CHPPC Module 30, Section 30.4: Tube System Failure Playbook
MODULE 30: OVERRIDE & BEDSIDE REALITIES

Section 30.4: Tube System Failure Playbook & Hand-Carry Rules

Mastering crisis management when the hospital’s circulatory system fails and every delivery becomes a manual, high-stakes decision.

SECTION 30.4

Tube System Failure Playbook & Hand-Carry Rules

Your guide to maintaining order and patient safety during a hospital-wide logistical heart attack.

30.4.1 The Hospital’s Circulatory System Fails

The pneumatic tube system is the unsung hero of the modern hospital. It is a vast, hidden network of pressurized tubes that functions as the institution’s circulatory system, whisking thousands of critical items—lab specimens, blood products, and, most importantly, medications—from point to point with incredible speed and efficiency. The central pharmacy is the heart of this system, pumping out a constant supply of life-saving drugs. You become so reliant on its seamless function that it’s easy to forget it can fail. But it can, and it will.

A system-wide tube system failure is a logistical heart attack for the hospital. Suddenly, your primary method of delivery is gone. Every single dose, from a routine tablet to a STAT IV antibiotic, must now be delivered by hand. The phones begin to ring incessantly. Nurses are anxious. Patients are waiting. The organized, technology-driven workflow of the pharmacy evaporates, replaced by a state of controlled chaos. In this moment, the pharmacy’s ability to respond is not a matter of convenience; it is a matter of patient safety on a massive scale.

This section is your emergency playbook for a tube system failure. It is a step-by-step guide to transforming your pharmacy from a state of reactive chaos into a proactive, efficient, and highly communicative command center. You will learn how to triage requests, prioritize deliveries, deploy staff into new roles, and manage the safety risks of manual medication transport. This is a masterclass in crisis management, a skill that will define you as a leader in the eyes of your colleagues and hospital administration.

30.4.2 Phase 1: “Code Tube”—The First 15 Minutes

The moment you learn the tube system is down, the clock starts. The actions your team takes in the first 15 minutes will determine whether the rest of the outage is a manageable crisis or a catastrophic failure. The goal is to move from confusion to control with a clear, pre-defined set of actions. This is your “Code Tube” response.

The First Question: “Local or Global?”

Your very first action is to diagnose the scope of the failure. Is it a single, local station that is offline, or is the entire hospital-wide system down? This distinction is critical. A local failure is an inconvenience; a global failure is a crisis.

How to check: Try tubing an item to a different, distant station (e.g., from the central pharmacy to the ED). If it goes through, the problem is likely localized to the original unit. If it fails, you must assume a global outage and activate the full playbook.

Masterclass Table: The “Code Tube” Triage Checklist

Time Elapsed Action Step Detailed Rationale and Script
T=0 min Confirm Scope of Failure As described above, perform a test to determine if the outage is local or global. Do not proceed until you know the scope of the problem.
T=1 min Initiate Communication Cascade Information is your most valuable tool. The faster you inform the hospital, the faster you can manage expectations.

Script to Nursing Supervisor/House Supervisor: “This is [Your Name] from Pharmacy. I’m calling to report a system-wide pneumatic tube system failure. We are activating our downtime procedures. We are currently triaging all medication requests and will be hand-delivering only the most urgent items first. Please communicate this to all nursing units. We will provide updates as we get them from Engineering.”
T=2 min Appoint a “Dispatcher” All communication must flow through a single point of contact. This prevents multiple pharmacists from taking the same call and multiple runners from being sent to the same unit. Appoint a pharmacist with strong communication skills to be the dispatcher who answers the priority phone line and logs all requests.
T=5 min Halt All Non-Essential Workflow Immediately stop all routine processes. This includes filling routine 24-hour cart fills or preparing medications for the next batch. All available technician and pharmacist resources must be re-deployed to manage the crisis. Any medication tubed before the outage was confirmed may be stuck in the system; make a note to retrieve these later.
T=10 min Establish a Staging Area & Runner Pool Designate a physical space in the pharmacy (e.g., a large counter) as the “Staging Area.” All outgoing medications will be brought here. Assemble your “Runner Pool”—all available technicians, interns, and even other pharmacists who can be spared for manual delivery.
T=15 min Begin Triage Using the Prioritization Matrix The dispatcher begins to log incoming calls. For each request, they will apply the prioritization matrix (detailed in the next section) to determine its urgency and assign it to a runner. The system is now in place.

30.4.3 Phase 2: The Prioritization Matrix – Deciding What Moves First

During normal operations, the pharmacy operates on a “first-in, first-out” basis. During a tube system failure, this model is abandoned. It is replaced by a ruthless, clinically-driven prioritization system. You cannot deliver everything at once. Your team’s limited bandwidth for manual delivery must be reserved for the medications that are most critical to sustaining life and preventing harm. The Prioritization Matrix is the clinical brain of your downtime response. The dispatcher will use this framework to triage every single request.

Masterclass Table of the Medication Prioritization Matrix

Priority Tier Definition & Target Delivery Time Medication Categories & Specific Examples Designated Delivery Personnel
Tier 1: STAT / Life-Threatening

Medications needed to treat an immediate, life-threatening condition or to prevent catastrophic clinical deterioration.

Target: < 15 minutes
  • Code Blue/RRT Meds: Epinephrine, amiodarone, atropine, calcium, dextrose, sodium bicarbonate.
  • Cardiovascular Emergencies: STAT antiarrhythmics (adenosine), vasopressors for hypotension (norepinephrine bolus), alteplase for stroke/STEMI.
  • Respiratory Emergencies: STAT RSI kits (etomidate, succinylcholine), nebulized albuterol for status asthmaticus.
  • Neurologic Emergencies: STAT benzodiazepines for status epilepticus (IV lorazepam).
  • Hemorrhage Control: Factor products (KCentra, FEIBA), massive transfusion protocol components (tranexamic acid).
  • First doses of STAT antibiotics for Sepsis: The first dose of ceftriaxone or Zosyn for a patient with septic shock.
 Pharmacist or Designated STAT Runner. These are too critical to be delayed. The most available, qualified person takes it and goes immediately.
Tier 2: Urgent / Time-Sensitive

Medications that are not for an immediate life-threat, but where a significant delay (>1 hour) could lead to patient harm, therapeutic failure, or loss of clinical control.

Target: < 60 minutes
  • First doses of new antibiotics (non-septic): The first dose of vancomycin for a stable patient with a new infection.
  • Pain & Symptom Management: First doses of IV opioids or antiemetics for a patient in severe distress.
  • Scheduled High-Risk Meds: Scheduled doses of IV heparin infusions, insulin infusions, scheduled IV anticoagulants.
  • Time-Sensitive Oral Meds: Immunosuppressants for transplant patients (tacrolimus), anti-parkinson’s drugs (carbidopa/levodopa). Missing a dose can have severe consequences.
  • Loading Doses: Loading doses for antiarrhythmics (amiodarone) or antiepileptics (levetiracetam).
 Technician Runner Pool. These runs can be batched. A runner can take all the Tier 2 medications for a specific floor or nursing unit at once.
Tier 3: Routine / Scheduled

Scheduled maintenance medications where a delay of 1-2 hours is unlikely to cause significant harm. This constitutes the bulk of daily medication orders.

Target: < 2-3 hours
  • Oral Maintenance Meds: Most oral antihypertensives, statins, oral diabetes medications, PPIs.
  • Routine IV Piggybacks: Scheduled, non-time-critical IV antibiotics after the first dose has been given.
  • Maintenance IV Fluids: A new bag of normal saline for a stable, hydrated patient.
  • PRN Medications (Non-urgent): PRN acetaminophen, docusate, diphenhydramine.
 Technician Runner Pool (Lower Priority). These are delivered after all Tier 1 and Tier 2 requests are cleared. Often delivered during scheduled runs to each floor.
Tier 4: Non-Essential / Hold

Medications or supplies that can be safely held until the tube system is restored without any impact on patient care.

Target: Deliver After System Restored
  • 24-Hour Cart Fill Bins: The routine exchange of patient medication drawers should be postponed.
  • ADC Stock Refills (“Stock Outs”): Routine replenishment of ADC pockets must wait. Nurses will need to call for patient-specific doses if a pocket is empty.
  • Multivitamins, supplements, and other non-critical medications.
  • Discharge Medications: Prescriptions for patients going home can be prepared but should not be delivered until the patient is confirmed ready for discharge.
 No Delivery. These workflows are placed on hold. Communicate this clearly to nursing leadership.

30.4.4 Phase 3: The Logistics of Manual Delivery & Hand-Carry Rules

Once a medication is prioritized, it must be transported safely and securely. Manual delivery introduces a new set of risks that the automated tube system normally mitigates. Every runner must be trained on these fundamental safety rules to ensure that the solution (hand-delivery) does not create a new problem (a lost dose, a compromised medication, or a safety event).

The Absolute “Do Not Hand-Carry” List

Certain medications are too hazardous or too sensitive to be transported by hand through public hospital corridors by routine runners. These require special handling, even during a downtime. Your institution will have a specific policy, but it almost always includes:

  • Hazardous Drugs: All chemotherapy agents and other drugs on the NIOSH hazardous list must be delivered by a specially trained individual (often a pharmacist or chemo tech) in a sealed, labeled hazardous drug transport bag.
  • Controlled Substance Wastage: Do not transport un-witnessed controlled substance waste back to the pharmacy. Nursing must follow the standard procedure for wasting in the ADC or with another nurse on the unit.

When a request for one of these comes in, it must be routed to the appropriate specialist (e.g., the oncology satellite pharmacist) to handle with the proper procedure.

Masterclass Table of Hand-Carry Protocols

Medication Type The Risk of Manual Transport Required Hand-Carry Protocol
General Oral & IV Medications Loss, mis-delivery to the wrong unit, dropping and breaking an IV bag.
  • All medications must be in a sealed bag with a clear label containing the patient’s name and room number.
  • Runners should carry a “manifest” or list of all medications they are delivering on a given run.
  • Medications must be handed directly to a licensed staff member (e.g., the unit secretary or a nurse). Never leave medications unattended on a counter.
Controlled Substances Diversion, loss, and failure of chain-of-custody documentation.
  • Must be transported in a sealed, opaque, tamper-evident bag.
  • Must be delivered directly to a licensed nurse. The nurse must sign a delivery receipt or a logbook confirming they have received the substance.
  • The runner must immediately return the signed receipt to the pharmacy dispatcher to close the loop.
Refrigerated Medications Loss of stability and efficacy due to temperature excursion.
  • Must be transported in a validated cooler with a cold pack.
  • Delivery must be prioritized to minimize time out of the refrigerator.
  • Upon arrival, the runner must ensure the nurse immediately places the medication into the unit’s medication refrigerator.
Light-Sensitive Medications Degradation and loss of potency due to light exposure.
  • The medication must be prepared in a light-protective (amber) IV bag or have a light-protective cover applied in the pharmacy.
  • Transport in an opaque bag to provide an additional layer of protection.

30.4.5 Retail Pharmacist Analogy: The “Main Computer is Down” Playbook

A Deep Dive into the Analogy

A hospital-wide tube system failure is a terrifying prospect. But you have likely already survived its retail pharmacy equivalent: a total failure of your pharmacy’s computer and network systems on the busiest day of the month.

The Scenario:

It’s a Monday morning, the first of the month. Your pharmacy is full of patients. Suddenly, your primary computer terminal freezes. Then the next one. Your internet connection is down. You can’t receive e-prescriptions, you can’t process insurance claims, you can’t access patient profiles, and your automated pill counter is offline. The phones are ringing off the hook. You have just experienced a “pharmacy down” crisis.

You Instinctively Activate Your Playbook:

You don’t panic. You and your team instinctively switch to your downtime procedure, which perfectly mirrors the hospital’s “Code Tube” playbook:

  • Phase 1: Triage & Communication. You immediately put a sign up at the counter informing patients of the system issue and the potential for delays. You designate one person to answer the phones and manage the waiting patients (your “Dispatcher”).
  • Phase 2: The Prioritization Matrix. You can’t help everyone at once. You triage. The mother with the sick child who needs their first dose of amoxicillin becomes your Tier 1 priority. You’ll figure out the billing later. The patient waiting for their routine vitamin refill becomes your Tier 3 or 4; you politely ask them if they can come back later.
  • Phase 3: Manual Logistics. You abandon your automated counter and start counting by hand with a tray and spatula. You pull out the old paper prescription pads to write down information for verbal orders. You get out the credit card imprinter for manual billing. You have switched from an automated workflow to a completely manual one.

The core skills are identical: crisis communication, ruthless prioritization based on clinical urgency, and a rapid switch to manual, safety-focused procedures. You have already proven you can manage a logistical heart attack within the four walls of your pharmacy. A tube system failure is just the same challenge on a larger scale.