supply of medicines:-


Medicine supply reaching at any health care unit should mainly depend upon its distribution
process. Efficient distribution process should be achieved by designing an effective network of
storage facilities & transport facilities. Keeping in view the geographical layout of the health care
unit, it is essential to work out an appropriate roadmap and strategy for delivery of medicines at
all places.

(4) Avoiding Storage of expired medicines:-


By adopting “ Good Store Keeping Practices (GSKP) “, medical stores & pharmacies have
reduced their wastage and streamlined the availability of medicines in the health care units.

(5) Improving dispensing process:-


Dispensing is a major step taken by the dispenser & patients. The dispenser (Pharmacist or
compounder) dispenses the medicines to the patients, prescribed to him/ her by the prescriber.
The dispenser should realize that patients themselves should not choose their medicines but
should be asked to take all the prescribed medicines. Therefore, it is a major role of the dispenser
to educate the patients about each prescribed medicines and dispense the desired quantity of
medicines to the patients.

(II) Selection of Pharmaceutical products:-


The major & the 1st step of a health care unit is to prepare an “Essential Medicine List (EML)” to
promote regular supply & Rational Use of Medicines.
The main objective of the “EML” is to satisfy the priority health needs of the community. From this
it is to be ensured that all medicines required for treating priority diseases among people are
available at all health care facilities and dispensed to patients in desired quantity, dosage form
and strength at all times.
Guide Mat er ials for Medical St or es Managem ent Tr aining 10

Effective Procurement:-
An effective procurement can be achieved by adopting following methods:-
o Procure the right medicines in the right quantities.
o Obtain the lowest possible purchase price.
o Ensure that all medicines procured must meet recognized standard quality.
o Arrange timely delivery to avoid shortages, overstocking and stock outs.
o Ensure supplier reliability with respect to service and quality.
o Set the purchasing schedule, formulas for ordering quantities and maintain safe stock
levels to achieve the lowest total cost at each level of the system.
o Achieve these objectives in the most efficient manner possible.

Who will prepare “ EML” : -


The “Essential Medicine List (EML)” should be prepared by a committee (e.g. Drugs &
Therapeutic Committee, Pharmaceutical Committee) of committed individuals with
representations from: -
(a) Qualified experts i.e. Pharmacologists & Pharmacists.
(b) Clinicians.
(c) Disease Control Program Managers.
(d) Nursing/Paramedical staffs.
(e) Stores personnel.
(f) Purchase Development Staff.

Preparation of “ EML” : -
Before preparation of “Essential Medicine List “it is important to select the medicines by studying
the morbidity patterns and patient profiles at the health care units & latter on
Some steps should be followed which are as follows: -
A) Drafting by Expert committee.
B) Review of draft by Expert committee
C) Revision by the Experts
D) Finalization by the committee
E) Publication and popularization
F) Updating of the list periodically (e.g. every 3 yrs)
G) Revision form to be used for addition/modifications/deletions proposed by others.
Guide Mat er ials for Medical St or es Managem ent Tr aining 11

Receiving And Arranging Commodities


(A) Receiving Health Commodities: -

When you receive health commodities: -


(1) Ensure that there is sufficient storage space.
(2) Prepare and clean the areas used for receiving and storing the products.
(3) Inspect packages for damaged or expired products.
If ------------------------------------------------------------------------------…Then
(a) Products those are damaged or expired-----------------
1. Separate the damaged or expired stock from the usable stock
2. If damage or expiry is discovered while the delivery truck is still at your site, refuse to
accept the products and note the problem(s) on the delivery note.
3. If damage or expiry is discovered after the delivery truck has departed, follow your
facility's procedure for handling damaged or expired stock.
(b) Products are not damaged or expired-------------------
1. Count the number of units for each product received and compare to issue voucher.
2. Record the date and quantity received on stock card and bin card (if applicable).
3. Ensure the expiry date is visibly marked on every package or unit.
4. Arrange products in the storage area to facilitate the first-to-expire, first-out (FEFO)
procedure.
(B) Arranging Commodities: -
Arrange the storeroom and shelves as follows: If using pallets, stack cartons of pallets-
o At least 10cm (4inches) off the floor.
o At least 30 cm (1 foot) away from the walls and other stacks.
o No more than 2.5m (8 feet) high (general rule).
Guide Mat er ials for Medical St or es Managem ent Tr aining 12

For all storage:

o Follow the manufacturer or shipper's directions when stacking and follow labels for
storage conditions.
o Place liquid products on the lower shelves or at bottom of stacks.
o Store products that require cold storage in appropriate temperature controlled
zones.
o Store high security / high value products in appropriate security zones.
o Separate damaged or expired products from the usable stock without delay and
dispose of using established disposal procedures.
o Always store all commodities in a manner that facilitates FEFO policy for stock
management.
o Arrange cartons as arrows point up and ensure that identification labels, expiry dates
and manufacturing dates are visible. If this is not possible, write the product name
and expiry date clearly on the visible side.
Guide Mat er ials for Medical St or es Managem ent Tr aining 13

Stock Rotation
When issuing products, it is important to follow the FEFO policy.

Following FEFO minimizes


wastage from product
expiry.

o Always issue
products that will
expire first,
ensuring they are
not too close to or
past their expiry
date. The shelf-life
left must be
sufficient for the
product to be used
before the expiry
date.

o To facilitate FEFO, place products that will expire first in front of products with a later
expiry date.
o Write expiry dates on stock cards, so stocks can be sent to facilities at least with a later
expiry date.
o Write expiry date(s) on stock cards, so stocks can be sent to facilities at least 6 months
before they expire.
Remember, the order in which you received products is not necessarily the order in which they
will expire. Products you received most recently may expire sooner than the products you
received earlier. So it is extremely important to always check the expiration dates and to make
sure the dates are visible while the products are in storage.

Orderly Arrangement Of Essential Medicines


Medical stores must have an well laid out system for classifying or organizing medicines and
must ensure that all employees know the system being followed.

Some common systems for arranging medicines include:-


(a) Alphabetical Order by Generic Name: - Often seen in both large and small facilities.
When using this system, the labeling must be changed when the Essential Medicines
List is revised or updated.
(b) Therapeutic or Pharmacologic Category: - Most useful in small storerooms or
dispensaries where the storekeeper is very knowledgeable about pharmacology.
Guide Mat er ials for Medical St or es Managem ent Tr aining 14

(a) Dosage Form: - Medicines come in different forms, such as tablets, syrups, injectables and
external use products such as ointments and creams. In this system, medicines are
categorized according to their dosage forms. Within the area for each form, a fixed, fluid or
semi-fluid system is used to store items. Any of the other methods of categorizing can be
used to organize the items more precisely.

(b) System Level: - Items for each level of the health care system are kept together. This works
well in stores at a higher level when storage of kits is required.

© Frequency of Use: -Frequently used products that move quickly or very often through the
store should be placed in the front of the room or closest to the staging area. This system
should be used in combination with another system.

(d) Random Bin:-Identifies a specific storage space or cell with a code that corresponds to its
aisle, shelf, and position on the shelf. This system requires computer automation.

(e) Commodity Coding: - Each item has its own article and location code. This system has the
greatest flexibility, but it is also the most abstract. Stores staff do not need any technical
knowledge of the products to manage this system because the codes contain the information
needed for storing products properly, such as temperature requirements, level of security
and inflammability. This system works well in computerized inventory systems.

Special Storage Conditions


Some products need storage in an access controlled environment.
? It is important to identify products that are under risk of theft or abuse or have the
potential for addiction and we have to provide increased security for those items. This
also includes products that are in high demand or have the potential for resale (black
market nuisance value).
? Usually, National Essential Medicines List (NEML) includes several narcotics and
psychotropic medicines: one or two will be on facility lists. Typical examples are-
Narcotics:-
Morpphine, opiate preparations, pethidine, diamorphine, papaveretum, hydrocodone and
oxycodone, dipipanone and tramadol.

Other opoid and strong analgesics:-


Pentazocine, codeine, dihydrocodeine, dextropropoxyphene, dextromoramide and
buprenorphine.
Guide Mat er ials for Medical St or es Managem ent Tr aining 15

Psychotropic Drugs:-

Usually the group of drugs called “benzodiazepines”, the more common being diazepam,
temazepam, Lorazepam, nitrazepam, flunitrazepam and oxazepam. Clonazepam, used to treat
epilepsy, may be found under a different class and is not always under the same restriction.
Strong tranquilizing medicines, such as chlorpromazine may also be found under this heading.

o Some of the medicines mentioned above are controlled substances, which are
medicines handled under international control. These medicines need greater attention.
There are specific procedures in place for the procurement, reception, storage,
dispensing and administration of controlled substances. Special ordering forms should
be used.

o Note: Other medicines including antiretroviral used to treat HIV/AIDS may need storage
in a controlled facility, because they are scarce, expensive, and in high demand.

o Organizations donating medicines may require that those medicines be stored in a


controlled environment. These may be products donated for a specific condition that can
also be used for other conditions. Examples include medicines used to treat sexually
transmitted infections that might also be on the NEML and used for other conditions; or
HIV test kits that may be donated for use in specific programs, such as preventing
mother–to-child transmission, but can be used for other purposes, such as ensuring
blood safety

Examples of Access- Controlled Storage


If you have products that need increased security, you must establish access-controlled storage.
This will probably include storing the products in-
o A separate locked room, cabinet or shelf or
o A locked wire cage within the storage facility.
Ideally a warning light or bell will be activated if the products are accessed improperly.
Entry to the location of the access-controlled products must be limited to the most senior
storekeeper or pharmacist and one other staff member.
Limit the number of keys made for the controlled location and keep a list of people who have
keys.
Guide Mat er ials for Medical St or es Managem ent Tr aining 16

Flammables

? Some flammable liquids commonly found in health facilities include acetone,


anaesthetic ether, and alcohols (before dilution) and kerosene.
? Store large supplies of flammable in a separate location away from the main storeroom,
preferably outside the main storeroom but on the premises and not less than 20m away
from the other buildings. Fire fighting equipment should be easily available.. Large
supplies of flammables should never be stored in the same areas as medicines.
? A small stock of flammables may be kept in a steel cabinet in a well-ventilated area, away
from open flames and electrical appliances. Mark the cabinets to indicate that they
contain highly flammable liquids and display the international hazard symbol. In addition,
the shelves of the cabinet should be designed to contain and isolate spillage. Always
store flammables in their original container.
? Flammable liquids each have a flash point, which is the minimum temperature at which
the liquid gives off vapor in sufficient concentration to form an ignitable mixture with air
near the surface of the liquid. The flash point indicates the susceptibility to ignition.

o Acetone and anaesthetic ether have a flash point of 18 degree centigrade.


o Undiluted alcohols have a flash point of 18to 23 degrees centigrade.
o The flash point for kerosene is 23 to 61 Degree centigrade.
It is not necessary to store flammables below their flash point, but it is very important to store
them in the coolest location possible and never in direct sunlight .It is important to control the
evaporation rate and avoid the build up of pressure.

Corrosives
? Corrosive or oxidant substances commonly found in hospitals or other high-level health
facilities include trichloracetic acid, glacial acetic acid, concentrated ammonia solutions,
hydrogen peroxide, silver nitrate, sodium nitrate and sodium hydroxide pellets.
? Always store corrosive substances away from flammables, ideally in a separate cabinet
to prevent leakage. Use appropriate industrial-type protective gloves and eyeglasses
when handling these items.
Guide Mat er ials for Medical St or es Managem ent Tr aining 17

Keeping track of products in your storeroom


o Each medical store should maintain a standard list of stock items that includes all
products they handle, with their specifications, including form, strength, and quantity per
package. The list should be regularly updated and distributed to sub-stores and units.

o Do not order for products that are not on the standard list unless you have special
permission. You should not accept deliveries of products not on the list unless special
circumstances have been identified.

o Inventory records should be maintained for all products on the list.

Stock Records
The minimal information that should be collected on stock records for medicines and other
health products includes
o Product name/description (including the form [e.g., capsule, tablet, liquid suspension,
etc] and strength)
o Stock on hand/ beginning stock balance.

o Receipts
o Issues
o Losses/ adjustments
o Closing/ ending balance

o Transaction reference (e.g. Issue voucher number or name of supplier or recipient)

Depending on the system, stock records might also include additional product information such
as-
o Special storage conditions (e.g. 2degree –8 degree centigrade)
o Unit prices

o Lot numbers/bin locations


o Item codes
o Expiry dates.

A logistics information system must have three different types of records: stock keeping records,
transaction records, and consumption records.
Guide Mat erials f or Medical St or es Managem ent Training 18

Inventory control card- Stock records might also include certain calculated data items. These
are determined by mathematical formulas, that depend on system design parameters (e.g. how
often orders are placed). Calculated data items include-
o Consumption data, such as average monthly consumption (AMC)
o Lead times for ordering / requisition
o Maximum and minimum stock levels
o Emergency order point
A storage and distribution system may not necessarily use all these forms, but it will need forms
to record stock keeping data and product transactions. Standard forms used for inventory
control include-
o Stock cards
o Bin cards
o Requisition /issue vouchers
o Receiving forms (packaging slip/freight bill)
o Delivery /issue vouchers
o Expired stock disposal forms
o Physical inventory forms
o List of approved medicines and prices

CYCLIC PHYSICAL INVENTORY CAN BE


ORGANIZED IN MANY WAYS-
Dosage Form: Count tablets in January, capsules in
February, and liquids in March, etc.
Location in the store room: Count shelves 1-4 in
J anuary, 5-8 in Febr uar y, etc.
Time availability: Count a few items each day whenever
staffs have time.

Stock on hand:
On a periodic basis, count each item for which stock on
hand is at or below the minimum inventory level. This
method may be faster, since there are smaller quantities
to count.

If cyclic physical inventory is used, count each product at least once during the year. Count fast-
moving items and full supply products more frequently.
Guide Mat er ials for Medical St or es Managem ent Tr aining 19

Steps in conducting a physical inventory

(1) Plan
o For a complete physical inventory, schedule the day(s) and time.
o For a cyclic or random physical inventory, identify which products will be counted and the
corresponding time period for those products.

(2) Assign Staff

(3) Organize the storeroom


o Arrange products according to FEFO.
o Make sure open cartons and boxes are visible.
o Separate damaged or expired products

(4) Count the usable products


o Count the products according to the units by which they are issued (e.g. tablet or piece)
not by the carton or box.
o Estimate quantities in open containers for products packaged in bulk. If a bottle of 1,000
capsules is 2/3 full, estimate 650 or 700 capsules. If you have a one liter bottle of syrup
that is ½ full, estimate 0.5 liters.

(5) Update the stock keeping records


o Write the date of the physical inventory and the words “Physical Inventory”
o Using different color ink, write the quantity of the product that you counted during
stocktaking.

(6) Take action based on the results of the physical inventory:


o If the results of the physical inventory differ from the balance on the stock/ bin card,
update the balance by adding or subtracting the excess or missing quantities.
o Dispose of damaged or expired products found during the physical inventory.

o For either of the above, identify, document, and correct the cause of the problem.

(7) Discuss the findings of the inventory with the facility staff:

o Congratulate the staff, if appropriate.

o Take corrective actions, if required.


Guide Mat er ials for Medical St or es Managem ent Tr aining 20

MAINTAINING THE QUALITY OF PRODUCTS


AT YOUR DISPOSAL
Monitoring of problems related to quality:
Products of different types show damage in different ways. Some indicators to detect damage
are:
All Products:
o Broken or ripped packaging (vials, bottles, boxes, etc)
o Missing, incomplete or unreadable label(s)
Liquids
o Discoloration
o Cloudiness
o Sediment
o Broken seal on bottle
o Cracks in ampoule, bottle, or vial
o Dampness or moisture in the packaging
Light –sensitive products (such as X-ray film)
o Torn or ripped packaging
Latex products:
o Dry
o Brittle
o Cracked
Lubricated latex products:
o Sticky packaging
o Discolored products or lubricant
o Stained packaging
o Leakage of the lubricant (moist or damp packaging)
Pills:
o Discoloration.
o Crumbled pills.
o Missing pills (from blister pack)
o Stickiness (especially coated tablets)
o Unusual smell
Guide Mat er ials for Medical St or es Managem ent Tr aining 21

Injectables:
o Liquid does not return to suspension after shaking
o Transparant injectables (glucose,saline etc)developing suspension or sediments.

Sterile products (Including IUDs)


o Torn or ripped packaging.
o Missing parts.
o Broken or bent parts.
o Moisture inside the packaging.
o Stained packaging

Capsules:
o Discoloration.
o Stickiness
o Crushed capsules

Tubes:
o Sticky tube (s)
o Leaking contents
o Perforations or holes in the tube

Foil Packs:
o Perforation(s) in packaging

Chemical reagents

o Discoloration
Damaged products should never be issued to facilities or dispensed to clients. If you are not sure
if a product is damaged, check with someone who knows. Don't issue or dispense products that
you suspect are damaged.
Report any defects and send the defective products back to facility that issued them to you. If an
inspector visits your facility, report any problems to him or her.
(See on waste management for additional information)
22

PREVENTING DAMAGE AND CONTAMINATION


Physical Damage:
Avoid crushing products stored in bulk. Products should be stacked no more than 2.5m (8feet)
high, as a general rule. Heavier or fragile items (such as those packaged in glass) should be
placed in smaller stacks. Bind sharp edges or corners in the store with tape. Most important,
ensure that nothing in the store can fall and injure members of the staff.

Dirt:-
Write and paste the schedule and instructions for cleaning the storeroom in multiple locations
around the facility. Sweep and mop or scrub the floors of the storeroom regularly. Wipe down
the shelves and products to remove dust and dirt. Dispose of garbage and other waste often, in
a manner that avoids attracting pests. Store garbage in covered receptacles.
Infrastructure:-
Ensure the storeroom has easy access to a water inlet and outlet for cleaning. If no running
water is available, set up a system, for example, several 55-gallon drums on an elevated
platform connected to pipes running into the store. Refill the drums regularly. When
rehabilitating an existing storage facility or constructing a new structure, install water inlets in
several locations inside the structure so that water is easily available from any location in the
storeroom.
Cleaning Materials:-
Keep a budget for buying cleaning materials. Use industrial detergents when possible,
particularly for larger facilities, although imported detergents can be expensive. Try to use
locally available detergents, particularly for smaller or more remote facilities. Clean with
chlorine bleach regularly (once a month, for example).
Outside the facility:-
Bury or Burn garden rubbish and cardboard cartons, etc., when garbage collection is not
available. Use the necessary precautions to keep the fire under control, and do not burn
materials close to the building. Make sure the wind is not blowing towards the building.
Guide Mat er ials for Medical St or es Managem ent Tr aining 23

PROTECTING AGAINST FIRE


To prevent damage to products from fire-
o Make standard fire extinguishers available in every storage facility according to national
regulations.
o Visually inspect fire extinguishers every 2-3 months to ensure that pressures are
maintained and the extinguishers are ready for use.
o Service fire extinguishers at least every 12 months.
o Place smoke detectors throughout the storage facility and check them every 2-3 months
to ensure that they are working properly.
o Strictly prohibit smoking in the store.
o Conduct fire drills for personnel every 6 months.
o Clearly mark emergency exits and check regularly to be sure they are not blocked or
inaccessible.
o Display fire precaution signs in appropriate places in the storage facility (especially
locations where flammables are stored.)
o Use sand to extinguish fires where there are no fire extinguishers. Place buckets of sand
near the door.

Four main types of fire Extinguishers:-


(1) Dry Chemical: These extinguishers contain an extinguishing agent such as potassium
bicarbonate KHCO3 (similar to baking soda), and use a compressed gas as a propellant.
KHCO3 when comes in contact with fire / heat generates Carbon Dioxide (CO2) which
extinguishes fire. They are effective for multiple types of fire including combustible solids
like wood or paper, combustible liquids like gasoline, Kerosene or grease, and electrical
fires.
(2) Water: These extinguishers contain water and compressed gas and should only be used
on ordinary combustibles, such as paper and wood. Never use water on fires caused by
liquids (such as gasoline or kerosene) or electrical fires.
(3) Carbon Dioxide (CO2): These extinguishers are most effective on fires caused by
liquids (such as gasoline or kerosene) and electrical fires, but not on fires caused by
combustibles like paper, cardboard, or lumber. The gas disperses quickly and does not
leave any harmful residue.
(4) Halon: These extinguishers are often used in areas with computer equipments or other
machinery because they leave no residue. They can be used on common combustibles,
flammable liquids, and electrical fires. However, halon is dangerous to inhale and
harmful to the environment. They are most effective in confined spaces, but remember
that masks must be used while applying these extinguishers and the area will need to be
ventilated before it can be reoccupied.
Guide Mat er ials for Medical St or es Managem ent Tr aining 24

5. Be sure medical store staffs are trained in how to use fire extinguishers

Pull the pin at the top of Aim the nozzle toward the base S q u e e z e t h e h a n d l e t o Sweep the nozzle back and forth
The extinguisher. of the fire. discharge the extinguisher at the base of the fire
(stand approximately 2.5 m [8 ft]
away).

The P.A.S.S. method is accepted for some dry chemical and CO2 extinguishers; however, other
methods are needed when using water and other extinguishers and with special fires, such as
flammable liquids. Additionally, the P.A.S.S. method may not be appropriate for all dry chemical
and some CO2 extinguishers. BE sure to carefully read the instructions for the extinguishers in
your facility.

PROTECTING AGINST PESTS


Prevention inside the storage facility: -
o Design or modify the storeroom to facilitate cleaning and prevent moisture.
o Maintain clean environment to prevent conditions that favor pests. For example, store
garbage in covered garbage bins. Regularly clean floors and shelves.
o Do not store or leave food in the storage facility.
o Keep the interior of the building as dry as possible.
o Paint or varnish the wood, as needed.
o Use pallets and shelving.
o Prevent pests from entering the facility.
o Inspect the storage facility regularly for evidence of pests.
Packaging and shipping cartons can be treated to prevent pest infestation. For example,
cartons can be shrink-wrapped or non-toxic desiccating (dehydrating) agents can be added.
Guide Mat er ials for Medical St or es Managem ent Tr aining 25

Precaution outside the storage facility:-


o Regularly inspect and clean the outside premises of the storage facility, especially areas
where garbage is stored. Check for any rodent burrows, and be sure that garbage and
other waste are stored in covered containers.
o Check for still or stagnant pools of water in and around the premises, and be sure that
there are no buckets, old tires, or other items holding water.
o Treat wood frame facilities with water sealant, as needed.
o Use mercury vapor lighting where possible, and locate the lighting source away from the
building to minimize the attraction of pests.

Strategies for specific pests:-


Rodents: Rodent problem are best solved by prohibiting of rodent entry and maintaining a dry,
clean facility. Other alternatives include keeping cats; traditional / spring loaded snap traps
baited with food; blue boards, which are disposable plastic or wood trays partially filled with non
toxic, adhesive glue; bait boxes, which are shoe-sized boxes with lids and holes on each end
containing toxic rodenticide packets; electronic ultrasonic devices, which emit high frequency
sounds, causing rodents to avoid the area; or rat poison.
Birds or bats: If the facility has space between the ceiling and the roof, cover all the openings
with fine wire mesh to prevent birds or bats from entering the storeroom.
Flying pests: The best prevention is to keep all doors and windows of the storage facility closed
or screened off from the outside. Make sure, there are no holes in the walls, floor, or ceiling.
Insect electrocuting light traps (bug zappers) hanging electric grids that attract flying insects via
a bright fluorescent or ultraviolet light damages a number of products (especially latex products,
such as male condoms)
Guide Mat er ials for Medical St or es Managem ent Tr aining 26

Reptiles (Snakes and Lizards etc.): Most snake species are innocuous and can be managed
with noisemakers and by keeping the outside of the facility clear of bushes. If snakes are an
especially difficult problem in your area, you can construct a snake–proof fence around the
perimeter of the facility .The fence should be made with heavy, galvanized metallic screen with
6mm wire mesh.
The fence should be 90cm tall with the lower end buried at least 10-16 cm in the ground. The
above ground portion of the fence should be slanted at a 30-degree angle outward from the base
and away from the building, using supporting stakes inside the fence. Also, spraying of Carbolic
Acid around your premises is advisable.

Termites / Structural pests:


There are two primary treatments for subterranean termites, but both are expensive and require
a specialist. The first treatment involves injecting a termiticide into the soil in the ground beneath
the facility. If the problem is severe, or if the first treatment is not feasible, the building must be
fumigated. All stored goods must be removed from the site during fumigation. Replace wooden
structures severely damaged by structural pests.
There are alternative methods of controlling structural pests-
o Use nontoxic heat or liquid nitrogen treatments.
o Build metal barriers into the foundation of a new building with sheets of metal protrude
from protrude from between the foundation and walls of the building. The sheets are bent
downward at an angle, but not touching the ground. When termites or ants attempt to
climb up the foundation, they encounter the metal barrier that they cannot climb around /
upword.
o Construct sand barriers around the building as a preventive measure. However, the
grains of sand must be of specific size, so this method can be expensive.

CONTROLLING TEMPERATURE
Humidity:
When product labels say, “protect from moisture,” store the product in a space with no more than
60% relative humidity. To reduce the effects of humidity consider-
Ventilation:
Open the windows or air vents of the storeroom to allow air circulation. Ensure all windows have
screens to keep out insects and birds, and either have bars or are not open wide enough for
anyone to climb in. Put boxes on pallets and ensure there is space between pallets and the walls
of the storeroom.
Guide Mat er ials for Medical St or es Managem ent Tr aining 27

Packaging:
Secure all lids. Never open a new container unless necessary.

Air Circulation: Use a fan to


circulate fresh (outside) air. In
bigger storerooms you may need a
ceiling fan. Standing pedestal fans
are more useful in smaller
storerooms. This requires
electricity and some maintenance.
Air Conditioners: If possible, use
an air conditioner. This is costly,
depends on a constant supply of
electricity, and requires regular
maintenance. Depending on
climatic conditions, a dehumidifier
may be a less costly option.
However, they also need a
constant supply of electricity and
require regular attention to empty
the water containers.

Sunlight: Some health products are


photosensitive and will be damaged if
exposed to light. These include multiple
vitamins, Frusemide, and Chlorpheniramine
Maleate, Hydrocortisone, latex products
(such as male condoms), and x-ray film.

To protect products from sunlight:-


o Shade the windows or use curtains, if they are under direct sunlight.
o Keep products in cartons.
o Do not store or pack products in sunlight.
o Use opaque plastic or dark glass bottles for products that require them.
o Maintain trees on the premises around the facility to help provide shade, but check them
regularly to ensure that there aren't any branches that can damage the facilities.
Guide Mat er ials for Medical St or es Managem ent Tr aining 28

Heat:-
Remember that heat will affect many products. It melts ointments and creams and causes other
products to become useless. Following the guidelines listed earlier for protecting products from
humidity and sunlight will also help protect products from heat.
It is important to have thermometers in various parts of the storeroom to monitor temperature
(see section on monitoring temperature). But, even if you feel hot, your products are probably
hot, too.

Monitoring:-
Consistently and Regularly monitor
the temperature of the different areas
within the storeroom.
o Ke e p t h e r m o m e t e r s i n
various places for monitoring.
o Keep the storeroom well
ventilated (see section on
humidity). For better
ventilation, store boxes on
pallets and leave room /
space between rows of
stacked boxes

o Keep direct sunlight out of the storeroom.

Refrigerators and Freezers:-


o Refrigerators that open on the top are more efficient than vertical ones, because hot air
rises while cold air falls.
o The coldest part of vertical refrigerators is at the bottom.
o Store products that are sensitive to freezing or very low temperatures on the upper
shelves.
o Always have enough frozen icepacks to transport items requiring cold storage in cold
boxes and / or vaccine carriers. Use only icepacks. Do not use icepacks filled with water.
Do not use icepacks pre-filled with other liquids, which are usually blue or green.
o When ordering cold chain equipment, larger facilities should reassess the needs for
icepacks and icepack freezer space.
o If there is enough space, place a few plastic bottles of water in the refrigerator. This will
help maintain the temperature for a longer period of time if the power is cut off.
o Place refrigerators and freezers with space between and about an arm's length away
from the wall. This will increase the air circulation.
Guide Mat er ials for Medical St or es Managem ent Tr aining 29

o Under ideal conditions, rooms with multiple refrigerators and /or freezers should have air
conditioning. Refrigerators and freezers generate large amounts of heat, which can
damage the equipment over time.
o If it is not possible to have air conditioning, install fans around the equipment to increase
airflow. If installing fans, remember to place the fans in such a way that the air also flows in
the spaces behind the refrigerators.
o Ideally, larger facilities should have a cold room rather than numerous refrigerators.
Power supply:-
Arrange for a solar panel generator or alternative supply of electricity to ensure uninterrupted
power supply for cold rooms and refrigerators if the main source of electricity is not reliable. If the
generator is not Solar-powered, maintain a stock of fuel sufficient to run the generator for at least
a few days (see section on storing flammables). Run the generator on a regular basis (at least
once a month) to ensure the system is working properly. Larger facilities may want to contract
out/source out the maintenance of the generator and electrical system.
If your electricity supply is unreliable, use kerosene or solar powered refrigerators. Kerosene
dependant appliances require frequent maintenance. Trim the wick regularly so the flame is not
too high, clean the chimney monthly, and keep a back-up supply of kerosene (see section on
storing flammables). Place the refrigerator away from the wall on a balanced and level surface.
The appliance must be placed on a level surface or it will not function properly. Monitor the
temperature regularly. The flame on a kerosene appliance should always be blue; if it is yellow,
trim the wick.
Common Terms:-
The following terms relate to temperature and medical supplies. It is important to follow the
manufacturer's recommended storage conditions for all products.
(a) Store frozen: Some products, such as certain vaccines, need to be transported within a cold
chain and stored at-20o C (4o F). Frozen storage is normally for longer-term storage at higher-
level facilities.
Guide Mat er ials for Medical St or es Managem ent Tr aining 30

o o o o
(b) Store at 2 -8 C (36 -46 F): Some products are very heat sensitive but must not be frozen.
These are usually kept in the first and second part of the refrigerator (never the deep freezers).
This temperature is appropriate for storing vaccines for a short period of time.
(c) Keep cool: Store between 8o-15oC (45o-59oF)
o o o o
(d) Store at room temperature: Store at 15 -25 C (59 -77 F).
(e) Store at ambient temperature: Store at the surrounding temperature. This term is not widely
used due to significant variation in ambient temperatures. It means “room temperature” or
normal stage conditions, which means storage in a dry , clean, well ventilated area at room
temperatures between 15-degrre to 25-degree Centigrade(59-degree-77-degree Fahrenheit)
or up to 30-degree Centigrade, depending on climatic conditions.
Medicines with stability problems under tropical conditions:
Oral Solids (tablets):
Acetylsalicylic acid
Amoxycillin
Ampicillin
Penicillin V
Retinol
Oral Liquids (syrups):
Paracetamol
Injections/ Injectables:
Ergometrine
Methylergotamine
Adrenalin
Reconstituted antibiotics

PROTECTING AGAINST THEFT


During Transport:
o Verify documents.
o Ensure packing seals are used.
Use strong boxes/ containers.
o Provide reliable / well maintained vehicles.

o Ensure drivers are reliable.


o Ensure rapid clearance at air and sea ports and through on-land borders.
Guide Mat er ials for Medical St or es Managem ent Tr aining 31

At Storage facilities:-
o Limit access to only designated staff.
o Limit the number of keys made for the facilities; keep a list of people who have keys.
o Secure all locks and doors. Make unannounced spot checks. Provide for independent
stock count / inventory control.

In Health Centers:-
o Lock the storeroom / cupboards.
o Have inventory control cards for each product
o Set maximum dispensing quantities
o Have dispensers' records, individual prescriptions and maintain prescription or
dispensing registers.
o Limit dispensing to authorized staff members only.

Monitor selected products:-


As additional protection against theft, monitor items that are fast moving, chronically in short
supply, in high demand by customers, expensive, life saving and can be carried hiding them.

Two techniques for monitoring medicines:-


Select medicines likely to be stolen or misused
1 Check inventory records for stock in hand. Then conduct a physical inventory and
compare the results.
2 Check the inventory records to determine the consumption during a specified period.
Then, check medicine charts or prescription ledger and count the number of
treatment courses during the same period. Convert treatment courses into dose
units and compare this figure with the stock issued from the storage area.
3 If you find significant discrepancy, investigate further.
Guide Mat er ials for Medical St or es Managem ent Tr aining 32

Setting up your Medical Store


Constructing a Medical Store:-
When constructing a medical store, consider the following:
1. Location: The store must be accessible to all the health facilities or units to be served.
Ideally, a medical store should be located by itself on a separate lot to enhance security
and minimize human and automobile congestion. Ensure road access for the largest
vehicle that might ever need to come to the store. Do not build the store close to trees
with big roots. This can kill the tree, and conversely, trees with aggressive root systems
can damage the building's foundation.
2. Shading: Locate the store in an area where trees can be planted to provide shade and
offset high temperatures.
3. Trees: Although it is ideal to have trees planted for shade, check the condition of any tree
already on the site regularly. Cut down any weak tree and its branches so they do not fall
on the building during inclement weather. Trim the other trees to avoid falling branches.
4. Drainage: Build the store on a raised foundation to allow rain water to drain away from
the store. If possible, locate the store in an area on higher ground.
5. Accessibility: Locate the store so that supplies can be easily received and distributed.
This can be near an airport, or near the national road or canal system.
6. Security: Provide the store with adequate security from thieves, fire, etc. Fencing or
perimeter walls are often used to improve security and control access.
Designing a medical store:-
Consider the following when designing a storage facility:
1. Capacity/ Space: Storage facilities must have the capacity for both storage and
handling. Ideally, space should be evenly divided between the two. New products and
packaging innovations, as well as an increase in products related to the prevention and
treatment of diseases like HIV/ AIDS, malaria, tuberculosis, and hepatitis B, have
increased the volume of products and medical consumables that flow through
warehouses. These include items such as bed nets and insecticides for preventing
malaria and more medicines to treat TB because of the increasing number of TB cases
due to HIV/ AIDS. When designing a new facility, do not underestimate the storage
requirements.
Plan the medical store with staging areas for the preparing shipments (issuing) and
unloading deliveries (receiving). Separate the receiving and shipping areas to avoid
confusion and to enhance efficiency and security.
If a facility will be repackaging products, plan a separate clean preparation area to
conduct the repackaging. Try to locate the area close to the issuing area.
Guide Mat er ials for Medical St or es Managem ent Tr aining 33

2. Cold storage: In larger facilities, it is more efficient to use cold rooms rather than numerous
refrigerators or freezers (which generate heat). Ideally, larger facilities should have one
room with a negative temperature for frozen products (-200C) and another room with a
positive but cold temperature (2o-8oC) for products requiring refrigeration.

3. Secure Storage: All medical stores should have a well secured storage area for products
that are likely to be stolen or abused. A locked cabinet or cupboard may be sufficient for
some facilities, while other facilities may require a vault or cage.

4. Ventilation: The location and design should ensure maximum air circulation to avoid
concentrations of fumes or gases and to prevent condensation of moisture on products or
walls. Use an extractor fan to remove gases, fumes and moisture.

5. Roof: Design a slanting roof to allow water run-off. Extend the roof over the windows to give
extra protection from rain and direct sunlight.

6. Ceiling: Install a double ceiling to provide insulation and ensure that supplies are kept cool.

7. Walls and floor: The walls and floors of a medical store should be permanent and smooth
for easy cleaning. Walls preferably should be constructed of brick or concrete blocks.
Perforated or bored bricks might be used for the upper portion of the wall to allow ventilation.
But, these should be screened to prevent the entry of rodents and other pests. Construct or
treat floors of larger facilities to ensure they can withstand the frequent movement of heavy
products and equipment. This should be done with the guidance of an engineer.

8. Doors: Plan doors wide enough to allow for the free and easy movement of supplies and
handling equipment. Large facilities such as those at the central level, often use forklifts and
other handling equipment. Ensure doors are strong and reinforced to provide adequate
security. Fit them with strong locks, and install metal grills for extra protection.

9. Lighting: Plan the storeroom in such a way that as much natural light (indirect sunlight) in
the day as possible can come to avoid the use of either florescent or incandescent bulb
lighting. Florescent lighting emits ultraviolet rays, which have a negative effect on certain
products. Incandescent bulbs emit heat. At the same time, take care to ensure that products
are not in direct sunlight.

10. Windows: Plan windows that are high and wide to allow adequate ventilation. They should
be high enough not to be blocked by shelves, have wiremesh to keep out insects and be
burglary proof.

11. Cupboards: Provide cupboards for the storage of specific products that must be kept free
from dust or light.
Guide Mat er ials for Medical St or es Managem ent Tr aining 34

12. First aid: Keep a well stocked first aid kit to treat employees or visitors who are injured in
your facility. Place the first aid kit in a central location that is easily accessible to all
employees and all are aware of its location and contents.

13. Shelves: Arrange shelves and racks in lines with a passageway not less than 90cm wide.
Avoid placing shelves only around the edge of the room, which wastes a lot of space. Place
the shelves 90cm from the walls of the storeroom to ensure they are accessible from both
sides. Ideally, use adjustable shelves.

Materials Handling equipment and storage media

1. Shelves and cupboards: Use shelves and cupboards to store smaller products. Adjust
the shelves as needed to allow space for packages of different sizes.

2. Tables in the packing area: Provide large tables in the packing area for staff to use
when assembling and packing shipments. Keep the tables clean.

3. Pallets: Pallets are used to store bulk items and larger cartons. They keep things off the
floor and can be used with forklifts or dolly to move around groups of larger items. Pallets
are generally used only in larger facilities because storing and moving pallets can be
expensive. Smaller facilities might have a few pallets left in place to ensure air circulation
and keep products off the floor.

If your facility uses pallets, remember to-

o Always inspect pallets before loading them with material. Ensure that pallets are
solid and sturdy with no loose or cracked boards and no protruding nails. Damaged
pallets can break while being lifted and cause serious injuries and product damage.

o Pile empty pallets neatly and out of aisles.

o If possible, keep pallets indoors, away from elements that can gradually break
down the wood.
Regardless of the material they are made of; pallets increase the risk of fire because they
provide open space for oxygen to fuel a fire to burn. Always follow the safety precautions
discussed in the fire protection section of this guide.
Shelves, cupboards, tables, and pallets can be made of wood, metal, and plastic. Metal shelves,
cupboards, and pallets may be steel, stainless steel, or aluminum. These tend to cost more, but
are stronger, more durable, and less flammable
Guide Mat er ials for Medical St or es Managem ent Tr aining 35

How to Manage a Drug Store in Peripheral Level


Prof. Tapas Kumar Bhattacharyya,
Head, Department of Pharmacology,

The aim of material management is to maximize the availability of material of right quantity at
right time at the right place for accomplishing the objective of an organization. Therefore,
material management is to develop a system of supplies which will ensure right quantity of stock
of items properly stored and distributed for usage at its peripheral units. The system consists of :
o Material Planning & estimation of right quantity
o Procurement of estimated material as per demand
o Storage of the material
o Issue from store for use
o Maintenance.
Learning Objective: -
1. Describe the need for management of Drugs and other supplies;
2. Estimate quantity of drug and vaccines required for the defined area, served;
3. Procure drugs, vaccines and other material in right quantity and at right time;
4. Store drugs, vaccines and other materials properly till their utilization (issue these to the
peripheral units for proper disposal and use)
5. Maintain all types of consumable (expandable) and capital (non-expandable) materials
& equipments;
6. Maintain stock register for all items supplied to you and issued to peripheral units.
DEMAND ESTIMATION:- Should be prepared at organization (unit) level based on
identified service and submitted for necessary approval and supply. The regular supply
should be provided on quarterly basis.
Requirement of vaccines, drugs and materials will be dependent on the work- load of the
services provided at the unit and at peripheral level within its jurisdiction. Since there are no
fixed targets imposed from the higher level, each health worker at the periphery is expected
to estimate service needs for the community members of the catering area and prepare an
estimation of required vaccine, drugs and materials. Usually, the following categories of
materials are required:
o Drugs & Vaccines
o Medical Supplies & Family Planning Supplies
o Non-medical supplies
o Equipments & Instruments
o Facilities
These materials need to be supplied according to the estimated requirement submitted as
Annual Action Plan.
Guide Mat er ials for Medical St or es Managem ent Tr aining 36

ESTIMATION:-
Iron & Folic Acid Tablets (IFA):-
For Pregnant mothers:
Suppose, number of mothers registered (or, planned to be covered) is 100;
100 tablets for each mother-100x100=10,000 (for prophylaxis);
50% (or, more?) of the mother - 50/100x100=50 expected to be anaemic and would need double
the dose.So, additional requirement of IFA will be =50x100=5000.
Hence, the total requirement of IFA tablets would be =10,000+5000=15,000
In case more IFA tablets for some of the IUD, MTP and tubectomy cases are required, indent this
extra amount.
IFA tablets (small) for children:-
IFA small tablets are required for children between the ages of 1 to 5 years, who show visible
signs of anemia (rural areas, ESP.). Each child is to be given 1 tablet/day for 100 days.
Let, the total number of the children (1 to 5 years) in the covered area is 400 (Approx). Number
expected to show the visible signs of Anemia (50%) =50/100x400=200;
Requirement of IFA (small) is then 200x100=20,000
ORS Packets:
A child under 5 years of age, suffers on an average 3-4 episodes of diarrhea every year. Thus, in
the same community, 400x4 (upper limit) =1,600 episodes of diarrhea is expected. One packet
of ORS (usually) is required for each episode. That means 1,600 packets will be required for
those children. However 10% of these episodes are with such dehydration which would require
an additional packet of ORS. That means 10/100x1, 600=160 more episodes will require
another 160 packets. Thus, the total requirement of ORS packets in every year will be
1,600+160= 1,760 packets.
However, all children may not report for each episode. In view of the past performance, usually a
pre-determined amount is supplied. In case you fall short you can always ask for more packets.
Sudden increase in reporting and consumption of ORS packets is an alarming sign for
anticipating epidemics of diarrhoeal diseases.
Co-trimoxazole (Paediatric) tablets:
The total episodes of acute respiratory Infection (ARI) at the rate of 4 episodes per child (1 to 5
years) in a year would be equal to diarroeal episodes of 1,600 cases as calculated above. Only
10 percent of the episodes of ARI are pneumonia requiring antibiotic therapy. Thus
10/100x1,600=160 episodes of pneumonia will on an average need 20 tablets (4 times a day for
5 days) of Co-trimoxazole each. Hence, the total annual requirement of Co-trimoxazole Tablet
would be 160x20 =3,200. Compare all these estimates with the estimates and actual use of the
last year and verify whether the same has increased by 5-25 percent.
Guide Mat er ials for Medical St or es Managem ent Tr aining 37

Collect all the action plans prepared by each unit, note down this requirement and add these up
with the estimated requirements for the sessions to be conducted. This will be total vaccines and
drugs required for your central unit.
Since, existing practices are changed, you have to give quantity of each material/ supply used in
previous year, the amount /quantity available in stock and the amount required for the next year.
PROCUREMENT:
This means indenting from your central unit. Having prepared the total requirement the next step
is to fill the action plan form along with the Materials & Supplies required.
Submit this to your central unit Officer-in-charge from where you will receive the supply. You
MUST ENSURE that the supplies sent from the central unit or the other supplier, as the case may
be, are PHYSICALLY verified, CHECKED and only then received.
“Lead-time” is the time lag between the placement of an order and getting supply against the
same order. Hence, the time lag between submission of your annual action plan along with the
estimation of material required and supply of these will be referred as 'lead-time' for your
supplies. You may receive your supplies in 4 installments on quarterly basis. However, if you
exhaust your stock (explain), you may ask for replacement earlier.
STORAGE:
Material after being inspected, verified, checked and received are stored in the storeroom till its
consumption. It is usually specified if the material (medical) need to be stored at a particular
temperature. You must store those materials at 2-80c which needs to be stored at low
temperature, others can be stored at room temperature. Try to arrange the supplies on rack with
both front and back sides open, so that you can fill this rack from back-side and take out from the
front. This helps in maintaining the principles of 'first-in-first-out' (FIFO) - for use of those
materials first which are received earlier and avoid getting material old, stale and even expired!
The stock of usable material is also referred to as 'inventory'. Inventory control is one of the major
responsibilities in materials management. Aim of inventory control is to avoid 'out of stock'
situation. Amongst the various methods, two widely known methods such as 'Two-Bin method',
and 'Buffer-stock' can be used for proper inventory control and maintenance of emergency
stock.
Two-Bin Method:
The entire stock is separated in two boxes. One box contains the main stock and the other holds
the quantity required during the 'Lead-time'. As soon as the main box gets empty, another order
should be placed for replacement.
In many places, it is practised to issue a sub-stock for a week or month from the main stock to the
pharmacist who maintains the daily consumption of each item. Based on this average daily
consumption, it is easily estimated the quantity required during the 'lead-time'. This amount
should be kept separately in the second box.
Guide Mat er ials for Medical St or es Managem ent Tr aining 38

Buffer-stock:
Buffer-stock is the emergency stock for meeting the demand during unforeseen situation
resulting from either sudden increase in consumption of a particular material/drug or under
extension of 'lead-time', e.g. failure of timely supply.
For maintaining Buffer stock- identify those items which you consider very crucial for providing
your committed services and keep about 10% of the total requirement of these items as 'Buffer
stock' whereas for the rest of the items 5% of the local stock is adequate as Buffer stock.

HOW TO GET THE BEST OF A REFRIGERATOR:


TRY DOING ALL THESE:
o Keep the equipment in a cool room away from direct sunlight and at least 10 cm away
from the wall
o Keep the equipment straight upright and at a higher level.
o Fix the plug permanently to the socket
o Use a voltage stabilizer
o Keep the vaccines neatly with space between the stacks for circulation of air
o Defrost periodically
o Check the temperature inside once a day at least, and maintain a record which should be
supervised regularly
o Take remedial action if the temperature is not maintained within the prescribed limit
o Outside the equipment paste a notice containing the following that help the user during a
breakdown:
1. Whom to contact and where to check for a blown fuse;
2. Alternative place for vaccine storage.

TRY NOT TO DO:


o Do not keep drugs
o Do not open the door/ top unless necessary
o Do not keep food or drinking water in the refrigerator
o Do not keep anything for more than one month in the refrigerator
o Do not keep more than one month's requirements
o Do not keep vaccines which are expired
Guide Mat er ials for Medical St or es Managem ent Tr aining 39

Storage of Vaccines:
Sl.No. Vaccines Temperature Duration for which vaccines Remarks
remain potent from the date
of manufacture
0
1 Oral Polio -20 c 1 year Avoid repeated thawing,
0
Oral Polio 4-8 c 3 months Keep on ice while using

2 Measles 0-20c 2 years Should be used


immediately after
reconstitution
0
3 BCG 4-8 c 1 year Reconstituted vaccines, if
not used within 4 hours,
must be discarded.
0
4 DPT (Dual 4-8 c 2 years Must not be frozen
Antigen)
0
5 DPT (Triple 4-8 c 2 years Must not be frozen
antigen)
0
6 Typhoid 4-8 c 8 months Must not be frozen
0
7 Tetanus Toxoid 4-8 C 8 months Must not be frozen,
Unused portion is to be
discarded

Guidelines for optimal storing of vaccines in Refrigerator:-


o Stock of vaccines for not more than 1 month's requirement should be kept in the fridge at
a time
o Do not keep any vaccines in door panel
o Never keep DPT,DT, Typhoid in the freezer chamber of the fridge; these should be kept in
lower compartment
o Keep the OPV vial, which is in current use in central compartment to avoid repeated
freezing and thawing. Store those OPV vials, which are not in use in the freezer chamber
or in the chamber closest to it
o Can also store the BCG and measles vaccines in either the freezer or the shelf nearest to
it
o Transfer the vaccines to cold box/ vaccines carriers containing ice-packs during
defrosting of the refrigerator.
o The refrigerator should be used exclusively for storing vaccines only as far as
practicable.
o During an immunization session which may last for long duration, vials of vaccines taken
out of the fridge should be kept in a cup/box containing ice cubes.
NOTE: Vaccines are not expected to be for peripheral units.
Guide Mat er ials for Medical St or es Managem ent Tr aining 40

ISSUES/DISTRIBUTION PROCEDURE:-
Store officer has to provide drugs/materials to all the peripheral units under his control. He
receives these supplies from his higher authorities and supplies those to peripheral units on
quarterly basis. Replacement, if needed, would be made even earlier. ALWAYS ENSURE that
there is a stock for one or two months at each peripheral unit. Larger quantities of stock at any
peripheral unit should be taken back for either over-indenting or non-performance or under-
utilization of services provided.
Stock-Register:-
Maintain stock register by making entries with dates of supplies/ procured from higher authority.
Quantity issued to the peripheral units for timely use must be entered in this main stock register.
Peripheral units must maintain a separate register for entering daily use of each drug in separate
entires. If you issue any extra or premature supply from your main stock before the schedule
then this quantity must be entered in the main stock register.
At the end of each month, CHECK the balance and compare it with the usage by way of
PHYSICAL VERIFICATION.
Managing equipments:-
Usually two types of equipments and materials are supplied. These are consumable or
expendable and capital or non –expendable. Consumable equipment is that which is used within
a short time. These are also called as recurring equipment or material. Non-expandable or
capital equipment is such equipment, which lasts for several years and used repeatedly. These
are also known as non- recurring equipment. These need care and maintenance for extending
its use for long time e.g, furniture, refrigerator, vaccine carrier, weighing scale,
sphygmomanometer, instruments, vehicle etc. Consumable equipment includes materials like
cotton, gauze, bandage, chemicals, syringes, needles etc. The management of these including
estimation of each item required, placing an indent and procuring that from higher ends or other
suppliers and proper storage is equally important.
Prepare an estimation of each item based on services planned for coming year. You must
compare this estimation with the consumption during the previous year and ensure that it is at
least 10% higher than that. For non- recurring items, a fair consideration should always be given
towards their depreciation values.
These items are usually supplied quarterly or on half- yearly basis. These also can be
replenished if the stock exhausted. Try to ensure economic use of material to avoid wastage or
over-use and establish a 'control' mechanism to prevent pilferage.
Storage of equipment:-
Equipment is stored in two places:
o A main or reserve store (stock of usable but idle items, i.e. the items waiting to be used)
o At the place of use.
The new items of equipment are always received and stored in the main store
Guide Mat er ials for Medical St or es Managem ent Tr aining 41

Receiving new items:-


A new item is usually delivered along with a document of specifications of the equipment. Some
of the equipment are purchased centrally and supplied to you. However, you only have to ensure
that you are provided with the right type of equipment and in good functional condition.
After receiving the equipment, enter it in the stock- book or ledger, which usually has a separate
page for each item. ENSURE that the following items of information are entered in each page in
the ledger:
o The date of receipt of the item
o The reference number of the item
o The quantity of items received
When an item is issued for use, subtract it from the main stock and calculate the balance
remaining in the stock. When the balance reaches to a certain pre- determined point of quantity,
it indicates that it is the time to order for replacement. This order is referred as 'Re-order' level.
For each item, you must have the re-order level Indicated to help you to prevent 'stock-out'
position.
Controlling and maintaining equipment:-
Recurring /consumable items must be used economically to avoid wastage to the possible
extent. ESTABLISH a system which will help you in avoiding wastage of consumable items and
maintain capital or non-capital items in good working conditions.
PRACTISE the following skills:-
o Convincing the staff about the importance of maintenance, so that they realize that
equipment must be cleaned, inspected and kept in good order. They should report
defects immediately as soon as noticed and must return the equipment to its correct
place after use.
o Using of inspection check- list and inspection schedule: INSPECT the equipment by
using check-list what is present and compare with the stock position. Inspection
schedule is to be prepared based on the frequency of checking needed. Frequency of
checking depends on whether it is consumable or non- consumable. Consumable items
need to be checked more frequently than non-consumable ones like furniture,
refrigerator etc. However, non-consumable but delicate items which are liable to easy
break-down like sphygmomanometer, electric sterilizers etc need regular and more
frequent check-ups. In order to avoid missing this task, you must prepare an inspection
schedule and fix up day/ and time for checking up of the equipment.
o Detecting and interpreting discrepancies: Discrepancy means difference between what
is expected to be there and what is actually there. The difference between the amount of
a consumable items used and the amount normally expected to be used or a difference
between the equipment entered in the inventory ledger and the equipment actually
present must be detected and reasons identified for taking appropriate actions.
o Demonstration of handling and functioning of the existing and new equipments received.
Guide Mat er ials for Medical St or es Managem ent Tr aining 42

Cold Box:-
Cold boxes are big insulated boxes. They come in two sizes; 5 liters and 20 liters. They are
supplied with requisite number of ice-packs. The 5 liters cold box can hold one month's vaccine
supplies of a 30,000 populations. 20 liters cold box have enough space to transport one month
supply for one lakh population.

Uses:-
o Collect large quantities of vaccines
o Transport large quantities of vaccines by vehicle to out- reach sites;
o Store vaccines for transfer up to five days' requirement if necessary for out-reach sites or
0
when there is power cut. The hold over time is more than 90 hours at +43 C ambient
temperatures. You can also store vaccines in it while ice-packs are being prepared in
freezer.
o Store vaccine properly in a different place in case of break down of the refrigerator.

To pack:-
o Place fully frozen ice packs side by side against the inside walls and floor of the cold box.
o Stock vaccines and diluents in the box;
o Place packing material between DPT/DT/TT vaccines and the ice-pack to prevent
vaccines from becoming frozen.
o Secure the lid tightly.

To keep Cold Box in good condition when not in use:-


o Clean and dry after use;
o Examine inside and outside surface for cracks after every use;
o Check that the rubber seal around the lid is not broken; if broken replace immediately;
o Adjust the tension on the latches so that the lid closes tightly;
o Lubricate hinges and locks routinely

Vaccine Carriers:-
Vaccine carriers can be used for carrying small quantity of vaccines (16-20 vials) to the area the
vaccine carriers are made of insulated material. The ice-packs for lining the sides of the carriers
should be fully frozen and the lid of the carriers should be closed tightly. The vials of DPT, DT and
TT vaccines should not be in direct contact with frozen ice-packs. Before using or packing the
vaccines in the vaccines carrier, the precautions need to be observed:
o Take out vaccines carriers and conform that there are no cracks in its body;
o Take out the required number of ice-packs and wipe them dry;
o Place fully frozen ice-packs in the carrier and wait for few minutes for temperature to fall
to less than 80Celsus.
Guide Mat er ials for Medical St or es Managem ent Tr aining 43

o Put vaccines vials and ampoules in a polythene bag and close it.
o Stock vaccines and diluents in the carrier;
o Place some packing material between DPT vaccines and the ice-pack to prevent them
from touching the ice-packs;
o Close the lid tightly.

How to keep vaccines carries in good condition when not in use:-


Some of the tips to this effect are mentioned below:
o Clean and dry inner side of carrier after use;
o Examine the carrier both from inside and outside for any crack after each use;
o Keep the carrier away from direct sunlight and other sources of sunlight, as this may
cause the plastic to crack.
o Do not sit or place anything heavy on a vaccine carrier;
o The carrier with four ice-packs can keep the vaccines cooled for 2 days provided the ice-
packs used are fully frozen and the lid of the carrier is kept tightly closed.

Key points:
o Estimate the quantity of drugs and vaccines based on estimated quantum of services to
be provided at each peripheral units as well as the central unit.
o Do not stock vaccines for more than one-month's requirement
o Arrange your store in such a way that it helps you in maintaining the principles of FIFO.
o Maintain Two-Bin method or arrange items in two different shelves to maintain reader
level.
o Maintain buffer stock of emergency drugs to avoid out-of-stock out of positions
o Maintain non-consumable/non-recurring equipment in good condition for longer use.
o Maintain stock register for each item of material and equipment.
o Try to avoid over use, misuse and pilferage of materials.

Few points to be highlighted:


o Essential Drug list.
o Procurement, Accounts, Quality Control, Warehouse Monitoring etc, will be done
electronically.
o Standard Treatment Guidelines (STG) will be prepared by an Expert Committee for
common diseases prevalent in Odisha.
o 80% of budget / fund should be utilized for purchase centrally through the Central Unit;
20% should be allotted to the peripheral unit.
Guide Mat er ials for Medical St or es Managem ent Tr aining 44

o The 80% of the drug budget (plan and non-plan) meant for central purchase will be
allotted to the Purchase Officer/ Administrator. This will be utilized for purchase,
transportation and quality testing of drug and medical consumable for deliveries to the
different medical stores (ware house)
o 20% of the drug budget will be spent by the peripheral unit.

The peripheral unit will spend 20% on the following:


o Emergency purchase of drugs and medical consumables not exceeding Rs. 1,000/- at a
time, either from the approved suppliers or from the open market.
o A committee consisting of the suitable men from doctors, medical teachers, social
activists and Store Officer will finalize all the procurement. If any particular drug or
instrument is procured the concerned specialists' view must be taken into consideration
as a technical expert.
o The annual drug budget of each health institution will be allotted before hand. If there is
any additional budget, it will be over and above this entitlement.

PROCUREMENT:
o All drugs (except for 20% of the budget earmarked for peripheral unit) will be purchased
by the State Government through the Purchase Officer/ Administrator under the
supervision of the committee earmarked for this specific purpose and distributed to the
different medicine stores (warehouse)
o All the items except those included in the Emergency Purchase Medicines rate contract
list will be purchased by open tender every year through National/ Regional/ State
Competitive Bidding.
o Open tender should be called only of drugs listed in the Essential Drugs List (EDL).
o After finalization of the tenders, an “Approved List” shall be drawn up containing the
names of the drugs, the names of the supplier, and the cost of the drug.
o All drugs and medical consumables will be purchased in generic names.
o No brand name will be mentioned anywhere in the strip/ box/ carton/ packet/ foil/ vial etc.
This condition may be relaxed for drugs and surgical items where the purchase order is
less than a predetermined annual sum.
o All the drugs and medical consumables and surgical and suture items should be
purchased directly from the manufactures. Only manufactures should be eligible to
quote in the tender.
o In case of non-supply of any item either from valid approved list, it can be purchased from
the DGS and Drug rate contract holding units.
o Firms having I.S.O/ I.S.I and W.H.O/ G.M. P will be given preference to other firms.
Guide Mat er ials for Medical St or es Managem ent Tr aining 45

EPM RATE CONTRACT ITEMS:-

o Certain drugs and medical consumables are earmarked by the State Government for
purchase from approved local S.S.I units. These will be purchased only from the
approved local S.S.I units taking there past performance (i.e. quality, timely supply) and
capacity of production into consideration. For this, local S.S.I units should have:
o A valid drug and manufacturing licence.
o A valid E.P.M. rate contract.
o The costing of items will be done in consultation with the Expert Committee, from time to
time taking the recent I.P/B.P/U.S.P and the packing standard into consideration, to
ensure that quality is maintained. The costing will be approved through a State Level
Committee (EPM).
o All the items (except, Emergency Procurement) will, unless otherwise specified, be
delivered at the Central unit.
o Where the EMP rates stipulate “inclusive of transportation charges” no transportation
cost can be claimed by the S.S.I units.
o The S.S.I. units will start supply of items within 30 days and complete the supply within 60
days from the date of issue of purchase order or in case of emergency the time given by
the Administrator / purchase Officer. Otherwise the firm will be declared part supplier/
non-supplier and the Organization can purchase the same items by calling open tender/
quotations.
o If S.S.I Units supply two or more than two NSQ (Not of Standard Quality) items or can not
supply as per specification, the Organization may revise the policy from time to time and
delete the items including in the rate contract list and put it in the “Exclusive list” in the
interest of encouraging competition.
o The Administrator should be allowed to go for quotation/ tender and purchase the same
items for the benefit of the patients.

Forklifts and pallet lifters:-


If you plan to use forklifts or pallet lifters in your facility-
o Ensure the floor is even and able to withstand the weight of the loaded lifter.
o Ensure the lifter has room/space to load and unload products.
o Consider the appropriate lifter for your facility. Forklifts and pallet lifters can be powered
by gas, diesel, liquid propane gas, or electricity, all of which affect the capacity and cost.
Also, consider the warehouse ventilation and environment.
o Keep an extra battery or a battery charger, if needed. Ensure the battery can last a full
day.
Guide Mat er ials for Medical St or es Managem ent Tr aining 46

o Ensure the lifter can reach the highest pallet rack.


o Keep a record of maintenance and serving of the lifter in a secure, visible place.
o Maintain and paste picture identification of employees who have been trained and are
authorized to operate the lifter.
Pallet lifters come in two types, walkies and seated, and each has some advantages. Walkies
are better when space is limited because the turning radius is smaller. However, they are very
slow moving and are not as useful in larger warehouses. Seated lifters move much faster but are
much more expensive.

Waste Management
Considering waste Management:-
Ground of and around the storage facility, including the area around health centers, must remain
free of health care waste and other garbage. Maintaining a clean environment where
pharmaceuticals and other health supplies are stored will reduce the number of pests-insects
and rodents-and reduce the number of people, including children, who may be injured or
infected/affected by used medical equipment or discarded medicines.
Check with local officials about laws that pertain to health care waste management and
environment protection before instituting a disposal technique.
Plan storage, transportation and disposal techniques that are practical, cost-effective and
simple. Monitor disposal practices on a regular, frequent basis.

Types of Waste:
Different types of waste that must be destroyed safely and effectively and their methods of
disposal include-

1) Non-medical waste:-

(a) Garden rubbish:-


Compost leaves, sticks, weeds, and trimmings from shrubs and trees, if feasible.
Designate a separate area for composting.

(b) Cardboard cartons:-


If possible, recycle cardboard; otherwise, treat like ordinary rubbish.

© Ordinary rubbish:-
Where municipal solid waste disposal facilities exist, dispose of rubbish in the municipal
dump. Otherwise, burn or bury it.
Guide Mat er ials for Medical St or es Managem ent Tr aining 47

(d) Human waste:-


Use pit latrines or other toileting facilities to dispose of all human waste.

2) Health care waste-


(a) Sharp wastes:-
Single-use disposable needles, needles from auto-disposable syringes, scalpel blades,
disposable tracers, sharp instruments requiring disposal, and sharps wastes from
laboratory procedures.
(b) Other hazardous medical waste:-
Waste contaminated with blood, body fluids, human tissue; compounds such as
mercury; pressurized containers; and wastes with high heavy metal content.
(c) Pharmaceuticals:-
Expired, damaged or otherwise unusable medicines and items contaminated by or
containing medicinal substances.
Disposal Methods
Burial pits and encapsulation are suitable in locations without shallow groundwater and for small
volumes of waste.
Burial pits: The bottom of the pit should be 1.5m above the groundwater level, 3-5m deep, and
lined with a substance of low permeability. Surround the opening with a mound to keep run-off
water from entering the hole, and build a fence around the area. Periodically, cover waste layers
with 10-15cm of soil.
Encapsulation: Cement-lined pits or high –density plastic containers or drums are filled to 75%
capacity with health care waste. The container is then filled with plastic foam, sand, cement, or
clay to immobilize the waste. The encapsulated waste is then disposed of in a landfill or left in
place if the container is constructed in the ground.
Incineration: Medium-and high-temperature incineration devices require a capital investment
and an operations and maintenance budget. They operate on fuel, wood, or other combustible
material and produce solid ashes and gases. Pollutants are emitted to varying degrees. The ash
is toxic and must be buried in a protected pit. Combustible waste is reduced to incombustible
waste with a decreased volume. The high temperature kills harmful microorganisms.
Medium-temperature incinerators, commonly a double chamber design or pyrolytic incinerators,
operate at a medium-temperature combustion process (8000-1,0000 C).
High-temperature incinerators, recommended by WHO, treat health care waste at a
temperature of >1,0000C.
Guide Mat er ials for Medical St or es Managem ent Tr aining 48

When operated by staff trained in correct use and maintenance, incineration in a device like this
one-
o Completely destroys needles and syringes.
o Kills microorganisms.
o Reduces the volume of waste.
o Causes less air pollution than low temperature burning.
o
Low-temperature burning: Burning devices not exceeding 400 C include single-chamber
brick hearths, drum burners, and burning pits. They burn incompletely and do not fully destroy
waste. They may not kill microorganisms. Given these shortcomings, low-temperature burning
should be used only as a short-term solution.
Burn and bury: Pit burning is a low-cost but relatively ineffective means of waste disposal. A
fence should surround the pit to prevent children, animals, and others from coming into contact
with waste. The pit location should avoid walking paths (high-traffic areas). The fire, usually
started with a petroleum-based fuel and allowed to burn, should be supervised by designated
staff and located down-wind of the facility and residential areas. The low temperature fire emits
pollutants, and ash and remaining material should be covered with 10-15 cm of dirt.
Other methods: In addition to the common methods, other methods are used in some settings,
including needle removal/ needle destruction, melting syringes, stem sterilization (autoclaving
and hydro laving), and micro waving ( with shredding).
Managing health care waste is a comprehensive program that requires support at all levels of the
health care system. Staff involved in health care waste management must be given training and
support.

WASTE TYPES NOT TO BE INCINERATED


o Pressurized gas containers.
o Large amounts of reactive and radioactive chemical waste.
o Silver salts and photographic or radiographic wastes.
o Halogenated plastics such as polyvinyl chloride (PVC).
o Waste with high mercury or cadmium content, such as broken thermometers, used
batteries, and lead-lined wooden panels.
o Sealed ampoules or ampoules containing heavy metals.

Pharmaceutical Disposal:-
It is very important to dispose of pharmaceuticals properly because there can be very negative
consequences to improper disposal. Improper disposal can result in-
o Contaminated water supplies.
o The diversion and resale of expired or inactive medicines.
o Improperly incinerated products, which can release toxic pollutants into the air.
Guide Mat er ials for Medical St or es Managem ent Tr aining 49

The usual disposal methods for various categories of pharmaceuticals are identified in the
following table.

CATEGORY DISPOSAL METHODS COMMENTS


Solids Landfill No m ore than 1% of the daily
municipal waste should be
Semi-solids Waste encapsulation
disposed of daily in an
Powders Waste inertization untreated form (non-
Medium and high temperature immobilized) to landfill.
incineration (cement kiln
incinerator)
Liquids Sewer Antineoplastics not to sewer
High temperature incineration(
cement kiln incinerator)
Ampoules Crash ampoules and flush Antineoplastics not to sewer.
diluted fluid to sewer
Anti-infective drugs Waste encapsulation Liquid antibiotics may be
diluted with water, left to stand
Waste inertization
for several weeks and
Medium and high temperature discharged to a sewer.
incineration(cement kiln
incinerator)
Antineoplastics Return to donor or Not to landfill unless
manufacturer encapsulated
Waste encapsulation Not to sewer
Medium and high temperature No medium temperature
incineration incineration
(cement kiln incinerator)
(chemical decomposition)
Controlled drugs Waste encapsulation Not to landfill encapsulated.
Waste inertization
Medium and high temperature
incineration
(cement kiln incinerator)
Aerosol containers Landfill Not to be burnt: may explode.
Waste encapsulation
Disinfectants Use No undiluted disinfectants to
sewers or water courses.
To sewer or fast –flowing
watercourse: small quantities
Maximum 50liters per day
of diluted disinfectants(max -
diluted to sewer or fast -
50liters per day under
flowing watercourse.
supervision)
No disinfectants at all to sloe
moving or stagnant
watercourses.
PVC plastic, glass landfill Not for burning in open
containers
Paper, cardboard Recycle, burn, landfill
Guide Mat er ials for Medical St or es Managem ent Tr aining 50

Particular attention must be given to disposal of the following categories of pharmaceuticals-


o Controlled substances, such as narcotics and psychotropic medicines
o Anti-infective drugs.
o Antineoplastics
o Cytotoxic anti-cancer drugs, toxic drugs
o Antiseptics and disinfectants.

Safety Boxes:-
Safety boxes or sharps containers are puncture- and water-resistant, impermeable containers.
When used in correctly, they produce the risk of skin-puncture injuries that may spread disease.
o Do not recap syringes before disposal.
o Place the syringe and needle in the sharps box immediately after use.
o Keep the sharps box where the injections are given.
o Do not over fill the sharps containers (about ¾ full).
o When 3/4th full, close box tab completely to cover the opening and tape it shut.
o Store the box in a safe and secure location until ready for final disposal.
o Do not empty and refill sharp boxes. Fill once and discard immediately.

WHAT ARE THE BOOKS AVAILABLE IN CDMU ON


MEDICAL STORE MANAGEMENT?
Following are the books available in CDMU on Medical store Management.
1 Guide Materials on “Medical Store Management” developed by CDMU- Orissa.
2 Good Store Management Practices- A Training Manual Developed by Delhi Society
of Promotion of Rational Use of Medicines.
3 Guidelines for the Storage of Essential Medicines and other Health Commodities:
Developed by WHO and UNICEF.
4 WHO Model Formulary: Developed by WHO
5 Medical Store Management in Bengali: developed by CDMU-West Bengal.
6 Banned and Bannable Drugs by Voluntary Health Association of India.

Apart from these books there are so many soft copies available in the market to maintain the
medical store in computer. The individual members can develop soft packages suitable for their
Guide Mat er ials for Medical St or es Managem ent Tr aining 51

individual need of the hospitals, clinics, medical stores for retailers or wholesalers.
However, some of the soft packages available in the market are:
1 Trade Link Packages, B-II Software's.
2 MSupply for inventory management
3 Tally 7.2
4 Tally special package for medical shop & others.

CASE STUDY FOR DISCUSSION


Suppose an NGO serving a community for last 10 years with buying medicines from
CDMU and others helps poor people to get treatment. Some compensation for getting
medicines is paid by them. They have no drug license to store medicines at their clinics.
Recently Drug Inspectors visited them and told them to stop clinical and medicines storing
work till they get valid license to store the medicines. To get license they need special room
with required size with concrete roof. Their office is under asbestos sheet and no Pucca
roof top. Drug license cannot be obtained with Asbestos sheet roof. The NGO does not
have funds to have such a building. Hence, what shall they do? Should they stop Work? If
yes, why? If not, why? What to do to overcome the problem? What role can be played, by
them? What CDMU should and can do for them in this situation?
Guide Mat er ials for Medical St or es Managem ent Tr aining 52

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