3. The Impact of FMD Implementation on the Supply Chain of a Hospital
A proposed supply chain is detailed with the relevant impact of the implementation of the FMD in operations. The support activities, regarding infrastructure for FMD implementation, and the need for extra human resources to implement automation, can be a solution and the procurement of an automated solution can be considered. Normally, companies provide automation provide scanners for the rest of the operations that cannot be done through automation. If not, procurement of 2D bar code scanners needs to be made 
Regarding human resources, if the option of automation is not pursued a recruitment process needs to be planned, and if automation is pursued, a training is normally done by the company that supplies the solution, but a possible plan for training needs to be implemented.
The IT department possibly has to adapt the dispensing software with the final interfaces of verification and decommission that are going to be delivered by the blueprint provider. If automation is implemented normally, new software comes with the solution that needs to be implemented and integrated with the dispensing software, so IT needs to liaise with the automation company if any issues arise with the dispensing operations.
The procurement of medicines can be done directly through the pharmaceutical industry that selects the products containing aggregation to reduce operational dispensing time 
. Delivery to other hospitals can re-think other options that can be pursued by accessing the costs of outsourcing or through tender processes to evaluate if there are more inexpensive ways of delivering to reduce the impact of expenditures in daily deliveries. Public tender processes for automation and possibly new scanners are needed.
The primary activities have the biggest impact in terms of adapting to the FMD regulatory requirements.
The inbound logistics continue to be done by the manufacturers. Nevertheless, change can be adapted to achieve better efficiency. Procurement can be done centrally but the dispatch of certain drugs can be done directly to the specific hospitals. Instead of being received by the case hospital centrally and then dispatched, this can transfer delivery costs to the supplier. Large infusions and medications that are recurrently used can be delivered from the industry, bypassing especially the ones included in Annex I of the DR. Also, manufacturers deliver medicinal products with the respective unique identifier in each medicine package. If automation is an option, inbound goods to the robot need to occur at this point.
In terms of operations, orders are going to be received in the same way; if automation or semi-automatic solutions are pursued, the operator needs to select the order and dispense it through the system. Decommission needs to be performed on goods outside of the solution. Other possible solutions for the dispensing operations are mobile scanners because of the pharmacy’s infrastructure; the decommission of medicinal products at the dispensary eases the workflow and the distribution of medicinal products for the internal hospital and external ones 
To optimize the operations, there is a need to change the storage format; items that need to be authenticated should be close to the dispensary. The others included in Annex I of the DR can be stored in other locations so that the staff easily differentiate the products that need to be decommissioned or not.
Other regulatory implications for operating in a FMD environment are required. If a split pack is dispensed, the original container should not leave the dispensary until its entire content is used; the pharmacy cannot re-sell or supply other pharmacies with this product. For products sent to the wards and to external hospitals, the authentication can be done when the item is dispensed to the wards. Because this decommissions the serial code from the database, this needs to be the last step of the workflow. Manual authentication should also be performed in the last step by an accredited pharmacy technician or pharmacist 
. Drugs manipulated in the cytotoxic clean room can also be authenticated in the dispensary before being distributed to this area.
Other recommendations in terms of operations achieved in other studies also impact the supply chain. A verification of the serial code can be done if necessary at any point of the supply chain, including in the workflow of the pharmacy. Medicines identified as falsified or recalled should be quarantined for inspection by suitably qualified professionals. Also, once a national medicines serial code repository is established and in operation, any medicine returned to the pharmacy, intended for re-use, should be verified. Authentication should be incorporated into departmental procedures. Incidents, when medicinal products leave a dispensary without authentication, should be classed as a dispensing error. If a medicine has been authenticated but is no longer required for the current dispensing process, there should be an option to return the unique identifier scanned to the national repository database 
. Products that become non-compliant with FMD during the duration of the directive are considered in the system as unverifiable and their codes will cease to be active when the expiry dates are reached. It is the most economical solution because it is cost-free.
The outbound logistics can also be adapted. A better assessment of the resources, in terms of medicines, a hospital needs should to be made to understand if logistics can be changed. Large orders of electrolytes and high consumables can be delivered once a week by bulk, instead of being included in a daily order. The manufacturer can directly deliver medicinal products that are included in annex I of the DR to other hospitals. Orders should be done three times a week instead of daily to reduce the cost of logistic operations. The cost of possible outsourcing of logistics needs to be confirmed to investigate the impact on the overall costs of logistics. A secure supply chain to the wards and other hospitals under GDP is needed to be implemented to safeguard the authentication process 
Hospital wards deliver the drugs to the patients.