PHT hospital Pharmacy
Introduction
Pharmacy should be defined basically as a system which renders a health
service by concerning itself with knowledge about drugs and their effects
upon men and animals. Pharmacy generates knowledge about drugs ;
acquires relevant knowledge from the biological chemical, physical and
behavioral sciences; it tests, organizes and applies that knowledge.
Pharmacy translates a substational portion of that knowledge into drug
products and distributed them widely to those who require them. The
knowledge system of pharmacy through it's therapeutic use is a
substantial and significant segment of health care. The hospital
pharmacist can no longer be regarded only as a dispenser of medicines.
He has an important role as a consultative and manager. He should be
responsible for the planning of pharmaceutical services and the
establishment and maintenance of safe systems of work within his
department and the collection of data on drug use. He has also to
cooperate medical and nursing staff in securing the most effective safe
and economical use of drugs. The specially of hospital pharmacy has
been defined as follows:
The department or services in hospital which is under the direction
of a professionally competent, legally qualified pharmacist and from
which
all medications are supplied to the nursing units and other
services, where special prescriptions are filled for patients in the hospital
where prescription are filled for ambulatory patients and out patients,
where pharmaceuticals are manufactured in bulk, where narcotic and
other prescribed drugs are dispensed, where biological are stored and
dispensed where injectable preparations should be prepared and sterilized
and where professional supplies are often stocked and dispensed.
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Goals for Hospital Pharmacy
The American Society of Hospital Pharmacists developed a
statement on the goals for hospital pharmacy which , are consistent with
its objectives. The 6 goals should be the focus of attention for the hospital
pharmacists of the future and are therefore cited.
Coordinate plans must be drawn and implemented
1. Teach
hospital
pharmacists
to
assume
responsibility
for
professional practice .
2. Strengthen and expand the scientific and professional aspects of
the practice of hospital pharmacy including the consulting role of
the hospital pharmacist his teaching role and his activities in the
field of investigation and research.
3. Strengthen and perfect the administrative of management skills
and tools essential to the hospital pharmacist in his role as a
department head.
4. Attract a greater no of well trained pharmacist to hospital practice,
including those with specialized education and training in hospital
pharmacy.
5. Promote a payment of realistic salaries to hospital pharmacists to
attract and retain the services of career personnel.
6. Utilize the resources of hospital pharmacy to assist in the
development and improvement, of the profession as a whole.
Drug Distribution floor stock system
Each pavilion on the hospital, has a supply of drugs stored in the
medicine cabinet even though the nursering unit is serviced by a unit dose
system.
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Drugs on the nursery station may be divided into:
A. charge floor stock drugs
B. non charge floor stock drugs
may be defined as those medication Represent that gp of medications
that are socked on the nursing that are placed at the nursing station
stations all time and are charged to for the use of all patients on the
the patient account after they have pavilion and for w, there is no
been administered.
direct charge to the patient account.
today there are 4 systems in general use for dispensing drugs for in
patients. They may be classified as follows:
i.
Individual prescription order system.
ii.
Complete floor stock system.
iii.
Combination of both and (ii)
iv.
Unit dose method
Individual Prescription order system
This system is generally used by the small and or private hospital because
of the reduced manpower requirements and the desirability for individual
service. In this system in the possible delay iu the obtaining the required
medication and the increase in cost to the patient.
Advantage:
1. All medication orders are reviewed by the pharmacist
2. Provide for the interaction of pharmacies doctor nurse and patient
3. Provide close control of inventory
The complete floor stocks system
Under this system, the nursing station pharmacy call both charge and non
charge patient medications.
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 Rarely used or particularly expensive drugs are omitted from floor
stock but are dispensed upon the receipt of a prescription for the
individual patient.
Advantage:
1. Ready availability of their required drugs.
2. Elimination of drugs returns.
3. Reduction of number of drug order transcript to pharmacy.
4. Reduction in the no. of pharmacy personnel required.
Disadvantages:
1. Medication errors may because the evidence of medication orders
is eliminated.
2. Increased during inventory on the pavilions.
3. A greater opportunist for pilverage.
4. Increased hazards associated with drug deterioration.
5. Lack of proper storage facilities in the ward.
6. Greater in roads are made upon the nurses time.
Combination of individual drug order and floor stock systems.
Falling in this category are those hospitals which use the individual
prescription order system as their primary means of dispensing but also
utilize a limited floor stock. This combination system is probably the
most commonly used in hospitals today’s and is modified to include the
use of unit dose medication selection of non charge floor stock drugs.
Here, consideration is usually given to the cost of the preparation, the
frequency of use, the quantity used, and the effect upon the hospital
budget. In many hospital, the list is exceptionally small and therefore the
patient is billed for numerous single doses of drugs.
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Outpatient and Inpatient Dispensary services
There are various means employed by the hospital pharmacy to dispense
and distribute various categories of drugs of the hospital.
1. Dispensing of charge nonfloor stock drugs. One method adopted
by the hospital to identify pts, is the principle of the charge plate.
Here by use of a plastic or metal card prepared on the patients’
admission to the hospital or clinic, much nursing time is
conserved. As a matter effect all newly printed hospital forms
usually reserve a space of the form for the information on the
identification plate. Accordingly all charge stations are equipped
for using this time saving device w yields an important by product
legibility of identify. Many drug order forms may have such
information as name of drug, dosage from and route of
administration printed on it, thereby again conserving time by
requiring only a minimal effort to select the drug, the desired form
and route of administration.
- Drug order forms may be prepared on duplicate of triplicate
snaport forms w, provide a copy for the pharmacy and
accounting department and a control copy for the pavilion.
The Envelop system
One hospital has developed a system whereby an envelop is used to
dispense drugs to the nursing station and at the same time is also used as a
charge ticket under this system the pharmacist fills prelabeled envelopes
with the specific drugs and places a predetermined quantity on the
nursing unit when the drugs administered to the patient, the nurse places
the patient’s name and room no. on the envelop and places it in her out
basket, which is picked up by the messenger service and is delivered to
the pharmacy w is priced and forwarded to the accounting office.
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Dispensing and distribution of non charge floors stock drugs
Drug Basket Method
Under this systems the might nurse checks the medicine closet, utility
room and drug refrigerator inventory of supplies against a master list
provided by the pharmacy and the nursing service. The nurse places
check marks on the no required for each drug on the requisition for floor
stock supplies where there is an empty container, she places it in the drug
basket. On the procedure is completed, the drug basket containing the
empty containers and requisition for floor stock supplies in them solute to
the pharmacy. Immediately upon opening in the morning the pharmacy
staff commences to fill each container and dispense the requested
ampules and vials as ordered. Once the basket is completed, it is
delivered to the floor via a messenger service.
Mobile Dispensing Unit For the hospital
 Pharmacy utilizes a specially constructed stainless steel mobile
thruck. Under this system two mobile units are put into operation
to permit one unit to be in use while the other is being serviced .
 The frequently of delivery and the hours during w the mobile unit
will visit the pavilion can be selected in cooperation e, the nursing
service.
 By using this system it will not be necessary for the night nurse to
check the pharmacy inventory or have empty containers
transported to the pharmacy. Instead, the pharmacist maning the
mobile unit will inventory the pavilion drug cabinets and check off
the items and quantity of supplies left. The carbon copy of the
requisition for floor stock supplies is left on the pavilion as a
record of delivery and the original is returned to the pharmacy
where it will serve 3 purposes:
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1. To restock the mobile unit.
2. To determine rate of use or consumption.
3. To serve as a charge document for the internal allocation of costs.
Advantages:
A. The drugs and nursing station drug cabinets will always under the
supervision of professional personnel.
B. The pharmacist is brought out of the pharmacy and made
available for on the spot consultations by clinical and nursing
staffs.
C. Through the routine checking of the medicine closet, deteriolated,
out dated and non approved drugs and drug samples may be
quickly removed of.
Unit Dose Dispensing
Definition:
Unit dose medication have been defined as:
Those medications w, are ordered, packaged, handled, administered and
charged in multiples of single dose units containing a predetermined
amount of drug or supply sufficient for one regular dose, application or
use
Advantage of the unit dose system
1. Patient receive important pharmaceutical service 24 H a day and
are charged for only those doses w are administered to them.
2. All dose of medication at the nursing station are prepared by the
pharmacy thus allowing the nurse more time for direct patient care.
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3. Allows the pharmacist to check a copy of the physician original
order thus reducing medication errors.
4. Eliminates excessive duplication of orders and papers work at the
nursing station and pharmacy.
5. Transfers I.V. preps and drug reconstitution procedures to the
pharmacy.
6. Conserves space in nursing unit by eliminating bulky floor stock.
7. Eliminating
pilfereage and drug waste. Permit for moleculate
medication charges and Prevent the loss of partitals used
medication.
8. The pharmacists can get out of the pharmacy and onto the wards
where they can perform their intended function as drug consultants
and help provide the team effort that is needed for better patient
care.
9. Surve personnel time both in the pharmacy and on the nursing
service.
10. Eliminate
labeling
errors
medication
distribution
as
the
responsibility of the pharmacy. The pharmacists with the
assistance of the pharmacy and therapeutic committee and the
department of nursing must develop comprehensive policies and
procedures that provide for the safe distribution of all medication
and related supplies to in patient and out patient.
Dispensing Procedures
 Unit dose dispensing concept may be introduced into the hospital
either of two ways the first method is the centralized unit dose drug
distribution system. CUDD, and decentralized unit dose drug
distribution system DUDD. The characteristics features of
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centralized CUDD are that all in patient drugs are dispersed in unit
doses and all the drugs are stored in a central area pharmacy and
dispensed at the time the dose is to be given to the patient. To
operate the
system effectively, delivery systems such as
medication carts and dumbwaiters are need to get the unit doses to
the patients, also suction tube systems called pneumatic tubes or
other areas are required to send a copy of the physician’s original
medication order to the pharmacy for direct interpretation and
filling.
DUDD
Unlike the centralized system, operates and small satellite pharmacies
located on each floor of the hospital. The main pharmacy in this system
becomes
procurement, storage, manufacturing and packaging center
serving all the satellites the delivery system is accomplished by the use of
medication carts. This type of system can be used for a hospital with
separate buildings or old delivery systems.
The following is a step by step outline of the procedure entailed in a
decentralized unit dose system.
1. Upon admission to the hospitals the patient is entered into the
system. Diagnosis, allergies and other data are entered onto the
patient profile card.
2. Direct copies of medication orders are sent to the pharmacist.
3. The medication orders are entered on to the patient profile card.
4. Pharmacist checks medication order for allegies, drugs interactions,
drug lab test effects and rationale of therapy.
5. Dosage scheduled is coordinated with the nursing station.
6. Pharmacy technician picks medication orders, placing drugs in bins
of a transfer cart per dosage schedule.
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7. Medication cart is filled for particular dosage schedule delivery.
8. Pharmacist checks cart prior to release.
9. The nurse administers the medication and makes appropriate entry
on her medication record.
10.Upon return to the pharmacy the cart is rechecked.
11.Throughout the entire sequences the pharmacist is available for
consultantnsy
the doctor spend nurses: In addition he is
maintaining a surveillance for discontinued orders.
Dispensing to Ambulatory patients
Ambulatory refers to patients not occupying beds in hospitals or other in
patient settings and to care given in physician offices, clinics, health
centers, and other places where ambulatory patients usually for health
care.
I.e, Ambulatory care generally refers to providing health care to patient
who how are not restricted to bed.
The level of care may be primary, secondary or even tertiary.
The outpatient pharmacy dispensing area should be located somewhere
along the normal patient traffic flow. According to hospital bed size the
services can be provided from:
a. A separate outpatient pharmacy.
b. A combined inpatient and outpatient unit service provided
from the same windows.
c. A combined inpatient and outpatient with service provided
from separate windows. In all cases waiting area should be
available.
The five pharmacy services that should be expected in all ambulatory care
facilities include the following:
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1-
The ambulatory care pharmacy must be directed by a qualified
pharmacist.
2-
The appropriateness of the choice of drug and its dosage, route of
administration and amount must be verified by the pharmacist.
3-
All medications dispensed to patients will be completely and
correctly labeled and packaged in accordance with all applicable
regulations and accepted standards of practice.
4-
On dispensing a new medication to the patient, the pharmacist
will ensure that the patient on his or her representative received
and understands all information required for the proper use drug.
5-
All drugs in ambulatory care services are will be properly
controlled.
The Dispensing routine
The dispensing pattern involved in providing clinic patients as well as
these patients being discharged with take home drugs is identical e that
carried by a common pharmacy. If there is a waiting period before
dispensed the drug or medicine to the patient a prescription cell checked
which numerically identifies the patient and the finished prescriptions is
used by the pharmacy once in the hands of the pharmacist the prescription
and labeled are numbered by a numbering machine, the directions and
other information are placed on the able. Ancillary labels are affixed, the
proper medications placed in the containers, a check for accuracy is then
conducted and finally the prepared prescription is wrapped and dispensed.
Hospital Formulary
Definition of formulary and for mulaly system
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The formulary is a continually revised compilation of pharmaceuticals
(plus important ancillary information) that reflects the current clinical
judgment of medical staff.
The formulary system: is a method whereby the medical staff of an
institutions, working through the pharmacy and therapeutic committee,
evaluations, and selects from the numerous available drug entities and
drug products those that are considered most useful in patient care. The
formulary system is an important tool for assuring the quality of drug use
and controlling its cost.
The formulary system provides for procuring, prescribing, dispensing and
administering of drugs under either their non properitary or proprietary
names in instances where drugs have both names.
Formulary intent and organization
The primary objective of the formulary is to the formulary system is a
method whereby the medical staff of an institutions working through the
pharmacy and therapeutic committee, evaluates, and selects from the
numerous available drug entities and drug products those that are
considered most useful in patient care. The formulary system is an
important tool for assuring the quality to drug use and controlling its cost.
The formulary system provides for procuring, prescribing, dispensing and
administering of drugs under either their non proprietary or proprietary
names in instances where drugs have both names.
Formulary content and organization
The primary objective of the formulary is to provide the hospitals staff
with.
1. Information on what drug products have been approved for use by
the pharmacy and the therapeutic committee.
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Non proprietary named generic or official established names should be
the most prominent patient of the label. Special characteristic of the
dosage should be a part of the label e.g. sustained release, packages
should be labeled as to their route of administration if other than oral of
topicals in a package containing injections the acceptable injectable route
must be stated special notes such as condition of storage, expiration
should be part of the label e.g. sustained packages should be labeled as to
their route of administration times of the other than or feects topcals in a
packager containing injections of acceptable injectable route must be
stated specied notes such as
condition
of storage, expiration dates
preparations (shake well), moister administration must to be chewed) that
are not about form the form designated are to be inclined at the of the
label
14(c) Out patient
Labeling out patient prescriptions
1. The outpatient prescription label should bear the following
information:
a. patients full name
b. Date of issue
c. Prescription identification no
d. Specific directions for use
e. Name for initial of dispenser
f. Name of prescribing physician
g. A keep out of children label
h. Name address and telephone no of hospital
2. Prescription should have noted there on, at the time dispensed, the
source and batch identifying number of the medication and the
initial of the dispensaries.
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3. An identifying check system to
insure proper identification of
outpatient should be established .
4. Drugs which required and expiration date should show this date on the
immediate container and when this container is packaged incarton, the ex
date should be placed on the carton.
Patient medication profile (PMP) and outpatient service.
As a tool the pharmacist uses PMP with the objective of monitoring drug
therapy to averty and or to solve drug therapy related problems such as:
1. Duplication of active prescription for the same drug.
2. Duplication of an active prescription for a similar therapeutic
entity.
3. Patient under or over utilization of drug
4. Potential drug-drug or drug-food interactions.
5. Potential diseases drug contraindication.
6. drug allergy or hypersensitivity.
A particularly important element of PMP use in out patients services is
compliance with therapeutic drug regimens. PMP enables the pharmacists
to detect over or under utilization of medications based on refill
frequency.
Hospital Formulary
Definition of formulary and formulary system:
the formulary is a continually revised compilation of pharmaceutical (plus
important ancillary information) that reflect the current clinical judgment
of medical staff.
The formulary system: is a method whereby the medical staff of an
institution working through the pharmacy and therapeutic committee,
evaluations, and selects from the numerous available drug entities and
drug products those that are considered most useful in patient care. The
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formulary system is an important tool for assuring the quality of drug use
and controlling it cost.
The formulary system provides for procuring, prescribing, dispensing and
administering of drugs is under either their non proprietary or proprietary
name in instances where drugs have both names.
Formulary content and organization
The primary objective of the formulary is to provide the hospitals staff
with:
1. Information on what drug products have been approved for use by
the pharmacy and therapeutic committee.
2. Basic therapeutic information about each approved item.
3. Information on about hospital policies and procedures governing
the use of drugs.
4. Special information about drugs, such as drug dosing rules,
hospital approved abbreviations, sodium content of various
formulary items.
Contents of the formulary
Formulary should consist of three main parts:
Part one; Information on hospital policies and procedures concerning
drugs.
Part two: Drug products listing
Part three: Special information about three drugs.
E, respect to part one the following items may be included:
1. Formulary policies and procedures including such items as restrictions
on drug use (if any) and procedures for requesting that a drug be added to
the formulary.
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2.
Brief description of the pharmacy and therapeutics committee,
including its membership, responsibilities and operation.
3.
Hospital regulations governing the prescribing, dispensing and
administration of drugs, including the writing of drug orders and
prescription.
4.
Pharmacy operating procedures as hours of services out patient
prescription policies, pharmacy changing system prescription labeling
and packaging practices, impatient drug distribution procedures the
handling of drug information requests and specialized services of the
pharmacy. (e.g. patient education programs, pharmacy bulletins).
5. Information on using the formulary, including how the formulary
entries are arranged, the information contained in each entry and the
procedure for looking up a given drug product. References to sources of
detailed information on formulary drugs (e.g, American hospital
formulary service, pharmacy drug information service etc.) should be
included here.
Part two drug product listing. it is the heart of the formulary and consist
of one or more descriptive entries for each formulary item plus one or
more indexes to facilitate use of the formulary.
Formulary item entries
The entries can be arranged in several ways:
1. alphabetically by generic name,
2. Alphabetically within therapeutic class usually following the
American Hospital formulary service (AHFS) classification
scheme.
3. A combination of the two systems where by the bulk of the drugs
are contained (alphabetically in a general section w, is
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supplemented by several special sections such as ophtantmic otic
drugs dermatogicials and diagnostic agents.
The type of information in each entry will vary at a minimum each
entry must include:
a. Generic name of the basic drug entity or product,
combination products may be listed by generic common lf
trade name.
b. Common synonym (s) and trade name(s) there should be a
note in the direction for use.
c. Dosage form, strength, packaging and size stocked by the
pharmacy.
d. Formulation (active ingredients) of a combination product
and
e. AHFS category number
Additional information that can be included:
1. Usual adult or pediatric dosage ranges or both.
2. Special cautions and notes such as, do not administer IV, or
refrigerate.
3. Controlled substances symbol.
4. Cost information, this generally will be the most useful where the
therapeutic classification is used. Or alternatively, lists of similar
drugs (e.g. oral steroids) may be prescribed relative cost data.
Indexers to the drug products listing
There are tow indexes which will facilitate the use of the formulary. They
are:
1. Generic name Brand, synonym cross index. The proper page no.
reference should be included in each entity. An example of this
type index is:
Ophtaine : brand of propara carine P114
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Ophtetic : brand of propara caine P114
Opium tincture, campholated synonym for paregolie, P103 paragoric :P103
This index also could be integrated into the drug products listing rather
than being a separate entity. the listing in this event, must be arranged
alphabetically.
2. Therapeutic (pharmacologic index)
It is useful in ascertaining what therapeutic alternatives exist for a given
situation as patient allergy to a particular drug. And e.g. of this type of
index is :
4.00 Antihistamine drug
Bromphniramine maleate, P14
Chlorpheniramine maleaste, P14
Diphenhydramine HCl, P14
Promethazine HCl, P20
The enteries should include the AHFS code no.
Special Information
Examples of the type of items often found in the special information
section of hospital formularies are:
1. Nutritional product list.
2. Tables of equivalent dosage of suimialr drugs.
3. List of hospital approved abbreviations.
4. rules for calculating pediatric dosage.
5. Table of the sodium content o f antacids.
6. List of content of emergency carts.
7. List of sugar free drug products.
8. Pharmacokienetic dosing and monitoring information.
9. Metric conversation scale and tables.
10.List of dialyzable poisons.
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11.Table of drug interactions, drug interference e, diagnostic tests and
parenteral drug in compatablities and poison control information.
12.Examples of blank or completed hospitals forms such as
prescription.
Distribution of the Formulary
Copies of the formulary should be placed at each patient care unit,
including clinics and other outpatients care areas such as the emergency
room. Each division of the pharmacy (in pt, out pt, dispensing, drug
information service etc) should receive a copy heads of departments
providing direct patient care should receive a copy as should hospital
administration each member of the medical staff should receive a copy of
it.
The necessary steps shod be taken to ensure that the nursing and medical
staff are familiar the formulary and know how to use it.
Keeping the formulary current
The formulary will need to revised annually addition and deletions to the
formulary changes in drug products, removal of the drug from the market
place and changes in hospital policies and procedures all will necessitate
periodic revision of the formulary. There should be a system for including
between revision changes in the current edition for the formulary on
method, is to attach formulary supplement sheet to the inside back covers
of the formulary books use of non formulary drugs.
In many institution a non formulary drug will not be dispensed from the
out patient pharmacy with respect to inpatients, a physician is allowed to
order a non formulary drug to a specific patient by the use of a special
non formulary drug request. Chart B.
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Formulary Vs drug catalogue or list
Too many people use the terms formulary and drug list interchangeably.
There is a big difference in the scope and preparation of a formulary over
a drug list. A formulary usually consist of therapeutic agents by their
genetic names followed by information on strength, from, toxicology use
and recommended quantity to be dispensed, where as drug list usually
consists of listing of therapeutic agents by their generic names followed
by the data on strength and form there may or may not be any addition
information.
The formulary is the more information type of publication and may exert
an important rule in the education aspects of drug therapy particularly in
hospital with an active intern and training program and school of nursing.
If a formulary type of publication is desirable, then the committee has the
option of either preparing a private formulary for the hospital or to
subscribe to a drug monograph service such as the American hospital
formulary service, a publication of the American society of hospital
pharmacists. Either of their will provide the hospital with adequate
information concerning drugs each has its own advantages.
Hospital Pharmacy II PHT 453
Dispensing to inpatients
A great deal of nursing time was consumed by frequent trip to the
pharmacy to obtain medications and other ancillary supplies. As a result
new systems for the distribution and dispensing of drugs are developed.
One such approach was the stocking of drugs on the nursing station in
bulk quantities, thereby eliminating the pharmacists control for here the
physician prescribed and the use dispensed and administered. But it has
stated that drug administration is a nursing act which consists of the
removal or with drawl of a single dose from a drug container and its
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administration to a patient on the order of a physician or dentist. But
dispensing is a pharmacy act and consists of the pharmacist removing two
or more doses from a bulk drug container and placing them in another
container for subsequent use. So nurses are not authorized to dispense
drugs.
A mole rational approach, might be the installation of a messenger
service between pharmacy and the nursing stations, installation of
mechanical covenyor systems or pneumatic tube systems or to develop
emergency boxes or the placing of charge floor stock drug on the pavilion
after a limited selection of drugs for this use has been made by the PTC.
Many examples are recorded in the literature that illustrate the
relationship between a drug distribution system and the nursing system.
Studies show that 22% increase in the amount of time nurses were able to
spend at the patient’s bedside as a result of changing the drug dispensing
system.
The following are guidelines for planning and evaluating hospital drug
distribution systems.
1. before the initial dose of medication is administrated the
pharmacist should review the prescriber’s original order or a direct
copy.
2. Drugs dispensed should bear adequate identification including,
name of names of drugs, strength or potency, route (s) of
administration, expiration date, control No., and such other special
instructions.
3. Facilities and equipment used to store drugs should be designed
that the drugs are accessible only to medical practitioners
authorized to prescribe, to pharmacists authorized to dispense to
nurses authorized to administer such drugs.
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4. Facilities and equipment used to store drugs should be designed to
facilitates routine inspection of the drug prior to the time of
administration.
5. Mechanical or electronic drug storage and dispensing device as
require or encourage the repackage of drug dosage forms from the
manufacture’s original container should permit and facilitate. The
use of a new package which will assure the stability of each drug
and meet u.s.p standards for the packaging and storing drugs and
all other standard of GMP.
6. In considering automated devices as pharmaceutical tools, the
distinction between the accuracy required in accounting practices
versus that required in dispensing practices
should be clearly
distinguished.
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