CHPPC Module 5, Section 3: Pneumatic Tube System Best Practices – Council on Pharmacy Standards
MODULE 5: AUTOMATION, DISTRIBUTION & CONTROLLED SUBSTANCES

Section 3: Pneumatic Tube System Best Practices

This section covers the hospital’s circulatory system for medication delivery. You will learn that the pneumatic tube system is a powerful tool for rapid delivery, but its use is governed by a strict set of safety rules. As a pharmacist, you are the ultimate gatekeeper, ensuring that this superhighway is used safely and effectively.

PART 1

The Hospital’s Superhighway

Understanding the Pneumatic Tube System

The pneumatic tube system (PTS) is a network of pipes, often hidden behind walls and above ceilings, that crisscrosses the hospital, connecting the central pharmacy to nearly every nursing unit, operating room, and clinical area. It uses compressed air and vacuum pressure to propel cylindrical carriers (or “tubes”) at high speeds, delivering medications in minutes that would otherwise require a technician or pharmacist to walk considerable distances. It is an indispensable tool for responding to STAT and NOW orders, but its power comes with significant risks that you are responsible for mitigating. Your mastery of this system is a core operational competency.

The Retail Pharmacist Analogy: The High-Speed Courier Network

In your retail pharmacy, the final delivery is a direct, face-to-face hand-off to the patient at the counter. Now, imagine your pharmacy served an entire 50-story office building, and you had a network of high-speed delivery tubes to send medications to any floor in seconds. The pneumatic tube system is that courier service. It provides incredible speed and efficiency, allowing you to get a STAT antibiotic to the 45th floor in under two minutes. But just like a real-world courier like FedEx or UPS, it has strict rules about what can and cannot be shipped safely. You wouldn’t ship a live animal, a hazardous chemical, or a priceless piece of art through the mail. The same principles apply here. You are the shipping and receiving expert, responsible for knowing these rules and ensuring they are followed without exception to protect the product, the system, and the people who use it.

PART 2

The “Do Not Tube” List

Your Non-Negotiable Rules of the Road

Every hospital’s Pharmacy & Therapeutics (P&T) Committee establishes a strict list of items that must never be sent through the pneumatic tube system. These rules are not suggestions; they are absolute prohibitions based on the principles of patient safety, worker safety, medication integrity, and regulatory compliance. As the pharmacist, you are the final checkpoint and the ultimate enforcer of this critical policy. When a technician is preparing a medication for delivery, your final sign-off includes confirming the correct delivery method. Overruling this policy is a serious safety event.

Deep Dive: Understanding the “Why” Behind Each Prohibition

Memorizing the list is not enough. A true professional understands the rationale behind each rule. This allows you to educate others and make sound decisions in ambiguous situations.

Prohibited Item Category Core Rationale Deep Dive Explanation
Chemotherapy & Other Hazardous Drugs Contamination Risk This is the #1 prohibition. The risk of a carrier breaking or leaking and aerosolizing a cytotoxic or hazardous drug is catastrophic. It would contaminate the entire multi-million dollar pneumatic tube system, requiring a complete shutdown, specialized decontamination, and potential replacement. More importantly, it would expose countless healthcare workers to potent carcinogens and teratogens. This is a major violation of USP <800> guidelines.
Controlled Substances Diversion Risk The tube system is not a secure, closed-loop system for chain of custody. Carriers can be mis-routed, sent to the wrong station, become stuck, or be picked up by unauthorized personnel. Sending a high-value, high-risk narcotic like hydromorphone or fentanyl through this system breaks the required chain of custody and creates a significant opportunity for diversion. All controlled substances must be hand-delivered and signed for.
Certain Biologics & Proteins Fragility The violent acceleration, deceleration, and shaking inside the tube system (known as “agitation”) can physically destroy the complex three-dimensional structure of protein-based medications, rendering them ineffective. This includes: Albumin, Immunoglobulins (IVIG), Clotting Factors (e.g., Factor VIII, Kcentra), and thrombolytics (e.g., Alteplase). Shaking can cause aggregation, precipitation, or denaturation.
Blood Products Hemolysis Risk While not dispensed from pharmacy, it’s a critical rule to know. The mechanical trauma of the tube system can cause red blood cells to rupture (hemolysis), releasing free hemoglobin into the plasma. This not only renders the product useless but can be harmful to the recipient.
Glass Items & Fragile Containers Breakage Risk Glass ampules, glass vials, and glass IV bottles are strictly prohibited. The risk of breakage is extremely high. This would waste the medication, create a significant sharps hazard for staff, and potentially damage the system itself. This also extends to certain brittle plastic syringes.
High-Cost / Irreplaceable Items Financial/Clinical Risk Even if physically stable, very expensive medications (e.g., certain monoclonal antibodies, gene therapies, specific orphan drugs) are often excluded. The financial loss if a carrier is lost or damaged is too great. More importantly, the clinical delay in replacing a dose of a critical, hard-to-obtain medication can cause significant patient harm.
PART 3

Best Practices, Troubleshooting, and Downtime

Ensuring Safety and Responding to Failure

A Practicum on Safe Tubing: The Pharmacist’s Pre-Flight Checklist

Before a technician sends a medication and you give your final approval, you must run through this mental checklist to ensure every aspect of the delivery is safe and correct.

  1. Is the item on the “Do Not Tube” list? This is the first, non-negotiable gate. If the answer is yes, the process stops, and the item must be hand-delivered.
  2. Is it packaged correctly to ensure integrity?
    • Liquids: All IV bags, syringes, and oral liquids must be sealed in a zip-top plastic bag. This provides a crucial layer of containment in the rare event of a leak.
    • Padding: All items must be padded with foam inserts. This prevents the medication from rattling and slamming against the walls of the carrier, which could damage the product or the container. A loosely packed carrier is a recipe for breakage.
  3. Is the destination correct? You must double-check that the technician has entered the correct destination address (e.g., “5 West Station 1” vs. “5 East Station 1”). Sending a STAT medication to the wrong floor can cause a critical, and entirely preventable, delay in care.
  4. Is the priority correct? Most tube systems have a “STAT” or “Priority” function that places that carrier at the very front of the queue, bypassing all routine traffic. You must ensure that truly urgent medications (e.g., a STAT antibiotic for sepsis, a bolus for a code) are sent with this priority, but also that the function is not overused for routine meds, which would clog the system.

3.1 Troubleshooting Common System Failures

Even the most robust systems can fail. Your ability to respond quickly and logically to a system error is a key operational skill.

The Scenario: A Stuck Carrier

The system alerts you that a carrier is stuck somewhere in the pipes. It has not reached its destination.

Your Action Plan:
  1. Identify Contents & Notify: Immediately identify what was in the carrier and notify the nurse on the receiving end about the delay and the reason.
  2. Re-Dispense & Hand-Deliver: Immediately prepare a replacement dose. This new dose must be hand-delivered by a technician or pharmacist. Do not wait for the original to be found.
  3. Contact Engineering: Contact the hospital’s engineering or maintenance department with the carrier’s last known location (provided by the system) so they can physically retrieve it.

The Scenario: A Mis-routed Carrier

A carrier you sent to the ICU arrives in the ER. The ER nurse calls you.

Your Action Plan:
  1. Secure and Return: Instruct the ER nurse to secure the carrier and send it directly back to the pharmacy. Never ask them to forward it to the correct location, as this creates a confusing and untraceable chain of events.
  2. Communicate the Delay: Notify the ICU nurse about the error and the delay.
  3. Re-send Correctly: Once the carrier returns to the pharmacy, verify its contents and re-send it to the correct destination.

Deep Dive: Downtime Procedures – When the Superhighway Closes

The pneumatic tube system is a complex mechanical system that requires regular maintenance and can experience unexpected hospital-wide failures. When it goes down, the pharmacy must immediately pivot from a primarily automated workflow to a completely manual one. This is a high-stress “all hands on deck” situation where your role as a leader and triage officer is paramount.

  1. The Initial Alert & Communication: Whether the downtime is planned for maintenance or an unplanned failure, the pharmacy is responsible for immediately notifying the entire hospital via overhead page, mass notification system, and direct calls to critical areas (like the ED and ICUs).
  2. The Pivot to a “Runner” System: The pharmacy must immediately designate available staff members—technicians and pharmacists alike—to act as “runners.” These individuals become the manual delivery system for the entire hospital.
  3. Your Role as Triage Officer: This is where your clinical judgment is most essential. All outgoing medications must now be manually sorted by priority. You must constantly scan the queue of waiting medications and make critical decisions. The STAT norepinephrine for the septic shock patient in the ICU goes first. The NOW dose of IV antibiotics for a new admission goes next. The routine, scheduled dose of lisinopril can wait for the next scheduled delivery run. This requires constant communication with your runners and with the nursing staff on the floors to manage expectations.
  4. Post-Downtime Recovery: Once the system is back online, the pharmacy communicates this to the hospital. There is often a significant backlog of deliveries to catch up on, and your triage skills remain essential until the workflow stabilizes and returns to normal.