CHAPTER 16
HOSPITAL PHARMACY
CHAPTER OUTLINE
• Hospital Pharmacy
• Technician Roles
• Hospital Pharmacy
Areas
• Hospital Formulary
• Communication
• Computer Systems
• Medical Records
• Medication Orders
• Order Processing
• Inventory Control
• Organization of
Medications
• Unit Dose System
• Sterile Products
• General Hospital Issues
• Calculations
• Review
HOSPITAL PHARMACY
• Pharmacy technicians play an important role
in the preparation, storage, and delivery of
medications to patients in the hospital.
• Training requirements vary by hospital, but
most are seeking technicians with certification
(CPhT).
ORGANIZATION OF A HOSPITAL
• Patients with similar problems are grouped
together and located on nursing units.
– Examples: Cardiac Care Unit (CCU), Obstetrics (OB)
– The nurses’ station is the work station for medical
personnel on a nursing unit.
• Ancillary areas
– Other areas of the hospital that provide patient care
– Examples: Emergency Room, Cardiac Catheterization
Lab
• The Pharmacy Department services nursing units
and ancillary areas with medication.
THE HEALTHCARE TEAM
• A team of healthcare workers help provide
care and medications to hospital patients.
– Prescribe medications for patients
• physicians, physician assistants and nurse
practitioner or advanced practice nurses
– Administer medications to patients
• registered nurses, licensed practical nurses and
respiratory therapists
– Assist with getting medications to patients
• pharmacists, social workers, patient care techs,
and pharmacy technicians
PHARMACY TECHNICIAN ROLES
•
•
•
•
•
•
•
•
•
Front counter
Satellite pharmacies
Delivery
Outpatient pharmacy
Order processing
Compounding/Unit dosing
Monitoring drug therapy
Investigational drug service
Inventory control
•Narcotics/controlled substances
•Cartfill
•Automation
•IV/clean room
•Chemotherapy
•Quality assurance
•Pharmacy technician supervisor
•Staff development
HOSPITAL PHARMACY AREAS
• Inpatient pharmacy
– Located inside the hospital; serves only patients in the hospital and its
ancillary areas
• Pharmacy satellite
– Branch of inpatient pharmacy
– Responsible for preparing, dispensing, and monitoring medication for
specific patient areas
– Examples: Pediatric, OR, and Oncology
• Central pharmacy
– Main inpatient pharmacy (when also have satellites)
– Most medications prepared and stored here
– The sterile product area, or clean room, usually located here
USP <797>
• Set of regulations issued by the US
Pharmacopoeia for compounding sterile
products
– Intended to decrease infections transmitted to
patients through drug preparation, and
– better protect staff in their exposure to
pharmaceuticals.
• All hospitals accredited by The Joint
Commission (TJC) must be compliant with USP
797 standards.
HOSPITAL FORMULARY
• Hospital Formulary
– List of drugs stocked in the hospital and selected based on
therapeutic factors as well as cost.
– The Pharmacy and Therapeutics Committee (P&T committee) adds,
removes, and evaluates medications on the formulary.
• Closed formulary
– Requires physicians to order only medications in the formulary.
• Non-formulary drugs
– Medications not on the formulary list and not regularly stocked.
• Therapeutic interchange
– Allows pharmacist to change certain non-formulary medication orders
to equivalent formulary medications.
COMMUNICATION
• Ways other areas of the hospital
communicate with pharmacy:
– pneumatic tubes
– telephones
– computers
– in person at the pharmacy’s front
counter
Images copyright Perspective Press and Morton Publishing Company. May not be copied, re-used, reproduced, or re-transmitted without express written permission
from the publisher.
HEALTH INSURANCE PORTABILITY AND
ACCOUNTABILITY ACT (HIPPA)
• Safeguards patients’ protected health information (PHI) when it
is spoken, written, or transferred electronically.
• Information in the hospital information system is highly
confidential.
• Illegal to give information to any unauthorized person.
• Never look at a patient’s information unless necessary in
fulfilling an assigned task.
MILITARY TIME
• Most hospitals use a 24-hour clock (also known as
military time) to indicate when medications are to be
given and when they expire.
12–hour clock
Midnight
1 a.m.
2 a.m.
3 a.m.
4 a.m.
5 a.m.
6 a.m.
7 a.m.
8 a.m.
9 a.m.
10 a.m.
11 a.m.
24–hour clock
00:00
01:00
02:00
03:00
04:00
05:00
06:00
07:00
08:00
09:00
10:00
11:00
12–hour clock
24–hour clock
Noon
1 p.m.
2 p.m.
3 p.m.
4 p.m.
5 p.m.
6 p.m.
7 p.m.
8 p.m.
9 p.m.
10 p.m.
11 p.m.
12:00
13:00
14:00
15:00
16:00
17:00
18:00
19:00
20:00
21:00
22:00
23:00
MEDICAL RECORDS
• Health records (aka medical records)
– Detailed, chronological accounts of a patient’s medical history
• Electronic medical record (EMR) or electronic
health record (EHR)
– A computerized patient medical record
– Allows authorized health care providers to access a patient’s medical
information from any secure location
– Integrates patient medical records with billing and appointments
COMPONENTS OF A MEDICAL RECORD
Demographics
Personal identification
information
Allergies
Drug and/or food allergies and the
allergic response experienced
Medical history
Disease states (previous illnesses,
surgeries, prescriptions, OTC and
herbal medications)
Medication orders
Orders written by a physician for
patient’s medication
Medication administration
record
Tracks medications given to a
patient, time they were given, and
who administered them
Lab/test results
Blood tests, X-rays, microbiology, etc.
Documentation flow sheet
Vitals on an hourly or scheduled
basis, hourly rates of IV fluids and
medication drips, etc.
Progress notes
Detail patient’s current progress
MEDICATION ORDERS
• All written pharmacy orders for a hospital patient
are done on a medication order form.
– Unit clerks, nurses, pharmacists or pharmacy technicians may be
responsible for entering these orders into the computer system before the
pharmacist reviews them.
• Computerized physician order entry (CPOE) is an
electronic alternative.
– Physicians can enter orders directly into the computer system, decreasing
the chance of transcription errors.
TYPES OF MEDICATION
ORDERS
• Standing order
– Patient receives medication at scheduled intervals (e.g., 1 tablet every
8 hours)
• PRN order
– Medication administered only on an as needed basis (e.g., 1 tablet
every 4 to 6 hours as needed for pain)
• STAT order
– For medication to be administered immediately
Image copyright Perspective Press and Morton Publishing Company. May not be copied, re-used, reproduced, or re-transmitted without express written permission
from the publisher.
TYPES OF MEDICATION ORDERS
• Restricted medications
– Medication orders requiring approval by a specialty service (e.g.
Infectious Disease) prior to processing
– Some protocols also restrict which physicians or medical services can
place orders for certain medications (e.g. chemotherapeutic agents)
• Stop orders
– Orders limited to a certain amount of time (e.g., 7 days) after which a
new order is required to continue with the medication
MEDICATION ADMINISTRATION RECORD
Image copyright Perspective Press and Morton Publishing Company. May not be copied, re-used, reproduced, or re-transmitted without express written permission
from the publisher.
ORDER PROCESSING
• The technician fills the medication order once the
pharmacist has approved it.
• Many medications look similar and the same
medication may come in different sizes or forms.
– Be sure the correct medication, dose, and dosage
form is
being filled.
• Double check the strength, quantity, expiration
date, base solution, and volume (if applicable).
ORDER PROCESSING
• Missing doses
– Doses that should have been delivered to the
nursing unit but cannot be located
– This can be a challenge in hospitals
• There are several questions a technician
should ask before refilling a missing dose.
ORDER PROCESSING
• Can be manual
or automated.
• Often, it is a
combination
of both.
Image copyright Perspective Press and Morton Publishing Company. May not be copied, re-used, reproduced, or re-transmitted without express written permission
from the publisher.
ORDER PROCESSING
Manual
Automated
1. Medication order is written in patient
chart
2. Copy of medication order is removed
from chart
3. Order is picked up at nursing station or
faxed or tubed to the pharmacy
4. Medication order is entered into the
pharmacy computer system
5. Pharmacist reviews and verifies
medication order
6. Medication order is filled by a pharmacy
technician and checked by pharmacist
7. Patient-specific medication is manually
delivered or tubed to nursing unit
1. Physician or agent of the physician
enters medication order directly into
hospital computer system which
automatically communicates order to
the pharmacy
2. Pharmacist reviews and verifies
medication order
3. RN retrieves medication from point-of
use automated medication station
4. Pharmacy technician fills inventory as
medication supplies fall below par
INVENTORY CONTROL
• Inventory control responsibilities
– Order medications, store and maintain par levels,
check order invoices, and deal with drug recalls
and shortages
– Follow state and federal law when
dealing with controlled substances
•
Drug inventory is usually ordered
through a program that
communicates with the
distributor/wholesaler.
Image copyright Perspective Press and Morton Publishing Company. May not be copied, re-used, reproduced, or re-transmitted without express written permission
from the publisher.
INVENTORY MANAGEMENT
• Par
– Amount of drug product that should be kept on the
shelf
• Drug recall
– Voluntary or involuntary removal of a drug product by
the manufacturer
– Usually pertains only to a particular shipment or lot
number
• Emergency drug procurement
– Quickly obtaining a medication not currently in stock
when the drug is urgently needed
DRUGS REQUIRING REMS (RISK
EVALUATION AND MITIGATION
STRATEGY)
• Tracleer® (bosentan)
• Aranesp® (darbopoetin alfa)
• Tikosyn® (dofetilide)
• Epogen®/Procrit® (epoetin alffa)
• Botox/Botox Cosmetic®/(onabotulinumtoxin A)
• Thalomid® (thalidomide)
ORGANIZATION OF MEDICATIONS
• Alphabetical, using the generic drug name
• By route of administration
– e.g., intravenous, oral, ophthalmic, etc.
• Narcotics and other controlled substances are
often stored in a secure area of the pharmacy.
ORGANIZATION OF MEDICATIONS
• Many hospitals have a designated area for
compounding oral solutions and suspensions.
• If an oral medication is needed in liquid form
but is not available commercially, it may be
extemporaneously compounded.
COMPOUNDING
• Bulk compounding log
– Record of medications compounded in bulk
for non-specific patients
– Records all the ingredients, amounts used,
manufacturer, lot numbers, and expiration
dates of all ingredients used
• Reconstitute
– Adding water or other diluent to commercially
made drug bottles or vials to make a solution
or suspension from a pre-made powder form
of the drug
• Extemporaneous compounds
– Medications prepared following a specific
recipe or formula, usually because they are
commercially unavailable
Images copyright Perspective Press and Morton Publishing Company. May not be copied, re-used, reproduced, or re-transmitted without express written permission
from the publisher.
UNIT DOSE SYSTEM
• Unit dose
– Contains the amount of a drug required for one dose
– Eliminates need for nurses to withdraw medication from
large bulk bottles
– Decreases the chance of making an error
• Medication cart
– Has an individual drawer or tray for each patient on the nursing
unit
– Patient drawers are filled daily with the amount of
medication(s) required for 24 hours.
Image copyright Perspective Press and Morton Publishing Company. May not be copied, re-used, reproduced, or retransmitted without express written permission from the publisher.
UNIT DOSE PACKAGING
PACKAGING TYPE
USED FOR
plastic blister
tablets/capsules
foil blister
tablets/capsules
packet
powder
tube
ointment/cream
foil/plastic cup
oral liquid
cartridge
injection
vial
injection
ampule
injection
foil/plastic
suppository
IV syringe
injections
oral syringe
oral liquids
Image copyright Perspective Press and Morton Publishing Company. May not be copied, re-used, reproduced, or re-transmitted without express written permission
from the publisher.
CART FILLING
• Technicians play a large role in
manually filling medication carts.
• Some hospitals have cart filling
robots.
– Technicians fill and run the robot.
• Some nursing stations have
automated dispensing systems (ADS).
– Pharmacy technicians stock the ADS.
Image copyright Perspective Press and Morton Publishing Company. May not be copied, re-used, reproduced, or re-transmitted without express written permission
from the publisher.
UNIT DOSE SYSTEM
• Some hospital pharmacies may buy ready- to-use
unit-dose packages of medications.
• Other hospitals buy bulk bottles of medication and
use machines that automate unit dose packaging.


Oral liquids are drawn up in oral syringes
either manually or using a special machine.
Hospital pharmacies must keep
documentation logs of any medications they
package.
Image copyright Perspective Press and Morton Publishing Company. May not be copied, re-used, reproduced, or re-transmitted without express written permission
from the publisher.
STERILE PRODUCTS
• A large portion of hospital medications
are administered intravenously.
• Requires special training:
– Aseptic technique
– Correct drug, concentration, volume, base
solution
– Double checking calculations
– Single vs. multi-dose vials
– SVPs, LVPs, chemotherapy, TPN
Image copyright Perspective Press and Morton Publishing Company. May not be copied, re-used, reproduced, or re-transmitted without express written permission
from the publisher.
STERILE PRODUCTS – USEFUL TERMS
• Total parenteral nutrition (TPN)
– A type of large volume parenteral containing protein,
carbohydrates and essential nutrients given through an IV
line
• Epidural
– Sterile, preservative-free medication administered into a
patient’s epidural space (located near the spinal cord and
backbone)
• Short stability
– Medications that expire soon after preparation
(i.e., within 1–6 hours after preparation)
GENERAL HOSPITAL ISSUES
• Some conditions of employment that may not be
required in other pharmacy settings:
–
–
–
–
Physical exam and drug testing
Hospital-wide orientation
Probationary period
Annual/semiannual performance review
• Regulatory agencies that oversee hospital operations:
– The Joint Commission (TJC)
–
–
–
–
–
Centers for Medicare and Medicaid Services (CMS)
Department of Public Health (DPH)
State Board of Pharmacy (BOP)
United States Pharmacopoeia (USP)
Drug Enforcement Administration (DEA)
SAFETY
• Code Cart
– Cart with medications and equipment commonly used in
medical emergencies
• Universal precautions
– Practices and guidelines that reduce the probability of exposure to bloodborne pathogens
– Include the use of protective barriers (gloves, gowns, masks, and
protective eyewear)
• Material Safety Data Sheets (MSDS)
– Contain information for safe handling of harmful chemical substances or
drugs
• Sharps container
– A RED container designated for disposal of used needles or other items
that may cut or puncture the skin
Image copyright Perspective Press and Morton Publishing Company. May not be copied, re-used, reproduced, or re-transmitted without express written permission
from the publisher.
CALCULATIONS
• Hospital pharmacy technicians must perform
many calculations:
– Drawing up unit dose syringes
– Calculating flow rates / drip rates
– Determining time of subsequent doses
– Performing percent calculations
– Calculating the amount of drug and diluent
needed for SVPs, LVPs, and dilutions