Hospital Pharmacy Practice
HOSPITAL PHARMACY
denartment or service in a hospital under the direction of a qualified pharmacist where all
the medicines and related supplies are stocked, dispensed on prescription to in- and
Outpatients, supplied to the nursing units. manuractured in bulk, and injectable are
Hospitalp pharmacy is defined with reterence to a department or to service. It is a
prepared and sterilized.
Besides the primary functions mentiored above, a modern practice of hospital pharmacy
renders more and specia proressIOnai servIces. Tnese servIces include participation in
education programs ror paiches, urses and meaical proression, poISon control centre
activities, drug information centre, preparation ot patient drug use protiles. parenteral
nutrition programs. Communicating new product inlormation
research and dispensing or radiopharmaceulicals.
A pharmaceutical service in an institution has numerous components, the inost prominent
nospital personne.
being
1. The procurement, distribution, and control ot all pharmaceulicals used within the
facility
The evaluation and dissemination of comprehensive information about drugs and
their use to medical staft and patients.
Monitoring, evaluation and assurance ol the quality of drug use.
PAST, PRESENT AND FUTURE
Among varlous pharmacy Occupations. hospltal pharmac ist was the ist recognicu
ICpresentative ot the pharmacy profession. Hospital pharmacists were employed in tne
cany nospitals most of which had gardens for the cultivation of medicinal herbs. In 1>.
Tcsyivanla iospital appointed a hospital pharmacist alter which this prolessio
cecivea a protessional recognition. In 19405, American Society ol Hospilal Pnaracisis
was formed and the profession achieved a remarkable progress Futher greatest strides m
ne prolession were made when this sOciety initiated publishing ot ts ofical organ.
merlcan Journal of Hospital Pharmacy T oday this profession has been recognizcd
World over. Hospital Pharmacy
Hospital pharmacy in Pakistan
The institutional pharmacy practice, in Pakistan has not yet received
However, hospital pharmacists are rendering their services at district i
hospitals. Advanced private hospitals are realizing that phärmaceutical
capable off storing, handling, pricing
a
ntum jump.
level government
personnel are
and dispensing drugs and allied stances. As a
result, many hospitals. have retain the services of pharmacist. Practice and
he
bulk to ward
responsibilities of the hospital pharmacist inclade supply of medications
vices
ks and extemporaneous compounding. A first step in the uplift of pharma
project
in extent to Punjab province has been taken in 1999 under the pharmaceutical
a brief overview, the primary function of the project is to gain complete optimizat As
this
drug deployment with economic usage of resources. The scope and function o
project is
Specil services
Routine services
an
Participation in cducation, poison control activity, drug
information centre, research activity
Preparation of parenteral nutrition and radiopharmaceuticals
Dispensing of parenteral nutrition and radiopharmaceuticals
Preparation of patient drug use profiles
Stocking of drugs and allied substances
Dispensing to in- and out- Patients on prescription
Supply of the drugs to nursing station
Bulk manufacturing/compounding
Table 1:
Summary of routine and special services rendered by hospital pharmacy
. To establish pharmacy and therapeutics committee according to the guidelines.
2. To prepared hospital formulary by pharmacy and therapeutic committee. Each doctor
and prescriber shall adhere to hospital formulary.
3. Proper bierarchy will be established in pharmacy under the direction of a chief
pharmacist or director of pharmacy. Deputy chief pharmacist or deputy director will
accountable to chief pharmacist. Managers or senior pharmacist will report to deputy
chief pharmacist. Deputy manager or pharmacist will next in hierarchy line.
4. The chief pharmacist will act as director of pharmacy services and will be a member
of pharmacy and therapeutic committee, deputy chief pharmacist will look after the
drug information centre and training residents. The senior pharmacist will take care
of pharmacotherapy issues like therapeutic drug monitoring and other clinical
functions while the deputy manger will manage the satellite pharmacies.
o establish project directorate in order to establish, develop and monitor
establishment of pharmaceutical services in Punjab hospitals.
A project director (pharmacy) shall be appointed who will be the pharmacy graauai
wIth relevant experience particularly as hospital pharmacy with minimum or **
years and exposure or training from abroad in hospital pharmacy or
pharmacy and should be competent in all aspects of pharmacy services in genia
.The services of pharmacy students (preferably final year) could be utilizea
Similar tashion to the role a 'house job' student assists doctors. Vacant nous
posts could be converted and utilized for this project or a recent graduate Cou
appointed for this purpose.
.
job
d beHospital Pharmacy Practice
8. Integration of pnarmaceutical serVICes in clearly detined stages such as:
a. Stage I for formulation of pharmacy ana therapeutics committee and preparation
of Punjab Drug Formulary in the style or the British National Formulary.
b. Stage 2 for establishment of drug intormation centre and ward rounds.
c. Stage 3 for adverse drug reaction (ADR) monitoring.
d. Stage 4 for drug utilization evaluation (DUE) or Drug utilization review (DUR).
e. Stage 5 for the total parenteral nutrition (TPN) preparation.
9 Establishment of regional drug intormation and poison control centre.
These stages have been mentioned im igure . 1he implementation of this project will
uplift the pharmacy services at Punjab level and will be a motivation for authorities of
other provinces also to implement the same in rest of provinces.
Various Stages of Pharmaceutical Project
stages
T.PN.
D.u.E.
A.D.R. Drug Interactions
Drug Information Ward Round
& T Comm., Hosp. Formuary,
ouse Pharmacy
N ******:
orlation o
wuEo PatientA
PD
Dec. 2000
Jan
JMe
1998 Dec. 1999 jan.
(Courtesy of Pharmed Journal)
Figure 1:Stages of Pharmaceutical Projeet
Kecently, a model hospital pharmacy has been established in The Institute of Cnila
Health, Lahore that will offer more than thirty pharmaceutical services. One or ne
Services would be of drug information that will be operated round the clock thrOugna
elepnone. Kadiopharmaceutical services will also be provided from
aepartment. Successful provision of pharmaceutical services througn tns
pnarmacy would be basic to merit professional recognition at government ievci a
ne depth that lies within the grasp of hospital pharmaCists.
del
Advanced role of hospital pharmacists
pnamacy practice has been evolved from drug orientation to patient oncna
CDY a pharmacist is not only involved merely in stocking and dispensingoS
but
3Hospital Pharmacy
also provides other signiticant services for better patient care.
Pharmacists must now ready to recognize themselves as vital players in the health o
Care
am. acting such important capaciles as therapeutic experts, drug
specialists, nutritional service memoeTS, and pnarmacokinetic consultants
must share the responsibility Tor proviaing pharmaceutical care that results i
defined outcomes that imprve tne patients quality of life. The pharmaes eving
program, curriculum and working nabits of pharmacists must be modified t dlon
current and future needs and responsibilities of the profession. In this cOnnocet the
emphasis must be given To tneCinical pharmacy, biopharmaceutice
acokinetics, patient counseling, ereetve communication skills, drug interactior
achi
and
In this chapter information wII be given so as pnarmacists can assume their new role as
hospital pharmacists.
etc.
ROLES AND RESPONSIBILITIES OF HOSPITAL PHARMACY
A hospital pharmacist is a vital link in chain of health professions.dedicated to the care of
hospitalized patients. The role of a hospital pharmacist and the responsibilities of hospital
pharmacy department are parallel. The presence of hospital pharmacist in a hospital can
be beneficial for both, patjents and hospilal as well. A hospital pharmacist can counsel,
and educate the patient for a safe drug usage and on the other hand, by bulk
manufacturing and preparing parenteral solutions can reduce the cost of medication for
hospital. Following are the services of pharmacy department and that of the pharmacist:
Purchasing
The pharmacies of the governmental hospitals purchase drugs through Medical Store
Depot (MSD), a gOvernmental owned concern for the manufacture of drugs. Bidding
method is used for purchase of drugs that are not produced by MSD. Private institutions
purchase drugs and allied supplies from manufactures, from drug wholesaler, and when
emergency situation demands so, from retail pharmacy. Purchase from the pharmacy
retaii outlet is done in case of an earlier than predicted out-of-stock situation but is rare
and volunie of such purchase is very low. The purchase from the former two can be done
either by a direct purchase, through bids, or by a contract purchase system. The contract
purcnase reduces the cost. Details of all these purchase methods have been presented in
Chapter on purchasing and inventory control.
ne responsibilty and authority of purchase is assigned either to hospital's material
purenase departient, to its purchasing agent or to the pharmacist. In either case, except
when the pharmacist has purchasing authority, pharmacy requests the required items oa
special request form. This request form is sent to the purchase department or
pur castng agent. T he selection of brands and vendors is left to the discretion or tnc
purenasing agent. However, pharmacist furnishes specifications both as to quality and
sources for the purchase. which may or may not restrict the selection to the product of a
h
manufacturer. Under another system, the pharmacist's knowledge is utilized and thou
ticle
the agent accomplishes drug purchase yet pharmacist has empowered to reject any a
not complying with specifications. Under yet another system, the pharmacist 15
authorized to purchase drugs and related items while the payment is made througn
material purchase department. Hospital Pharınacy Practice
Purchasing is an important administrative function and now is simp ified by advancea
technology, such as computer-generated purchase orders.
Inventory control
Hospital pharmacies usually take periodic (e.g., quarterly, semi-annual or annual)
physical inventories to determine value of undispensed medications. To maintain the
proper inventory, the pharmacy's turnover rate can be determined. The turmover rate s
calculated as follows:
l urnover rate= Cost of goods in period /cost of inventory in hand
A 1ow turnover rate may indicate that inventory is to0 high, often associated wi
multiple stock location (e.g., satellite pharmacy)
Drug distribution
The drug distribution is the primary responsibility of a hospital pharmacy. Under this
activity, the drugs are distributed to nursing station for subsequent patients use either by
floor stock drug distribution or unit-dose distribution system.. The floor stock drug
distribution is a traditional drug distribution system and involves a separate storage area
in a secured area on each patient care floor. The floor stock may include many bulk
supplies of the medications carried out in the hospital pharmacy.
The unit dose distribution system has largely replaced the fioor stock system since this
system reduces medication errors. In unit dose distribution system, medications are
ordered, packaged, handled, administered and charged in multiples of single dose units
containing predetermined amount of drug sufficient for one regular dose. Besides
allowing pharmacists to review and dispense all medications, the unit dose helps to cut
pharmacy costs by eliminating fioor stock medication supplies and reusing certain doses.
Readers can find more detail about two distribution systems in the Chapter on Dispensing
to Inpatients. The intravenous admixture program is also carried out under this system.
Intravenous admixture program is preparation of patient-specific doses for unit-dose
system by. specially trained pharmacy personnel. Pharmacy personnel allow for
standardized dosing. labeling, and packaging. Centraliżed manufacturing allows bulk
preparation and minimizes waste. Typieal admixture areas minimize environmental
contamination by using laminar airflow hoods, which also protect manufacturing
personnel form exposure to potentially toxic products.
Manufacturing bulk and sterile
The in-house preparation of drugs in hospital pharmacy may be categorized into bulk
compounding, preparation of nonsterile drugs and sterile manufacturing. Under the bulk
compounding programs, commercially unavailable drugs or the modified drugs for
clinical or investigation purposes are formulated. The sterile manufacturing is used for
preparation of sterile topical solution, small volume injectables, and special sterile
products for clinical and investigation purposes, I/V admixtures, total parenterals and
cytotoxic drugs in the hospital pharmacy.
Manufacturing in hospital pharmacy enhances the prestige of pharmacist. A pharmaCist
under this program must nave the knowiedge to implement controls over process, budget
and quality. Maintenance ot the.equipments needed for such manufacturing is tne
responsibility of the pharmacist.
5Hospital Pharmacy
A
ar
Distribution of ancillary supplies
not o
1gnificant
involved merely in stocking and dispenSing or arugs out aIso provides other signiG
better patient care. The proVISiOn orneain-acessories or information
Under the evolved pharmacy practice o pauent orientation a pharmacist is.
regarding them to the patients 1s one of these specialized services.
Health accessories, also referred to as parapnarmaceuticals are used to improve
quality of lite and provide maximum physical independence. To render this tr
separate section can be establishea in pnarmacy. wnich may stock a wide variety e
health accessories. Under this service, ambulatory aids, bed aids, and bathroom saf
equipments, orthopedic braces and seif-test care Kits can be dispensed to the patients.
The distribution of ancillary service also encompasses the distribution of surgical
supplies such as surgical dressing, operation room Supplies and suture and ligatures.
services TOr
atet
Clinical function
The clinical functions of phamacy department in a hospital include:
Therapeutic consultation: Therapeutic consultation is the most important service provided
by the hospital pharmacist. Under this service, a hospital pharmacist can provides:
1. Therapeutic consultation of complex drug regimens tor acute care patients who are
typically receiving multiple drug therapy
2. Selecting a therapy regimen or parenteral nutrition formula,
3. Monitoring the pharmacokinetic aspects of any therapy, and
4. Assessing for drug interactions and monitoring for drug adverse effects.
Drug intormation: A drug intornation centre functions under hospital pharmacist and
provides the information internally to the medical staft, nursing staft and patients and
externally to the discharged patients from own institution as well as from other hospitals,
and to public who inquires. This centre is accessible by heath care professionals, both
within and outside the hospital. As it is a source of drug information, textbooks, journals,
and on-line computer information sources are needed.
Miscellaneous clinical functions: The other clinical functions are education programs tor
physicians, nurses, and other allied health personnel and for patients. Clinical pharmacy
practice also involves in the preparation of patient drug profiles, recording patient drug
history, advising physicians of possible drug-drug interactions and drug ettects on
clinical laboratory test results. It also encompasses the preparation of patient dirug use
review, colection of the pharmacy-patient data base, therapeutic monitoring, auditing o
therapeutic regimens, monitoring of specific adverse drug reactions to decrease their
nciaences, and management of chronic care patients. All these topicS nave Dcch
discussed in details in the next chapters.
Special functions
Under special tunctions of pharmacy department, included radiophamaceutical servIcCs
and drug research. Sometimes, sterile manufacturing is also included in special pnarnaey
functions.
Ine radio- or nuclear-pharmacy is a patient-oriented service involving the purchase,
preparalion, and quality control of radiopharmaceutical used for diagnosiS, therapy a
palliation.
6Hospital Pharmacy Practice
A large number ot privatee and Pakistan Atomic Energy Commissio
and clinics of the country are currently using radioisotopes for diagno
research purposes but perhaps none has radiopharmacist. Hospital pna artment The
potential to expand protessional services rendered by the pharmacy
Radiopharmacy practice is in its infancy in Pakistan particulariy and of course,
making the responsibilities and challenges of a pharmacist more excum
rewardin8
omic Energy Commission - owned hospitals
ng radioisotopes for diagnostic, therapeutic anda
Research function
A hospital pharmacy Is regarded as a contributing member of the health protessi
encourages ts practitioners towards greater participation in research.n
pharmaclSt possesses adequate education and training and thus can participate in rc
with full confidence. This research may be to improve the existing ther nduct
to formulate a new drug or to confim some aspects of drugs. A phartnap
pharmaceuticat research, can participate in, and support medical research orngna
the medlcal stan. 1he hospital pharmacist can use resources of pharmacy departtne
support a paricular medical research study. The details of medial research nave oeen
presented in Chapter on Pharmaceutical and Medical Research. In pharmaceuica
research a hospital pharmacist can act as the principal or co-investigator. n
pharmaceutical research pertains to packaging, distribution, manufacture, and Storage o
pharmaceutical preparations. There exists also the opportunity to develop new dua
forms, 1mprove exiting ones and to develop new and more accurate methods for
analyzing the final product.
Problem research may include the inquiry into the problems of pharmaceutical
administration, quality control, professional practice, and the sociological aspects of
patient care as related to the practice of the hospital pharmacy.
thus i
tal
earch
on,
conduct
Educational function
Because of unique educational background and special training, a pharmacist is may
involve in teaching courses in pharmaceutical mathematics and pharmacology to nursing
and other medical personnel.
Serving function for vital committees
The hospital pharmacist of today's hospital serves on such vital institutional committees
as
Pharmacy and Therapeutics Committee The pharmacy and therapeutics committee
oversees the use of medications in hospital. Working with the committee chairperson
(usually a physician), the pharmacy director sets the committee agenda. (Other pharmacy
staff - for instance, a clinical pharmacist- also may hold committee membership. The
committee determines which drugs should be carried on the hospital's formulary and also
looks after the use of investigational drugs and the handling of hazardous waste. The
committee oversees quality assurance and quality improvement activities, and reports on
medication incidents as well as adverse drug events.
The other institutional committees of which a pharmacist may hold membership include
infection control, research reView, antio1otics, planing, ambulatory and standardization
committees. Hospital Pharmacy
All of the above roles and functions of pharmacist are outiined in Figure 2,
Community relations
A hospital pharmacist may coordinate community outreach programs
and hypertension control and cholesterol screening. poison prevention awareetes
substance abuse prevention progams.
such as diabetes
tion awareness, and
Purchasing &
Formulary
Development Inveniory
Manu
facturing
Drug
Interaction
Sunveillance
Bulk
&
Sueril
Patient-Care
Audits
Safe Usc of
Medicalions
Dispensing to
Inpaticnts
harmacoeconomics
Pha
Dispensing to
Outpaticnts
Therapeutic
Drug Monitoring
Hospital
Pharmacy
Adverse Drg
Reaction
Dispensing of
Controlled
Substances
Dispensin8
during
off-hours
Drug Utilization
Revicw
Distribution of
Surgical Supplicy
Education
rma
ceutical o NucicarInfommabo
Medical
Distributio
of Health
Drug
Rescarcly Pharma-nlomation cocssories
Ccutical&Poison
Control Ccnic
Service
Figure 2: Over all Functions of Hospital Pharmacist/P harmacy
ROLE OF PHARMACISTS IN SMALL HOSPITALS
in smail hospital, remuneration for a pharmacist may be less but have a lot ofr lean
opportunities. His role is more diversified and along with all jobs mentioned beroreHospital Pharmacy
Practice
hospital pharmacist may also serve as an assistant to hospital administrator, purchasing
agent, supervisor of the central sterile supply room and in some instances as a laboratory
technologist. The pharmacist may also be asked to involved in controlling ot some
supporting services like dietary service, medical record, and some diagnostic services 5y
combining all these duties, a hospital pharmacist is within the financial reach ot every
hospital, iTespective of the size.
FUTURE ROLES
The ruture roles of pharmacists are further advanced and extended. hese roles
mentioned below are actually played by pharmacists in advanced coutries:
Nursing home-extended care facilities: The other titles of this service are nursing home,
extended care facility, long-term pharmacy practice or hospice service. Nursing home
facility Is designated, staffed and equipped for the accommodation of individuals who afe
not in need ot hospital care but require nursing care and related medical services which
are prescribed by or pertormed under the direction of a licensed medical professional to
provide such care. This is a program for palliative and supportive Services, Wnic
provides pnysical, psychological, social, and spiritual care for dying persons and their
families. A medically supervised interdisciplinary team of professionals including
pharmaciSt and volunteers provides the service. This service may be available in either
home or in an institutional setting
In this setting a pharmacist provide services including drug distribution system record
keeping, emergency drug supply, and audit system for controlled substances. A
pharmaciSt can also provide Just a consultation to the nursing home settings.
Residental care programs: The residential care program is also called home health care
and is provided by a team of healthcare including pharmacist, physician and nurse. This
care proVides equipment and services tor restoration or maintenance ot the maximal ieve
of comfort, function, and heaith of patients in their homes. Residential care program
concept is acceptable in advanced countries and is a cost-effective alternative of
hospitalization. Under this service, various services can be provided but the
pharmaceutical service offered is home infusion therapy. This program includes
administration of total parenteral nutrition, antimicrobial therapy, parenteral analgesic
therapy, home chemotherapy and hematopoietic growth façtorS. The role of pharmacist
will be initial patient assessments, pump selection, therapeutic drug monitoring, patient
education, parenteral product preparation.
Consultant pharmacy practice: A pharmacist can provide consultation for: (a)
development of a policy and procedure manual, (b) implementation of formulary system,
(c) therapeutic drug monitoring and clinical trials, (d) in-service education programs, and
(e) medication review.
MINIMUM STANDARDS FORA PHARMACY DEPARTMENT
For the provision of pharmaceutical services etectively, the pharmacy in an institution
must have the following standards:
Administration (Authority)
The pharmaceutical service is to be directed by a professionally trained registered
pharmacist. The director of pharmacy shall nave the same level of authority in theHospital Pharmacy
institution's administration structure as the direciors of other services have. Thed
will be responsibie lor the:
1. Setting of the short- and long-term goals of pharmacy in accordance with th
developments in health care and institutional goals.
2. Planning, scheduling and co-ordination for achieving the previously set goals
3. Supervising implementation of the plan tor achieving 8oals and routine activities
associated with it.
4. Assessing whether the goals and schedules are met.
5. Instituting of the corrective actions where necessary
r services have. "The director
he
new
tivities
Facilities
Lecation: For efficient working. a hospital pharmacy must be located in an area that
facilitates all its functions and the provision of services to the patients. It muşt be so
located that it can effectively be integrated with transportation systems.
Space: The space must be suitably availabie for ecquipments and must be adequate to
provide secure and environmentally controjled storage of drugs. A pharmacy must have a
private arca for pharmadist-patient consultations.
Equipments: Adequate cquipments must be available to provide environmental controlled
storage and to facilitate the professional and administrative functions of the pharmacy.
Drug information90urces The current drug information sources including
pharntaceutical jourmals, official as well as text bookS, and other referral literature must
be available.
MINT
Drug procurement, distribution and control
Within an institution, à pharmacy shall be responsible for the procurement, distribution,
and control of all the drugs and allied items to in-patients and when policy dictates so, to
the ambulatory patients. The development of policies and procedures governing these
functions shall be the responsibility of the hospital pharmacist. Various effective
procedures and policies are also the responsibility of a pharmacist.
Drug information
The phacmacy shall be responsible for (a) maintaintng of up-to-date drug information
resources and able to use them effectively, (b) provision of accurate and comprehensive
information to the medical staff regarding drugs used in institution, dosage torms,
packaging drug interaction etc., and (c) supplying adequate information particularily to
the out-patients about the drugs they received. As has been mentioned earlier, the
pharmacy will also serve as a centre for the drug information.
Assuring rational drug therapy
Hospital pharmacy shall be responsible for maximizing the rational drug therapy in an
institution by developing clear cut policies and procedures for assuring the qually
drug therapy. This can be achieved by
Colecthon ot sutticient imformation, maintaining and review of these informaton
ensure meaninghul and effective participation in patient careHospital Pharmacyy PracuctC.
situation)
2. Review of all physicians medical orders (expect in emergeny
IO1
appropriateness prior to the dispensing of the i verse drug reno
3. Developing a mechanism for reporting and review
4. Establishing a patient-care evaluation prograli
5. Developing and maintaining of hospital formulary y
actions.
Research in a health care institution may be categorized as pharmaceutical, inves opeia of
Resea rch
tional
Ciunicaresearch. The pharmaceutical research may no
packagin8, distribution, manufacture, quality control, age form, impro
pharmaceutical preparations. It may be developic hods for analyzing **
CXSnB ones and to develop new and more accurate metnous
product.
na
ystems,
ciologicai
operatonal research includes assessment of pharmaceutical s
P Sn pharmaceutical administration, pharmaceutical practice and socOB
aspects o1 patient care.
The clinical research is a collaborative study involving pharmacist (clinical), and tah medical
rL a eE absorption, disposition and excretion or drugs and their metabones.
nC nospltal pharmacist should conduct pharmaceutical and operational Sca
participate in, and support clinical research.
MINIMUM STANDARDS FOR PHARMACEUTICAL SERVICES
The following are the minimum standards required for the pharmaceutical services
offered from a hospital pharmacy
.A professionally competent and qualified pharmacist shall direct pharmaceutica
services.
2. Space, equipments, and supplies shall be provided for the professional and
administrative functions ot the pharmaceutical service as required tor promoting
patient safety.
3. The scope of the pharmaceutical services shall be consistent with the medication
needs of the patients as determined by the medical staff.
4. Written policies and procedures pertaming to arug distribution system shall be
developed.
Written policies and procedures pertaminE to Sate administration of drugs shall be
established.
6. The quality and appropriateness o Patiaeuca servIces shall be monitored and
evaluated and identified probiems are to be resolved.
ABILITIES REQUIRED OF HOSPITAL PHARMACISTS
The operation o P demonstrate this breadth of expertise. However, all hospital
rmacy department is divei e and no one pharmacist may possess or
have opportunity to demonStrate ns Dreadth of expertise
pharmacists must have develop the ability and competencv to carryout collectively the
following service functions:
EfTicient management of the departmentHospital Pharmacy
The efficiency of any service rendered from the hospital pharmacy will depend largelv o
the expert management and administrative procedures. The broad areas of managerial
responsibilities of pharmacy administrator include planning and coordinating profession
services, budgeting, inventory control, cost review, cost effectiveness, audit, maintenance
of records and preparation of reports. As a basis for these responsibilities, pharmacy
personnel must be thoroughly familiar with institution's functions, health care systems
hospital organization, staff and relationship with appropriate lines of communication.
Since the pharmacy activities are to be coordinated with medical, nursing and other
services and with the administrative elements of the hospital, the pharmacy administrator
must be able to coordinate and integrate all these professional services, No need to
mention that this coordination requires a written communication to the hospital staff
concerning pertinent pharmacy matters.
Administrator of the pharmacy is also accountable for the expenditure of funds on
various pharmaceutical services for patient care. He must be able to analyze and interpret
prescribing trends and the economic impact of new drug developments that must serve as
forecast of the future drug expenditure for budgeting purpose. For cost effectiveness,
pharmacy administrator must be able to maintain an adequate system of stock, inventory
control and able to control operational costs without comprom ising quality of services.
The pharmacy director is responsible for maintenance of-records of all pharmacy
operations as an administrative and legal requirement. The competencies required
regarding record keeping inckide drug purchases, data on prescriptions dispensed,
controlled drugs dispensed, and operational improvements. The computerized system
may allow more effective and eficient handling of pharmacy records and data. Pharmacy
personnel must also have a basic knowledge and understanding and be able to apply this
automated system to various pharmacy operations.
Assimilation and provision of drug information
A pharmacist's knowledge of drugs and their actions are fundamental to his contribtion
to healthcare. Updated information is needed for a pharmacist himself, to provide
information to the medical staff of institution and to the patients. Furthermore, the
pharmacy department is considered to be a primary source of information concerning
drugs. To accomplish this, pharmacy department must maintain appropriate informatjon
Sources and a mechanism for evaluating information and transmitting to the protessional
Staft and patients. A hospital pharmacist must have knowledge of all sources of
inrormation and be able to retrieve and evaluate the information. He must also be familiar
to use the computerized resources of information.
Product formulation and packaging programs
requenty a hospital pharmacist has to prepare formulations not available commerciany
nuravenous admixtures, total parenteral nutrition and radiopharmaceuticals. Inus a
adequate knowledge and understanding of the principles involved in the formulation
the above are needed. The formulation pharmacist must familiar with, IOr oru
pnarmaceuticals, the concepts of physicochemical, pharmaceutics, drug stao
pnarmacokinetics, microbiology, quality control and techniques of medicau
aaministration. For total parenteral nutrition and radiopharmaceuticals, the phara
must also understand pharmaceutical calculations, patient variables such as eleuroy
12balance and fluid balance, and such factors as personal hygiene,
and equipment performance. Additionally, the pharmacist mus on and other items
evaluate the cost of labor, raw materials, space, equipment depra
of fixed overhead.
Hospital Pharmacy Practic
ontrol
Development and conduct of patient-oriented services
services The overall that program of pharmaceutical services umbrellas a wideange Aisnensing. of clinica
Thes
services that may not directly relate to drug storage, distributo of the hospita
clinical serviceshave been mentioned under the clinical un f toxicology.
pharmacist. A hospital pharmacist must have adequate ki rovide all these
pathophysiology, therapeutics, clinical pharmacy, automation etc. P
services effectively.
Conduct and participation in educational activities
Educational activities may be directed, internally towards tne
hospital/clinical pharmacists, pharmacy supportive personnel, student nurses, dd* *
and patients and externally to public, patients and university's pharmacy studon
A nospital pharmacist must be able to plan well coordinated programs so a
meaningul education program can be tailored for individual needs.
Development and conduct of a quality assurance programs for pnarmaceu
services
medical staff,
The quality assurance of services offered and the products distributed through out an
institution and dispensed to patients from hospital pharmacy is its major responsib
hospital pharmacist must be able to monitor and evaluate the appropriateness ot all
pharmaceutical services to assure their quality and to affirm the patient benefits of all
services offered. He must also be capable of resolution of the identified problems.
Conduct and participation in research
Advancement in health care system is poSsible, due to research that causes it to continue
to grow. A pharmacist must have abilty to contribute his knowledge and potentials to
conduct pharmaceutical and operational research as a principal investigator and
participate in the clinical research as co0-Investigator. An institutional pharmacist may
also support any sort of medical research by providing information, helping in study
design, collecting appropriate data, interpretation ot data, statistical analysis, drawing of
some meaningful inference, and transmiing or tne results in an adequate manner.
Therapeutic drug monitoring and pharmacoKinetic evaluation are also the particular areas
where a pharmacist must be abie to contribute his capabilities.
Besides directly involvement in research, a pharmacist
structured research report
st be capable of writing a well-
13Hospital and Its Organization
HOSPTIAL
A hospital is an organ ization utilizing combinations of specialized scientific equipment
and functioning through qualified and trained personnel for restoration and maintenance
of good health. The hospital is also serves as medium through which the medical
professional staff pools their eftorts for the betterment of public health. In this instit ution
medical services are provided to patients for regaining health. The provision of medical
services is facilitated by the medical and associated technical staff of nurses, dieitians
etc. The character and extent of hospital services are adjusted continuously to keep
abreast of changes and advances
The patient is a focal point about which all the activittes ot a hospital revolve. This
patient may be an in-patient (cloistered within the hospital and occupy a bed for some
period) or an out-patient (utilizing the hospital facility by not occupying iis bed). The
extent of medical services is largely depends on the nature of the insutution. More
usualy, primary emphasis is placed on the care of in-patients. Recently. hospitals are
assuming more responsibility for preventive medicine programs for improvement of the
overall public health. Under this program, the scope of medical services has been
extended from the care af in-patient, to the potentially sick person in his normal living
situation.
medical sCience.
An additional point regarding hospitals is that it iš a working environment for hospital
pharmacist. The objective of this chapter is to familiarize the pharmacists who want to
adopt hospital pharmacy as a career so as they will not feel its environment strange
CLASSIFICATION OF HOSPITALS
1ospitals may be classified in number of ways. However, ît is worthy to note that a singe
nseirution may fall into more than one grouping. The following is a general classitica
of hospitals.
Based on services
General hospitals
Speciality
2.1
2
Medicine
Internal Medicine
Psychiatric and nervous diseases
Tuberculosis
Communicable disease
PediatricsHospital Pharmacy
2.2
Surgery
Orthopedic
Gynecologic
Otolaryngologie
Cardiology
Maternity
2.3
Based on ownership and control
.1
Governmental
Armed forces (Naval, Combined Military Hospitals etc)
Federal Governmental Hospitals
Provincial Hospitals (Head Quarter Hospitais, Social Security
Hospitals, Civil Dispensary, Rural dispensary, Basic health
units etc.)
Teaching hospitals
Non-governmental
Private for profit
Private charity
3.3
3.4
A teaching hospital provides clinical instruction to medical college students. In these
hospitals, a medical graduate undergoes one year of compulsory hospital training as
house job. Some non-governmmental hospitals also maintain intern and residency programs for the training of the medical graduates in various specialties. After graduation,
most of the physicians look for positions in teaching hospitals because these institutions
offer further educational opportunities and broad experiences in clinical care of the
patients.
Numerically, about 15 teaching hospitals of country can care for a little of total
hospitalized patients in country However, Since teaching hospitals act as referral centers
for the more seriously ill patients, third party payers give more preference for
reimbursement to these hospitals than private institutions. Furthermore, due to economy
of services provided, mass seeks treatment from these institutions.
Ideally, a teaching hospital should support educational and research programs but the
National teaching hospitals have no or veTy ntie research programs yet in real sense.
ORGANIZATIONAL PATTERN
Only the general view of the compleX organizational structure of hospital will be
presented here in' this text. The organizational patterm of a hospital resembles with that of
pharmaceutical industries. The only aierence Is o positions and titles assigned in
hospitals.
Figure 1, 2 and 3 illustrate thee organizational patterns tor government teaching, private
and military hospitals, respectIvely. Ine Smalier the hospital the fewer the administrative
positions of associate or assistant drctO nd conversely, the large institutions may
further subdivide the general areas o cinicar unns under the aegis of assistant directors.
The board of trustee is standard tor all private hospitals.
MANAGEMENT
The government, military and private hospitals have different management systems. A
15Hospital & ts Organization
medical superintendent who IS appoinc oylsuyo nealth manages the former
military hospital is managed Dy commanang ocer. while a private hospita
an organized goveming body which ls respons1Ole for the conduct of t
consistent with its objective oaking avanaoie ngn quality patient care. The
g officer. While a private hospital usually has
body which 1s responsioie r ne conauct or the hospital in a
total number of members in BOVemng DOuy w vary trom nospital to hospital.
The partnership of some hosplais may cOnsist a large number of people from
scattered areas, a representative group iroOm witnin tne membership, is elected for a hos
of trustees. This group is also kngwn as the goveming board, board of governors
of managers or board ot directors. ueneraly ue Tepresentauves are selected for their
ability to contribute to its effective management.
As part of the organizational process, tne govermng Dooy lects its otficers one of which
acts as chief executive and causes to appoint a wue variey or committees necessary for
the discharge of its duties. I nese may ncude an Executive Committee, Building
Committee, Investment and Finance Commitee and a Joint Conference Committee.
The goverming body iS responsible for defining of the
. Powers and duties of the governin8 DOay omcers, commitees and chief executive
board
board
ficer
2. Qualifications for goverming body membership.
3. Method of selection for membership.
4. Tenure.
5. Committees -kinds, app0intment and membership tenure
6. Evaluation of performance or employees.
ADMINISTRATION
The board of trustee of a hospital delegates hospital's active management to an
administrator and his statf of associates, assistanfs, supervisors and departmental heads.
The administrator of a hospital is responsible for operation of the entire institution,
2ssuring institutional staffs and patients of highest possible standards of services and
econony by planning, directing, and coordination of the activities. Thus the future of an
institution depends on the capabilities of its administrator.
The administrator of a hospital is described as specialist in administration and must
specially be qualified and trained for his position. Usually an administrator holds the
degree of Master of Hospital Administration. However, qualified individuals holding
other degrees can also be appointed as administrator.
The main functions of the administrator are to:
. Enforce trustee policy in the daily management.
2. Establish organizational structure to carry out programs of the hospital and to nece
needs of the to patients.
.mplement the governing body's policy on the financial management of the hospita.
4. Devel0p and implement a comprehensive management reporting system througnou
the hospital
. Provide, maintain, and safeguard appropriate physical resources in the instuu
6. Look at the weakness influencing any aspect of institution.
MEDICAL STAFF
Medical staft is the group of individuals who are fully licensed to practice mealcuc
18
orHospital Pharmacy
De
denustry Ihe medical staff is the backbone of any healthcare institution, tnus
Ver we Organized and controlled so as can perform at an optimal level or pro
pertomlance. I he organized medical staff is accountable to the hospital goveming
and has Overall responsibility for qualicy of medical care, profess1o nal serv P
and the ethical conduct in the hospital.
he structure ot medical staff will vary from hospital to hospital due to varying8 SiZ ad
activities of the hospital and its staff. However, typically, this staff may be diVided ino
varous Caregories. The active medical staff is at the forefront of health provISIon and
aehvers dominantly the medical service. Most of members of this staft are involved n
the organizational and administrative duties pertaining to the medical statt.
The assoCiate medical staff functions for the advancement to the active medical stalt.
Whereas the courtesy medical staff consists of practitioners given rnghts to admit an
Occasional patient to a hospital. The consulting medical staff comprised of medical
practitioners of recognized professional abilities but are not members ot the precealng
categories.
ed
The honorary medical staff consists of former stafi members, retired or emeritus, and or
other practitioners whom the medical staff chooses to honor.
DEPARTMENTALIZATION
Departnentalization is the grouping of various sections and divisions according to the
same nature of services provided. The degree of departmentalization of the hospital
depends entirely upon the extent of specialization of the staff. Typically, the department
categories mentioned in proceeding sections can be observed in a hospita.
CLINICAL DEPARTMENTS
The extent of departmentalızation of clinical services in a hospital depends upon the
degree of specialization of the medrcal statt. in small hospitals, only two departments medicine and surgery will provide all the clinical services. Other significant services may
either offered on a limited basis or sought extemally trom the outside facility. Supportive
services such as radiology and pathology are usually acquired externally. In a large
hospital, hospital staff is highly specialized and therefore there are greater subdivisions
within a clinical department. Cinical department is broadly divided into medicine and
surgery
Generally, the department of medicine includes the following subdivisions:
Internal Medicine Allergy
Cardiology
Infectious Diseases
Endocrinology
Immunolo8y
Nephrology
Psychiatryy
Rheumatology
Gastroenterology
DermatologY
Geriatrics
Pediatrics
Neurology
Pulmonary Diseases
The department of surgery is generally divided-into the following
General Surgery
Neurologic Surgery
Ophthalmology
Orthopedic Surgery
Obstetrics & Gynecology
Dental & Oral Surgery
9Hospital & Its Organization
Otolaryngology
Urology
Plastic surgery
Thoracic Surgery
Proctology
oucn suddivisions, can be observed in a teaching hospital. Each or these subdivisions
usually has a chief-of-service whọ in turn, is responsible to the deparmental chief, In
adnons, the medical staff is otganized in such a manner as to proviae lair representation
OCacn individual on the staff through to the administration and the goveming body.
SUPPORT SERVICESs
ne runctioning of clinical department is facilitated by supportive or non clinical
Services. The supportive services inciudę pharmacy department, nursing department,
cay Service, laboratory service, medical records department, blood bank, central
STeriie supply, social service department, biomedical department (for clinical
instrumentation), maintenance and engineering divisIOn.
Pharmacy department
The pharmacy depatment is staffed with pharmacists and is supervised by director of
pnarmacy or pharmacist-in-chief. This department offers the foliowing services:
. Drug distribution, including floor-stock and unit dose distribution
2. Dispensing of drugs to out-patients
3. The intravenous admixture program
4. The clinical services provided from the hospital pharmacy may. include therapeutic
consultation, drug information, for physicians, nurses, and other allied health
personnel and for patients. Clinical pharmacy practice also encompasses preparation
of patient drug profiles, recording patient drug history, advising physicians of
possible drug-drug interactions and drug effects on clinical laboratory test results. It
also involves preparation of patient drug use review, collection of the pharmacypatient data base, therapeutic monitoring, and auditing of therapeutic regimens,
monitoring of specific adverse drug reactions to decrease their incidences, and
management of chronic care patients.
5. Purchasing and inventory control of drugs and allied items.
Conduct and support of pharmaceutical and clinical research, respectively.
Education service for pharmacy personnel, medical profession, nursing staff and for
patients
8. Serving funetion for vital committees such as pharmacy and therapeutics committee,
infection control, research review, antibiotics, ambulatory and standardization
committees.
Special services may include the provision of radiopharmaceutical services, total
parenteral preparation, central sterile servIce and p0Ison control centre.
Pharmacy's role in the hospital
The pharmacy department is one of the many departments of a hospital that exerts a grea
deal of influence on professional position of the institution as well as upon its economics
of the total operational costs. It is all due to its inter-relation with and the inter
dependency of other services upon it.
20n
Hospital Pharmacy
In a nospital setting. the doctor diagnoses and prescribes. the pharmaciSt dispenses tne
medication and the nurse administers the drugs to the patient (unless the patient is on a
self-medication regimen).
Cleariy tnen, the pharmacist who practices his profession in an institutional environment
must e a ware or the torces operating around him. and he must learn not only to
understand tnem, but to assist marshalling them towards the ultimate goal of better
patient care.
n
n a teaching hospital a hospital pharmacist has innumerable opportunities to participate
in and to develop educational programs for pharmacy, medical, nursing staff and for
patients.
Nursing service
Nurse is an individual who attends. helps. teaches. counsels and takes care of the patients.
particularly who acquire beds in hospital. Nursing care is an integral part of total healtn
care system and necessary tor regaining and maintaining health. A nursing team is made
up or workers with vary ing degrees of nursing skill and' directed by a professional nurse.
Helping the patients to help themselves is a new element of nursing practice. his IS
because encouraging selfcare by the patient helps to an early recovery. Another element
is diversification and specialization of nursing individuals. Now a nurse may be
specialized in oncology, blood bank, night nursing care, floor nursing care etc
Nursing is a noble job and a nurse must respect individuality, dignity, and rights of every
patient, regardless of race, color, national origin, and social or economic status
The nursing service is organized similarly to other service in the hospital and is headed
by Director of Nursing with administrative authority. The director of nursing must be an
experienced nurse with administrative talent.
As an administrative staft, the director nursing participRates in 1ormulating policies and
devising procedures required tor achievement of objectives. and in developing and
appraisal of the quality of nursing services. In some institutions, the director of nursing
service is also responsible for administration and operation of the school of nursing.
Dietetic services
Dietetic service is one of the essential services in an institution. It is statfed by adequate
humbers of dietitians, technical and clerical personnel and is directed by a person with
proressional qualifications in nutrition. This is responsible for preparation of palatable
and appropriate food by applying eftectively the principles of nutrition science. In
Taistan, only establishments of larger private hospitals have instituted this service.
The dietetic service, if existed is responsible tor:
Furchasing, planning and preparation of menus for both patients and employees.
Kecording of dietary histories of patients such as those unable to accept a limited diet
regimen.
nterviewing patients regarding their food habits,
Ounseling patients and their families concerning normal or modified tood regimens.
lCOuraging patients to participate in planning their Own normal or modified
regimens.
.
Partic pate In appropriate ward rounds., research activiies and conterences.
6.
21Hospital & ts Organization
Medical records department
Patient record keeping is the responsioity or medical records department of t
This department is staffed by technicay skilied personnel and is headed
qualified individual. Every hospital is required oy law to maintain adequate medit
ords of their patients.
The purpOses of the medical record are to:
. Serve as a basis for planning and ror continuity of patient care.
Provide a means of communication among the physician and professionals
contributing to the patient's care.
Furnish documentary evidence Tor course or a patients illness and treatment during
each hospital stay
4. Serve as a basis for review, study ad evaluation of the care rendered to the patient
5. Assist in protecting the legal interest or the patient, hospital and responsible
practitioner
6. Provide data for use in retrospective research, education and for legal issues.
rec
A sufficiently detailed medical record includes:
(a) Identification of patient.
(b) Patient's sociological data.
(c) Personal family history.
(d) History of present ilness.
(e) Physical examination.
(1) Special examination such as consultations, clinical laboratory data, X-ray etc.
(g) Provision of working diagnoSis.
(h) Medical or surgical treatment.
(0) Gross and microscopic pathological findings.
) Progress notes.
(k) Final diagnosis.
() Conditions on discharge.
(m) Follow-up.
(n) Autopsy findings in case of the death of patient.
Parts of Medical Record
Admission sheet: This sheet generally is used for placing of the patient identification
data. It contains unit record number. patient's name, address. sex, age, marital status,
nome telephone number. name and address of referring physician, admission diagnosis,
aate and time of admission, and destination within the hospital. Admission sheet aib
aacnes consent forms for authorization for medical or surgical treatment, release
nformation to other physicians and for release of information to re imbursing authorny
any.
Admission_ history sheet: On the admission history sheet generally recoraed
the
intormant s name, name of individual taking the history, patient's chief complaints
and a
description of present illness. A provisional or admitting diagnosis is also mentioncu
on i
which is usually made on every patient at the time of admission. It also inciud ast e
liness, with their subsequent diagnosis, operations and major injuries experienccu ent
patients. 1mmunization, histories of transfusion, reactions and complications,
currentHospital PharmacCy
medications, diet, height, weight, occupational history, health ot spouse, in case of female
patients the pregnancies, their outcomes and complications and tamily history.
Physical examination sheet: Physical examinatton Sneet consists of a routine systematic
review of skin. head and neck. breast gastrointestnal. genitalla. Iymph nodes, muscular
skeletal and extremities and allergy. This information helps the physician to proceeds for
a suggested treatment program on medical recora to be roliowed during hospitalization of
the patient.
Laboratory sheet: The laboratory sheets are entered into the patient's medical record after
each laboratory test during patient s hospitallzatton. Inis inciudes reports on preprinted
forms obtained from chemistry, hemato10gy, micTOoIOToBy Serology. pathology as well
as radiology. Some reports, instead o recoralng are directiy pasted as original on to the
medical records.
Medical record sheet: The medical record sheet provides the space for recording of all
treatment procedures pertormed upon the patient. It also includes the operative notes
containing description of findings detailed account ot techniques used and tissue
removed. Progress notes are made in the medical record tor the purpose of providing the
physician with a chronological picture and analysis ot the clinical course of the patient. A
definitive final diagnosis can also be entered in the same sheet of patient s medical record
after the completion of all of the diagnostiC procedures.
Discharge Summary shee!: Upon discharge trom the hospital, a discharge summary sheet
IS entered into the patient s medical record as an outlines of patient's hospitalization. This
sheet contains a briet history. results of the physical examination, laboratory data,
description of patient's hospital course, diagnosis, operation performed, complications
disposition. present condition, medications_prescribed during and after hospitalization
and an estimated length of disability if any.
AUtOpsy sheet: The autopsy report sheet is included if the patient dies during
hospitalization. This contains complete protocol of the lindings resulted from the
autopsy
A Complete and ideal medical record has the following features:
ACCurately doCumented s0 as an effective patient care can be provided at anotner
time.
Readily accessible as this will facilitate the easy consultation with other physiclans
and enable an emergency treatment.
Easily used for retrieving and compiling information.. This helps in the retrospectvc
data analysis etc.
5.
g al Signilicant and detailed clinical information to enable an ece
CO ng care to patient in the same institution at another time, another practitOne
the
au dssume the care of patient at any time and a consultant can give opmon a
examination of medical record of the patient.
Pathology services
Ihe department of pathology services has personnel who are aac
Aeenced in laboratory work. This department is supervised by a qualitied physican
with training in pathology and is able to assume pio ection, clinical 1a0.
administrative responsibility for the services rendered. The cytologic sect
mical chemistry, microbiology, clinical microscopy, hematology, seroloey ad
s
he
2.3Hospital & lts Organization
section for drug analysis in blood sampies may b ne subaivisions of a patholouy
athology
department. In some institutions, blood bank 15 aiso included under the path
VIces.
Most hospitals operate their own blood bank because or tne essential nature of blood
therapeutic agent and to get ensured quality. In some nospitals. this service is operated
independently while in other. it function as a subsection or pathology department because
of its laboratory-like operation. It operating inaependenty tnis department is staffed by
hematology technicians and supervised by a hCensed py sic lan having basic interest in
hematology.
Blood bank
s
ause
Radiology
The department of radiology is a vital department for the diagnostic application of radiant
energy particularly in the form of x-rays. 1his department is under the supervision of a
qualified physician who has also obtained an adequate training and experience in general
radiology. An adequate number of radiology technologists are staffed to provide services
from this department. This service is provided oniy ater a written direction from an
entitled physician.
Nuclear medicinę
Nuclear medicine department is an integral part of an institution which proVides oncology
service. The services of this department include the use of radiopharmaceuticals for thhe
diagnosis. palliation and treatment. This department is staffed with physician with
specialization of nuclear medicine. hcalth /medical physiCist, nuclear pharmacist,
technologists, and oncology nurse.
Radiotherapy department
X
The radiotherapy department generally consists of physicians who are trained as
radiotherapist. medical physicists, radiation technologists, radiopharmacist, nurses, and
secretarial personnel. A physician adequate ly trained and experienced in general radiation
principles supervise this department. The services provided from the radiotherapy
department are performed only on the written order of medical staff member who has
been entitled to direct for such services.
Radiation department provides the therapeutic services of the radioactive radiant energy
Tor the treatiment of tumors and carcinomas. An appropriate dose is calculated tor
irradiation of the patient with isotope. particularly cobalt-60. Recently brachytherapy has
been introdiced in which a radioactive source is inserted with incision in the tumor or
carcinoma for a calculated period of time to treat them. For this purpose, cessium-i5
and I192 (Cs or Cs)is used.
Diagnostic services
Kadioiog (N-ray ). Computerized tomography. (CT). ultrasound, nuclear magnet
resonance and radio1sotpicC imaging are the diagnostic serVices otfered in a
institution. Dare to lheir different basic principles, techniques and obviously skilled. an
these can not be grouped under one department.
24Hospital Pharmacy
Apharmacist would be interested to know something about these services. CT can
detines the precise location and limits of a clot. tumor and other anlments h py
imaging technique with the help of computerized slicing of acquired mage,
ultrasound are the diagnostic modalities based on the use of x-rays and ultrasouna.
y Nuclear magnetic resonance provides there-dimensional image data sets
nd
providing precise anatomical displays based on proton density
Medical social service department
he medical social service department is an important relationship betwcen the hosptal
and the palient and his community. This department has a professional focus on the soctat
aspects ot the patient and patient's family. Social service personnel generaly prOv
information relating to medical social study of appropriate patients. social therapy n
rehabilitation of patients. home environmental investigations for attending phy sician
cooperative activities with community agencies. monitory helping patient. social service
summaries and follow up reports of discharged patients. confirming disposition. wn
obtained.
Anesthesia service
A trained physician who is a medical stafl member directs the anesthesia service ot a
hospital. The director of anesthesia service is responsible for quality of anesthesia care in
Surgical and obstetrical areas and availability of equipment necessary for administering
anesthesia and for related resuscitative eflects. The other duties of the head of anesthesia
service are the development of regulations concerning anesthetic safety and retrospective
evaluation of all anesthesia care.
Anesthesia care is usually provided by anesthesiologists. other qualified physician
anesthetist. qualified nurse anesthetist, or appropriately supervised trainees in an
approved educational progranm. The nurse anesthetists can employ general anesthesia
under a supervision of the departmental director or his designee.
XMaterial management department
A department having operational responsibility over purchase. receiving. inventories
print shop. central sterile supply. laundry. distribution, messenger service. trallic and
disposal activities. An individual with training and abilities supervise this department
The other duties of this department are:
I.Issuance of purchase orders.
2. Maintenance of purchase records.
3. Follows-up on delayed orders.
4. Initiates competitive bidding procedures.
5. Obtains quotations from specified sources.
yBiomedical engineering department
The biomedical engineering department is under the control of a qualified biomedical,
electrical or electronic engineer. For functioning of this department, an adequate nunmber
of engineers in the fields of biomedical clectrical. electronics and mechanical and well
trained technicians are required. The basic responsibility of this department is to keep all
clinical and laboratory instruments working.
25Hospital & Its Organization
SHAREl
Central sterile service department
The central sterile service department prOvIdes prOressiona Supplies and equipments
sterile and non-sterile. to all specialized departments. 1 he special departments that
served through this division are nursing statrons, Cinics and the operating rooms.
department practices total decontamidtoad S pOSSOnal support and service for
improved patient care by maintaining high processing standards.
The sterile supply may include the re-usadie and disposable materials. In addition t
dispensing these materials, central steresuppiy room may also be involved in the
cleaning, storage and dispensing or spectallzcu cyupmens such as suction pumps, car
diac catheters: monitoring equipment, Surgical aressing carts, resuscitation carts, and a
myriad of special kits and trays.
In some institutions. procurement, storage and astribution of supplies as well as the
preparation of various sterile soutionsS are under pnarmacist s management. In others,
nurses are for the operation or central Sterie suPpiy room. In a third option, the central
sterile supply room is under dual control or pnarmacist and nurse. The functions of
cleaning. packaging and distribution oI medical equipment and supplies as well as the
manufacture of sterile fluids are under pharmacist. I he nurse is responsible tor the former
and a pharmacist is responsible for the later operation.
The central sterile supply room 1s, in many nosptals, consIdered as a sub-department and
operated under control or operating room superVIsor or nursing service. Under this type
of organization, the director, supervisor or manager ot the unit does not report to the
administrator or his assistant but to some major department head. In some hospitals,
central sterile service is included, along with operating rooms, recovery rooms and
ntensive surgical care unit, under a divISIon of surgical care. The surgical care division is
section of the general nursing service. In still-other hospitals, the manufacture of sterile
injectable or irrigating solutions is from the central sterile supply room and this "solution
room is placed within the administrative scope of the pharmacist. Under this
arrangement, the pharmacist reports directly to the administrator or to one of his
assistants.
ents,
are
This
In proceeding Chapters, the students will be provided with a greater insight about this
department.
Finance/account department
I hough a pharmaciSt may believe that finance is a subject which does not concern nim o
nis department. In reality, the finances of the hospital affect every patient, employee, Stai
member, trustee and the community at large. The finance department is startea o
accountants and financial personnel and a well trained and qualified indiviaua
Supervisors. This department is responsible for the financing of all operations o
hospital and delivery of salaries to the institutíonal employees. The folloWIng is a d
resume oT the sources from which income may be derived to meet operating eXpense
Tne primary source of revenue is derived from the billing of patients for service
renaered, A patient receiving such a statement usually pays it in full by himselt. Ano
ouc O payment is reimbursement from third party coverage system whereby emp
Or the patlent pays patient' s bill in full-or pay a specified portion and remas
patient.
om
26Hospital Pharnmacy
SHARED SERVICES
Sharing of services olrers a vidbie opllon to any organization in providing high uality
technical services In a very cost erective manner. Such services include both
administrative and clinical activities. Shared servIces of an administrative nature are
support services not invoiving the delivery ol direct patient care and are not normally
revenue producing. These services are easier to develop than clinical shared services
programs because they do not directly involve the medical staff. have less external
elements. and often can be implemented easıly.
Clinical shared services involve delivery of direct patient care services or research on .
clinical aspects of drugs. Shared services enabies an institute to protect present and future
assets, develop and safeguard a wide variety of new sourcès of revenue. attract additional
funds through charity, and to raise venture apd .cquity capital through cooperative
ventures. 3
Pharmacy and Its Organization
Pharmacy organization encompasses erective departmentalization, staffing, controlling
and coordinating personnel to achieve pnarmaceutical practice of optimum level. As has
been mentioned before, departmentalization is subaiVISIon of allied activities in particular
grouping so as to accomplish objective eftiCientiy after delegation of responsibilities to
each section. Stafting is the determination or number of personnel, hiring, maintenance,
and job description and delegation of responsibilities to each and every member. The
controlling and coordination ol personnel means motivating of the staff members and
harmonization of their activities to achieve predefined objectives.
Though drug dispensing is a vital responsibility yet currently it is not the only function of
the pharmacist. The pharmacists are assuming important new roles such as clinical
pharmacist. drug information specialist and drug consultant etc. Healthcare is a dynamic
system and adopts new devices. techniques and modalities in practice of medicine and
surgery, hospital operations and particularly drug manufacture. This has led to greater
demand for pharmacy. remarkable improvements in the provision of pharmaceutical
Services and has broadened its scope. Broadened scope of pharmaceutical services
obviously demands more manpower and dictates for the hospital pharmacist multifarious
roles to play.
A hospital pharmacist would be able to direct more of attention to professional tasks only
if he is freed from performing routine non-judgement-based tasks. These routine tasks
can be delegated with supervision- to trained supportive personnel. by this way a hospiral
pharmacist can make maximum use of unique body of knowledge for developing
pharmaceutical services yet undefined and unrealized in the institutional setting A
modern pharmacy department provides manifold services thus requiring a diversified
pharmacy statf.
PHARMACY ORGANIZATIOON
STAFFING
The pharmacy staff includes the professional as well as supportive personnel as wc d
1ay personnel.
PROFESSIONAL PERSONNEL
Larger hospitals require a diversified professional pharmacy staff including ciinca
pharmacist. drug intormation specialist and pharmacists skilled in other specialtiesHospital Pharmacy
harmacy specialists
elinical pharmacists are spectaltZed m the sub-medical or pharmaceutical sn
such as chiatry, geriatrics, oncology, hucicat ncutcnc and Pediatrics and admixturing
service pnarmacists.
Drug inlormation specialists
information specialists provIae mrOratron egarang drugs to pharmacy. medical
nursing staff and as welt as to patents. Sonme major private and government.
ana
cnitals are already using pnarmacisis as consuitants on drug therapy. A drug
in formation pharmacist serves ds source o arug data ror physicians and may particin
in ward rounds with the stat, proviang valuadie arug intormation on both old and
drug products. Though. presCription is not pharmacists sphere, yet a pharmacist may
enable physicians to prescribe by Keeping up more effectively with drug information. In
ipate
new
come hospitals. this role ot pharmacist nas hot been recognized, but the pharmacists in
these institutions are competent to do so
Job description and responsibilities
Job description is the performance and responsibilities required for patient care. It
depends on the activities of the pharmacy department. ypically, responsibility of a
hospital pharmacist include the following:
1. Planning. organizing, and directing pharmacy policies and procedures in accordance
with established policies of hospital
2. Implementation of decisions of pharmacy and therapeutics committee.
3. Compounding and dispensing ot drugs, narcotic and controlled substances according
to prescriptions.
Developing and implementation a control over requisitioning and dispensing of
drugs and pharmaceutical supplies.
Filling and labeling of all drug containers ISsued to services and indicates the
direction for use on the containers for patients.
6. Preparation and sterilization of injectables medication manufactured in hospital. and
manutacturing pharmaceuticals.
Maintenance of a perpetual inventory of drugs. narcotic and other controlled drugs.
8. Inspection of all pharmaceutical supplies on all services.
9. Maintenance of an approved stock of antidotes and other emergency drugs.
T0. Formulating specification for purchase of all drugs, chemical, and biologicals used in
hospital.
.Establishment and maintenance. in cooperation with accounting department, ot a
System of records and bookkeeping in accordance with policies of hospital 0r
charges to patients.
Freparation of periodic reports on progress of department.
suring accuracy in use of pharmaceutical equipments tor compounding and
3.
dispensing of drugs.
Follows prescription in details for any drug interaction or tor any error (cncu
4
prescription intervention)
rurnishing information concerning medications to physicians, nurses and to patients.
" C0operation in teaching courses to nursing and medical students. Pharmacy & Its Organization
3
17. Carrying out, participatto and stupporting research.
18. Performs any fessional related duties assigned other than th0se mentioned here
DETERMINATION OF PROFESsiONAL STAFF
There are no standard rules ror tne stattng of a hOspital pharmacy
in this text. Varied pharmaceutical services provided in different de quoted
requiring different average me cxpendture and non-measurable workload make vities it
here
difficult to give a precise Tormua tor start determination. The number o
employees can effectively be determined by following considerations professional
1. Scope and-range of services rendered.
2. Workload (number of in- and out patients served per day).
3. Spectrum of duties that can be assigned to pharmacy technicians.
Following are different approaches used for the determination of employees:
Performance evaluation review technique
To accomplish the personnel requirements, it is suggested to diagram the department's
major activities to represent its over-all functions. Based on activities diagram, a flow
process chart for each activity IS prepared. Inis Is caied pertormance evaluation review
technique (PERT)) This enables to evaluate the time and motion involved in the
performance of each job. The PERT can be successtully employed in the determination
of the average time and motion required tor dispensing ot a non compounded and
compounded prescription, dispensing and supply of pre-packaged medication, clinical
pharmacy activities etc. A simplified diagrammatic representation of activity chart for
dispensing is presented in Figure 1.
PERT requires for each activity, determination of purpose, significance. place of
performance. times. and perfomed by whom and how the activity will be accomplished.
Here, judgement and non judgement jobs can be differentiated and an inference for the
number of personnel required can be drawn. PERT and the above details involved in
performance of a particular job streamline the tasks so as to require a minimal inputs of
employees and their time, motion, and energy for maximal productivity.
As a result of the preparation of flow charts, and PERT, a pharmacist is in a better
position to visualize the volume of and time required for a particular activity and number
of personnel necessary to carry it. In a time and motion study, a pharmacist must provide
time for non-measurable workload such as administrative work, purchasing. teaching.
sick time. and vacation time.
Based on queuing theory
The Queuing theory provides a mathematical tool in scheduling the pharmacist
manpower needs, particularly of a hospital outpatient pharmacy. However this technique
can be implemented in every activity of hospital pharmacy. To apply this a pharmacISt s
required to maintain time records to indicate "time in, 'time start" and "time finish o
various types of activities. The difference between "time in" and "time finish" is the
waiting time (queue) of the patient and for another activity.
Ine number of pharmacists on duty can be harmonized to the fluctuations in the
prescription order arrival rate and the performance of sequence of activities with an equal
Workload.
30Hospital Pharmacy
SUPPORTIVE PERSONNEL
Supportive personnel are the individuals without formal pharmacy education but trained
and work strictly under the supervision of a competent pharmacist. These individuals are
also called pharmacy technicians, pharmacy associates, or pharmacy helpe. Whatever
may be their title, Supportive personnel may undertake any of the non-judgement based
routine activities of pharmacists under pharmacist's supervision. The head of the
pharmacy department must be conscious that assigning duties to supportive personnel
must not result in dilution of pharmaceutical talents and shrank pharmaceutical services.
Prescription
Received by
Pharmacist
Drug selection
Prescription
Filling
Labeling
Regular
Prescription File
Pricing
Preseription
Filling
Controlled Drug
Prescrip. File
Dispensed to
Patient
Cash
Receipt of
Payment
Other
Freel Charge
Figure 1: Simplified Dispensing Activity Chart for PERT
Depending on' the level of training and categories of supportive hospital pharmacy
personnel, functions and responsibilities that can be assigned t0 each category ot
Supportive personnel must be defined and differentiated from those, which can be carried
Out only by the pharmacist. To train individuals from each category of supportive
personnel, hospital pharmacy must develop on-the-job training programs.
various pharmacist's functions can be assigned to pharmacy technicians which a
31Pharmacy & ts Organization
DE
L
clan can perform independent of pharmacist supervisIon and under supervision,
wnie for some functions. technician is strictly prohibited.
be
w
unction performed by technician independently
The supportive personnel may perform the following non-judgement based duties
independent of pharmacist's supervision:
Locating prescription order and filing immediately prior to pnarmacist's filling of
prescription.
Inventory supplies and restocking of prescription items.
3.
Calculating prices for prescriptions dispensed by pháarmacists.
4 Clean bulk manufacturing and pre-packaging and other prescription equipments.
Delivering prescriptions to patients but refer any question to pharmacists.
6. Billing to patients and/or third party and pay pharmacy accounts.
.Delivering of preseription drugs to physicians and nurses in hospital or office for
professional use.
Functions performed by technician under supervision
Under the supervision of a pharmacist. a pharmacy associate can perform the following:
Typing of labels from prescription orders to be later attached to containers by
pharmacist
. ASsembling of prescription ingredients immedialely prior to pharmacists tilling of
order
3. Printing of labels tor pre-packaged drugs.
4. Pre-packaging of prescription drugs.
5. Affixing of pre-printed labels to containers of pre-packaged drugs.
6. Packaging of finished dosage forms immediately prior to pharmacist's checking of
prescription, weighing and measuring ingredients in bulk compounding of
pharmaceuticals.
7. Ordering and checking in pharmaceuticals.
8. Calculating prices for prescriptions dispensed by pharmacists.
9 Maintaining family prescription records.
10, Maintaining drugs and narcotic drugs inventory records.
STAE
Functions strictly prohibited
Among those functions which a technician is strictly prohibited from doing are actually
Judgement based and include:
ITaking of telephone orders for new prescription or for prescription refills.
Weighing or measuring ingredients for compounding ot preseriptions.
3. Mixing of already weighed or measured ingredients.
4. Compounding of prescriptions.
5. Calculation of percentages in prescription compounding.
6. Atfixing of prescription labels to medication containers.
7. ProvIding of information on use and precautions to patients and protessiona
personnel.
The foregoing classification may not coincide with practice undertaken locally. axtion
Hospital Pharmacy
sion
DETERMINATION OF SUPPORTIVE PERSONNEL
LIKe determination or professional personnel, a precise formula is not avalao can
be applied to reveal the magic number of supportive personnel. However. Oa
workioad and the non-judgement-based jobs. number of supportive personnc
determined. ldeally. on the average, there is approximately one technician cp
each pharmacist.
the
uties
a
for
of
DETERMINATION OF LAY PERSONNEL
The indiViduals included in this category are secretarial or clerical workers, deve
and nospta pharmacy technician-helpers. The secretarial or clerical workers heip n u
administrative tasks. The number of people required depend on the amount or purcua
inventory control and accounting procedures. Number of hospital committees upo w
the pharmacist serves as secretary, the frequency of departmental publications, Cu
or lormulary updating, maintenance of literature files and pharmacist's invoO1venc
active teaching and research programs are the other factors which influence the numoDe
of lay persons.
for
he delivery men pick up and deliver supplies from pharmacy to other departments. A
Sma hospital pharmacy has no need for delivery services or hospital pharmacy
technician-helpers. On the other hand. a larger unit needs for this category off employees.
However. with modern means of communication. as vertical conveyor systems and
pneumatic tube devices. the pharmacy of a larger hospital requires a litle or no delivery
Service. A Tew delivery men would be needed to transport certain types and sizes ot
products for which the above systems can not be used. In the instances of less transport
volume. the pharmacy may utilize the services of a messenger of other departments or of
central transport and messenger service of the hospital, if one exists. If. on the other hand
none of the above mentioned modern conveyance devices are available, then the need for
human transporters becomes obvious.
y
pf
The act of hiring of pharmacy personnel in private hospitals is responsibility of the
director of pharmacy service in collaboration of hospital personnel department. In
governmental hospital. hiring depends on the number vacant post and is through public
service commission. Hiring does not mean just to acquire another pair of hands but for
hiring. qualification, competencies, training for specialized function of hospital pharmacy
are considered. Generally a six-month probationary period is given to new employees. An
evidence of the professional competency and proof of moral character reflecting a
successful completion of probation period and the employees are shifted on the regular
pay role.
For the hiring purpose, the application for the employment should be so designed that all
the vital information of employee can be obtained. This vital information includes the
personal history. education. previous jobs. skills etc. All of the above information is
matched with the position that the applicant seeks. This information will also helpful as
an evidence of the reasons for selection of an employee.
STAFFING- HIRING OF PERSONNEL
3Pharmacy & lts Organization
Arer selection of personnel, their performance is regulary montored. he director
pnarmacy services will do the job of appraisal objectively andmpartially for each
personnel in pharmacy department. For the fulfilimen s nanagerial activity
CONTROL OF PERSONNEL
of
anking. person-to-person comparison, grading. graphic scales, checklist, forced choice
aescription. selection of critical incidences and management dy oDjective (MBO).
All appraisals are done on a prescribed form what is known as pertOTmance rating form.
Tnis appraisal system will help for a quantitative pertormance evauation, warning to the
employee of his deficiency in certain areas, ranking or go0d, Talr, and poor employees.
the corrective actions and whether a particular employee shoula be given an annual
increment or any incentives.
eTficiently. the director of pharmacy services must be faminar witn appraisal systems OIce as
Organogram is also charting or organizational Structure OT pnarmacy department. This
reflects the flow of administrative authority and who is accountable to whom. Charting is
essential after selection and categorization of employees. Obviously, in small
departments. this is generally simple but in large units with more number of personnel
and subdivisions. it is complex.
ORGANOGRAM FOR PHARMACY DEPARTMENT
Once the organogram is prepared and approved, it 15 posted at prominent place for each
of the departmental employees to read and adhere to. Figure 2 illustrates an organogram
for a well segregated pharmacy department.
Pharmaceutical Services
A pharmacy mainstream service is the drug dispensing to the inpatients and where
hospital policy permits. to outpatients. Besides this activity. depending on the size of
hospital, other important additional services requiring pharmacist's skills and potentials,
can also be offered. These additional programs offer at one hand great financial savings
for hospital and on the other hand pride and prestige to the pharmacist. These extended
areas will be discussed in greater detail in later Chapters.
Following are the various services mentioned on charting for pharmacy along with ther
function:
Administrative Services Division
Plan and coordinate departmental activities.
Develop policies.
Schedule personnel and provIde superVIsion to professiomal, supportive and office
staff.
Coordinate administrative needs of the pharmacy and therapeutics committee.
In-Patient Services Division
Provide medications for all in-patients of the hospital on round-the-clock basis.
Inspection and control of drugs on all treatment areas.
Looperate with medical drug research. Sometimes this is included under researcn
division.
34ation
Hospital Pharmacy
tor o
Out-Patient Services Division
Cach
tivity
Compound and aispense oul-patient prescriptions.
Inspect and control all clinics and emergency service.medication Statons.
Maintain prescription records.
ms as
hoice
Provide drug consultation services to staff and medical students.
form.
Medical Director
the
yees,
nnual
Pharmacy
nerapeuties
Committee
Chiel' Pharmacist
This
1g
mall
IS
Training
Deputy Chief
PharmacIst
Residents
nnel
TDM, ICU
each
ram
Senior
Sentor
Senior
Pharmacist
Senior
PharmacIst
Manager
Pharmacist
4
Pharmacist
ere
Central
of
Pharmacy
als,
Research
Sterile
ngs
ded
Drug &
. Dispen'sing
Admix-
Satellite
Poison Info.
In-& Oulturing
Pharmacies
Centre
Patients
eir
Stenographer
Pharmacy
Technetians
Office
Secretary
Assistant
ice
Figure 2: Organogram lor a well segregated harmacy Department
Departmental Services Division
Control and dispense intravenous fluids.
Control and dispense controlled substances.
h
55
Coordinate and control all drug delivery and distribution systems. Pharmacy && Its Organization
Purchasing and lnventory Control Division
Purchase all drugs.
Receive. store and distribute drugs.
Maintain drug inventory control.
Interview medical servicè representatives.
Central Supply Services Division
Preparation of sterile solution and fluids.
Develop and coordinate distribution of medical supplies and imigating fluids. This
service is sometimes rendered through ancillary supply division.
Manufacturing and Packaging Division
Manufacture wide variety of items for use at the hospital.
. Operate an overall drug packaging and prepackaging program.
Undertake program in product development.
. Maintain a unit dose program.
VSterile Products Division
.Produce small volume parenterals.
Manufacture sterile ophthalmologic, irrigating solutions etc
Prepare aseptic dilution of lyophilized and unstable sterile injections for
administration to patients.
Ancillary Supply Service
Supplying medical. surgical laboratory supplies and ward floor stocking.
Distribution of health accessories and parapharmaceuticals.
Providing information on the above.
Radiopharmaceutical Services Division
Centralize the procurement. storage and dispensing of radioisotopes
Labeling of radioisotopes with appropriate kit formulations.
Quality assurance in section and quality control of radiopharmaceuticals.
Radiopharnmaceulical rescarch.
Mntravenous Admixture Division
Centralize the preparation of intravenous solution admixture.
Review cach I/V admixture for physiochemical incompatibilities
Preparation of total parenteral nutrition (TPN).
Assay and Quality Control Division
Perlorm analysis on products manufactured and purchased.
Develop and revise assay procedures.
Assist research diviISion in special formulations.
6Hospital Pharmacy
Drug Intormation Services Division
Provide information on drugs and drug therapy to medical. pharmacy and u =
staff and to patients.
Maintain a drug information center.
Prepare the hospital's pharmacy newsiete 1
Maintain literature files.
Helps in updating of formulary.
Poison control centre
Provide information on poisons, poison prevention and tirst aid.
Maintain list of antidotes.
Edueation and Training Division
Coordinate educational programs of pharmacy, medical and nursing stan
rarICipate in hospital-WIde educational programs involving nurses, aoctors ec.
Train newly employed pharmacy department personnel.
Pharmaceutical Researeh Division
Develop new formulations of drugs. especially dosage forms not commerclany
available. and of research drugs.
Improve formulations of existing products.
Cooperate with the medical research staft of projects involving drugs.
Service monitoring and auditing
Appkaise, audit and monitor each of the pharmaceutical services for quality
assurance.
Takes corrective measures if not up to the standards.
After-hours Pharmacy Services
DISpensing of the drugs when the pharmacy 1s closed.
Each of the abave service 1s coordinated and managed by head or manager who report to
the chief pharmacist. Physical Plant and Its Equipment
PHYSICAL PLANT AND ITS EQUIPMENT
The physical plant and its equipments refer to locations, physical space, equipments and
their space allocation and furnishings of a particular service. To have adequate
pharmaceutical and administrative facilities is one of the minimum required standards for
the pharmacies in a hospital (Chapter1). The planning of physical plant an
equipment is included in the equipment planning, architectural design, controlled
environment design and other architectural aspect such as plumbing and finishing. This
planning is done following master planning and functional.planning. The master planning
dictates goals and objectives, whereas the functional planning sets forth the operational
demands and the equipment planning. The architectural planning translates these two into
physical space, equipment and furnishings. The equipment planning will largely depend
on the functional objectives of the pharmacy set forth in the master planning of the
hospital.
The architect may gather information on objectives and goals of the pharmacy
department by attending various meetings with hospital administrator, pharmacy
departmental head and hospital building committee.
A hospital pharmacist can guide architect regarding departmental objectives, functional
and equipments planning: space needed and other requirements for each facility.
its
As has been mentioned previously, the equipments and facilities can be planned after the
functional planning. The development of functional program for hospital pharmacy may
include the following steps:
1. Determination of pharmacy objectives and plan of operation must be in accordance
with the hospital objectives.
2. Determination of functions to be performed.
Determination of workflow and procedures.
4. Estimation of workload.
5. Determination of work areas needed.
6. Determination of personnel to be accommodated in each work area.
7. Determination of space, shape, furniture, equipment and service needs of each work
area.
8. Determination of interrelationships between work areas and between the pharmacy
and other departments.
9.
Arrangement of work areas to maximize the performance functions.
10. Designing of schematic floor plans to meet requirements.
11. Evaluation of effectiveness of each design for meeting requirementS, Hospital Pharmacy
12. Review the above steps until an optimal design emerges.
LOCATION
The location of the pharmacy should be so as it can conveniently provide services to
many departments of the hospital. It should also be easily accessible to inpatients and it
policy dictates, to outpatients. To provide services to the number of departments o
hospitals and all nursing stations, pharmacy should be located on the first floor, In the
center of the activities it is called upon to service frequently. It must also be immediateiy
adjacent to the outpatient department. The convenience of provision of the services, ca
accessibility by both in- and outpatients are required for rendering of efficient pharmacy
services and to conserve man hours.
The location of the pharmacy at the first floor of the hospital is an ideal condition,
however, this condition may be deviated in case of larger hospital or when the first floor
space is very important for other purposes. However, the basement of a hospital is not
desirable for the location of hospital pharmacy.
In hospitals where the pharmacies have constructed before the provision of outpatient
services may not be adjacent to the outpatient area. This problem can be resolved by
combining the services of the in- and out-patients dispensing under one ceiling. However,
if the volume of work is too low to justify it is suggested not to provide outpatient
service.
CONCEPT OF SUB-PHARMACIES
A hospital in which all the inpatient clinical departments are not in close vicinity of the
pharmacy department, a concept of sub-pharmacies can be implemented. Under this
arrangement, the sub-sections of main pharmacy can be established in the adjacent area
of each clinical service. This concept has been resulted from the advent of clinical
pharmacy programs, which necessitated the development of satelite pharmacies on more
than one patient area to cut the cost on transportation system. These sub-pharmacies are
direct under the control of the main pharmacy, staffed with a pharmacist and receive their
supplies from the main pharmacy. The number of the satellite pharmacies depends on the
diversity of the clinical services and distance of each service from the main pharmacy
The advantage of this concept is of being able to respond to clinical needs of the patient
on a current basis. In addition, such a system will enable the pharmacist to provide
pharmaceutical services to the patient, physician, and nurse in a clinical capacity rather
than as just a dispenser of medications. By being on the nursing tloor, the pharmacist is
available for taking of patient drug histories, maintaining patient drug policies, observing
the patient for drug reactions and toxicity and dispensing unit-doses and intravenous
products with additives.
FLOOR SPACE
The literature-cited method of space allocation to a floor is based on the number of beds
or workload of outpatients. The allocation on the basis of beds perhaps works well when
a Single service of dispensing is to be provided as in past. Presently, the pharmaceutical
services in the hospital have expanded considerably. Under current pharmacy practice
varied functions and services are being provided, ranging from standard type dispensing
methods to unit dose 'dispensing methodologies. Involvement with intravenous additivePhysical Plant
and lis Equipment
programs. drug information centers and clinical pharmacy programs demand an efiectiv.
method ol space allocation. This method is not availabie at present untortunately. This
because. a hospital is incomparable with others for the purpose or determining the square
and
Tootage requirements despite both having sinmilar parmaceutical involvement
The space requirement of the hospital pharmacy Is dictated by the following factors.
Degree or scope of services rendered.
ype of equipment used in the programs.
Expected future expansions.
It is noteworthy that an area is measured in square roo or square meter but exclusive of
the walls and partitions.
The floor space is required for the following areas:
Services.
CLEANUP AREA
A cleanup area is the demand of a pharmacy involved in compounding or manufacturing
of extemporaneous preparations. The desirable features for cleanup area include
appropriately located pass-through windows and a floor area with a floor drain.
A cleanup room shared by central sterile supply room (see Chapter 9 on Pharmacy Sterile
Services) and pharmacy is the most efficient, and prevents dupication at both sites and
would there fore be economical.
Pyepavaan
NONSTERILE MIXING AND FILLING ROOM
Stoee
This area is specified for the mixing and filling of the nousteri le extemporaneous
preparations. In this area. the mixing and filling of liquids must be separated from that of
the ointments, though both may be in the same room. In this area, besides mixing and
stirring, the provision of weighing and measuring, homogenization, filtration and filling
should also be made. Adequate space must be provided for storage purpose.
PREPACKAGING AREA
An area in pharmacy for the packaging of oral solid dosage forms into containers is
called prepackaging area. If the space is available at the extemporaneous preparation
area. prepackaging can be accomplished in this area.
INJECTION RECONSTITUTION AREA
The injection reconstitution area is a place for addition of water for injection for
powdered injectables. This area must be equipped with adequate number of laminar
airtlow hoods. horizontal as well as vertical depending upon the product handled for
aseptic handling of injectables and the process of reconstitution.
LABELING AND INSPECTION ROOM
Ihe labeling and inspection room of hospital pharmacy-manufactured products. is to
TOcated adjacent to tilling areas, separated by pass-through windows. This pass-througn
Window is used for transfer of unlabeled products to eliminate any possibIy
premature usage. At this area. sufficient storage space must be availabIc o
printing machine accessories, torms etc.
f
eir
0
labels, Hospital Pharmacy
QUARANTINE STORAGE AREA
ne qualdlnine stOrage area is an area where the manufactured or filled produc
pharmacy are detained until declared pass the chemical and biological quany
testing.
ntrol
TEMPERATURE CONTROLLED STORAGE FACILITIES
Hospital pharmacists are well aware of the need for air conditioning and tempt
control in hospital pharmacy. Storage requirements of drugs are the important Staoy
Tactor ror them. Ihe drug storage temperature requirements are any one of the toilowil
Refrigerator
are
A remigerator is a cold place providing a temperature of between 2°C- 8C.
Cold place
A storage condition has a temperature not exceeding 8°C.
Cool place
A cool place specifies a temperature of 8°C - 15°C.
Room temperature
Room temperature is between 15°C to 30°C.
Excessive Heat
The excessive heat indicates temperatures above 40°C. This temperature is forbidden for
various drugs by mentioning 'avoid excessive heat which means that the drug must not
be exposed to a temperature above 40°C.
Drug storage and safety is the responsibility of a pharmacist, so a pharmacist must ensure
the availability of appropriate storage facilities respective to each drug. A refrigerator and
a freezer will solve this purpose. In larger hospital, the refrigerator is too small to
accommodate the inventory requiring refrigeration. The workable alternatives are the
purchase of additional refrigerators or borrowing refrigerator facility of some other
department. However, later arrangement is not a safe practice because of the lack of
control over the drugs stored in area other than pharmacy.
An innovative approach that provides adequate space and appropriate cold temperature
for storage of drugs is the construction of a cold room. The cold room is artificially
cooled area with a regulated temperature of 12-15°C. The construction and operation of
cold room is economical and provides a convenient method of cold storage of drugs
within the pharmacy or at area other than pharmacy but under the control of pharmacy
department.
The features of the cold rooms are:
. The walls of room may be constructed of concrete, concrete blocks. or bricks.
2. The door should fit tightly, be no larger than necessary, and be provided with a good
automatic door closer.
3. The windows in a cold room are double-paned and sealed against the outside
atmosphere.
4 The switch controlling the light fixture is to be on
entrance to the room.
outside wall nearest the
5. An electric motor-driven air cooled Freon compressor unit with a remote blowertype cooling coil is needed to provide necessary refrigeration. This unit is installed
41Physical Plant and Its Equipment
Vith thermostat and expansion valve required to maintain the desired temr
range.
ntain the desired temperature
6. The blower is mounted in the cold room. 1o it, a small waste line is installed to drain
away the condensate, which collects on the remgerator coil. The compressor may be
nstalled outside of the cold room in order to conserve space within.
7. The room can be equipped with necessary shelving, storage binds, cabinets, and
work bench.
ENVIRONMENTAL CcONTROLLED FACILITY- VENTILATION
Air conditioning of the pharmacy is desirable for following reasons:
1. It provides the ventilation even when the windowS and doors are closed. Opening of the
windows and doors is associated with the entrance of dirt, dust and other environmental
contaminants.
The use of various autoclaves, ovens and steam jacketed kettles may render the working
environment too hot.
It permits maintenance of a temperature compatible with official storage requirements for
drugs irrespective of climatic conditions.
Adequately rerhoves strong odors characteristic of the chemicals used in the manufacture
of the various galenicals, preservative fluids and reagents.
Since the doors and windows can be kept closed, there can be effected a saving in the
cost of housekeeping service in the pharmacy.
EOUIPMENT PLANNING
he equipment planning and subsequent purchase of major equipments for pharmacy is the
joint responsibility of hospital administrator, pharmacist, purchasing agent of the material
management department and an architect. The purchasing agent usually purchases commonty
used equipments in daily professional practice after consulting with pharmacist.
The equipment planning will largely dependent on the number, varieties and per day
duration of services offered from the hospital pharmacy. No need to say for example, if' a
hospital pharmacy plan to offer radiopharmaceutical service, it must have the equipment
for the safe handling and dispensing of radioisotope, quality control equipments ana
radiation measuring instruments.
he ype and number of equipments can be evaluated on the basis of determination of
their relative significance and rating by classifying them into deserving essential
considerations, 'requiring further study before being included or excluded', and 'can be
included. This principle can be implemented for all of sections, services, functions and
activities of the pharmacy department.
The following are the parameters, which will dictate the equipment planning:
Services options
Ihe options for servIces are inpatient services, outpatient services, bulk compounding
packaging. pharmacy education, research program, drug information, poison conuo
centre, night emergency service and drug surveillanc
Choices of internal activities
The internal choices of activities may include type of distribution system, filling at ordc
2Hospital Pharmacy
delivering of orders to nursing station, handing of /V admixtures and controlled drugs.
maintenance of the medical profile.
Workload and workflow
Equipment planning will require the determination of workload and workflow in the
department.
Automation
Degree of automation required and location where it is required.
Work areas
The space requirements for administrative offices, officers offices, and for other work
areas.
Ways of communications and transport
Ways of communications and transport include the number of telephone/fax required,
Internet ete.
Environmental control requirements
Type of temperature and humidity controls, aseptic environment.
In addition to the above cited parameters for equipment planning, other factors taken into
consideration are volume of dispensing, number of people who will be in any one sector
of the pharmacy at any single time, peak dispensing hours, number of nursing stations
and other departments to be serviced.
EQUIPMENT SELECTION CRITERIA
Each equipments is carefully selected on the basis of some criteria as mentioned below:
Efficient provision of services.
Affordable operating cost.
Requiring minimal maintenance.
Offering maximum safe performance.
It is advisable that, for a particular section of the pharmacy, high-value equipments are to
be purchased first and the low-value equipments after ward. This keeps the expenses
within the budgetary allowance of the department.
For budgeting point of view, the estimated cost of equipment should be avoided. This
may be an under estimation and mostly insufficient funds are available for the purchase
of the desired equipment. Clearly then, once the equipment list is prepared, it behooves
the pharmacist to consult freely with the purchasing agent, manufacturer's representatives
and vendors as well as to examine through the latest editions of the catalogues.
Equipments required tor the pharmacy are categorized into fixed and movable types.
Fixed equipment
The equipment requiring installation and is to be attached to the building is called fixed
equipment. The equipments attached With electric power lines of the building electric
system are not regarded as the fixed equipment. The examples of such equipments are
43Physical Plant and lts Equipmeni
cabinets. counters, Sinks, elevators etc.
Currently. built-in equipments such as cabinets, counters and other types of casework,
available. The selection of such equipments depends on the required dimensions
materials used in the construction, suitability ot the equipments tor particular activity
Such details are available from the manufacturer's catalogues
Special attention should be given to the counter tops and these must:
1. Ofler resistance to corrosion and abrasion.
Are
vity
2. Withstand impact without laking or peeling.
No or little ellect of high humidity
Tigh color retention quality il colored to resist appreciable discoloration.
Must have the abrasion resistant finish-coat.
6 Reagent resistant linish-coat to acids. alkalies, oils and solvents.
Movable equipment
Movable equipments are capable of being moved and are not intended to be permanently
aftixed to the building. This equipment category includes large items of furniture and
equipment having a reasonable fixed position in the building but which can be moved.
Examples of movable equipment are carts. desks, balances, mixers etc.
EQUIPMENTS REQUIRED
Varied scope and services of pharmacy departments of various hospitals make it difficult
to prepare a standard list of equipments, which will meet every needs. However, a check
list for area wise equipments inventory can be prepared as a guide from the catalogues of
cquipments provided by equipment manufacturers.
OTHER UTILITIESX
Other utilities in the department are require consideration. These utilities include electric
ghting. transport system. plumbing and furnishes.
ELECTRIC LIGHTING AND SERVICE
Smooth and safe lunctioning of any activity require the appropriate electrical lighting and
a suflicient number of ground electrical outlets. Lighting will based on the characteristic
o the operation. location and environment. Sufficient lighting must be provided for the
Critical work areas such as prescription dispensing area, manutacturing area.
adinixture area and library.
oround electrical outlets should be provided in all areas in which the use of electrical
equipment may be indicated.
TRANSPORT SYSTEM
ransportation of different items from pharmacy to various destinations in hospitals is
less
routine matter. The transport. done with help of messenger, porter or heipe
Cicrent and time consuming. Tte modern technology has made avai labie so
automated means of transporting including the conveyor belt and the pneumat
system. hese systems have been successfully implemented in neary a
pharmaceutical manu facturing units of country but not yet experienced in hospla
44Hospital Pharmacy
pharmacy ot any institution.
Under these systems. the drugs and supplies can automatically conveyed through moving
belts to the nursing station and desired destinations. This transport system, conserves
pharmaceutical manpower. For the purpose ot the selection and installation of such
systems. an advice can be sought from various manufacturers and distributors of such
devices
PLUMBING
The plumbing is the system of pipelines for the supply of water to desired areas and
disposal of wastes. A pharmacist has to advise the architect about particular details and
requirements of points for hot and cold water for pharmacy and nature of materials which
will be disposed ot through the various waste lines.
By so doing, the plans will properly specify acid resistant piping, adequate hot and cold
water mixing valves, elbow-handled taps. stainless steel or soapstone sinks, distilled
water lines and attached equipment, which will allow filling of specitic containers with
connecting hose.
FINISHES
Work Counters
The work counters in pharmacy include those for just writing, dispensing. counting of
drugs, receipt of drugs, etc. The worktops for preparation must be of such material that
does not show peeling, distortion, erosion or sticking. Such work tops may be constructed
of stainless steel. Other activities do not require such construction. For these units.
Formica or a similar material is suggested as an efficient and durable surface
Floors
The floors of the pharmacy should be smooth, non-slippery, stain resistant and yet
complimentary to the existing or proposed decor of the department. Many flooring
materials of these features are currently available that are highly satisfactory, economical
and serve the intended purpose. Some of the floor coverings currently in use are asphalt
tile, vinyl tile, rubber tile and heavy duty linoleum.
Carpeting of floors gives aesthetic impact yet in a pharmacy, it has not been
complementary to its operations. It generate static electricity and has flammable nature
and thus not acceptable particularly in work areas.
The tloors of the manufacturing and parenteral solutions room should be supplied with a
covered drain system.
Walls
The walls of pharmacy should be painted with a material that permits periodic washing
without the danger of losing its original color. The walls of the areas like manufacturing
and parenteral products rooms, should not be painted because it is usually unable to
withstand constant washing necessary for maintenance of desired degree of asepsis. Here,
ceramic tile or other comparable material should be utilized6
Hospital Formulary
A formulary is a continually revised list of drug products, along with ancillary
information recommended or approved for use in an institution. There are number of
available drugs for a particular treatment. The multiplicity of drug availability
necessitates a sound program for drug evaluation, selection, and their use in institution ta
ensure that patients receive the best possible care.
The drugs on the formulary are listed after a careful evaluation, appraising and selection
from among the numerous available drug products. This selection of drugs is made on the
basis of patient acceptability, efficacy, safety and drug price. The compilation of
formulary is a collaborative task whereby hospital pharmacists, prescribers and medical
professionals are involved. All these work through the pharmacy and therapeutics
committee which selects drugs products considered most useful in patient care.
The people expected to use a formulary that must have an opportunity to give their views
on its contents. If their opinions are not asked, they may feel that it does not apply to
them and will be less likely to be used by them. In a formulary, information on dosage,
indications, side effects, contraindications, formulations and costs may also be included.
Only those so selected drugs are routinely available from the pharmacy. A formulary
therefore, may be thought of as a prescribing policy, because it lists which drugs are
recommended,
Since the formulary is a vehicle by which medical and nursing staffs make use of the
system, it is important that it be complete. concise and easy to use. These guidelines are
offered as an aid to pharmacists for preparing a new or improving an existing formulary.
The pharmacists do not deal with specific drug products which might be included in a
formulary or with the selection process, but, rather, with the formulary's forimat,
organization and contents.
The formulary system provides for the procuring, prescribing. dispensing, and
administering of drugs under either their nonproprietary or proprietary names where
drugs have both names. To be effective, the formulary system must have the approval or
the medical staff, accepted by individual staff members, and functioning of a properly
organized pharmacy and therapeutics committee. The basic policies and procedures
governing the formulary system should be incorporated in the medical staff bylaws or in
the medical staff rules and regulations. The extent of formulary usage and adherence to it
is the measure of success for a formulary system. The formulary system is thus an
important tool for assuring the quality of drug use and controlling its cost.
In developed countries, the concept of formulary IS not new yet in Pakistan, this conceptHospital
Pharmacy
is not fuly practiced., Since 1977 the World Health Organization has published a list O
'essential drugs Wnich it recommends as necessary for basic healthcare
countries. Ihis essential drug list could serve as the basis for the advancement
formulary concepthne ministry of health Punjab has decided for development
implementation of formulary in governmental hospitals. Some larger private pitals
already have this program.
f
TYPES OF FORMULARY
A formulary may have the following categories:
NATIONAL FORMULARY
National rormulary 1s a compilation of all drugs available in a country. In Pakistan,
national Tormuiary IS under preparation. A National formulary must provide an Imparuar
information on drugs for prescribers in a user-friendly form. It gives some guidance on
selection or drugs and provides price comparisons to help user to become cost-consclous.
LOCAL OR PRIVATE FORMULARY
This formulary 1s also called a hospital owned formulary and is a compilation or drugs
used in an institution, may be similar in appearance to the National formulary. Local
formularies contain a restricted number of drugs and may include only some of the drugss
listed in National formulary. The advantages of a private formulary are:
1. Prepared locally by the hospital's own clinical staff which creates a feeling of a
sense of pride and loyalty as well as a determination to make the system succeed.
2. Contents and information are provided under each monograph according to the local
needs.
3. May include sections on related clinical matters which are characteristic to the local
hospital.
May be published in a more convenient Size and format.
Allows possibility of addition or deletion with greater frequency.
Certain drugs may be added to the formulary before they have attained sufficient
stature to be considered on a national level.
A PURCHASED FORMULARY
A drug monograph service such as the American Hospital Formulary Service, a
publication of the American Society of Hospital Pharmacists can be subscribe for a basis
Tor preparation of formulary in an institution.
SPECIALTY FORMULARIES
A formulary prepared for and provides intormation on very particular specialty products
is the specialty formulary. Increasing use or enteral nutrition products in hospitals
requires specialty formulary for use or tne medical and dietetic staffs. The formulary
reports product variables such as osmolaliny, caloric density, protein content, fat contents
and sources, freedom from lactose, and, TOr orai supplements, tlavors. The products are
categorized as follows: liquid supplemental Teedings, isotonic supplemental feedings.
isotonic tube feedings, high caloric/nign nirogen tuoe Teedings, and blenderized tube
feedings.
61Hospital Formulary
OBJECTIVES OFA FORMULARY
The primary objectives of a formulary are to provide the hospital staff with the
information on:
()The drugs approved for use by the pharmacy and therapeuties committee.
(2) Basfc therapeutics of each approved item.
(5) Hospital policies and procedure governing use of drug.
(4) Special aspects such as drug dosing rules and nomograms, hospital-approved
abbreviations etc.
ADVANTAGES OF FORMULARY SYSTEM
The formulary system ofters the following advantages
PROVIDES THERAPEUTIC MERITS
Under formulary system, drugs are carefully evaluated, appraised and selected from
among multiple drug products in terms of their safety, efficacy and cost effectiveness.
Thus, a formulary system provides the greatest benefit to the patients and physicians inn
that only the most efficient products are listed and available.
PROMOTES RATIONAL PRESsCRIPTION
A formulary recommends inclusion of specific drugs while exclude others. This coupled
with the guidelines to assist prescribers in using the drugs in a formulary and specific
treatment protocols enhance the rational drug prescription to the patients.
PROMOTES COST EFFECTIVENESS
A formulary contains selected drugs and eliminates brand duplication thus reducing
inventory diuplication, easier cash flow and the opportunity for volume purchasing. All
contribute to lower cost to the patients. Formulary encourages generic preseription which
may further reduces the cost. This program is the basis of appropriate. economical drug
therapy.
POSSESS EDUCATIONAL VALUE
The formulary contains variouS prescribing tips and drug information of educational
alue th
being beneficial for medical statff a
nurses.
PROMOTES KNOWLEDGE
Prescribers, who use a restricted range of drugs listed on the formulary. know more about
these drugs and their formulations. Increased knowledge reduces the risk of inappropriate
prescribing, interactions or lack of efficacy. Additionally. a formulary system encourages
the generic prescribing which has educational benefits.
CLOSE EXPIRY MONITORING
Formulary makes the possibility of a clOse drug monitoring for expiry dates as under
system only limited ahd fewer products are stocked.
IMPROVES RELATIONSHIP
Formulary system establishes and improves relationship between pharmacists, prescribcHospital
Pharmacy
and other medical protessionals since all i
formul ulary.
ai jointly input into developing an institutona
osSIBLE DEMERITS OF FORMULARY
Use of a rormuiary System in an institution has relatively few und
disadvantages
. Deprives the physician's freedom to prescribe and obtain brands of his prcie
which he developed over the years. Changing prescribing habits 1s a
achieve.Sometimes constant reminders are necessary to maintain prescrlon
the recommendations of a formulary, consuming pharmacist's time a o
spent in another beneficial activities.
2. Permits pharmacist to act as the sole judge to select brands of drugs tor purcnasig
and dispensing.
3. Allows for purchase of inferior quality drugs as there may not be an approprac
selection criteria, particularly in institutions where there is no staft pharmacist,
Unable too reduce cost of drugs to the patient or to the imbruing (third party payer
organization. Most of the institutions purchase large volumes of drugs at reauceu
rates but do not pass on reduction in costs to the patients.
oned
ence,
be
5. A continual updating of formulary requires lot of etforts. time and expendiures.
FORMULARY VS DRUG CATALOGUE OR LIST
A Tormuiary usually consists of a listing of therapeutic agents by their generic names
followed by information on strength. dosage form. posology. toxicology. use, and
recommended quantity to be dispensed. Whereas a drug list usually consists of a record
of therapeutic agents by their generic names followed only by data on strength and
dosage form. There may or may not be any additional information although some drug
lists may provide the prescriber with recommended quantities to be dispensed.
Clearly then, the formulary is the more intormational type of presentation with
educational value on drug therapy particularly.
FORMULARY MANAGEMENT SYSTEMS
The formulation management system constitutes the production, distribution and
updating of the formulary of drugs.
PRODUCTION
The production of a formulary, a lechnical. compleN and time-consuming task can be
accomplished by one or more small groups ot indiVIduals, expert in particular fields
under the advice of pharmacy and tnerapeuies committee. Obviously a pharmacist
should be included in all these groups. Ihe preparation of the hospital formulary
although the prime responsibility of pharmacy and therapeutics committee, yet rests upon
the Pharmacist-in-Chief. Formulary production involves the gathering of data on which
the drug selection will be based. This data may he published evIdence. prescribing data
and the opinions of the expert Gr group members.
A completely new formulary can l
formularies. Adapting another formulary to Sut local needs 15 much time saving than
starting from the first step. Whichever way Is cnoSen, studying existing formularies is a
prepared from start or canh be modified from existing
63Hospital Formulary
good way to begin. However, adopting it Without any changes is not recommended for
or
pharmacist. A form can be circulated among the medical staff to collect their preferences
Once the selection is made, the format of the material and the design of the final
document are to be considered.
If the budget allows, a perpetual drug monograph service such as American Hospital's
Formulary Service can be subscribed. It is a publication of the American Society of
Hospital Pharmacists and serves as a basis for preparation of formulary in an institution
The American Hospital Formulary Service provides adequate information concerming
drugs and has following advantages:
1. Continuing drug monograph subscription service officially published by the
American Pharmaceutical Association, the Catholic Hospital Association, and the
American Hospital Association.
Highly reliable as prepared by a reference panel of the country's outstanding
clinicians, pharmacologists and pharmaCists.
Each monograph contains a complete outline on drugs including physical and
chemical properties, pharmacologic responses, uses, toxicology, contraindications,
posology and preparations, and
4. Having classification and codes of drugs according to their pharmacological actions
and therapeutic indications by a system of numbers that can be adapted to the filing
of all informative drug literature in the pharmacy library.
The British National Formulary is another example, which can be used as a guideline for
the production of formulary.
2.
3.
DISTRIBUTION
On the completion, the copies of drug formulary are to be distributed among all the
prescribers, nurses, medical staff. It should be placed at each patient care unit, including
clinics and other outpatient care areas such as the emergency room. Each pharmacy
division such as inpatient dispensing, outpatient dispensing. drug information service, etc.
should also receive a formulary issue. Heads of departments providing direct patient care
should receive a copy as should hospital administration. Surplus issues of the formulary
must be available at hospital pharmacy and should be provided on demand from any ot
the medical professional.
The necessary steps should be taken to ensure that the nursing and medical statts are
familiar with the formulary and know how to use it. Enough formularies should be
printed to allow for replacement of copies which become lost or worn.
FORMULARY UPDATING
Despite of all efforts of producing of formulary and its distribution, soon after, it goes out
of dated. This is due to the:
. Introduction of new drugs.
2. Removal of ex isting drugs from marketplace.
3. Change in hospital polices and procedures.
Evidence of efficacy of existing drugs in novel indications.
5. Changing data on adverse reaction profiles as provided by post-marketing
4.
surveillance.
6. Demand for inclusion/exclusion of new/existing drugs from the formulary.
h4Hospital Pharmacy
The facts mentioned above necessitate periodic revision, as an efficient ro ating
respond tne ever-enangng demands of the practice. Furthermore, if formulary o
is allowed, the respect of a formulary may be declined. To avoid this, a formutay
revised conunuouSIy on siX months, biennial or annual basis. Methods are thererorc
needed to allow drugs to be considered for inclusion in or removal from the Tormuaty
Another means or Keeping a formulary current is through an organized system O See5
changes in the rOrmulary from the medical staff. All formulary users essentiay a
informed or any acceptance of a drug into or withdrawal from formulary a
modifications in arug indiIcations or in doses between revisions. An effective upaatg
can be accomplished by use of computers in hospital pharmacy
To be economical, there should be a system for including between revision changes in n
current edition of the formulary. One method is to attach formulary supplement sneeis a
inside back covers ot the formulary books.
he
1ary
must
CONSIDERATIONS IN AND GUIDELINES FOR COMPILING A FORMULARY
The following principles will serve as a guide to physicians, pharmacists, nurses, and
administrators in cinical tacilities utilizing the formulary system:
I. The medical staff shall appoint a multidisciplinary pharmacy and therapeutics
committee and outline its purposes, organization, function, and scope.
2. The formulary system shall be sponsored by medical staf based upon
recommendations of pharmacy and therapeutics committee. The medical staff should
adapt principles of system to the needs of particular institution.
3. The medical staff shall adopt written policies and procedures governing formulary
system as developed by pharmacy and therapeutics committee. T hese poliCies and
procedures shall provide guidance in evaluation or appraisal, selection, procurement,
storage. distribution, safe use. and other matters relating to drugs, and shall be
published in the institution's formulary or other media available to all members of
the medical staff.
4. Drugs should be included in the formulary by their nonproprietary names, even
though proprietary names may be in common use in institution, Prescribers should be
strongly encouraged to prescribe aruigs oy their nonproprietary names.
. Pharmacy and therapeutics committee must Set forth policies and procedures
governing the dispensing ot generic equivalents (arug products identical with respect
to their active components) and therapetic cquivalents (drug products differing in
composition or in their basic drug entty tnat are considered to have very similar
pharmacologic and therapeutic actVIies). nese poliCies and procedures should
include the following
5.1 Pharmacist is responsible tor selecting, rom available generic equivalents, those
to be dispensed following Pnysician S order Tor a particular drug product.
5.2 A prescriber has an oplion at tne tne O preseribing. to specify the brand of
drug to be dispensed for that particuta cdrcdllon order/prescription. However,
The prescriber's decision Snourd C Dasca On pharmacologic or therapeutic
5.3 The pharmacy and therapeutics CO ce is responsible for determining
druo products that shall be constdereu tetdpeutic equivalents. The conditions
for dispensing a nerapeutc aiternalve in place of the prescribed
65
considerations (or both relative to that patient).
and procedurHospital Formulary
6. The institution shall ensure that its medical and nursing stafts are informed about tho
existence of the formulary system, the procedures governing its operation, and
modifications.
drug shall be clearly delineated
any
7. Copies of the formulary must be readily available and accessible at all times.
8. Provision shall be made in the tformulary system for appraisal and use of nonformulary drugs, by the medical staff.
9. The pharmacist shall be responsible for specifications as to the quality, quantity, and
source of supply of all pharmaceutical preparations and allied substances used in
diagnosis and treatment. When applicable, such products should meet the official
standards.
FORMULARY CONTENT AND ORGANIZATION
The contents of a formulary will depend, largely on its purpose. The formulary intended
to merely use as a control that what drugs may be used by medical staft. requires a drug
listing with ancillary information that the pharmacy aind therapeutics committee deems
desirable. On the other hand, if purpose of the formulary in addition to its control va
to function as an intformative tool in the clinician's daily practice, then its contents should
be expanded to meet this goal.
To meet the objectives as mentioned before, a typical tormulary essentially have the
following three parts:
1S
Part 1- Information on hospital policies and procedures concerning drugs
Though the mate ial to be nclaain this section will vary from hospital to hospital yet
generally. the following items may be included:
1. Information on using the formulary, including arrangement of formulary entries, the
information contained in each entry and the procedure for looking up a given drug
product.
2. Formulary policies and procedures, including restrictions on drug use (if any) and
procedures for requesting addition of a drug to the formulary.
3. Brief description of pharmacy and therapeutics committee, including its membership,
responsibilities and operations.
4. Regulations governing prescribing, dispensing and administration of drugs, including
(a) writing of drug orders and prescriptions. (b) controlled substances considerations,
(C) generic and therapeutic equivalency policies and procedures. (d) automatic stop
orders. (e) verbal drug orders, () patients use of their own medications. (g) sel
administration of drugs by patients, (h) use of drug samples, (1) policies relative to
stat and emergency drug orders. () use of emergency carts and kits, (K) use O
floor-stock items. () requests by staff for medications for their own use. (m) standara
drug administration time, and (n) reporting of adverse drug reactions and medication
errors. Other topics should be included as deemed appropriate.
S. Pharmacy operating procedures such as hours of service, outpatient prescriptlo
policies, charging systems, prescription labeling and packaging practices, inpatient
drug distribution procedures. the handling of drug information requests, and
specialized services of the pharmacy (e.g.. patient education programs. pharmac
bulletins.
66Hospital Pharmacy
Part 2- Drug Products Listing
This section is the Core or a rormulary and comprised of one or more descriptive enu
for each formulary tem along with indices to facilitate use of the formulary. ne
formulary entries can be arranged in several ways: (1) alphabetically by generiC name.
with entries for synonyms and brand names containing only a "see (generic name)
notation, (2) alphabetically within therapeutic class, and (3) a combination of tne w
systems whereby the bulk of the drugs are contained (alphabetically) in a 'general
section which is supplemented by several "special" sections such as ophthalmic/otic
drugs, dermatologicals and diagnostic agents.
The type of information to be included in each entry will vary. At a minimum, each entry
must include:
a) Generic name of the basic drug produet; combination products may be listed by
generic, common or trade names.
b) Common synonym(s) and trade name(s), there should be a note in the "directions tor
use" section of the formulary explaining that inclusion or omission of a given brana
does not imply that it is or is not stocked by the pharmacy
c) Dosage form(s), strength(S). packaging(s) and size(s) stocked by the pharmacy
d) Formulation (active ingredients) of a combination product.
Additional information
Some additional information may be part of the drug entries in part 2 and may include:
a) Usual adult or pediatric dosage ranges, or both.
b) Special cautions and notes such as: do not administer I/V or 'refrigerate.
c) Controlled substances symbol.
d) Cost information is useful where therapeutic classification system is used or,
alternatively, lists of similan drugs (e.g., oral steroids) may be presented showing
relative cost data. This cost can be mentioned in variety of ways such as actual cost,
per unit cost or cost of the therapy.
e)Indexes to the Drug Producțs Listing: There are included to facilitate the use of the
formulary. They are:
Generic Name-Brand/Synonym cross index. 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
Therapeutic/Pharmacologic Index. This index is a listing of all formulary items
Within each therapeutic category. It is useful in ascertaining what therapeutic
alternatives exist for a given situation such as patient allergy to a particular dru8
1nlormation on prescription wriung
n on prescription writing is a valuable asset to physicians. This section should be
t should cover the important parts of the prescription, the use of the metric
, a ist of acceptable abbreviations, and the essentials ofa narcotic prescription.
prescriptions must be written clearly and correctly and must bear the following
Omation: (a) name and address of the patient, (b) date, (©) medication prescribed,
u strength of prescribed medication, (e) total amount to be dispensed, () signa,
Otdining the instructions to the patient, should be in clear, concise and simple
.
676
Hospital Formulary
terminology.
2. The physician should avoid mixing Latin and English abbreviations.
3. The term. 'As directed'. should seldom, if ever, be used. When refills are desired, the
number wanted should be indicated if this is not done, the prescription wll not be
refilled.
4. Prescriptions calling for a controlled substance must have. in addition to all of the
above information. the signature of the prescribing physician issuing them.
Other important data such as: (a) normal laboratory values. (b) tables of heights and
weights, (c) tables for calculation of percentages, milliequivalents and dosages, (d)
formulas of various diagnostics, and (e) other necessary information. Obviously, all of
inclusions are not possible without making the publication unacceptability at large and
expensive. Therefore, the judicious evaluation of each entry by the pharmacy and
therapeutics committee is vital
Part 3- Special Information
The material to be included in this section is of general interest to the hospital staff and
not readily available from other sources, Examples of the type of items often found in the
special information section of hospital formularies are:
I. Nutritional products list.
Tables of equivalent dosages of similar drugs.
3. List of hospital-approved abbreviations.
4. Rules for calculating pediatric dosages.
5. List of sugar-free drug products.
6. List of items available from central supply.
7. List of the contents of emergency carts.
8. Lists of dialyzable poisons.
9. Pharmacokinetics. dosing and monitoring information.
10. Metric conversion scales and tables.
1. Exanmples of blank or completed hospital forms such as prescription blanks, request
for non-formulary drug forms and adverse drug reaction report forms.
12. Tables of drug interactions, drug interference with diagnostic tests and parenteral
drug incompatibilities.
13. Poison control intormation.
PRESENTATION
The presentation of formulary deals with its format and appearance. The physical
appearance, structure and the way by which formulary contents is presented in the
formulary are significant factors for its acceptability and use. Although artwork 1S
unnecessary, the formulary should be visually pleasing, easily readable, and professionat
in appearance. The need for proper grammar. punctuation, correct spelling. and neanc
is obvjous.
There is no one Single 1ormat or arrangement which all formularies must tolloW
However. a typical formulary must have the following composition:
1. Title page.
2. Names and titles of the members of the pharmacy and therapeutics committee.
3.
Table of contents.
68Hospital Pharmacy
4. Information on hospital policies and procedures concerning drugs.
4.1 The pharmacy and therapeutics committee.
4.2 Objectives and operation of the formulary system.
4.3 Hospital regulations and procedures for prescribing and dispensing arug
4.4 Hospital pharmacy services and přocedures.
4.5 Information to use the formulary.
5. Products accepted for use at the institution.
5.1 Items added and deleted since the previous edition.
5.2 Generic-brand name cross reference list.
5.3 Pharmacologic/therapeutic index with relative cost codes.
5.4 Descriptions of formulary drug products by pharmacologic therapeutic class.
6. Appendix.
6.1 Central service equipment and supply list.
6.2 Rules for calculating pediatric dose.
6.3 Nomogram for estimating body surface area.
6.4 Schedule of standard drug administration times.
Several Techniques can be used to improve the appearance and ease of use o tne
formulary. Among these are:
1. Using a different color paper for each section of the formuiary.
Using an edge index.
3. Making the formulary pocket size (approximately 4 inch x7 inch).
4. Printing the generic name heading of each drug entry in boldface type or using some
other method for making it projected over the rest of the entries.
The format is extremely important since it will determine the practicality of daily use of
the formulary as well
development of the hospital formulary format, it i suggested that the hospital pharmacist
gather formularies from various hospitals for guidelines
2
the publishing costs. Prior to commencing work on the
A formulary that is sufficiently small and handy in size will, in all probability. enjoy
widespread acceptability and use in an institution
No specific size can be recommended, however, this determination can be arrived at after
careful study of the local need as well as the formularies gathered from local hospitals or
SIZE OF FORMULARY
other sources.
A formulary can be presented in loose- leat or bound type. A loose-leaf formulary is
unbound and thus can be kept current by inserting merely papers having modifications.
On the other hand, a bound volume is difficult to keep up-to-date and therefore requires
LOOSE-LEAF VS BOUND
more frequent reVision.
Those desiring a permanently bound volume also have many selections to choose form
ranging from paper to cardb0ard to plastic or its Substitutes. The controlling factor here
Will, in all probability, be the cost involved.
A printed hospital formulary IS GBviously more esthetic in appearance and easier to read.
69
PURLICATIONHospital Formulary
It also imparts to user the impression that hospital considers formulary as an cxtrem
important document and therefore worthy of cost of printing This does not mean ta
photocopy or computer printed formulary will not be used or is not good
The formulary is a professional publication and should reflect the high ethical standar
of the hospital and its staff. So drawings. colored ink, and colored paper should b
avoided. A white or slightly of-white paper should be used. Black ink is always in pud
taste.
Now computer. like all other fields is being used for preparing and publishing he
hospital formulary. Utilization of computer for this task are may lower the cos of
producing the formulary. The formulary information can be adopted for ftuy
applications resulting from computerized hospital information systems. Online services
are available to hospitals from which a hospital formulary can be prepared
ROLE OF PHARMACY AND THERAPEUTICS COMMITTEE
The role of pharmacy and therapeutics committee in formulary development is se
important that the formulary system's initial step demands selection of a competen
pharmacy and therapeutics committee. irespective of size. specalty. or conrol
Developing, maintaining and updating of hospital formulary is one of the major roles of
pharmacy and therapeutics committee usually dominates its other tasks.
The pharmacy and therapeutics committee has the following potential roles in preparation
of a formulary:
ASSISTANCE IN POLICY FORMATION
The pharmacy and therapeutics committee assists in formulation of broad professional
policies relating to drugs in institutions, including their appraisal, selection. procureme
storage. distribution, safe use, and policies and rules for admission of a drug to formulary
PREPARATION OFA FORMULARY
The preparation of hospital formulary is the prime responsibility of pharmacy and
therapeutics committee. This committee freely evaluates drugs for to be admited to or
rejected from the hospital formulary. After decision of the inclusion of drugs
formulary, a pharmacist undertakes the production aspects of preparation
The pharmacy and therapeutics committee selects the type of hospital formulary that best
suits the need among the various types such as a hospital owned formulary, simple dru
list or catalogue, or a purchased formulary service
Regular updating of the formulary requires evaluation, approval or rejection of drug
from the hospital formulary. It is the duty of pharmacy committee to develop a dru
evaluation process and form for this purpose (Figure 1).
The development ofa comprehensive data base is essential for evaluating drugs proposc
for admission to a hospital formulary. A thorough review of the pharmaceutical
medical literature is necessary when accumulating these data. The list of recommened
references include those sources that commonly provide useful information tn d
evaluation and have been mentioned in Chapter 17 on Pharmacy Library, Drs
Information and Poison Control Centre.
70Hospital Pharmacy
Drug evaluation form
(For accomplishment of evaluation procesS
Generic name and nanic all active eniities in the product in case of compound Ornug
Trade narmcts) most commornly uscd in the local arca.
Sourcets) ot suppiy. manataclurcr. suppiicr or marketing firm
Pharmacologic classilication
41 Comparison with existing drug
42 Mode of action
43 Clnical cticctiveness of the product and antibacterial spectrum in case of an antibiouc
Therapeutic indications.
S1 Approved uscs of the drug (prophylactic. therapeutic, palliative, curative, adjunctive, or supporuve
5.2 Uscs of drug in comparison with other established drugs preferably based on human dala and cove
eficacy. ucatment sSuccess, remission, sensitivity, ease of monitoring and treatment periou requrca
53 Non-approved (non-labeled) usesS for the drug
5.4 Potential drug-drug intcractions
Dosage forms available with cost of cach..
Bioavailability data for the most common route of administration and dosage o the arug.
Pharmacokinetic data.
8,1ADSOrption data including rate and extent of drug absorption by the usual routes of stration
factors poSsibly effecting the rate or extent of absorption and the therapeutic, toxic and lethal blood
levels. the time for onset of action. peak. and duration of therapeutic effect: the half-ile and factors
influcncing it are also included.
8.2 Distribution including the usual distribution of drug in body tissues and fluids. the drug's tendency to
cross the blood-brain barrier. placenta. or appearance in milk. protein binding and volume o
distribution
he
8.3 Metabolism. inclusive of information on its sites, extent, metabolic products and their activities.
84 Excretion, routes of elimination from the body. factors affecting it and the form(s) in which drug 1s
climinaled.
Dosage range
9.1 Dosage for differcnt route of administration.
92 Initial, maintcnance. maximum and pediatric doses.
10. Side cflects and toxicities
9.
T0.1 Side effects ol drug and their occurrence frequcncies in humans.
10.2 Means or methods of prevention or treatment of side elfects and toxicity.
103 Bencfits to risk ralio.
1 peCiai precaulion and contraindicalions.
12 Compare and list all advantages OT the orugB wIth extstung producis, using intormation trom
sections 5 10 as
basis of comparison
13 Disadvantagcs
4 Comparison of therapcutics
SComparison ol cost lor full treatment with the existing drugs.
16. Analysis of precedng dala, medical prelerences and drug availability.
17 Recommendations and action to be taken in regaro to the hospital tormulary status which is one of
the
following
17.1 Acoepted for inclusion in formulary.
Oncontrollcd ~ availabie for use by all medical staft
b. Monitored- availabie tor use by all medical statr, but with monitoring by a department
a Restricted- available for use by mcdical statt ot a specific service or department
b. Conditional -available for use by all miedical stat tor a specilic period of time
72 Rejected for inclusion
17.3 Deleted from current lopnulay
Figurel: Drug evaluation formHospital Formulary
SELECTION OF INFORMATION TO BE PROVIDED
The information provided in a formulary is the decision of pharmacy and therapeutics
committee. Insufficient information doeş not enhance the use and acceptance of the
formulary by the staff. On the other hand, the busy practitioner will reluctant to use a
Tormulary containing too much information. Thus the ideal situation lies somewhere in
between these two extremes
SELECTION OF FORMULARY CONTENTS
When pharmacy and therapeutics committee decides to formulate a formulary, a decision
must be reached as to have possible contents among the following available choices: fa)
section on prescription writing, (6) section governing the use of drugs, (C) tables of metric
weights and apothecary and household equivalents, (d) table of common laboratory
values. (e) section on the calculation of dosages for children based on established rules
and by use of the body srface method. ( pharmacological index, and (g) section on
reagents.
DECISION FOR THE FORMAT OF FORMULARY
The pharmacy and therapeutics committee also advises over the decision for the selection
of the type of the format of the formulary in terms of: (a) size, (b) loose leaf or bound, (c)
printed or computer printed or photocopies, and (d) extent of categorizing and indexing.
ADDITION OR REMOVAL OF DRUGS FROM A FORMULARY
As has been mentioned before, an efficient formulary system must be able to respond the
ever-changing demands of the practice. This can be achieved by a regular revision and
updating of the formulary. A formulary can be updated continuously by inclusion and
withdrawing of the drugs when situation requires so by using form mentioned in Figure
2.
The drug inclusion method must allow any prescriber to propose a drug for consideration
and should be able to provide an evaluated response within a reasonable time. Evidence
of any advantages the proposed drug has over formulary-listed drugs, in terms of
efficacy, safety, cost and patient acceptability will be essential. Inclusion must not be
restricted to a newly available drug in marketplace, rather, any drug not existing on
formulary can be proposed.
DRUG INCLUSION CRITERIA
The assessment of the worthiness of a drug for admission to the formulary is the most
difficult and troublesome among all other task of pharmacy and therapeutics committee.
This is due to the fact that no single member of the committee is qualified to evaluate the
therapeutic efficacy of every drug in every area of clinical specialization. The committee
should feel free to invite staff specialists to attend specific committee meetings for tune
purpose of evaluating preparations commonly used for inclusion into the formulary.
A drug can be included in a formulary only if it meets the following criteria
1. Having an official status, i.., has been included in any of pharmacopOcla
compendium, national formulary or their supplements.
2. Having known composition.
Has proven clinical value based upon experience of local general and speciality sta
72Hospital Pharmacy
with
Manutacturer having a proven integrity. dependability and reputatio
5. The drug 1s not naving a multiple composition if the same therapeutic etteCt ce
achieved througn the use ol a single drug entity depending on the insttaoa P olicy
4
for this.
Department of Pharmacy
Request 1or formulary change
Request for
Admission:
Deletion
Generic Name:
Trade Name (s):
Manufacturer:
harmacologie class
opica
Dosage lorm(s): Oral
Strength:
Tist of vehicles. preservatives, and solubilizers where applicable:
P'arenteral
. Other (specily)
Similar products included in lormulary:
Similar products by other manufacturers:
Justilication with reterences:
Will drug be used:
Widely for inpatients?
Widely for outpatients?:
B
C
On a limited basis?:
Requester s Name:
Department:
Signature
Telephone:
Date
Cost of the drug (to be completed by the Pharmacy Service)
Completed forms should be directed to the Department of Pharmacy Services
Accepted a) lor general lormulary
b) lor conditional formulary
c) for restricted use
Restricted Reasons:
Deferred Rcasons:
Date action taken:
Figure 2: Request for formulary change initiated by members of medical staff
Inclusion criteria for multiple composition drug
The multiple composition are also called tixed dose combination. The pharmacy and
therapeutics committees of some hospital do not recommend such drugs if the same
therapeutic effect can be achieved through the use or a single drug entity. This is in spite
of the fact that fixed-dose combinatons or arugs are sare and eifective and provide
Important advantages to patients and physic ians.
This basis for this policy 15:
1. The use of multiple composition drugs is, gccta 5 considered as a p0or practice
73Hospital Formulary
since in such drugs, fixed dose ratio of ingredients are determined by cturer
and not by physician.
2. Dosage and frequency of administration of the individual drugs may be varied in
accordance with a pátient's requirements and thus it is generally advisable to
administer multiple agents separately.
Unavailability of the substantial reasons or data to believe that each drug ingredient
will make positive contribution to intended effect and that the risks of adverse
reactions of each ingredient will not be multiplied or will overriding benefit.
4 Each drug is to be given at dose level expected to make its optimal contribution to
the total effect, taking into account the status of the individual patient and any
synergistic or antagonistic effects that one ingredient may be known to have on the
safety or efficacy of the other.
For a combination drug to be included in formulary there must be reasonable indication
that each active component contributes to claimed effect of the product.
Once the pharmacy and therapeutics committee agrees upon a set of guiding principles
regarding fixed dose drugs for their addition or deletions from hospital formulary, it is
recommended that these principles should be published and included in the finished
formulary. In addition, it may be desirable to circulate these amongst the medical stafi in
order that they may have prior knowledge of them and therefore acquire an understanding
of why a particular preparation may not have been included in the final publication.
DRUG WITHDRAWAL CRITERIA
The drugs are withdrawn from the formulary because of any of the following reasons:
1. The manufacture ceases its production.
2. Withdrawn of the product license by drug authorties.
3. Evidence of severe adverse effects as provided by post-marketing surveillance
studies.
4. The drug has not been prescribed for a long period of time.
USE OF NON-FORMULARY DRUGS
A formulary cannot be expected to cover all possible situations and thus a patient can
receive treatment out from a formulary's recommendations. This is called non-formulary
drug treatment. A limited supply of such non-formulary medicaments is to be stocked in
hospital pharmacy. The good pharmaceutical practice requires that there should be no
problem in supplying a non-formulary drug in an institution. Some hospitals require
completion of a form by a senior medical staff for every non-formulary drug, which is to
be prescribed. An efficient formulary system requires that all requests for non-formulary
drugs must accompany the reasons why a formulary drug is not suitable for the current
situation. This helps in evaluation of the frequency of requests and also acts as a
hindrance to prescription of non-formulary drugs. It is suggested to include the frequentiy
requested drugs in the formulary.
A non-formulary drug in many institutions is dispensed only to inpatients on a
physician's order by the use of a non-formulary drug request form as mentioned in Figurc
CATEGORIZING AND INDEXING
An effective categoriZing and proper indexing of the information on formulary s
74
Purchasing and inventory control
Purchasing and inventory control is necessary to maintain adequate stocks of drugs and allied items at
reasonable costs in pharmacy department. Purchase means to obtain an item by paying money per its
equivalent or to buy for a price. Inventory is an itemized list of goods with their estimated worth
specifically an annual account of stock taken up bya business . the world control specifies
exercising,directing, guiding or retaining of power-over. Thus purchasing and inventory controlspecifies
the obtaining , managing and maintaining of drugs and medical supplies in a pharmacy.
Purchasing and inventory controlis a main stream function of hospital pharmacy . a successful hospital
pharmacy is very much dependent on the effective purchase and inventory control of
pharmaceuticals .the over-all purchase and inventory control of an institutional pharmacy is the
responsibility of the administrative staff of the hospital or its duly authorized delegates.
The volume of the inventory of drugs and supplies will depend upon the variety of items and size ,
activity, and type of an institution . an inventory of a pharmacy of a teaching or large hospital may
include drugs , parentals and irrigating fluids ,surgical dressing ,rubber goods ,sutures ,surgical
instrument , syringes and laboratory supplies . generally the pharmacy inventory should be adapted
according to the individual hospitals needs taking into consideration its distance from asource of supply ,
storage facilities , and rapidity of inventory turnover.
Procurement procedure
Selection:
The selection of pharmaceuticals and other related items is a basic and extremely important function
that must be accomplished by hospital pharmacist. A pharmacist is at better position for making
decisions regarding products , quantities required , product specifications and source of supply . this
responsibility must not be delegated to another individual . it is the pharmacists obligation to establish
and maintain standards assuring the quality ,proper storage, control and safe use of all pharmaceuticals
and related supplies . though purchasing department can perform actual purchasing function, yet
setting of quality standards and specifications require professionals knowledge and judgment and must
be performed by the pharmacist.
Economic and therapeutic considerations take it necessary for hospitals to have an efficient ,well
controlled and updated formulary system. Under this system , it is the pharmacists responsibilityto
develop and maintain adequate product specifications to aid in the purchase of drug and related
supplies. The usp-nf is agood source for drug specifications. There should also be criteria to evaluate
acceptability of manufactures and distributors or items. A hospital pharmacist must have the authority
to reject a pharmacy drug product or supplier when the professional judgement dicates so. The
pharmacy and therapeutic committee recommends the guidelines for selection of the drug product.
Economy , quality, and efficacy must be considered for selection of a brand . there must be a proper
balance between quality and cost when more acceptable suppliers market a product meeting
pharmacists specifications . in selecting a manufacture , vendor or sorce of supply ,the pharmacist must
consider price , items, shipping , times, dependability , quality of service , returned goods policy and
packaging . however ,prime importance must always be placed on drug quality and manufacturers
reputation because the pharmacist is responsible for quality of all drugs dispensed by the pharmacyPage
1
PURCHASING
Drugs and allied items can be purchased by any of the following method:
Direct purchase from the manufacture or wholesaler
The direct purchase from the manufacturer or the wholesaler is the procurement of the
drugs and allied items from their manufacturers or wholeşalers. Usually this purchase is
not with any sort of discount and is not usual.
Bid from either manufacturer or wholesale Selet R
Under bid purchase, pharmacist estimates drug usage for a giveň period and the reputable
manufactures or wholesalers are invited to quote their prices for selected items. The
manufacturers submit their bid quotations (offers for prices of drug and other items). The
drug purchase order is forwarded to company with the lowest price, yet with standard
quality, usually receives the order for the material, after which the purchase order is
prepared.
With regard to bid purchasing, a word of caution needs to be considered. If the bids for
drugs are released to a selected group of reputable manufacturers, then the lowest bidder
should receive the purchase order and the hospital may be assured of receiving first
quality merchandise. If, on thẻ other hand, the bids are released to all vendors requesting
them, the lowest price does not always mean quality merchandise. Therefore, if this type
of bid release program is to be employed, it is strongly recommended that some
arrangement should be made for the analytical and clinical testing of samples of the
product. This testing program may be carried out by a local laboratory or by the hospital.
While estimating for the required quantities, it can be done even for a multiple-years
period. However, the hospital has the option to determine when and how much will be
shipped at any time during the contract period. The use of competitive bidding is
considered good practice where a drug is used in large bulk amounts. An annual purchase
the hospital pharmacist eliminates significant amounts of paper work and unnecessary
frequent bidding.
Page 1
Purchase from local retail pharmacy
Purchase from the local retail pharmacy is costly and is performed only in emergency
cases.
Page 1
The contract purchase arrangement can be done with manufacturer, wholesaler, or with a
company for hospital supply. This system is known as prime-vendor system. Under this
method, institution and a single manufacturer or supplier enter into a contract for supply
of drug products on whenever needed basis for a specified period of time. Thus, multiple
purchase orders are eliminated and ordering may be facilitated further using a computer
and even an order can be e-mailed on a daily basis. In this mode of purchase, the vendor
provides materials to hospital for a small percentage fee. This provides for a minimum
inventory at the hospital and provides for an optimum inventory rate. Many departments
seek a turnover of stock 10 to 20 times annually. In addition, the prime vendor can
provide the hospital with coordinated purchase data and cost-control reports also.
The cost on drugs can be reduced by prime vendor contract or cost plus prime-vendor
contract. Under prime-vendor contract, the pharmacy guarantees that it will purchase a
specific rupee amount from the wholesaler. In return for guarantee, the wholesaler
reduces the standard mark-up, which is a practice known as 'cost plus'. Under the cost
plus prime-vendor contract, the wholesaler may use a cost plus formula, charging only
the manufacture's price plus a significantly lower handling fee. The prime vendor
arrangements increase purchases from the wholesaler (rather than from the
manufacturer), thereby reducing inventory and increasing inventory turns.
The private hospitals use single or multiple procedures mentioned above during a
yearlong drug purchases. The small volume purchase in government institutes is
permitted to be done by adopting bidding purchase. However, the routine purchase, in
governmental institutions is done through a medical store depot (MSD). For this purpose,
a purchase cell has been established in secretariat under direction of a section officer of
provincial ministry of health. This purchase cell advertises for prequalification notice for
pharmaceutical firms whereby, pharmaceutical firms showing interest to supply drugs are
accepted and listed with cell for 3 years period. Obviously, this prequalification is done
after asserting that the firms 'comply with standards, quality of the products and, of course
its repute as judged by a technical team including pharmacist and medical staff. After the
prequalification, an advertisement is given in press for bid. The lowest offer of only the
prequalified firms is entertained for drug purchase. Purchased drugs are then sent to the
MSD which manage to routé the purchased drugs and allied items to government
hospitals as per their demands submitted previously.
It would be necessary to note that few years back a pharmaceutical manufacturing
program was running in Punjab drug testing laboratory under the umbrella of MSD. This
program has ceased now.
Under centralized purchase, an institutional material purchase department or its
purchasing agent is responsible for purchase of drugs and related supplies. Purchasing by
the purchasing agent involves that the pharmacist, like all other department heads
requests the items to be purchased on a special form. The selection of brands and vendors
is thereby left to the discretion of the purchasing agent. However, pharmacist furnishes
specifications both as to quality and the sources for purchase, which may or may not
restrict the selection to the product of a particular manufacturer.
nder another system in centralized purchase while retaining actual purchase function of
purchasing department. utilize benefits of pharmacist's technical knowledge. In such a
System the pharmacist develops and states necessary specifications for drugs and allied
items to be purchased and has the authority to reject any article below standard or not
complying with specifications. The pharmacist may consult with the Pharmacy and
Therapeutics Committee concerning specifications for drugs. On the other hand,
pharmacist can also guide and assist the purchasing agent in purchasing function
This system has certain control and economic merits and can effectively function. It
must, hOwever, depend upon the close cooperation between the pharmacist and
purchasing agent. They should work hand-in-hand, each recognizing the importance of
the function and contribution of the other which can be made to such a specialized
purchase.
Purchase by hospital pharmacist: The other system is purchase of drugs and related
items by the pharmacist per se. However, payment can be made from the material
purchase department form the pharmacy account. The pharmaceuticals and related items
constitute specialties that require the technical skills of a formally trained pharmacist for
their proper selection and purchase. Hospital pharmacy Is the only department in a
hospital for which it is not advisable to have purchasing done by a material department of
a hospital or its purchasing agent. Since pharmacist has responsibility for compounding
dispensing and manufacture of the drugs used in hospital he should also have the
justification to specify the drugs to be purchased.
Drug Storage: The storage of drugs and related items is an important aspect of the total
drug control system. The important consiuerations for stocking of drugs in pharmacy are
Stabilty-compatible storage: Proper storage control in terms of temperature, lignt,
humidity, sanitation and venti lation conditions. compatible with stability of stored
product must always be maintained. These conditions are need to ensure the
maintenance of stability of the stored product for their shelf lives.
Secure storage The drug storage areas must be well secured. drug shelves and
cabinets should be designated so that the drug accessibility is limited to authorized
personnel only. The storage is also financially, physically and chemically secured.
Safe storage: Safety is also an important factor, and proper consideration shou
given to the safe storage of poisons and flammable compounds.
4. Segregate storage: Externals should be stored separately from internal medications.
Medications stored in a refrigerator containing items other than drugs should be kept
in a separate compartment.
be
STOREROOM ARRANGEMENT Mean ScU
After receiving. drugs are stored in hospital pharmacy called centralized storage or in
hospital supply storage facility. The drug storage in centralized facilities demonstrates the
reduction in labor and record keeping. as well as the tight control afforded by
centralization. Furthermore, in centralized store. responsibility for storage of drugs has
been delegated to pharmacist or his authorized personnel under his superviSIon.
1O nave proper supervision by a pharmacist on drug storage. the drugs should be stored
in an area directly under his control. This furnishes pharmacist with freedom of stock
arrangement. instituting of inventory controls. adjustment of inventory based upon his
Knowledge of prescribing trends of staff and preparation of inventory cost reports to
management
There is no definite rule specifying how a pharmacy storeroom should be arranged. Each
individual may so arrange the area to meet both his and the institution's needs. Several
satisfactory methods of drug stocking in pharmacy department are available. Drugs may
be stocked in an alphabetical order or according to code number sequence, separating the
solid dosage forms from the remainder. The system adopted is a matter of local choice
though all systems should conform to some basic principles if proper records and
efficiency are to be achieved.
Each shelf, drawer, or bin is numbered or identified to facilitate location of the item
during the taking ofa phy sical inventory as well as to locate the item for new personnel.
This identification also enhances safe dispensing of the drugs and eliminates medication
errors. There are numerous ways to accomplish identification.
Shelf-stripping: Shelf-stripping is a technique that consists of applying a strip. having
identifying information to the front run of the shelves. The usual information placed on
strip tape consists of name and strength of product. unit S1ze. maximum and minimal
level. the re-order point being the minimal level. The strip applied may be a tape. plastic
or metallic. Stripping can also be achieved by attaching a card to wooden shelf run by
means of thumbtack or stapler. The plastic or metallic strips permit the insertion of a card
bearing the essential data.
Floor-marking: Floor marking 1s an 1dentification technique of floor and consists of
preparing a stencil with the necessary inlormation and painting it on the storeroom floor.
This is best done on concrete or wooden tloors. n areas where the floor is tiled or
marking the floor is not desitable, a good quality tape with adherability may be
employed.
In general hospitals handling a variety of supplies, the storeroom is divided in the
separate areas for drugs, controlled substances, biologicals and other cold room storing
drugs, narcotic vault, surgical supplies, sutures etc:
STOCK CONTROL Mean Stock Jea) Malukau
Adequate stock control is vital wherever medications are kept, whether in general storage
in main pharmacy, satellite pharmacies, nursing units, patient care areas, emergency
rooms, operating rooms, recovery rooms, or treatment rooms. Expiration dates of
perishable drugs must be considered in all of these locations and stock is rotated in these
different locations as required. For those products agreed to be held in stock at all times,
out-of-stock situation must be prevented and expiry dates must be recorded and acted
upon. A method to detect and properly dispose of out-dated, deteriorated, recalled, or
obsolete drugs and supplies should be established. This can be achieved by periodic
audits of all medication storage areas in the institution the results of which should be
documented in writing
Records. An adequate record keeping system must be devised and maintained where byy
numerous easily retrievable records are to be retained. These records are required for
management, inventory control, assessment of departmental progress and sometimes foe
legal protection. Records must be retained for at least the length of time prescribed by
institutional policies. Among the records needed in drug distribution and control system
are.
Purchase and inventory records
Controlled substance inventory and dispensing records.
Records of medication orders and their processing
Manufacturing and packaging production records.
Purchasing procedure
Usually plan of purchasing procedures is accomplished by a pharmacist and a hospital
purchasing agent collaboratively. The purchasing procedures initiated with completion.of
a purchase request form for the products desired by a pharmacist or a person authorized
by him. Drugs coming from the same vendor may be grouped upon a Single form. Thiss
form provides the purchasing department with the data concerning typically description.
en p( e
specification, packaging, price, quantity needed as well as information concerning the
inventory balance and anticipated monthly use. In addition, this form also is the source,
document for information for accounting office concerning cost and discounts etc. De
original of this form should be forwarded to the administrative officer responsible for the
department for approval. Upon his approval, this form is then forwarded to the
purcnasing agent. The copy is retained by the pharmacist as a record of the fact that the
merchandise is in the proces of being procured.
Upon the receipt of the approved purchase request, the purchasing agent prepares un
official purchase order. This form utilizes the data from the source documen, c
purchase request. The purchase order may take the form of any number of dierent p
- it may consist of a two-page or a many page snap-out form. The majority of institutions
prefer the multi copy snap-out form since it provides a copy for the vendor, accous
payable department of the hospital, purchasing number file, initiating department. wo
receiving reports and a history copy. The vendor's copy is sent to vendor
One copy 1S retained by the purchasing agent for his number file to serve as a Source or
intormation for purchase department whenever a question is raised relative to the
ISSuance of the order this is also used in ascertaining rates of use, etc wnile
1. One copy is forwarded to the accounting office where it is held until the invoice is
received from the vendor and the completed receiving reports from the initiating
department. Then and only then may the invoice be processed tør payment.
2. 1hree copies are returned to the pharmacy department. One copy should be matched
with the request for purchase to check for accuracy. The other two will also serve as
receiving reports. If the order is received in full; one copy is to be completed and
forwarded to the accounting office. Should merchandise be back ordered, the second
receiving report is utilized.
Some hospitals prefer to use a purchase order form and a receiving notice separately. T he
disadvantage in the use of this system is that the individual receiving the merchandise
must record by hand the name ot each item. This may cause error and, if rushed by the
load of work, a delay in receiving the completed memo in the accounting office, thereby
causing a loss of the discount for prompt payment.
Whenever merchandise that has been received by the hospital is to be returned to the
vendor for any cause, a returned goods memorandum must be prepared for' record
purpose, This form is of the snap-out type and provides copies for the accounting
department, purchasing agent, storeroom, Initiating department and the vendor
Once the merchandise is receivea, lt Is tne auty or the pharmacist to record upon a
Purchase Record the transaction for each item purchased. By so doing, he will have
available a source of reference for determining date of use, cost of drug, source, etc.
Some pharmacists feel that this card should be maintained by the purchasing agent and
made available to them whenever necessary. Whichever way the situation is to be
handled is irrelevant so long as the card 1s prepared and kept up to date. The final
decision as to whose responsibility it 1s rests with the desires of the administrator.
On occasion, merchandise may be ordered from the pharmacy at a time when it is out of
stock. This may happen quite frequently in pharmacy departments handling surgical and
laboratory supplies as well as drugs. When this happens, an out-of-stock form should be
prepared in duplicate and one copy sent to the initiating pavilion or laboratory. The other
copy is retained in the pharmacy. This form serves dual purposes. Firstly, it speeds up the
delivery of merchandise to the floor upon its arrival and secondly, it prevents the pavilion
or laboratory from reordering and creating a false sense of heavy demand, which could
result in over ordering by pharmacy
CONTROLS ON PURCHASES
The control on purchases can be instituted by inventory controlling. Various tools for
inventory management are:
ABC concept
A simple tool used ror inventory management is the ABC classification of inventories.
The basis of this ABC concept is the fact that relatively few items account for the major
part of the inventory. Under this concept, the drugs are classified as highest-, mediumand low-value items, regarded as A, B and C. respectively. The highest-value items are
few but have cost more. medium-value items amount for comparatively more in an
inventory but costs bit less as compared to the highest-value items while the low-value
items represent highest number in an inventory. The combined value in rupee of A and B
items which. are less in number than that ot C items but cost more as compared to C
items. When there are substantial number of items to be controlled, emphasis should be
given to A and B items since they constitute the major portion of otal inventory value
(usually about 90% or even more). The inventory levels of C items should be given little
attention and can even be kept at a high level Since they contribute only a small percent
of raising or lowering of inventories.
Money limitation on purchase order
Many administrators exercise a power of control over the volume of purchases by the
pharmacist by placing a money limitation on the purchase order. But in this method
15Suance of multiple small orders in the long run is morę costly for the hospital.
Inventory turnover based order
A more modern and reliable means is the computation of inventory turnover. Inventory
turnover is ratio of the cost of goods sold during the fiscal period by the average of
opening and closing inventories. This gives the number of times the inventory has been
turned during the fiscal period
A low turnover indicates:
1. Duplication of stock - ordering of the items already present in surplus quantities
2. Large purchases of slow-moving items purchasing of items having less turnover
Dead inventory- the items with no or very little turnover.
A high turnover of inventory may be due to small volume purchasing. Large volume
purchasing may take advantage of the maximum quantity discounts due to bulk purchase
A turnover of 6-8 times a year is considered satisfactory for most institutions. However
institutions with limited budget may wish to increase their turnover rate. This is a policy
decision and should be arrived at by discussion with the administrator.
Economic order quantity (EOQ) is another way to control purchase. Here the decision of
inventory volume is based on the cost keeping in view that larger the purchase volume
lesser would be the cost. Determination of how much to order is the EOQ factor. In
deciding the EOQ factor ascertaining the cost ordering and the cost of carrying inventory
are important. The following must be considered in ariving at the cost of ordering:
1. All labor in purchasing.
2. Labor cost in supporting areas such as the stockroom, receiving and material control.
Cost applicable to payment of invoices generated by the purchasing section should
apply to ordering cost.
COst of general operating supplies such as pencils, paper, forms etc.
5. Freight and telephone costs.
After all of the above are applied to total cost, and dividing the resulting figure by the
total number of purchase orders gives the ordering cost in rupees per order. To determine
carrying charges consideration must be given to the following:
1. Space charge (rent) for the storage area.
2. Labor costs for storage operations.
3. Cost of supplies for storage operations.
Taxes (if applicable).
5. Deterioration.
6. Pilferage.
Dividing the value of average inventory by the total of above cost results in carrying or
inventory holding cost for the particular inventory item. Thus, it may be advantageous to
order expensive items on a monthly basis and inexpensive items annually. In genera,
carrying charges may range from 18 to 30%.
Thus the formula for determining Economic Order Quantity is the following:
EQQ Unit cost x Inventory Carrying Cost
2x12x ordering cos
On the basis of the above equation purchasing agents have developed nomographs to
simplify figuring the EOQ. The EOQ equation shows that the most economic lot size is a
function square root of the monthly usage of items expressed in rupee.
Reorder Quantity Level,
The components of reorder point system are safety stock, order point, and order quantity.
Safety stocking is to ensure stocking of some extra units of items necessary to
compensate the errors in forecasting
inherent errors. Obviously, zero stock level must be avoided because it can cause serious
problems and this can be avoided by the system of safety factor. Ordering point is
replenishment ordering of supplying items when the consumption of items reaches a
predetermined number of items. The remaining number of items is determined depending
on the lead time. Lead time is the time lapse between placement of an order and time it 1s
received.
echnique since all forecasting techniques have
ldeally, the remaining inventory should be almost depleted before the arrival of the new
shipment. Reorder (RO) is determined by:
AU
RO-x AVLT+SF
3
Where AU is the average usage rate of a product per month in units of issue, 13 are the
number of weeks in a year plus I, AVLT is the average vendor lead time and SF is the
safety factor. The safety factors for vendor lead time have been cited in literature
In the application of the above formula, following points must also be considered:
1.Unanticipated large increases in usage.
2. Shelf life of the items involved.
3. Unusual delays in delivery caused by strikes or storms.
4. Necessity for rechecking the reorder quantity level periodically to allow for a change
in usage rate.
DISCOUNTS IN PURCHASING
There are three ways in which merchandise may be purchased at a discount or savings
Volume contracts
As mentioned under the section of contract, the volume contracts are offered by a
majority of pharmaceutical manutacturers and include contracts to cover total purchases
of pharmaceutical goods. Under this system, the institution approXimates its annual
consumption of the particular products and signs an agreement with the company to
purchase this amount on a contracted price. The contracted prices Is usually less as
compared to the price charged for usual purchase. Furthermore, a contract price is usually
protected from an increase whilst any reduction in price is passed onto the hospital.
Bonus Deals
Deals represent a type of transaction involving the purchase of a specified volume and
receiving certain quantities of the product on bonus at no additional cost, e.g., one free
with the purchase of a dozen. There is nothing wrong with this type of purchase if the
free goods remain in the pharmacy inventory. In order that the inventory not be under
stated, the entry 1nto the hospital inventory records should indicate that thirteen units
were received for the price paid.
Discounts
Discounts may be given to an institution tor the prompt payment of its drug bil
Because of the large volume of drug consumption, these discounts amount to a sizeable
sum of money at the end of a year. Other types of discounts are also available from the
manufacturers. A hospital pharmacist should immediately investigate the discount policy
of every new firm with which he deals.
CONTROL OF DATED OR PERISHABLE INVENTORY
Dated inventory such as biologicals or antibiotics requires special control in order to
insure potency at time of dispensing and to be sure that the pharmacy is not carrying
worthless stock in inventory. This can be accomplished by use of a form such as record
of dated pharmaceuticals (Figure 1)
Each dated product is entered on this sheet which provides name of the product, date of
purchase, manufacturer, control number and the expiration date. By lacing a check mark
in the box of the appropriate month, the pharmacist can tell at a glance which product is
expiring and should be replaced or returned for credit.
Some pharmacists prepare a separate sheet for each dated product. This modified sheet
eliminates the need for re-writing the name of the product each time it is purchased. I he
remaining information and format remains the same.
Kole of computer: A computer, operated with appropriate software could be very helpful
for purchasing and inventory control in a hospital. The computer can automatically
Subtract each items from the inventory on its dispensing and entering in it. This
subtraction is continued til the number of units for the product reached to a reorder point
and will alert the user about this.
This system also forewarns well in advance about the expiry of products and can generate
statistics for annual consumption and turnover of all products each year automatically
Thus. use of this artificial intelligence, can make the tasks of phanmacist easy and can
save his valuable time that can be utilized productively.
TAKING OF A PHYSICAL INVENTORY
Taking of a total physical inventory in pharmacy is required during an auditing to check
the hospital's fiscal operation internally be hospital itself or externally be an auditing
firm. Since the pharmacy inventory usually is the largest in rupee value. it receives a
great deal of attention. On the other hand, some auditing firms will require only a spot
check type of inventory on 10 or 20% of the high-cost, fast-moving items.
The following steps accomplish the physical inventory taking
PlanningB
The actual taking of a physical inventory cannot be undertaken without a great deal of
planning and attention to detail. Anything less than one's maximum effort will lead to a
fauity inventory and thus to a repeat performance.
Stock review
Some period ranging from 1 2 months before taking of an inventory. the pharmacist
should review his stock and remove from it all merchandise. which has not moved since
the last inventory. In addition, any merchandise should be removed which has been
purchased during the year but has not moved appreciably 'during the preceding three
months. These items should be returned to vendor for credit whenever possible. If such a
move is not feasible, they should be written off the inventory via an adjustment in the
books of account in the business office.
Once this has been accomplished, the inventory should be recorded on the inventory
sheets. This recording should consist of only the name of the item, or other identification.
The sheets upon which the recording is to take place should be in dupiicate, and should
have proper spaces to show the date, location, recorder and caller.
Receiving inventory
The actual taking of the inventory may start at the close of a business day or at a time
when there is no movement of merchandise. At this time the pharmacy staff and its
helpers may arrange themselves into teams of two - one to record and the other to call out
the name of the item, price, and count. As each sheet is completed, it is handed to the
auditor supervising the inventory. It is the right of the supervising auditor as to how many
entries he wishes to check out. The usual procedure is to check all high priced items and
to random check the less valuable entries.
Any merchandise ordered prior to the date of inventory and received on the day of
inventory or shortly thereafter need not be counted. The invoices pertaining to these
purchases should be clearly marked with the fact that they were received post
inventory. The accounting office will make the appropriate adjustment in the final
inventory figure to account for this merchandise.
PERPETUAL INVENTORY
A perpetual inventory maintains a record of all items on it, their balances in quantity and
in values. The maintaining of a perpetual inventory is, of course, an ideal situation if the
record-keeping- can be kept up to date. In many small hospital pharmacies, the
pharmacist, at the end of each day, summarizes all drug charge slips and makes the
proper posting in the perpetual inventory file. The process of tabulation may be
accomplished either by pegboard method, by use of punched cards or by use of a
computer.
Pegboard method
The pegboard method requires a pegboard and requisition forms with holes evenly spaced
and punched along the top. The forms are then aligned on the board so that the first sheet
is entirely visible and subsequent sheets covering all but the section showing the quantities ordered. The forms are then summarized across into one master requisition form
that-is used for posting the inventory records.
Automated method
By using an automated system, it is possible to have purchase orders, receiving reports
and disbursement requisitions forwarded to the tabulating department daily, where
transaction cards are punched which issue a comprehensive stock status report. This
report may be produced on daily, weekly or monthly basis.
Computer method
The latest and most sophisticated system for electronic data processing is the computer.
With one of these systems, a hospital can readily obtain a record of all inventory items,
and their balances in quantity and rupees value is maintained. The installation of either of
these mechanized systems is highly technical as well as costly and therefore the
institutional officers and pharmacist should avail themselves of the counsel and advice of
the various reputable manufacturers or consulting services before embarking upon such a
program.
MATERIALS MANAGEMENT
Materials management encompasses the movement of materials from point of origin to
point of use, and then to their final breakdown back into the environment. This definition
as applied to pharmacy will be the control over the drugs and related items from view
point of its procurement, storage, use, inventory control and disposition, if any. Material
management include the inventory forecast, availability of supplies at the right time at
right quantity, at right inventory investments (economical cost). This will leads to the
best patient service with the lowest inventory investment. To this effectively, a
pharmacist control over purchasing, receiving, stocking and distribution and dispensing.
Material management can be accomplished by a careful inventory control based on
statistical and mathematical approaches. An inventory is needed to satisfy future demands
In this Chapter, purchasing and inventory control has been discussed from the viewpoint
of the department of pharmacy. However, a pharmacist has not the complete control over
drugs from purchase to disposition. It is possible that the director of material management
has the responsibility over purchasing, receiving, inventories, central sterile supply,
laundry, and distribution, messenger service, traffic and material disposal activities.
In those hospitals utilizing the materials management concept, it is not uncommon to find
that the hospital pharmacist plays an important role in developing the program associated
with the acquisition, storage, distribution and disposition of biologicals, radioisotopes,
drugs and chemicals.
Safe use of medication
Insuring safety in handling and administration of drugs is the responsibility of pharmacy
and therapeutics committee as an ongoing program. Added to this, a pharmacist has a
moral, legal and professional duty for safe drug use in an institution. Safe use of drugs
encompasses an error free medication without occurrence of any drug interaction, adverse
drug reaction and drug toxicity. Unsafe medication rarely eventuated into fatality or a
sever injury but may increase patient expenditure for the additional treatment or a longer
institutional stay. The unsafe medication therefore, must be avoided and coped with.
Avoidance of medication erTors and rectification of the problems underlying medication
errors can implement safe use of medication program in a hospital. The other segments of
this program are: (a) medication error reporting system, (b) detection of adverse drug
reaction, (c) drug utilization review, (d) drug interaction surveillance, (e) drug product
defect reporting system, (1) therapeutic drug monitoring, (g) patient-care audits, and (h)
good pharmaceutical practice guidelines for safe drugs use.
Clearly defined hospital policies governing handling, dispensing or distribution of drug
products ensures safe medication in institution. If these practices are not being followed
in the institution, the hospital pharmacist is in the best position to judge, and is
responsible for development of required polices regarding handling. storage
administration or dispensing of drugs and related products.
MEDICATION ERRORS
A medication error simply is deviation of a medication dose from the physician's order or
prescription. in broader terms, medication error is administration of a wrong medicine,
dose, diagnostics, or to wrong patient. It also includes failure to administer prescribed
medication, at time specified for or in a manner it was prescribed. However, a wrong
dose that is detected and corrected before giving to patient is not regarded as a
medication error. The therapeutically inappropriate drugs or dose (therapeutic eors) are
excluded from the definition of the medication errors.
CATEGORIES OF MEDICATION ERRORS
Occurrence of one or another medication errors is a daily matter in a larger hospita
Following are the categories of medication errors:
Omission error
Omission error is failure t0 administer by nurse the physician's ordered dose. These
errors includes patient's intake of less than prescribed dose at any one administration,
discontinuing of drug before prescribed time and omitting dose prescribed as needed,
when it is needed. Omission error may lead to subtherapeutic level of the prescribed
drugs. The medication omission is not regarded as an error if a patient refuses to take
medication or if dose is not administered because of any recognized contraindications.
Unauthorized-drug error
Unauthorized-drug error is giving of drug dose not authorized for the particular patient.
In this medication errors included are the administration of drug to a wrong patient,
duplication of doses, and intake of an unordered drug. A dose given outside a stated set of
clinical parameters (e.g.. medication order to administer only if the patient's blood
pressure falls below a predetermined level) is also an unauthorized-drug error. These
errors may lead to unpredictable blood levels of the drugs in patient.
Wrong-dose error
A wrong-dose error is administration of wrong number of preformed drug units and it
may be above (2 tablets instead of 1) or below (1 tablet instead of 2) than the ordered
dose. It may be giving of the same drug from two different bottles simultaneously, taking
less or more than the prescribed dose at any one medication time or taking less or more
than the prescribed number of doses in any one day. In case of ointments, topical
solutions and sprays, wrong dose error occurs if medication deviates from dose expressed
quantitatively, e.g., 1 cm of ointment or two 1-second sprays or two bursts of an aerosol.
The wrong-dose error causes unpredictable blood/plasma drug levels. It might be
subtherapeutic or attain toxic level due to the administration of the less or more dose,
respectively.
Wrong-route error
he giving of a drug by a route other than the prescribed one is the wrong-route error, For
instance administration of drug through I/M route, instead of employing an I/V route or
oral intake of a transdermal patch.
Wrong-site error
It is a medication eror in which a dose is given at a wrong site, though via correct route.
Example for this error is instilling of drug into left ear instead of right. This error leads to
no therapeutic response
Wrong-rate error
The administration of a drug at a rate not specified in patient's order. The administration
of a short term infusion when a bolus I/V infusion was ordered is this type of error.
Wrong-dosage form error
Intake of a drug in a diferent dosage form than that of the specified in physician's order
Use of an ophthalmic ointment when a solution was ordered is the example of this type
error. A purposeful alteration, however (e.g., crushing of a tablet) or substitution (e.g.,
substituting liquid for a tablet) of an oral dosage form to facilitate administration is not
regarded a wrong-dosage error
Wrong-time error
The wrong-dose error is an administration of a dose of drug greater or lesser than its
scheduled medication time. A hospital sets a policy for maximum permissible deviation
of administration time. In most of the institutions, it is t I hour. Thikerror also includes
intake of a dose, prescribed as needed, at a time other than when needed in pro re nata
prescription.
Wrong-preparation of a dose
This type of error is an incorrect preparation of a dose not complied with physician or
manufacturer's instructions. The examples of this type error are use of incorect
reconstitution volume, wrong dilution, not shaking a suspension, not keeping a light
sensitive drug protected from light, and mixing drugs that are physically/chemically
incompatible. The use of an expired drug is also included under this error category.
Incorrect administration technique
The administration of drug by using an improper technique or a technique not consistent
with the instructions of physician though the drug is given through a correct route, at
right site and so forth. Examples are not using a Z-track injection technique when
indicated foř a drug. Z-track is an intramuscular injection technique used for medications
that stain upper tissue or irritate tissues. In this technique, the skin is displaced laterally
prior to injectipn, needle is inserted and syringe aspirated, and the injection is performed.
The needle is then withdrawn and the skin released. This creates a 'Z' pattern that blocks
the infiltration of the medication into subcutaneous tissue. The other examples of
incorrect administration technique include incorrect instillation of an ophthalmic
ointment and incorrect use of an administration device (e.g., use of inhaler or transdermal
device).
An error free medication is thus, administration of a drug following right instructions, to
the right patient at right time using right route at right site with right rate in a right dosage
form with right technique.
FACTORS CONTRIBUTING MEDICATION ERRORS
The most common factors, which contribute in occurrence of medication erTOrs, are
mentioned below:
1. Hospital administration related factors
Inadequate policies regarding safe use of medication.
Inadequate policies governing reporting of incidents in institution.
Inadequate policies concerning performance of task for supportive personnel.
Personnel related factors
Lack of hospital pharmacist.
Lack of administration nurse.
Overburdened personnel.
Techniques related factors:
Use of non-professional personnel in areas requiring professional judgment.
Inadequate labeling of drugs and allied items for nursing station.
Facility related factors
Inadequate storage and equipment facilities.
Inadequate drug stations on patient care areas
CORRECTIVE MEASURES
The reduction in patient expenditure on treatment, lowering the patient morbidity and
minimizing the stay in hospital is possible only when the therapy is effective and without
any medication error. The following are the measures that can be adopted to minimize
medication errors.
ADMINISTRATION RELATED MEASURES
In an institution, everybody from pharmacist to nurse, to physician to administrator is
responsible for the safe, effective and rational administration of medication. All the
healthcare members have their different roles and responsibilities to accomplish this task.
The administration of a hospital is mainly responsible for formulating policies regarding
all operations is an institution. An institute must have adequate and clear-cut polices as
for the safe drug use in the institute.
A comprehensive policy on incident detection and subsequent reporting system for each
drug accident in a hospital is to be formulated. It will force the employee to try their level
best for safe administration of drugs to patients. Such a policy contributes toward the
boasting up of patient care standards. This policy requires reporting of any happening not
consistent with routine hospital operations or routine patient care leading to a real
accident or a situation which might result in an accident.
The administrative authorities must also develop a stringent policy governing the role of
lay persons performing in the pharmacy department. The tasks that can be performed
independently, performed under pharmacist's supervision and the tasks strictly prohibited
must be discriminated. Once prepared, the policy should be recorded in the form of job
descriptions or each.
LACK OFA PERSONNEL
The medical care without a pharmacist may eventuate, into serious medication errors.
Large number of hospitals particularly medium sized and small private hospitals have not
deployed pharmacist to carryout pharmaceutical services. The same situation exists in
various government institutions. Some institutes though have pharmacists but without
actual job descriptions matching their knowledge and potentials. The majority of hospital
pharmacists of governmental institutions complains of lack of appropriate recognition
and is not admissible to cary out real responsibilities and tasks.
A pharmacist can prove his/her worth. For this, it is advisable that on receipt of a
prescription to place signature, it must be checked for its correctness and any potential
drug-drug interaction by using the up-to-date text on subject. The informative statistics
after a certain period of time can be presented to concermed authorities in a hospital. If
pharmacists do not receive any positive response, the information can be presented at
pharmacist and physician combined seminars, conferences etc. The recognition of the
profession will largely depend on the correctness of information and the way it will be
presented. The pharmacist, being equipped with the knowledge of all drugs related
aspects, can guide on the sare drug use in an institution. The institutions without a
pnarmacist should recruit and the institution where the pharmacists are not allowed to
utilize their potentials should acquire the full benefits of the pharmacists abilities and
convey these benefits to the patient care.
Suricient number of graduate pharmacists is available to take the responsibility as
hospital pharmacists.
Lack of administering nurse and over-burdened personnel are the other reasons for
medication error. Over-burdened workers are more prone to make mistakes. Thus ina
hospital, the pharmacy personnel should be staffed according to the work load of the
department for a productive division of labor.
USE OF SUPPORTIVE PERSONNEL IN PROFESSIONAL JUDGMENT TASKS
The areas requiring professional judgment have been mentioned earlier in Chapter o
Pharmacy and Its Organization. Such jobs are to be strictly prohibited from carrying out
by the lay personnel. These tasks briefly include: (a) taking telephone orders for new
prescription or for prescription refills, (6) weighing or measuring ingredients for
compounding of prescriptions, (c) mixing of already weighed or measured ingredient, (a)
compounding of prescriptions, (e) calculation of percentages in prescription
compounding. () affixing of prescription labels to medication containers, and g)
provision of information on use and precautions to patients and professional personnel
It must be the policy of an institution that the lay personnel should, under no
Circumstances, be allowed to exerCIse the asks, requiring professional judgment as
mentioned above. However, they may pertorm non-judgment jobs under supervISIon and
by doing so, the precious time or the prnarmacist can be made free which can productively
be employed in the accouplishment of professional tasks.
The director of the pharmacy service should developa strong policy governing the role of
lay persons performing n the pharmacy department.
INADEQUATE LABELING OF DRUG ISSUED TO NURSING STATION
The labels are affixed on to a container for two purposes, to identify the contents and to
bear certain information considered necessary. The labels can be served as an additional
safety factor through the use of a color coding system to discriminate various materials
and route of administrations. Under this system on white background, the labels with red
indicate poisons, blue indicate non-poison medications for oral use, green stands for
topical products, black for nasal preparations and purple indicative of ophthalmic
products.
Affixing labels should be an institutional policy matter and appropriate guidelines must
be provided. The containers dispensed to the nursing station must properly be labeled and
should, like the commercial labels bear information as to identity, strength,
administration route and cautions, if any. The format and type of information on the
labels varies and is according to individual pharmacist preferences. Many hospital
pharmacists prefer to mention generic name only and metric system on the pharmacy
labels. Others place trade name of product just beneath its generic name and some more
information to make a label more comprehensive.
Medication errors may occur due to wrong labeling, replacement of the labeling.
confusing label and insufficient information. The labels for medication containers,
therefore, must be legible, neat, uniform, understandable, unambiguous, comprehensive,
tactual and obviously with good adhesive quality. Prior to issue to nursing station,
pharmacist must ensure a uniform placement of labels upon each container. The labels
must be affixed at same height and position so as each container have a uniform
appearance on medication station.
Sometimes auxiliary labels are affixed along with the routine labels on a container to
provide additional and supplementary in formation on a special aspect of a particular
medication. Commercial availability of both main and auxiliary labels has made the job
of pharmacist very easy. In instances of commercial unavailability, labels can
computer-generated, printed or prepared by using typewriter. Affixing of labels on
medication containers is a judgement based task and is the responsibility of a pharmacist.
The labels can alternatively be affixed by supportive staff but under a strict pharmacist's
supervision.
INADEQUATE DRUG STATIONS ON PATIENT CARE AREA
Lack of facilities like inadequate space. poor lighting, storage of material necessary for
drug administration at different locations, inadequate equipments for storage and
administration and interference of passing personnel may distract the administrating
nurse and contribute to medication errors.
Following two apPproaches, largely depending on the siIze of institution are used for
resolving this problem.
Use of nursing station medication cabinet
The concept of nursing station medication cabinets effectively implemented in smal
hospitals or where constructions of separate medication room (details in next section) is
not possible. The ready-made commercially available stainless steel cabinets are
equipped with
medicine card rack, lockable narcotic cabinet, re frigerator for biologicals, light, syringe
drawer and wastebasket. These cabinets can easily be installed at a corner off from the
work-top counter, medicine cup dispenser, sink, medicine shelves,
main line of traftic or, where possible, to segregate the installation by a partition or
sliding-door arrangement.
Use of nursing station medication cabinet
The concept of nursing station medication cabinets effectively implemented in small
hospitals or where constructions of separate medication room (details in next section) is
not possible. The ready-made commercially available stainless steel cabinets are
equipped with a work-top counter, medicine cup dispenser, sink, medicine shelves,
medicine card rack, lockable narcotic cabinet, refrigerator for biologicals, light, syringe
drawer and wastebasket. These cabinets can easily be installed at a corner off from the
main line of traffic or, where possible, to segregate the installation by a partition or
sliding-door arrangement.
Provision of medication room
The medication room is purpose-built facility for storage and preparation of medications.
lt is enclosed for quiet, clear-glazed for observation both in and out, and sized to
accommodate more than one person to allow a team work when necessary.
Since the pharmacist is responsible for the safe use of medication, he can advice about
the minimum requirements of such a facility. The typical requirements for a medication
room are:
I. Divided shelves for individual patient medication, with a system for readily changing
patient identification by label system on each shelf division.
Secured and lockable narcotics safe.
3
Drawers underneath the work-top counter for storage of syringes and similar items.
Bulletin board at eye level in front to affix some preparatory procedures or
instructions.
5. Sink for hand washing. equipped with goose-neck nozzle and elbow-run handle
6. A refrigerator mounted above the counter is more convenient, provides better
visibility for drug storage, and allows greater ease in cleaning.
SAFE DRUG USE PROGRAM
A program for insuring safety in handling and administration of drugs is responsibility of
and therapeutics committee. A pharmacist is morally, legally and professionally
responsible for a safe drug use in an institution. Therefore, knowledge of all segments of
a safe drug use program will be of worth.
MEDICATION ERROR DETECTION AND REPORTING SYSTEM
An independent error detection system must be established in a hospital to minimZe
errors in medication. This system facilitates reporting of a medication error of clinical
significance to patient's physician and therapeutics committee when detected.
On receipt of the reports, reason or reported error is ascertained and errors are classifiecu
as non-significant, minor, significant, and critical. in case of a clinically significant error.
appropriate action is taken to minimlze the reCurrence of the medication in future.
A medication error must be reported on a standard medication error form typically
containing
a. Patient's identification.
Name of the drug, c. strength and route of administration.
b.
Time and date of the error.
Name and title of person wh0 made error
e. Category of error such as one from any mentioned below.
Name of doctor or nursing supervisor to whom incident was reported.
g. Brief description of treatment or the orders given by doctor as a result of the erO
h. A statement by nursing supervisO as to measures taken by nursing service to p
such error from recurring.
d.
f.
event
MONITORING ADVERSE DRUG REACTION
Broadly, adverse drug reaction (ADR) is any response to a drug which is noxious,
unintended and, which occurs at doses level used for prophylaxis, diagnosis-or therapy
feading to precipitation of a pathological condition. The adverse drug reaction may
include such events as toxicity caused by overdose (therapeutic, accidental, and
homicidal), hypersensitivity. allergy, or injury from any medication error.
The therapeutic use of drugs involves unavoidable risks of developing ADR in some
patients. An ADR may cost heavily to a patient for treatment and in severe cases, may
lead to patient fatality. An effective monitoring program for ADR or adverse drg
experience (ADE) can reduce treatment expenditure, minimize patient morbidity and
helps overall patient care.
ln an institute, pharmacy and therapeutics committee assumes responsibility of ADR
monitoring and to formulate effective prevention system and treatment. It develops and
institutes a prompt reporting procedure for an adverse drug reaction on a standard adverse
drug reaction report form available on every nursing station. Under this ADR reporting
program, pharmacy and therapeutics committee advises the following:
.
Medical staff is to report an ADR to chairman pharmacy and therapeutics commitec
In some 1nstitutions, nurses are also involved in reporting of an ADR because of thei
close contact with patients. A pharmacist can effectively be involved in reporting O
a potentialADR. Sometimes, allowance has also been given to patient for reporting a
reaction on a standard form. This can be effective in detecting both common and rare
ADR even in outpatient patients.
Based on the reports from all hospital healthcare members, a data bank for ADR
Occurrence can be formulated for study and to implement an effective prevention
program.
3, Besides, ADR reporting, other monitoring schemes may include P& TC - supported
postmarketing surveillance carried out collaboratively by hospital pharmacy and
pharmaceutical industry.
DRUG UTILIZATION REVIEW
Drug-use review (DUR) is an authorized, structured, ongoing system for impróving
quality of drug used within a hospital in which, pharmacy and medical staff are involved
collaboratively. DUR program requires development of an evaluation process for
prescribing, dispensing, administering, and ingesting of prescription drugs. DUR leads to
corrective measures that helps identitying problems in drug use, reduces adverse drug
reactions, optimizes drug therapy and minimizes drug-related expenditures.
The pharmacists always have recognized their responsibility to check safety of the dosage
regimen for each medication dispensed. Checking safety of a dosage regimen is more
complex today because of higher potency drugs, their use for more than one clinical
indication, their non-labeled uses and multiple drugs for one clinical situation. These
factors may multiply occurrence of drug interactions, and may cause greater likelihood of
allergic, idiosyncratic or adverse reactions. Under DUR, manifestation of these events is
to be documented to prevent their occurrence in future.
DUR iS accomplished by taking patient history, patient medication profile and laboratory
test profiles. A clinical pharmacist takes medication histories of every patient admitted to
hospital or seen in ambulatory care section. Medication history is taken by personal
interview or via a computerized questionnaire specifically designed for the purpose. The
medication profiles, in addition to personal identification and general diagnosis, contain
the following information:
1. Medication history inclusive of prescription, OTC drugs, and home remedies used at
time of admission and during the recent past.
2. Chronic disease status.
History of drug allergies, idiosyncrasies, and adverse reactions
4. Laboratory tests performed and diagnostic agents ingested.
5. Idiosyncrasy towards food products if any.
The Patient Medication profile is developed by the pharmacist to help:
1. Improvement in drug prescribing practices by promoting the safe and rational use of
drugs.
Detection and prevention of potential drug interactions.
Detection and prevention of adverse drug reactions in sensitive patients.
Detection and prevention of I/V additive incompatibilities
Detection of drug-induced laboratory test abnormalities.
6. Detection of possible drug-induced diseases
7
3.
Detection and prevention of potential drug toxicities.
When the patient medication profile, patient history and laboratory procedure protile ares
compared, the pharmacist is in an excellent position to monitor proper drug utilization
These will help the pharmacist to be aware of each patient, inclusive of all the
medications that the patient is taking currently when evaluating the safety of a newly
prescribed medication or perform DUR.
The manual compilation of drug utilization is a tedious task that can be simplified by
automated system. A computer-based system provides for the entry of the information
into the computer through keyboard or scanning device. Under this system prescription of
a new drug or any modification made in therapy is entered into computer. The following
information are entered: patient's name, age, sex, ethnic background, diagnosis, drug
product, manufacturer, therapeutic class, dosage form, strength, route of administration
directions for use, amount dispensed, days of therapy, drug efectiveness, toxicity
adverse reactions, reasons for termination of therapPy, prescriber's name and specialty.
This data can be incorporated in retrospective, concurrently or prospective reviews for a
continuing surveillance of drug utilization. A drug utilization review committee of the
hospital does this review. Hospital Pharmacist could be it member since this committee
requires to be broadly representative by various professional practice carried out in the
institution.
Responsibilities of the pharmacist in these activities include the following
Preparing, in liaison with medical staff, drug use criteria and standards.
2. Obtaining quantitative data on drug use (e.g., information on the amounts and types
of drugs used, prescribing patterns by medical services and types of patients). These
data will he useful in setting priorities for the review program
Reviewing medication orders against the drug use criteria and standards
4.
Consulting with prescribers on the results from (3) above
5
Participating in follow-up activities of review program (e.g., educational programs
directed to prescribers, development of recommendations for the formulary, and
changing drug control procedures in response to the results of the review process)
1he pharmacy records such as purchasing. monthly usage data, drug profiles t0
inpatients and outpatient, adverse drug reaction reports, etc. can also be used for DUR
DRUG INTERACTION SURVEILLANCE
Drug-drug interactions are not classified as adverse drug reactions, although they may
contribute to often avoidable, adverse drug effects. An interaction may either increase the
toxicity or reduce the therapeutic efficacy of a drug. Safe drug use in hospital requires
drug interaction monitoring.
Drug interaction surveillance is a program for a method to check on effect of one drug
action by concomitant administration of other drug or laboratory test agent. Maintenance
of the drug interaction surveillance is essential to ensure the patient and physician or total
drug safety. In a drug-drug interaction and drug-laboratory test reactions, multiple
mechanisms may be involved. This coupled with complexity of each mechanism
involved makes classification of drug interaction difficult, To recognize and surveillance
of a potential drug interaction, pharmacy practice theretfore requires a specialization in
pharmacy.
Drug interaction surveillance can be accomplished by devising a program of working
from a direct copy of the physician's original order sheet, preparing a patient drug profile
(PDP), and a drug interaction reporting form (DIRF), Up-to-date available texts on the
Subject can be used to evaluate a potential drug interaction. Now computer sottwares are
available tor a ready evaluation of interacting drugs in a prescription. Readers are
referred to the computer-aided dispensing (CAD) that can very effectively be used for
purpose of safe drug administration without occurrence of an interaction. Briefly, under
nis system, computer networking among the physician, pharmacist and nursing 15
employed. The physician enters order in his computer that is displayed on the computer
available in pharmacy. The pharmacist checks accuracy of physician's order and any
drug interaction by activating appropriate computer program for this purpose.
DRUG PRODUCT DEFECT REPORTING PROGRAM
The medications dispensed and supplied from pharmacy should meet high standards of
quality t0 assure safety and efficacy when used properly. Sometimes, an error or accident
happens with a finished product during its distribution whereby it does not conform its
specifications. A defect in drug may by anything which, in a professional opinion, is
considered to be defective or undesirably associated with the product. Any of the defects
may lead to an impaired therapeutic efficacy of product and prone to effect adversely the
health of a patient. It differs from adverse drug reaction where the drug conforms to its
specification.
The pharmacy committee sets down a system for drug defect reporting program whereby,
physicians or hospital pharmacists report any defect in a drug observed during its
distribution. The Reportable defects may include:
1. Inadequate packaging.
Confusing or inadequate labels or labeling.
Deteriorated, contaminated, or defective dosage forms.
Changed taste, color etc.
5. Inaccurate fill or count of a drug product.
6. Faulty drug delivering apparatus.
2.
4.
These product defect reports are judged for non-significance, minor, or major event and
for the corrective action required. Thesc repots can be shared with manufacturer or
distributor or drug regulatory authority for information and improvement.
The pharmacists play an important role in detection and reporting of product defects
through participation in defect reporting program. The information provided through this
program helps to hospital, manufacturer and drug authority in maintaining quality
standards of drug. These reports may result in changes in product labeling, warning
letters to health-care professionals regarding safe conditions of use, requirements for
further clinical/safety studies or, in some instances, withdrawal of the product from the
market.
Some institutions carrying out clinical studies employ automated computer-based system
to record, monitor and report suspected adverse drug experiences. Programs used for
reporting of ADR and of drug product defects can be combined under one program.
THERAPEUTIC DRUG MONITORING
Therapeutic drug monitoring Is a routine estimation of plasma concentration of a drug,
the pharmacologic or toxic effect of which has a direct correlation with its concentrations
in blood. The advancement in drug assay technology has made it possible to measure the
plasma concentration of the majority of drugs used in clinical practice. Since last decade,
clinicians have began to use such tests in monitoring and prescribing treatment world
over yet this is little practiced in Pakistan.
A clinical pharmacist having comprehensive training in clinical should ideally supervise
the TDM services.
Therapeutic drug monitoring (TDM) program provides clinician with valuable
information towards maximizing safety and efficacy of drug therapy. The patients
benefited from the TDM program includes that with impaired renal, hepatic functions and
with congestive heart failure. All these wi
levels of the respective drugs. Without TDM, a large number of patient populations
would have to receive dosages having concentrations outside the therapeutic range.
The measuring of plasma concentration of a drug in TDM program may be useful:
1. Confirmation of adequate dosage.
2. Identification of non-compliance.
If patient exhibits signs of poss ible drug toxicity.
4.
need dose adjustment based on the measured
When a patient responds poorly to therapy.
5. Ifa patient has a disorder that may alter drug disposition.
6. When a possible drug interaction is suspected.
The following guidelines indicate that therapeutic drug monitoring is appropriate il a
drug displays:
1.A narrow therapeutic index
2. Non-linear pharmacokinetics.
Large inter-individual pharmacokinetic variability.
Major side-effects related to the plasma concentration of the drug, together witn a
poorly defined clinical onset and end-point.
A steep dose response relationship.
The drugs commonly and occasionally monitored under TDM programs have De
mentioned in Tables I and 2. respectively.
3.
5
Other drug
Cardiovascular Agents
Digoxin
Disopyramide
Lidocaine
Procainamide
Quinidine
Antibiotics
Amikacin
Chloramphenicol
Anticonvulsants
Carbamazepine
Ethosusimide
Phenobarhital
Pheny toin
Cyclosporine
Lithium
Salicylic acid
Theophylin
Cientamicin
Tobramyein
Primidone
Valproie acid
Vancomycin
It is worthy to mention that the routine monitoring of plasma drug concentrations is of
proven clinical value for only a few drugs.
A pharmacist can advise on sample collection time after drug administration to facilitate
correct interpretation of results of therapeutic drug monitoring. Pharmacists can also be
involved in drug estimation using any of sensitive analytical modalities available in
pathology laboratory.
After the drug analysis. a meaningful data interpretation with the clinical context is
necessary.A full appreciation of pharmacokinetics and its variables is necessary to allow
such interpretation and for drawing of an inference.
PATIENT-CARE AUDITS
Audit means a comparison of actual practice with best practice to judge its quality.
Numbers of services are provided from hospital pharmacy and these have an impact on
patients, either directly or indirectly. Since provision of high quality care is consistent
with good pharmaceutical practices a pharmacist must undertake audit of services offered
from the pharmacyy.
Patient-care audits are needed for safe drug administration. Patient-care audit uses the
clear-cut measurable process and outcome criteria applied to a sufficiently large number
of patient records to evaluate quality of care being provided. The review of patient's
therapy record helps ascertaining effect of drug therapy on patient's stay in hospital
Clearly, good and effective therapy coupled with good clinical care can reduce the
patient's length of institutional stay. Contrary to this. poor therapy leads to complications
and thereby, increases the patient's hospital stay. The patient-care audits requires the
following profiling of
1. Choice of therapeutic agent.
2. Choice of dosage form.
3. Choice of route of administration.
4. Drug allergy, idiosyncrasy and pharmacogenetics.
5. Effect of therapy upon utilization of hospital facilities.
6. Foilow-up and discharge medications.
The poor or good and effective therapy will largely depends on the rational approaches
used in each of above.
GOOD PHARMACEUTICAL PRACTICE GUIDELINES FOR SAFE DRUG USE
The multiplicity of drugs, increased number and kinds of medications prescribed per
patient. increased number of both inpatients and outpatients being treated have led to
greater chances of medication errors. This has made it mandatory that a system of safe
medication practices be developed and maintained to insure that the patient receives the
best possible care and protection. To improve care of and safeguard hospitalized patients.
the follow ing guidelines of good pharmaceutical practice are presented for safe handling
of medications and diagnostic agents in hospital.
LABELING
Medication containers for general use
1. Prescription labels and pharmacy stock labels should be used only by hospital
pharmacy.
Labels should bear the name, address, and telephone number of the hospital
Labeling is performed by pharmacist or under the supervision of the pharmacist.
Labels should be printed, computer generated, or typed. Labeling with pen or pencil,
use of adhesive tape should be prohibited.
A label should not be superimposed on another label.
6.
The label should be legible, firmly affixed to container and free from erasures and
strike-overs.
The label for stock containers should be protected from chemical action or abrasion
One order or prescription should be filled and labeled at a time.
7
The following are similar accessory labels and caution statements that should appear
where indicated: (a), Poison. (b) Not to be taken internally, (c) Shake well before use
(d) For external use only, (e) For the (site) .
Warning: Not for injection, (h) Do not use after
Keep out of reach of children, (k) Caution: Potent Drug, () Caution: an
investigational drug
9.1 Accessory labels for proprietary name state that:
9.
() Instruction for storage, (g)
,i) Not to be swallowed, )
filled as per
Prescription or order for (Proprietary Name)
formulary
Contents are same basic drug as prescribed, but may be of another
a.
brand.
10. The metric system is to be used on all labels
11. The name of the therapeutically-active ingredients should be indicated in compound
mixtures.
12. Labels for medications should indicate the amount of drug or drugs in each dosage
form unless otherwise indicated.
13. Drugs in forms intended for dilution or reconstitution should carry directions for so
doing. Whenever possible, dilutions and labeling should be done in the pharmacy
14. For perishable drugs, such as antibiotics and biologicals, should clearly indicate the
expiration date on the label.
15. The routes of administration should be indicated for parenteral medications
16. Numbers, letters, coined names, and unofficial synonyms and abbreviations should
not be used to identify medications with the exception of approved letters or number
codes for investigational drugs.
17. For the medications brought into the hospital by the patient are to be checked
accordingly, and a supplemental label should be attached in the hospital pharmacy
providing information required.
18. Small container presenting difficulty in labeling should be labeled with no less than
the prescription serial number, name ot drug, strength, and name of the patient. After
minimum labeling. the container is to be placed in a larger container bearing a label
with the necessary information indicated under labeling and dispensing in- and tor
outpatient prescriptions
19. Floor stock medication labels should carry codes to identify source and lot number ot
medication.
20. The pharmacist should be consulted and should make recommendations concerning
labeling. containers and storage of housekeeping items, insecticides, cleaners and
such substances.
Labeling and dispensing inpatient prescriptions
n addition to the guidelines mentioned under general labeling in above section. the
inpatient prescription labels should bear, as a minimum, the following information
a. Patient's full name.
b. Nonproprietary and/or proprietary name of the drug actually dispensed.
Strength
d. Date of issue.
Name or initials of dispensing pharmacist.
The prescription or inpatient order should have noted thereon, at the time dispensed,
the source and batch identifying number of the medication and the initials of the
dispenser.
3. For inpatient brought drugs for self medication see in above section.
4. For inpatient discharged and prescribed self-care medication see the next section.
Labeling and dispensing outpatient prescriptions
1.The outpatient prescription label should bear the following information:
a. Patient's full name
b. Prescription identification number.
C. Specific directions for use.
d. Date of issue
Name or initials of dispenser.
Name of prescribing physician.
Where physician requests or hospital policy dictates, identity and strength
should be mentioned on the label.
h. A "Keep out of reach of children" label.
i. Name, address, and telephone number of hospital.
Prescriptions should have noted thereon, at the time dispensed, the source and batch
identifying number of the medication and the initials of the dispenser
3 An identifying check system to insure proper identification of outpatients should be
2.
established
4. Medications to inpatients who are being discharged should be returned to the
pharmacy for re-labeling.
Medication errors
1. Each hospital should set up a clear statement of policy for all medication errors. Such
policy should include:
a. Reporting
b. Recording
Review
C.
d. Channel for analysis and necessary action
e. Written report
If an error occurs in the administration of medication, the physician and the proper
administrative representative should be informed immediately.
3. A written report, in accordance with hospital policy, should be prepared and sent to
the proper hospital officials within 24 hours.
The pharmacy and therapeutics committee of an institytion can formulate guidelines for
the care of drugs and drug cabinets in nursing units, for medication order, administration
of medication and documentation of administration.
d. Channel for analysis and necessary action
e. Written report
If an error occurs in the administration of medication, the physician and the proper
administrative representative should be informed immediately.
3. A written report, in accordance with hospital policy, should be prepared and sent to
the proper hospital officials within 24 hours.
The pharmacy and therapeutics committee of an institytion can formulate guidelines for
the care of drugs and drug cabinets in nursing units, for medication order, administration
of medication and documentation of administration.
DISTRIBUTION
The supply. delivery and transitory storage of drugs at patient-care areas (nursing
stations) other than main hospital pharmacy for subsequent patients utilization is called
distribution. The drug distribution and utilization starts the prescription of drugs for
respective patients. The prescription to inpatients is called medication order. Nurses carry
out these medication orders and obtain required drugs from pharmacy. In the pharmacy,
these required drugs may have to be prepackaged (for future use) in proper quantities for
use by the nurse to administer to patient, compounded or manufactured, labeled properly.
assayed and checked for accuracy and eventually distributed to the nursing unit. At
nursing station. the drugs are stored again for continuous use by patients according to
physicians orders. The nurse prepares drugs for administration, brings it to the patients.
returns to the nursing unit and records this information on the patient's record.,
Some of the newer concepts and ideas in connection with hospital drug distribution
systems are centralized or decentralized unit dose dispensing, automated processing of
medication orders, inventory control and automated storage and delivery devices. What
may be the distribution system, the following guidelines must be followed:
1. Pharmacist must review the prescriber's original order before the initial medication
dose is administered.
Drugs dispensed should be as ready for administration to the patient as the
pharmaceutical technology permits.
Drug dispensed must bear adequate identification.
4.
The drugs must be stored $o as to be accessible only to the pharmacist or his
nominee for dispensing and by nurses for their administration.
5.
When automated system is in use as pharmaceutical tools provisions must be made
to provide the same in event of failure of the device.
The in-house packaging must permit and facilitate drug use, ensure its stability and
meet the standards of good pharmacy practice.
.
ADMINISTRATION
The administration is a nursing act consisting of removal/withdrawal of a single dose
from drug container and its administration to a patient on the order of a prescriber. A
nurse may administer drugs after the prescription has been dispensed by a licensed person
(pharmacist).
METHODS OF DRUG DISTRIBUTION
Generally there are following four systems of drug distribution to inpatients used in
various hospitals according to their size, availability of professional personnel and
budgets:
INDIVIDUAL DRUG ORDER SYSTEM
This is also termed as individual prescription order system and is used generally by the
small and or private hospitals due to desirability of an individualized service and for
availability of a reduced manpower.
Benefits
1. Possibility of a direct review of medication orders by the pharmacist.
2. Provides a better interaction among pharmacist, doctor and the patients.
3. Provides a closèr control of inventory.
Drawbacks
1. Results in a delay in obtaining the required medication.
2. Increased cost to patients
FLOOR STOCK SYSTEM
The floor stock drug distribution is a traditional drug distribution system and involves a
separate storage facility in a secured area on each patient care floor. Generally. each
nursing area has limited (10 to 100) dosage forms on hand for patient dispensing by
nursing staff. The floor stock may include many bulk supplies of the medications carried
out in hospital pharmacy. However, a limited selection of drugs is approved by the
pharmacy and therapeutics committee. These mediations are:
Charge floor stock drugs
The medications that are stocked on the nursing station at all the times are charged to the
patient's account after they are administered. Since each of these agents is chargeable to
the patient's account, all the decisions of the pharmacy committee regarding the storage
and other matters of such medication must be honored.
Selection of charge floor stock drug
The selection of the floor-stocked medication is the responsibility of pharmacy and
therapeutics committee with the consultation of the representatives of nursing service.
pharmacy and the hospital administration.
The responsibilities of pharmacist, after determination of a list of floor stock drugs,
include: (a) availability of drug, (b) enforcement of decision of therapeutic committee,
and (c) periodically submission of list to the committee for re-evaluation in light of later
experience and therapeutic trends
The charge floor stock drugs are supplied to nursing station on requisition submitted on a
prescribed requisition form. The paperwork for such activity must be stream ined to save
the time. Many drug order forms may already have printed information as name of drug,
dosage form and route of administration requiring only a minimal eftort to select a drug,
desired form and route of administration thus saving time. Usually used for the drugs
with heavy demand.
The drug order forms may be prepared on duplicate or triplicate snap out forms. The
original is then forwarded to the pharmacy while the duplicate is retained on the ward as
control copy for nurse's drug administration record. On receiving of the original copy,
the pharmacists then prepare charges to the patient's account and re-stock the inpatient
area with the items consumed. At the same time, the pharmacist is also required to
complete the form for the number of units dispensed and the cost price. This information
is required for internal auditing purpose
A drug order prepared in triplicate can be used in which original is forwarded to the
pharmacy, second copy is utilized in the billing procedure whereas the third copy is used
in the accounting department for internal audit purposes.
Another system for charging is the emvelope system whereby pharmacist fills pre-labeled
envelops with the specific drugs and places a predetermined quantity on the nursing unit.
After administration of the drugs to the patient, the nurse places the patient's name and
room number on the envelope and places in her "out-basket". This is later picked up by
the mesenger service and 1S delivered to tne pharmacy where it is priced and forwarded
to the accounting office.
Non-charge floor stock drugs
These drugs represent group of medications that are placed at the nursing station for use
in inpatient-care area without direct charging to the patients account but costing n the
per day cost of the hospital room. The single doses of drugs with less cost and
administered frequently to patients if billed to patient may generate a bad public relation
for the hospital. On the other hand if not billed to patients, the total of several such
charges for each dose is usually much heavy and must not be lost. To guard against
whenever possible under this system the cost of such drugs is calculated and included in
the þer day charges of the hospital stay.
Selection of the non charge floor stocked drugs
The selection of non-charge floor stock drugs is usually based on the cost of the
preparation, frequency of use, the quantity used and etfect of the hospital budget and
reimbursement from the third part payers. Usually this list is exceptionally small.
Dispensing/distribution of non-charge floor stock drugs
Following methods are used for the dispensing/distribution of non-charge floor stock
drugs:
Drug basket Method: Under this system, night nurse checks medicine cabinet, utility
room and drug refrigerator inventory of supplies against a master list provided by
pharmacy. The checking nurse places check mark on the number required for each arug
on the requisition for floor stock supplies. Where there is an empty container, she places
it in a drug basket. On completion of procedure, the drug basket containing empty
containers and requisition for floor stock supplies, is then sent to pharmacy. Immediately
upon opening in the morning. the pharmacy staff fills each container and dispenses
requested ampules and vials as ordered. Once the basket is complete, it is delivered to the
floor via a messenger service.
Mobile Dispensing Unit: A mobile dispensing system, also called medication cart system
utilizes a specially constructed stainless steel truck with appropriate dimensions to hold
all sort of the drugs and is equipped with swiveling wheels. The main compartment of the
cart is provided with two locking sliding doors, a handle for steering and pushing, a
heavy duty steel and rubber protective bumper and a 2-inch rim on the top to permit
carrying empty containers being returned to the pharmacy. The interior of the unit
consists of shelves., which allow for the transport of containers of all sizes.
One mobile unit is in use while the second is being serviced. The frequency and delivery
time can be selected in cooperation with the nursing service. In this system of
distribution, it is not necessary for the night nurse, as in basket method to check the
pharmacy inventory or have the empty containers transported to the pharmacy. It is the
duty of a pharmacist or of his nominee to check the inventory of the cabinets in all
inpatient care areas and check off items and quantity of supplies left. A requisition form
in duplicate is filled for floor stock supplies and the original is delivered to the pharmacy
while the duplicate is left on the area as a record of delivery. In pharmacy, the requisition
form for floor stock supply will serve the following purposes:
Restocking of the mobile units.
Determination of rate of use/consumption.
Charging for nternal allocation of costs.
Benefits
This method provides the following benefits:
Conserves the nurse time.
Pharmacist has better supervision and control over drugs and nursing station drug
cabinets.
Availability of a pharmacist for the on spot consultation by clinical and nursing
staffs.
Due to routine checking of drugs by the pharmacist, the deteriorated and out-dated
drugs may quickly be removed.
COMPLETE FLOOR STOCK SYSTEM
In a complete floor stock system the nursing station pharmacy/cabinet carries both the
charge and non-charge patient medications. For this system, the following two ways are
currently in use
Floor stock system under supervision of nurse
The supply. delivery and transitory storage ot drugs at nursing station are requisitioned
Dy nursing service and are distributed by pharmacy personnel. The rarely used or
expensive drugs are omitted from floor stock though, can be dispensed upon the receipt
or a prescription or medication order for an individual patient. This method is mostly
used in governmental hospitals and general hospitals.
Merits
Ready availability of required drugs at nursing station.
Reduction in nursing time consumed by frequent trips to pharmacy to obtain
medications/ancillary supplies.
No drug returns to the main pharmacy.
Reduction in the number of drug order for the pharmacy
Reduction in pharmacy workload and in number of pharmacy personnel required.
Demeritss
1. Increased chances of medication errors due to the elimination of a pharmacist review
on medication orders.
2.
Increased drug inventory on the patient-care area.
Increased chances of drug pilferage (theft). *
4. Increased chances for drug deterioration due to lack of proper storage facilities.
3.
5
Requires excessive nursing time.
The indiscriminate stocking of drugs on nursing station in bulk quantities eliminates the
pharmacist's control because of dispensing by nurse on physician's prescription a
situation. which is not appreciable because dispensiíg is not a nurse's function. Now
some of the disadvantages inherent with this system has been resolved by use a unit dose
system whereby floor stock drugs are supplied as unit-of-use packaging rather than a prelabeled multiple dose units. This system ensures a better control and identity of the
medications and will be discussed in the next section.
Floor stock system under supervision of Pharmacist-Satellite pharmacy
In some hospitals, the floor stock system is successfully operated as a decentralized
pharmacy under the direct supervision of a pharmacist. The various demerits associated
with floor stocking under nurse's supervision can be eliminated.
In summary. the floor stock system does not give pharmacist the opportunity to review
physician's order for accuracy of dosage and scheduling or potential drug interactions.
The medication nurse makes the choice of medications from floor stock without the
involvement of dispensing pharmacist. Pharmacists have no chance to review the
patient's medication profile to monitor drug therapy. They must guess, based on nurses
requests tor a re-supply. when a particular drug is being used. Modified floor stock
sy stems were developed in an attempt to address the issue of pharmacist review of
medication profile: however. these systems do not deal with the issue of nurses
dispensing drugs.
probably the most commonly used in hospitals today and is modified to include the use of
unit dose medications.
UNIT DOSE DISTRIBUTION SYSTEM
he unit dose distribution (UDD) system for medication supply is a pharmacycoordinated method and controlling medications. Under this system medications are
ordered, packaged. handled, administered and charged in multiples of single dose units
containing a predetermined amount of drug sufficient for one regular dose. The unit dose
concept was derived from the pharmaceutical manufactures preparing and selling pre
filled. single-dose disposable syringes, single-dose vials and single-unit foil or cellophane
Wrapped capsules and tablets. Though this method is a responsibility of a hospital
pharmacy yet it cannot be implemented without the cooperation of nurSing.
administrative and medical staffs. Thus a hospital pharmacist has to educate them about
this concept.
The unit dose distribution system has been developed to reduce medication errors and
this system guarantees pharmacist medication review and individual patient dispensing. It
has largely replaced the floor stock system. The unit dose system has two main
components:
a. A pharmacist reviews all physicians medication orders before they are dispensed.
The pharmacist may review orders directly in the patient care area or may review
copies ot orders sent to the pharmacy,
Medications are dispensed as unit-doses or units-of-use, in an individually labeled
box or drawer for each patient. 1 ypically, a 24-nour medication supply is sent. For
instance. for a patient wh0 1S to receive -50 mg of an antibiotic orally three times
daily. the pharmacy sends tnree indiviauaiiy packaged 250-mg capsules of that
antibiotiC.
The packages are dispensed in as ready-t0-administer form as possible.
Not more than 24-hours Supply or not availabie at patient care area at any time for
most of the drugs.
e. Concurrently mantenance or a patient medication profiles in pharmacy for each
patent.
Advantages of unit dose dispensing
Safer for patients
1Improved overall drug control and drug-Use monitoring.
Reduced chances of medication errors.
2.
Efficient and economical for lnstitution
1. Helps cut pharmacy costs by eliminating floor stock medication supplies and reuşing
certain doses and decreased total cOst of medication-related activities.
Reduction in the SIze of drug inventories located in patient-care areas as floor stocks
of drugs are minimized and limited to drugs for emergency use and routinely used
sale items such as mouthwash and antiseptic solution.
Greater adaptability to computerized and automated procedures.
Accomplishment of unit-dose dispensing
The implementation of unit-dose dispensing In a hospital requires a great deal of planning
both within pharmacy and within the nursing service. It can be initiated by distribution of
the as many injectables as possible in individual disposable syringes and distribution of
tablets and capsules in strip-packages and ultimately is entered into the concept of the
full-fledged unit dose system.
The unit-dose dispensing of medication can be accomplished by the following four ways:
Use of marketed single dose drugs
One way used to accomplish unit dose system in hospital is use of the commercial drugs
available as multiples of single units, Most of drugs are currently on market are prepared
in multiples of single dose.
In-house unit packaging
The other drugs can be packed by use of strip packaging, vial and syringe filling
equipments in hospital pharmacy along with a manual bench caper. The injectable drugs
may also be prepared for the unit dose system within the hospital but this will requires
personnel and additional budget. DispOsable glass syringes in 0.5, 1.0, 2.5, and 10-ml
sizes are commercially available and can be filled in the hospital using a syringe filling
stand and transfer needle. Once filled, the syringes are placed in a plastic tray and
labeled.
Purchasing of unit-dose packages of all drugs: The purchase of all drugs in unit dose
packages Is the third method for accomplishment of unit dose dispensing. This can be
arranged by making contract with pharmaceutical industry to provide combination of
single packaged and labeled tablets and capsules and pre-filled, or injectables in ready-touse plastic syringes.
Use of packaging service: A packaging service from an outside contractor or by the joint
purchase and sharing of equipment with a neighboring hospital can be another method for
unit dose dispensing. This method is not yet tried in Pakistan.
Methods of Unit-dose dispensing
The unit-dose dispensing concept may be introduced into the hospital either of the three
methods, namely centralized unit-dose distribution, decentralized unit dose distribution or
combination of these both.
Centralized unit-dose distribution (CUDD) system
Under this system, all drugs stored in central pharmacy and are dispensed in unit-doses
Ihe drugs are dispensed through help of messenger service on receiving medication order
at the time the dose is due to be given to patients.
Decentralized unit-dose distribution (DUDD) system:_1The decentralized unit-dose
distribution system, unlike the centralized system, operates through small satelite
pharmacies located on each floor of the hospital. The main pharmacy in this system is
responsible for the procurement, storage, manufacturing and packaging centre serving all
the satellites. The drug delivery system is accomplished by the use of medication carts.
A typical sequence of the drug dispensing to the patient is as:
Sending of the medication orders to the pharmacist.
Entering of the medication order on to the patient profile card.
Checking of the medication order for allergies, drug-interactiorn, drug laboratory test
effects and rationale of therapy.
Coordination of dosage schedules with the nursing station.
Picking of medication order by the pharmacy technician and placing drugs in bins of
the transter cart per dosage Schedule.
Checking of the cars by the pharmacist before release for transfer to the inpatient
care area.
Administration oft the medication by the nurse and making of the appropriate entry
on the nurse medication record.
Rechecking of the cart on returning to the pharmacy.
Throughout the entire sequence, tne pharmacist 1s available for consultation by the
doctors and nurses.
Combined CUDD-DUDD svstems
Under this system, some hospital operate the dispensing of drugs from the main
pharmacy as well as from the satellite pharmacy simultaneously.
The unit doses not administered
The unit doses/drugs not dispensed to the patients must be accounted for the purpose of
preventing medication error. For this purpose, hospitals with unit-dose disjising have
developed communication forms for use by nurses to inform pharmacists. The
communication forms contain the patient identiTIcation, drug identity and dose. reason for
the drug not being given, comments of the prescriber and any new time for administration
if so. These are usually placed in the bin with the returned medication and sent to
pharmacy.
The dispensing of total parenterals and cytotoxic drugs has been mentioned in Chapter on
Manufacturing Bulk and Sterile while dispensing of radiopharmaceutical has been deait
in Chapter on Nuclear Pharmacy.
entrance to cach patient's room, which can be opened from another room also. This
means that cach drawer has two-way access. from the patient room and as well as from
another room under the use of a pharmacist. This allow the pharmacist reach without
leaving his room and nurse access to the patient's medications and chart without leaving
the patient's room. However, this concept is costly and imnpractical that is why not
accepted.
AUTOMATED DISPENSING SYSTEM
The process of drug dispensing is initiated with medication order. Nurses or some
messengers carry these medication orders and obtain required drugs from pharmacy. On
receiving of orders in the pharmacy, the required drugs may have to be prepackaged (for
Tuture use). compounded or manufactured. Then labeled appropriately, checked for
accuracy and eventually distributed to the nursing unit.
Time is consumed for carrying of medication orders from nursing unit to pharmacy
department. The checking of the medication order in pharmacy also requires time. This
combines with waiting time needed for messenger or nurse till the mediation order is
filled or compounded in pharmacy.
The time of all personnel can be saved by use of a computerized dispensing system
known as computer aided dispensing (CAD). This system utilizes computer networking
among physician. pharmacist and nursing. Under this system, the computers of physician
pharmacist and of the nursing station are networked with each other. The prescriber
enters a medication order in computer and by pressing of a button of keyboard. entire
series of events take place. The order is displayed at pharmacy's computer. A pharmacist
checks this medication order and by using appropriate computer software, evaluates drug
drug interaction. After assurance of correctness of the order, just by pressing a button, the
required labels will be printed out from the printer connected with his computer and
pharmacy inventory will be adjusted. Simultaneously, due to the presence of computer at
nursing station, a nurse is altered to administer the medicati0n. Another press of button
by nurse after drug administration enters this fact on patient's medical record If a
computer of accounts branch is also linked with this network, a charge is also possible to
enter on patient's account. The Figure 1 depicts these events.
The computer can also notify the doctor if the drug is not in inventory, not prescribed
according to the dose/route of administration recommended in the hospital formulary and
will alert the nurse if she has failed to administer the drug within a predetermined period
of tinie.
The use of automated system saves time of nurse's and that of messenger service and
minimizes delays in distribution. It also reduces the chances of medication error.
Moreover, its use can generate a body of useful statistical data governing drugs and their
use. The functions of CAD do not end here, the drugs dispensed from the pharmacy are
deducted from the inventory. If inventory for that particular drug reaches at the point set
for ordering (order point) then, the system informs or automatically e-mail the order to
the suppliers. Advance information of the expiry dating of the drugs is also a possibility
of CAD.
It is necessary to mention that when this system is in use, an alternative system for the
provision of pharmaceutical service must also be there to work in failure of the device or
mechanism
12
Dispensing to Outpatients
Outpatient or ambulatory patient refers to patient not bedridden in a hospital or other
inpatient setting and able to walk. It is also referred to the care given in physicians
offices. clinics, health centers, and other places where ambulatory patients usually go for
healthcare. Ambulatory care encompasses the provision of healthcare services and
education to patients who seek medical attention yet not requirng admission to an
institution tor healthcare needs. A patient unable to walk and is on wheelchair but not
institutionalized is also regarded as an ambulatory patient. This type of patient has
responsibility for obtaining medication, storing and taking it,
Various hospitals provide services of ambulatory patient care. Since the pharmacist is a
member of healthcare team, it is important for him, to have an understanding of such
patients so as the best possible ambulatory patient care may be provided through proper
use of knowledge and judgment.
CATEGORIES OF AMBULATORY PATIENT CARE
The hospitals break down their ambulatory patient load into three categories:
PRIMARY CARE
P'rimary health or majority care is a range of initial services adequate for meeting the
great majority of daily personal health needs. This care is used by most of people, at most
of the time for most of their minor health problems. It is provided to the patients as an
entry point into a comprehensive healthcare system. This majority care includes need for
preventive health maintenance and for evaluation and management on a continuing basis
of general discomfort, early complaints. symptoms, and chronic intractable aspects of
disease. However. an intensive and/or a very specialized service are not included in
primary care. This care is responsible for assuring continuity of all the care that the
patient may subsequently need.
EMERGENCY CARE
The term emergency care is self-explanatory and it is an advanced and comprehensive
care proVided to patients in emergency situations.
REFERRAL OR TERTIARY CARE
Tertiary care is also a comprenensive Care proOVIded to the patients. It is the intensive or
specialty medical care needed subsequcniy arter primary care as a continuity of the
Prary care. The tertiary care. there fore is a service beyond that of initial or primary
care.
ajority of institutes including the governmental hospitals has the out patient services.
ne concern for increasing access to healthcare services has led to increased demands ro
ambulatory patient care services in healthcare settings. Thus the new healthcare delivery
System is predominantly ambulatory oriented. This coupled with the evolution of patientoriented pharmaceutical services has extended the role of pharmacist beyond the
traditional preparation and dispensing of medicaments. Due to this evolution. the
practitioners of ambulatory care pharmacy have become specialized in this branch of
pharmaceutical services.
The scope of extended pharmaceutical activities may vary with institution to institution.
but typically include:
1. Obtaining and documenting patient medication histories
Monitoring the safety and efficacy of drug therapy through the maintenance of
medication profiles.
Providing drug information to prescribers.
Assisting prescribers in the proper selection and adjustment of drug therapy through
application of pharmacokinetic and other principles.
Utilizing assessment skills in the management of acute and chronic diseases and
providing appropriate referrals to other healthcare providers.
Detecting and reporting adverse drug reactions. interactions and non-compliant
patient behavior.
Educating and counseling patients and the general public for proper use of
medications.
Participating in drug-use reviews, patient care audits, and clinical drug
investigations.
9. Participating in the education of healthcare providers.
10. Developing systems for the delivery or pharmacy services in the institutional setting.
Director of pharmacy services in institutions has responsibility to develop and maintain
comprehensive pharmaceutical services matching with the individual needs of each
healthcare setting. The evaluation and documentation of the healthcare benefits of such
services are also included in his responsibility.
However. providing all these services in all institutions at all the times is not feasible. At
a minimum following critical pharmaceutical services of ambulatory care pharmaceutical
service program must be provided:
I. A qualified pharmacist must direct the ambulatory-care pharmacy program
The pharmacist must verity the appropriateness ot the choice of drug and its dosage.
route of administration, and amount.
All medications dispensed to patients will be completely and cormectly labeled and
packaged in accordance with regulations and accepted standards of practice.
4. Upon dispensing a new (to the patient) medication the pharmacist will ensure that the
patient or his representative receives and understands all information required for
5.
proper use of the drug.
5.
All drugs in ambulatory-care service areas will be properly controlled.
DISPENSING TO OUTPATIENT
Dispensing is the streamline activity of the pharmacist. The elements that are to be
considered in dispensing to outpatients are:
LOCATION OF OUTPATIENT DISPENSING AREA
Some of suitable options for the outpatient dispensing area are:
Independent outpatient pharmacy
A separate set up with specialized function for provision of outpatient pharmaceutical
services operating under the main pharmacy. This pharmacy is established whenever
outpatient department and pharmacy are geographically widely separated. Being a
independent, separate and distinct unit and having specialized functions are the merits of
this arrangement. The disadvantages include need of separate staff and consumption of
time, on the part of other pharmacy department personnel in transporting supplies and
drugs to the area.
In- and outpatient com bined pharmacy
The in- and out-patient combined pharmacy unit eliminates the demerits inherent with an
independent outpatient pharmacy. Possibility of a greater degree of control and,
supervision is an additional advantage of this setup. In combined pharmacy, the both, in
and outpatient services can be provided either from:
Combined pharmacy with one window: Whereby, both of the in- and outpatients can be served from the same window of the pharmacy.
Combined pharmacy with separate Windows: Under this arrangement, the
service is rendered to in- and out-patients from the different windows.
PRESCRIPTION TYPES RECEIVED IN PHARMACY
The types of the prescription received in an outpatient pharmacy depend on institution
local rules, kind of hospital and location of the outpatient pharmacy department.
Generally received prescriptions include:
Clinic patients
The clinic patients are one who acquire ambulatory care from the institutional out-door
department. In an outpatient pharmacy, the largest volume of prescriptions is received are
from such patients.
Discharged hospital patients
As has been mentioned previously, the discharged patients with take home drugs are
considered to be the outpatients.
Employees
The prescriptions of the hospital employees are also entertained from the outpatient
pharmacy section.
Patients recruited for research studies
The institutes are sometimes involved in active research on investigational drugs,
prescription habits, correlation between diagnosis and drug prescribed and the
pharmacoeconomics studies involving assessment of cost of drugs to both hospital and
patient. In either case., the prescription blanks must. preferably be different to serve the
purpose efficiently.
Private patients
The patients who receive prescription from another hospitals or physician are regarded as
private patients. The outpatient pharmacy service is seldom rendered to the private
patients. This service is provided only if permitted by institutional local rules. The
hospital outpatient pharmacy department is in a very favorable position to attract private
patients. However, its location, a limited stock of health supplies, and limitations by
formulary system are obstacles of proVision of such services.
Different colors can be given to various prescriptions to facilitate the identification
internal audit, and billing etc.
SAFE AND EFFECTIVE USE OF DRUGS
The safe and effective drug use in ambulatory patients is the responsibility of a hospital
pharmacist. The components of a safe and effective drug use are patient counseling, drug
utilization review, adverse drug reaction, and drug interaction. The patient counseling and
the drug utilization review will be discussed herein. The adverse drug reaction, drug
utilization review drug interaction surveillance and patient audits have already been
discussed in Chapter on Safe Use of Medications.
PATIENT COUNSELING
As mentioned before, the pharmacy care has been evolved from the drug orientation to
patient orientation which emphasis not only on safe drugs storage, but also on the safe
rational and effective use after its dispensing. In this new concept, pharmacist provides
counseling about the drugs to patient to achieve optimal therapeutic outcomes, which
improve the patient's quality of life.
The ambulatory patients take the drugs by themselves without direct medical supervision
as is the case with inpatients. The medication may be misused through personal ignorance
or inadequate information. This may lead to an ineffective treatment and even harmful for
a patient. Patient counseling enhances patient compliance. and reduces health-care costs
associated with mismedication problems. The patient counseling is the provision of the
information or discussing about the drugs with the patient.
A pharmacist should provide patients with adequate, understandable information on the
drugs they take or use to maximize the therapeutic outcome and prevent conceivable
problems (Figure 2 and 3) during therapy by ensuring that the patient will use the
medication sately and appropriately. I he counseling has three forms:
Active counseling
Active counseling Is the provision of verbal instruction to a patient about certain aspects
of drugs. Verbal communication creates a favorable environment which motivates the
patient for discussion at one hand and on the other hand, enhances the understandings of
the patients. By active counseling, particular and relevant information specific to a
particular patient can be provided.
Passive counseling
In the passive counseling, a pharmacCIst does not undertake the counseling actively but
makes use of printed, audiovisual and 1llustrative materials. This would include
appropriate materials provided within the package by the drug manufacturer or auxiliary
or cautionary labels, which can be affixed to the dispensed product. Computer software
packages allow the pharmaciSt to prepare, at the time of medication dispensing, product
specific and patient-oriented drug intormation. t is designed to furnish printed
instructions to supplement verbal instructions provided by the pharmacist.
T nis service, however is not a substitute for an active counseling and does not fulfil the
unique needs of patient. Additionally, due to low literacy rate, patients may be unable to
read or understand labels on their prescription medications leadingg to noncompliance
with directions.
Active-passive combined counseling
The patient's perception of verbal information can be increased by additional use of
audiovisual and illustrative materials. This counseling includes provision of verbal
instructions and appropriate printed materials provided within the package by the drug
manufacturer or auxiliary, cautionary labels, which can be affixed to the dispensed
product.
TYPE OF INFORMATION TO BE PROVIDED
The following information is helptul for the ambulatory patients:
Removing Drug from Package
The packaging is becoming more and more sophisticated, safe and tamper-resistant.
Removing medication Irom isS package iS qunte simple for and obvious to the pharmacist,
but not always to the patient. Thus a pharmacist Should demonstrate how to remove the
medicine from the package.
Administering Drug
It should not be taken for granted that the patient knows how to intake or use a drug. It is
important for the pharmacist to tell the patient regarding site of and route of
administration of a particular drug The pharmacist should insure that the patient
understands the details of using the medicine
Tablets: The most common method to administer a tablet is to place it on the tongue and
to swallow it with water. Most people. may assume mistakenly that a tablet must be
administered by mouth and proceed to do so. However, it can be administered in
following number of ways depending upon the medication and the type of tablet.
Place on tongue and swallow with water
Chew and swallow
2. Do not chew.
3. Let dissolve in mouth
4 Place under tongue and let dissolve. Do not swallow
Place between gum and cheek (buccal) and let dissolve
Do not swallow.
7
Dissolve in water and swallow.
8.
Dissolve in water and use externally.
9. Moisten with water and insert vaginally or rectally,
10. Take with a glassful of water for drugs that are irritating to the stomach.
A pharmacist must know that chewing a tablet unknowingly may lead to altered release
characteristics and may provide the entire effect of the medication at once. This could be
hazardous to the patient and at the same time not offer therapeutic coverage for the period
of time between doses.
Ophthalmic preparations: The pharmacist should be sure that the patient understands how
to use ophthalmic preparations. The way of instilling of eye solution, drops and ointment
must be demonstrated in front of the patient.
Inhalations: The dosage forms of oral and nasal inhalation are available, efficacy of
which depends on their proper use. 'he patient particularly first-time user must be
educated for use of inhalation products, storage, and cleaning by providing instruction.
The other instruction include about the inhaler requiring shaking before use, way of
holding and achieving coordination between inhalation and pressing down the inhaler to
release one dose. 1The patient should also be instructed to hold his breath for several
seconds, or as long as possible, to gain the maximum benefit from the medication. 1The
patient then is told to remove the inhaler from the mouth and exhale slowly through
pursed lips.
Suppositories: Several heiprui ltems or niormation are needed to be conveved to a
patient. These information include the storage and warming of suppository to room
temperature if refrigerated before insertion. 1he patient is to be advised to rub cocoa
butter suppositories gently wIth the tingers to neip meit the surface to provide lubrication
for insertion. The same lubrication is achieved for giycerinated gelatin or polyethylene
glvcol suppositories by moistened them with water. For polyethylene glycol suppository
not containing 20% water, dippine water Just pr1Or to insertion prevents moisture
from being drawn from rectal tissues ater seuon and decreases subsequent irritation
Vaginal inserts also should be dipped nto water quickly before insertion to provide
lubrication and to enhance disintegration.
Transdermal systems: Numerous transdermal systems (patches) are available in the
market. The duration of use for a patch may vary. Some requires replacing of old patch
with a new every day as nitroglycerin or after every 3 days as with estradiol. The
pharmacist must advise the patient for placing of adhesive side of the system on a clean,
dry, hair-free area of the skin. and other appropriate sites and for rotation of the site of
application to minimize the possibility of irritation. The pharmacist also must ensure that
the patient understands about the necessity to wear the patch the entire day or to remove
the patch after a set amount of time.
Use of Water: The pharmacist should clarify patients hoW much water to use and in what
manner when water has been directed for use with medication.
Timing of the Dose: The effectiveness of drug depends upon a maintained blood level in
the body. A patient therefore, should be instructed to space out equally through day.
appropriate dosing times. If the bioavailability of drug from oral administration is in
doubt when taken with food. it is best to recommend that the drug be taken either I hour
Derore or hours after meals. It would be important to emphasize to patient tnat evc
nougn a meal may not be eaten, the drug still should be taken. In the instances wnere un
orally administered drugs cause stomach distress pharmacist should encourage the patuee
to take the médication with food or milk to prevent this upset.
A medication calendar can be very useful to entirely satisfy patient's individual needs. t
can be used to reinforce correct time to take the medication. This also prevents problems
of forgetfuiness about whether a dose was taken or missed since the patient places d
check mark after each usage of the medication.
When needed type drugs.: The patient should be instructed about the correct use or
product prescribed on when needed basis. The patient should be told to use the
medication only as needed and not to prevent subsequent ailment. The other information
given to the patient is that when to take another and how much dose within the prescribed
time indicated on the label, bearing in mind that the drug may not prôvide immediate
effect.
Duration of Use: The pharmacist must ensure that the patient clearly understands the
length of time the medication is to be used. Chronic diseases require maintenance of
adequate blood levels of drug to control the disease process. hus, emphasis should be
given toward compliance regarding the medication and periodic revisits with the physician to assess the therapeutiIC regimen. At the same time, the pharmacist should provide
the patient with a reasonable time period, alter which the desired effect may be
experienced. After this time, should no effect be observed, the patient should be told to
contact his physician.
Early discontinuation of the medicaton, Decause or leeling better, should be discouraged
to prevent a relapse of the infection. his philosophy particularly is dangerous when
dealing with parents ot young chiraren who do not want to subject them to more
medication than they deem necessary or. simply Decause ot inconvenience, do not elect to
continue the medication once the child feels better.
Storage: The safety and stability of drugs depends on the proper storage oft the medicine
Although, the storage conditions are mentioned on the labels. yet the patient seldom
notice, read or even be able to understand an auxiliary labels. A pharmacist must instruct
about drug storage at place that is out of the reach of children. internal medication should
be separated from external medications and storage drugs away from extremes of heat
and humidity. The patient should also be instructed to inspect medication before using it.
Any color change or unusual odor may indicate degradation of the product.
The patient should be told to cap the bottle firmiy after each use. otherw ise
environmental humidity could deteriorate the drug. or the liquid vehicle may be
evaporated. Evaporation of liquid vehicle from liquid products could result in a more
potent and hazardous product due to increased concentration of active ingredients
Further, some products may degrade into toxic products, not merely useless products
Side Effects: The pharmacist should intorm the patient tacttully about possible
commonly encountered side effects and provide a mechanism by which to cope with
them. If not so instructed. the patient might discontinue the use of the product with no
benefit. A patient must be instructed tor the occurrence ol side ettects which demand thee
medical advice and which will not needing any further advice.
Drug interactions: The pharacist should bring the atention ot patient to other drugs that
may have potential to alter signilicantly the eflectiveness of the prescribed medication
Storage: The safety and stability of drugs depends on the proper storage oft the medicine
Although, the storage conditions are mentioned on the labels. yet the patient seldom
notice, read or even be able to understand an auxiliary labels. A pharmacist must instruct
about drug storage at place that is out of the reach of children. internal medication should
be separated from external medications and storage drugs away from extremes of heat
and humidity. The patient should also be instructed to inspect medication before using it.
Any color change or unusual odor may indicate degradation of the product.
The patient should be told to cap the bottle firmiy after each use. otherw ise
environmental humidity could deteriorate the drug. or the liquid vehicle may be
evaporated. Evaporation of liquid vehicle from liquid products could result in a more
potent and hazardous product due to increased concentration of active ingredients
Further, some products may degrade into toxic products, not merely useless products
Side Effects: The pharmacist should intorm the patient tacttully about possible
commonly encountered side effects and provide a mechanism by which to cope with
them. If not so instructed. the patient might discontinue the use of the product with no
benefit. A patient must be instructed tor the occurrence ol side ettects which demand thee
medical advice and which will not needing any further advice.
Drug interactions: The pharacist should bring the atention ot patient to other drugs that
may have potential to alter signilicantly the eflectiveness of the prescribed medication
13
Dispensing of Controlled Substances
The dispensing of controlled substances from pharmacy follows the same procedures as
that of used for other drugs but requires more stringent controls. A more strict control is
needed because stocking, handling and distribution of controlled drugs have the risks of
drug abuse. Drug abuse control in a hospital is a collaborative responsibility of
administrator, medical staff, pharmacist and that of the nursing personnel. The drug abuse
control is to protect health of patients and is the basis for control of the majority of
special drugs within the hospital environment
HOSPITAL CONTROL PROCEDURES
The components of the hospital control procedures on the controlled drugs are:
DEFINING THE CONTROLLED SUBSTANCES Mwp
A controlled drug may have a high potential tor abuse, lack of accepted safety for use and
the use of which may lead to severe psychological or physical dependence. The Drug
Law 1976. in schedule B furnishes a list of such drugs.
in a hospital. the substances (with above consequences are categorized into controlled
drugs or controlied substances.
ASSIGNING OF RESPONSIBILITY OF CONTROL M ANA N AUDAM
The check on the controlled substances in a hospital is a joint responsibility of hospital
administration, pharmacist and nurse. The hospital administrator, pharmacist and nurse
pool their efforts and roles for effective control of controlled drugs in institution. The
administrative head of the hospital is basically responsible for the proper safeguarding
and the handling of controlled substances. T he responsibility for the purchase, storage.
accountability and proper dispensing of controlled substances is delegated to the
Pharmacist-in-Chief. LikewISe, the Head Nurse ot a nursing unit is responsible for the
proper storage and use of the controlled substances at nursing unit.
Role and responsibilities of administration
A hospital administrator execute its responsibilities tor drug control by formulating
appropriate policies regarding ordering. prescription, dispensing, administration and
documentation of controlled drugs. For an ertective documentation of controlled drugs.
an administrator may direct to devise following forms:
1. Controlled drugs requisition form to be used by the head nurse to order drugs from
the pharmacy
2.
Daily controlled drugs administration form to have a 24-hour administration record
used for inventory count for each nursing shift, and to record of losses. This form can
be used also as a basis for review of errors.
3. Monthly Controlled Drugs Inventory serves as a monthly dispensing record for each
nursing unit and receipt for controlled substances dispensed directly from Pharmacy
Policies and procedures for ordering of controlled substances
Implementation of following policies and procedure promotes safeguarding of dug abuse
in a hospital:
Preparation of orders: All controlled substances orders and records are to be typed or
written in ink or indelible pencil and signed in ink or indelible pencil.
Doctor's orders for administration of controlled drugs The doctor's orders for
administration of ward stock controlled drugs must be written on the doctor's order sheet
or patient's chart. However, if the desired controlled drug is not on ward stock a complete
controlled drug prescription must be written on a hospital prescription blank. The signed
prescription must be sent to pharmacy.
Doctor s signature: The doctor's full name or initials are required on the doctors order
sheet and on a controlled drug prescription by doctor's own hand.
Pro Re Nata or Si Opus Sit (sos) orders: A pro re nata (PRN) or si opus sit (SOS) orders
for controlled drugs must be discouraged except under special circumstances
Telephone orders: A doctor may give a telephonic order of a controlled drug in case of
necessity. The nurse will, however, write this order on the doctor's order sheet,
mentioning that it is a telephone order and will place doctor's name and her own initials.
The controlled drug may then be administered at once. The order must then be signed by
the doctor with either his signature or his initials within 24 hours.
Verbal orders: In extreme emergency where the time does not permit writing an ordct
doctor can give a verbal order for a controlled drug The nurse must write the order on t
doctors order sheet. The doctor must sign the order with either his signature or his inittas
within 24 hours.
Qrderng non ward stock controlled drugs from_ pharmacy: Drugs, which are not stoch
on the nursing stations, may be ordered from the pharmacy written with ink- or inde iole
pencil-wWriten prescription only. The amount of drugs sent to nursing unit 1s the an
COvered on the prescription by the doctor's signature. If more is needed a new sig
preseription must be obtained. The prescription must have the following informatiol
Patient's full name.
2. Patient's address or hospital number.
3 Date
4. Name and strength of drug prescribed.
5. Total amount of drug to be dispensed.
Ordering ward stock controlled substances irom the pharmacy: The ordering of the ward
stock controlled drugs from the pharmacy requires the following steps:
1 A requisition for ward stock controlled substances is completed by placing a check
mark opposite the name, strength and form of the controlled substance desired. The
completed form is then sent to the pharmacy along with the empty containers and the
nurses inventory sheet.
Before issuance of new controlled substances to a ward, the previous supply is to be
fully accounted for. Therefore, each request for a new supply must be accompanied
by the 'daily controlled drugs administration form'. Whenever a new supply of drug
1S 1SSued, it is accompanied by one of these forms. This form serves three purposes:
(a) a 24-hour administration record for all controlled drugs administered, (6) allows
space for inventory count for each nursing shift, and (c) a record of losses and as a
basis for review of errors.
3. Whenever a dose of a drug is lost or wasted on the ward, the nurse in-charge must
prepare a special report on a prescribed form to cover the incident. This report is
prepared in duplicate and sent to pharmacy along with the nurses account sheet and a
request for new supply of drug. The original is filed in the pharmacy and the
duplicate is forwarded to the nursing otfice
Prescription for own personal use: A physician may not prescribe any drugs in category
of controlled substances for his/her own personal use.
Retiling: The prescriptions for controlled drugs should not be refilled.
ESCrioing controlled drugs in outpatient department: Prescriptions for controlled
Substances may be dispensed to outpatients from pharmacy and must include the
inrormation mentioned above. Besides the above an additional information required is the
frequency and route of administration
The prescription must be written in ink or indelible pencil and shall not bear cross outs or
erasures. Discharge prescriptions for controlled drugs must be picked up by a registered
nurse.
Dispensing of controlled substances
Dispensing of ward supply to patients for home use: The ward supplies of controlled
drugs are to be used only for patients in the ward. They may not be given to patients to
take home except as an emergency measure)
Dispensing to employees: The ward supplies of the controlled drugs are not for the
treatment of employees.
Dispensing of controlled drugs for home use during pharmacy off-hours: Occasionally
patients who require drugs for use at home are discharged from the hospital or released
from emergency ward during hours when the pharmacy is closed. Whenever possible, a
prescription must be signed by physician prior to dispense.
If no physician is available, or during pharmacy off-hours, the following procedure is
allowed, but only as an 'emergency measure:
The attending doctor will calculate the smallest amount of the drug necessary to treat the
patient until the pharmacy opens. He will write a prescription for this amount and the
nurse may dispense the medication irom nursing stoCK Supply. The prescription will be
presented to the pharmacy the followIng morning for replacement of stock.
Administration
Administration by nurse: The nurse should use proper number of tablets or ampules from
nursing stock and should record their number used and the doSe given in the proper
columns on daily controlled drugs administration form.
Information necessary on daily controlled drugs administration sheet: The full
information required on the daily controlled drugs administration Sheet is as follows: (a)
Date, (b) Amount, given, (c) Patient's full name, (d) Patient's hospital number, (e)
Number of tablets or ml administered, and (f) Filing out inventory column (to be retained
for Pharmacy).
Procedure in case of waste, destruction or contamination ete.: This section deals with the
aliquot part of the narcotic, wastage of the prepared dosage due the refusal by patients or
cancelled by physician. and the accidental destruction and contamination of the prepared
drug.
1. Aliquot part of controlled drug solutions: The aliquot part remaining in the ampule
after administration should be expelled into the sink.
Prepared dose refused by patient or cancelled by doctor: The drug prepared but not
used due to the patient's refusal or doctor's cancellation should be expelled into the
sink. This is to be recorded along with the reasons why the drug was not
administered. Examples: Discarded, Refused by patient" or 'order cancelled by Dr
(name)
The head nurse of the unit shall countersign the statement.
Accidental destruction and contamination of drugs: On accidental wastage or
contamination of tablet, or solution on nursing unit, the incident and the reasons are
to be recorded on a specified form.
Delivery of controlied substances to nursing station
The delivery of controlled drug from the pharmacy to the nursing station must be
assigned to a reliable person of the hospital pharmacy, nursing staff. or the messenger
staff. It is noteworthy that due to maintenance of adequate contr
substances that are delivered for illegal use would be immediately detected. Appropriate
measures if happen so are to be taken tor their recovery.
records any conrolled
Role and responsibilities of pharmacy department
A pharmacist is responsible for purchase, storage, accountability and proper dispensing
of controlled substances. The pharmacist is also responsible when assigned so, the receipt
and dispensing of controlled drugs tor research purpose. It is the responsibility of hospital
pharmacy to have a check on the controlled drugs in an institution. Various efficient
systems can be devised including:
System of controlled drug loss report.
Controlled drug delivery system for the nursing station.
Protocol for drug abuse and diversion.
Documentation.
Protocol for prevention of drug abuse or diversion
A poSsibility of drug abuse or diversion of controlled substances in a hospital exists. A
Protocol must be developed by the pharmacy director collaboratively with the director o
personnel and director of security for detection of abuse or diversion. Abuse is referred to
any problems such as unusual behavior which are suspected to be caused by the use of
controlled substances. Diversion is any unexplained loss or theft of controlled substances
By so doing, confusion is avoided when an incident occurs.
Various requirements for the protocol for prevention of drug abuse or diversion are as
follows:
1. The protocol needs to define the products that are included in this protoco.
Protocol's scope is extended to the employees, patients, and visitors, of hospital
Procedure for reporting suspected diversion or abuse.
The incident report will be filed in the pharmacy, or in some cases of abuse it will de
Tiled in the personnel department, and observed for the possible development of a
pattern
If diversion is suspected by the pharmacy or abuse reported by the employee health
clinic or the personnel department, then the outside agencies like local police will be
contacted.
An efficient record must be maintained that can be audited periodically to check any
illegal use of controlled drugs. Documentation provides a basis for appropriate
measures to be taken in case of this.
Role and responsibilities of nurses
Once the controlled drugs have been supplied from the pharmacy to nursing station, the
nursing service is responsible for administration, control and auditing of the inventory.
The auditing of narcotic inventory 1S to be carried out on change of nursing shift. The
auditing is accomplished by taking a physical count of narcotics on nursing station by
both the nurses coming on and going ot duty. 1he counted quantity IS mentioned on an
audit record and 1S Signed by both or tne nurses. On detection of any missing of
inventory, medications ordered for the day by physicians is checked so that omission of
recording can immediately be corrected. 1n instances when the quantity errors are
unexplained, then a narcotic loss report 1s Torwarded to the department of pharmacy.
CHARGES TO PATIENTS FOR NARCOTICS
are
as
Depending upon the policy O maviduar nospitals choices of charging systems
follows:
Charge of each dose received: Smaller hospitals, which purchase their controlled
Substances in ampule form find it necessary to charge for each dose administered
2. Flat charge to cover all controlled drugs: In some hospitals, the charging of the
controlled drugs is by charging a flat rage to cover all controlled drugs.
Charges included in per diem charge: Sometimes cost of controlled drugs isincluded
in per day expenditures. One factor affecting the decision as to which controlled drug
should be included in the per diem charge is its cost.
Without specific charge: Some hospitals include controlled drugs along with other
floor stock drugs for which no specific charge is made to patients. Some larger
hospitals may make controlled drugs available to the patient even at no charge.
Spilt charging: Some hospitals operates split charging policy whereby, there is no
charge for routinely used drugs but for those obtained on special order are charged to
patients.
14
Dispensing During Off-Hours
The dispensing of medication when the pharmacy is closed is called dispensing during
off-hours. It may be during closing of the pharmacy after an 8-hours duty or during a
holiday. The pharmaceutical services are integral part of the total care provided by the
hospital, and the services of a pharmacist should be available at all times. But this
depends largely on the availability of sufficient number of personnel, budgets and the size
of a hospital. In the instances, when these are not available, other procedure may be
adopted for dispensing of the medication. Before discussion of these ways, the requirements of the good pharmaceutical practice dealing with this sort of dispensing would be
of worth. These are:
1. A non-pharmacist must not dispense drugs to outpatients, hospital staff or emergency
room patient while the pharmacy is open.
2. Where around-the-clock operation of the pharmacy is not feasible, a pharmacist
should be available on an "on-call" basis.
3. The use of "night cabinets and drug dispensing by nonpharmacists should be
minimized, and eliminated wherever possible.
4. If it is necessary for nurses to obtain drugs when the pharmacy is closed and the
pharmacist is unavailable, following guidelines must be followed:
4.1 Written procedures covering dispensing by nurse should be developed.
4.2 A nurse should provide a limited supply of the drugs most commonly needed in
such instances
4.3 The drugs should be in proper single-dose packages
4.4 A log should be maintained of all drugs and doses removed. This. log must
contain the date and time the drugs were removed from the container.
complete description of the drug product(s), name of the (authorized) nurse
involved, and the patient's name.
5. For emergency room patients, when no pharmacist is available
5.1 The drugs must be delivered in packaged, to the extent possible, in single unit
packages
5.2 Not more than a singie day s supply of doses should be dispensed
5.3 Use of an emergency roomTommulary Is recommended.
MEANS FOR OFF-HOUR DISPENSING
There are various means wherepy a hospital can provide around-the-clock or 24-hour a
day pharmacy coverage. These are
PHARMACIST-ON-CALL
In case of shortage of pharmacy personnel, pharmacist may be assigned an on call duty
during off-hours. Giving some tringe benefits to the on-call pharmacist may encourage
this type of coverage. Many institutions have developed bonus or extra pay plans to
compensate the pharmacist delegated for such duty. A mobile phone or a pager can also
be provided to the personnel on call. In a hospital with a number ot pharmacists recruited,
a rotational plan of on-calls can be instituted which will not burden any single individual.
In advanced countries with the severe shortage of qualified pharmacists, in communities
where more than one hospital 1s h operation, tne pharmacists Join torces in providing
twenty-four hour on-call services. Under such a system, one pharmacist is assigned to oncall duty in two institution for any one period ot time and he, therefore, will answer the
needs of both institutions. 1his type of cooperation will spread out the frequency of oncall duty and, at the same time, acquaint a second person with the routine of each hospital
in case of an emergency or sick leave and vacation coverage
EXTENDING PHARMACY SERVICE HOURS
The extension in time of pharmacy services for a broader pharmaceutical coverage is
another way to dispense during off-hours. The emergency after-hour pharmacy services
are now being replaced by around the clock coverage by staff pharmacists but need more
number of pharmacists, which is a problem for smaller hospitals. The availability of
pharmacist is much more and the hospital administrations of such hospitals can be
convinced to financially support the broader pharmaceutical coverage. A hospital
pharmacist can utilize the following reasons to convince management to support the
extension of services:
1. Provision of continuity for the l/V admixture program.
Provision of continuity for the unit dose program.
Provision of medication t0 night shift that is least experienced and newest to the
hospitals; reluctance or refusal by, and the time constraints on the night nursing
supervisor allowed more involvement with nursing rather than pharmacy problems.
Provision of continuity with the drug information service.
2.
5. Provision of continuity for the drug monitoring system.
6. Helping to prevent serious medication error(s) at night.
DISPENsING FORM PHARMACY BYA NURSING SUPERVISOR
A commonest method under which the evening and night nursing supervisor is allowed to
enter pharmacy and provide a limited type of service. But realizing the basic fact that
dispensing is not the nursing area some quarters think it illegal and not free from inherent
risks. One may think the selection of a medicine from the drug cabinet on the patient-care
area by a nurse would be same as selecting it from the pharmacy. The inconsistency of
this view is the fact that medications delivered to the nursing station are in ready-to-use
form and have already been packaged, handled and labeled by a professionally trained
pharmacist.
However, in case of shortage of personnel, prohibitive costs and size of the hospital, this
method can be practiced but with caution. A clear-cut policy should be made regarding
this system and a nursing personnel serving in this category should be bound to dispense
medications from the selection of pre-labeled and prepackaged items in the pharmacy Tor
Such purpose. However. the nurse is prohibited to compounding of mixtures
EMERGENCY BOOx
the emergency box is an integral part of a twenty-four-hour a day pharmacy coverage
and is necessary for a quick treatment in situations where time is of the essence. The
emergency, or as it is often called the "STAT box, must have such dimensions that it can
accommodate the necessary supplies and yet sufficiently compact to facilitate handling
them. The box should be kept in a readily accessible place, known to all ward personnel.
and should be ready for use at all times. In order to accomplish this goal, the pharmacy
should have reserve boxes prepared so that the units may be handled on an exchange
basis and thereby reduce the period of time a ward may be without a ready-to-use emer-
gency bOx.
If it is the hospital's policy to make a charge for the supplies used from the emergency
box, then the nurse should prepare a charge ticket and submit it to the pharmacy along
with the "used" box.
The emergency box concept can be expandea to the concept of "emergency cart or "resuscitation cart.
EMERGENCY OR RESUSCITATION CART
The emergency or resuscitation carts are mobile units containing, along with emergency
medicines and supplies, facilities for the administration of oxygen, the application of
suction, and a cardiac pacemaker. This is the extension .of the emergency box which
contains only the emergency medicines and supplies.
A list of the pharmaceuticals and ancillary supplies that should be available in emergency
box. emergency cart or resuscitation cart must be prepared collaboratively. Where the
services of a pharmacy and therapeutics committee are available, the pharmacist shouid
consult with the Committee prior to the adoption of a specific list of supplies.
Once an emergency box system is put into eftect, a system of regular checking must be
implemented by the pharmacist because of the fact that most of the emergency drugs may
expired if not used within a reasonable period of time. After checking. the outdated
medicines are to be removed and replaced.
This system requires placing of an inventory and product control card in the box. This
card serves: as an inventory or the emergency box, shows when the unit was last
checked; and provides the nursing personnel with adequate directions for replenishing of
any item used.
Emergency Medication Supplies
A policy to supply emergency drugs when the pharmacist is ofl of the premises or when
there is insufficient time to get to the pharmacy should exist. Emergency drugs should be
limited to those whose prompt use and immediate availability is regarded by physicians
as essential in proper treatment of sudden and untoreseen patient emergencies. The
emergency drug supply should not be a source Tor normal "stat or "p.r.n. dnug orders.
The medications included should be primarily for the treatment of cardiac arrest
circulatory collapse, allergic reactions, convulsions, and bronchospasm. The pharmacy
ana therapeutics committee should specify the drugs and supplies to be included in
emergency stocks.
Emergency drug supplies should be inspected by pharmacy personnel on a routine basis
to deternine if contents have become outdated and are maintained at adequate levels
Emergency kits should have a seal, which visuailly indicates their opening. The expiration
date of the kit should be.clearly indicated on it.
NIGHT DRUG CABINETS
A night drug supply cabinet is basically an adjunct to the charge floor stock medications
already on the patient-care area. These units also range from a simple cabinet with
drawers to large elaborated installations, which include narcotic vaults- and refrigerated
compartments. The large cabinets are usually constructed in a wall of the pharmacy with
two side opening so that the unit may be serviced from within the pharmacy yet is ac
cessible from the corridor side to authorized nursing personnel also.
The night drug supply cabinet should be stocked with pre-packaged and labeled
containers of the drug listed in hospital formulary as advised by the pharmacy and
therapeutics committee. In addition, many hospitals also store certain medical and
surgical supplies such as Foley catheters, oxidized cellulose and elastic hosiery.
The nursing supervisor opening the unit is required to leave a properly identified charge
ticket listing the item removed and to whom it was administered. The next morning
pharmacy personnel restock the unit and forward the charge tickets to the accounting
office.
Although the cost of purchase and installation of a night service cabinet may be high yet
it provide a better control of inventory that will more than offset its initial purchase and
installation. Any plans for the construction of a new pharmacy or the renovation of
existing quarters may include such a unit.
DISPENSING BY PHYSICIANS
Next to the use of registered pharmacists, a safe administrative and legal practice require
that the physician enter the pharmacy and obtain any special medication not provided
through the floor stocks, night cabinets or emergency box. 1This method prohibits the
nurse from entering the pharmacy after hours.
The major drawbacks to this method are (a) physician might waste a great deal of time
searching for a product in unfamiliar surroundings, and (b) it can be an unfair burden to
place upon their already heavy work load.
This system does, however, possess one major advantage in that rather than entering the
pharmacy, the phýsician may be influenced to use a drug that will accomplish the same
purpose, yet is more readily available in the pharmacy.
around-the-clock basis.
Where there is more than one pharmacy in the community, care should be taken to avoid
any claims of favoritism or politics. One method by which this.may be accomplished is to
develop a set of specifications and requirements concerning the desired service and
request the local establishments to submit their bids (offers). Obviously, the specifications should be so prepared that only the retail pharmacies with adequate stafi,
inventory, and delivery service can quality to this.
In recent years, much has been done to make drugs available on patient areas in order to
cope with every emergency. Some of these methods include the use of mechanical
dispensing units, self-medication programs and centralized unit dose dispensing system
available around the clock.