PHT hospital Pharmacy Introduction Pharmacy should be defined basically as a system which renders a health service by concerning itself with knowledge about drugs and their effects upon men and animals. Pharmacy generates knowledge about drugs ; acquires relevant knowledge from the biological chemical, physical and behavioral sciences; it tests, organizes and applies that knowledge. Pharmacy translates a substational portion of that knowledge into drug products and distributed them widely to those who require them. The knowledge system of pharmacy through it's therapeutic use is a substantial and significant segment of health care. The hospital pharmacist can no longer be regarded only as a dispenser of medicines. He has an important role as a consultative and manager. He should be responsible for the planning of pharmaceutical services and the establishment and maintenance of safe systems of work within his department and the collection of data on drug use. He has also to cooperate medical and nursing staff in securing the most effective safe and economical use of drugs. The specially of hospital pharmacy has been defined as follows: The department or services in hospital which is under the direction of a professionally competent, legally qualified pharmacist and from which all medications are supplied to the nursing units and other services, where special prescriptions are filled for patients in the hospital where prescription are filled for ambulatory patients and out patients, where pharmaceuticals are manufactured in bulk, where narcotic and other prescribed drugs are dispensed, where biological are stored and dispensed where injectable preparations should be prepared and sterilized and where professional supplies are often stocked and dispensed. 1 Goals for Hospital Pharmacy The American Society of Hospital Pharmacists developed a statement on the goals for hospital pharmacy which , are consistent with its objectives. The 6 goals should be the focus of attention for the hospital pharmacists of the future and are therefore cited. Coordinate plans must be drawn and implemented 1. Teach hospital pharmacists to assume responsibility for professional practice . 2. Strengthen and expand the scientific and professional aspects of the practice of hospital pharmacy including the consulting role of the hospital pharmacist his teaching role and his activities in the field of investigation and research. 3. Strengthen and perfect the administrative of management skills and tools essential to the hospital pharmacist in his role as a department head. 4. Attract a greater no of well trained pharmacist to hospital practice, including those with specialized education and training in hospital pharmacy. 5. Promote a payment of realistic salaries to hospital pharmacists to attract and retain the services of career personnel. 6. Utilize the resources of hospital pharmacy to assist in the development and improvement, of the profession as a whole. Drug Distribution floor stock system Each pavilion on the hospital, has a supply of drugs stored in the medicine cabinet even though the nursering unit is serviced by a unit dose system. 2 Drugs on the nursery station may be divided into: A. charge floor stock drugs B. non charge floor stock drugs may be defined as those medication Represent that gp of medications that are socked on the nursing that are placed at the nursing station stations all time and are charged to for the use of all patients on the the patient account after they have pavilion and for w, there is no been administered. direct charge to the patient account. today there are 4 systems in general use for dispensing drugs for in patients. They may be classified as follows: i. Individual prescription order system. ii. Complete floor stock system. iii. Combination of both and (ii) iv. Unit dose method Individual Prescription order system This system is generally used by the small and or private hospital because of the reduced manpower requirements and the desirability for individual service. In this system in the possible delay iu the obtaining the required medication and the increase in cost to the patient. Advantage: 1. All medication orders are reviewed by the pharmacist 2. Provide for the interaction of pharmacies doctor nurse and patient 3. Provide close control of inventory The complete floor stocks system Under this system, the nursing station pharmacy call both charge and non charge patient medications. 3 Rarely used or particularly expensive drugs are omitted from floor stock but are dispensed upon the receipt of a prescription for the individual patient. Advantage: 1. Ready availability of their required drugs. 2. Elimination of drugs returns. 3. Reduction of number of drug order transcript to pharmacy. 4. Reduction in the no. of pharmacy personnel required. Disadvantages: 1. Medication errors may because the evidence of medication orders is eliminated. 2. Increased during inventory on the pavilions. 3. A greater opportunist for pilverage. 4. Increased hazards associated with drug deterioration. 5. Lack of proper storage facilities in the ward. 6. Greater in roads are made upon the nurses time. Combination of individual drug order and floor stock systems. Falling in this category are those hospitals which use the individual prescription order system as their primary means of dispensing but also utilize a limited floor stock. This combination system is probably the most commonly used in hospitals today’s and is modified to include the use of unit dose medication selection of non charge floor stock drugs. Here, consideration is usually given to the cost of the preparation, the frequency of use, the quantity used, and the effect upon the hospital budget. In many hospital, the list is exceptionally small and therefore the patient is billed for numerous single doses of drugs. 4 Outpatient and Inpatient Dispensary services There are various means employed by the hospital pharmacy to dispense and distribute various categories of drugs of the hospital. 1. Dispensing of charge nonfloor stock drugs. One method adopted by the hospital to identify pts, is the principle of the charge plate. Here by use of a plastic or metal card prepared on the patients’ admission to the hospital or clinic, much nursing time is conserved. As a matter effect all newly printed hospital forms usually reserve a space of the form for the information on the identification plate. Accordingly all charge stations are equipped for using this time saving device w yields an important by product legibility of identify. Many drug order forms may have such information as name of drug, dosage from and route of administration printed on it, thereby again conserving time by requiring only a minimal effort to select the drug, the desired form and route of administration. - Drug order forms may be prepared on duplicate of triplicate snaport forms w, provide a copy for the pharmacy and accounting department and a control copy for the pavilion. The Envelop system One hospital has developed a system whereby an envelop is used to dispense drugs to the nursing station and at the same time is also used as a charge ticket under this system the pharmacist fills prelabeled envelopes with the specific drugs and places a predetermined quantity on the nursing unit when the drugs administered to the patient, the nurse places the patient’s name and room no. on the envelop and places it in her out basket, which is picked up by the messenger service and is delivered to the pharmacy w is priced and forwarded to the accounting office. 5 Dispensing and distribution of non charge floors stock drugs Drug Basket Method Under this systems the might nurse checks the medicine closet, utility room and drug refrigerator inventory of supplies against a master list provided by the pharmacy and the nursing service. The nurse places check marks on the no required for each drug on the requisition for floor stock supplies where there is an empty container, she places it in the drug basket. On the procedure is completed, the drug basket containing the empty containers and requisition for floor stock supplies in them solute to the pharmacy. Immediately upon opening in the morning the pharmacy staff commences to fill each container and dispense the requested ampules and vials as ordered. Once the basket is completed, it is delivered to the floor via a messenger service. Mobile Dispensing Unit For the hospital Pharmacy utilizes a specially constructed stainless steel mobile thruck. Under this system two mobile units are put into operation to permit one unit to be in use while the other is being serviced . The frequently of delivery and the hours during w the mobile unit will visit the pavilion can be selected in cooperation e, the nursing service. By using this system it will not be necessary for the night nurse to check the pharmacy inventory or have empty containers transported to the pharmacy. Instead, the pharmacist maning the mobile unit will inventory the pavilion drug cabinets and check off the items and quantity of supplies left. The carbon copy of the requisition for floor stock supplies is left on the pavilion as a record of delivery and the original is returned to the pharmacy where it will serve 3 purposes: 6 1. To restock the mobile unit. 2. To determine rate of use or consumption. 3. To serve as a charge document for the internal allocation of costs. Advantages: A. The drugs and nursing station drug cabinets will always under the supervision of professional personnel. B. The pharmacist is brought out of the pharmacy and made available for on the spot consultations by clinical and nursing staffs. C. Through the routine checking of the medicine closet, deteriolated, out dated and non approved drugs and drug samples may be quickly removed of. Unit Dose Dispensing Definition: Unit dose medication have been defined as: Those medications w, are ordered, packaged, handled, administered and charged in multiples of single dose units containing a predetermined amount of drug or supply sufficient for one regular dose, application or use Advantage of the unit dose system 1. Patient receive important pharmaceutical service 24 H a day and are charged for only those doses w are administered to them. 2. All dose of medication at the nursing station are prepared by the pharmacy thus allowing the nurse more time for direct patient care. 7 3. Allows the pharmacist to check a copy of the physician original order thus reducing medication errors. 4. Eliminates excessive duplication of orders and papers work at the nursing station and pharmacy. 5. Transfers I.V. preps and drug reconstitution procedures to the pharmacy. 6. Conserves space in nursing unit by eliminating bulky floor stock. 7. Eliminating pilfereage and drug waste. Permit for moleculate medication charges and Prevent the loss of partitals used medication. 8. The pharmacists can get out of the pharmacy and onto the wards where they can perform their intended function as drug consultants and help provide the team effort that is needed for better patient care. 9. Surve personnel time both in the pharmacy and on the nursing service. 10. Eliminate labeling errors medication distribution as the responsibility of the pharmacy. The pharmacists with the assistance of the pharmacy and therapeutic committee and the department of nursing must develop comprehensive policies and procedures that provide for the safe distribution of all medication and related supplies to in patient and out patient. Dispensing Procedures Unit dose dispensing concept may be introduced into the hospital either of two ways the first method is the centralized unit dose drug distribution system. CUDD, and decentralized unit dose drug distribution system DUDD. The characteristics features of 8 centralized CUDD are that all in patient drugs are dispersed in unit doses and all the drugs are stored in a central area pharmacy and dispensed at the time the dose is to be given to the patient. To operate the system effectively, delivery systems such as medication carts and dumbwaiters are need to get the unit doses to the patients, also suction tube systems called pneumatic tubes or other areas are required to send a copy of the physician’s original medication order to the pharmacy for direct interpretation and filling. DUDD Unlike the centralized system, operates and small satellite pharmacies located on each floor of the hospital. The main pharmacy in this system becomes procurement, storage, manufacturing and packaging center serving all the satellites the delivery system is accomplished by the use of medication carts. This type of system can be used for a hospital with separate buildings or old delivery systems. The following is a step by step outline of the procedure entailed in a decentralized unit dose system. 1. Upon admission to the hospitals the patient is entered into the system. Diagnosis, allergies and other data are entered onto the patient profile card. 2. Direct copies of medication orders are sent to the pharmacist. 3. The medication orders are entered on to the patient profile card. 4. Pharmacist checks medication order for allegies, drugs interactions, drug lab test effects and rationale of therapy. 5. Dosage scheduled is coordinated with the nursing station. 6. Pharmacy technician picks medication orders, placing drugs in bins of a transfer cart per dosage schedule. 9 7. Medication cart is filled for particular dosage schedule delivery. 8. Pharmacist checks cart prior to release. 9. The nurse administers the medication and makes appropriate entry on her medication record. 10.Upon return to the pharmacy the cart is rechecked. 11.Throughout the entire sequences the pharmacist is available for consultantnsy the doctor spend nurses: In addition he is maintaining a surveillance for discontinued orders. Dispensing to Ambulatory patients Ambulatory refers to patients not occupying beds in hospitals or other in patient settings and to care given in physician offices, clinics, health centers, and other places where ambulatory patients usually for health care. I.e, Ambulatory care generally refers to providing health care to patient who how are not restricted to bed. The level of care may be primary, secondary or even tertiary. The outpatient pharmacy dispensing area should be located somewhere along the normal patient traffic flow. According to hospital bed size the services can be provided from: a. A separate outpatient pharmacy. b. A combined inpatient and outpatient unit service provided from the same windows. c. A combined inpatient and outpatient with service provided from separate windows. In all cases waiting area should be available. The five pharmacy services that should be expected in all ambulatory care facilities include the following: 10 1- The ambulatory care pharmacy must be directed by a qualified pharmacist. 2- The appropriateness of the choice of drug and its dosage, route of administration and amount must be verified by the pharmacist. 3- All medications dispensed to patients will be completely and correctly labeled and packaged in accordance with all applicable regulations and accepted standards of practice. 4- On dispensing a new medication to the patient, the pharmacist will ensure that the patient on his or her representative received and understands all information required for the proper use drug. 5- All drugs in ambulatory care services are will be properly controlled. The Dispensing routine The dispensing pattern involved in providing clinic patients as well as these patients being discharged with take home drugs is identical e that carried by a common pharmacy. If there is a waiting period before dispensed the drug or medicine to the patient a prescription cell checked which numerically identifies the patient and the finished prescriptions is used by the pharmacy once in the hands of the pharmacist the prescription and labeled are numbered by a numbering machine, the directions and other information are placed on the able. Ancillary labels are affixed, the proper medications placed in the containers, a check for accuracy is then conducted and finally the prepared prescription is wrapped and dispensed. Hospital Formulary Definition of formulary and for mulaly system 11 The formulary is a continually revised compilation of pharmaceuticals (plus important ancillary information) that reflects the current clinical judgment of medical staff. The formulary system: is a method whereby the medical staff of an institutions, working through the pharmacy and therapeutic committee, evaluations, and selects from the numerous available drug entities and drug products those that are considered most useful in patient care. The formulary system is an important tool for assuring the quality of drug use and controlling its cost. The formulary system provides for procuring, prescribing, dispensing and administering of drugs under either their non properitary or proprietary names in instances where drugs have both names. Formulary intent and organization The primary objective of the formulary is to the formulary system is a method whereby the medical staff of an institutions working through the pharmacy and therapeutic committee, evaluates, and selects from the numerous available drug entities and drug products those that are considered most useful in patient care. The formulary system is an important tool for assuring the quality to drug use and controlling its cost. The formulary system provides for procuring, prescribing, dispensing and administering of drugs under either their non proprietary or proprietary names in instances where drugs have both names. Formulary content and organization The primary objective of the formulary is to provide the hospitals staff with. 1. Information on what drug products have been approved for use by the pharmacy and the therapeutic committee. 12 Non proprietary named generic or official established names should be the most prominent patient of the label. Special characteristic of the dosage should be a part of the label e.g. sustained release, packages should be labeled as to their route of administration if other than oral of topicals in a package containing injections the acceptable injectable route must be stated special notes such as condition of storage, expiration should be part of the label e.g. sustained packages should be labeled as to their route of administration times of the other than or feects topcals in a packager containing injections of acceptable injectable route must be stated specied notes such as condition of storage, expiration dates preparations (shake well), moister administration must to be chewed) that are not about form the form designated are to be inclined at the of the label 14(c) Out patient Labeling out patient prescriptions 1. The outpatient prescription label should bear the following information: a. patients full name b. Date of issue c. Prescription identification no d. Specific directions for use e. Name for initial of dispenser f. Name of prescribing physician g. A keep out of children label h. Name address and telephone no of hospital 2. Prescription should have noted there on, at the time dispensed, the source and batch identifying number of the medication and the initial of the dispensaries. 13 3. An identifying check system to insure proper identification of outpatient should be established . 4. Drugs which required and expiration date should show this date on the immediate container and when this container is packaged incarton, the ex date should be placed on the carton. Patient medication profile (PMP) and outpatient service. As a tool the pharmacist uses PMP with the objective of monitoring drug therapy to averty and or to solve drug therapy related problems such as: 1. Duplication of active prescription for the same drug. 2. Duplication of an active prescription for a similar therapeutic entity. 3. Patient under or over utilization of drug 4. Potential drug-drug or drug-food interactions. 5. Potential diseases drug contraindication. 6. drug allergy or hypersensitivity. A particularly important element of PMP use in out patients services is compliance with therapeutic drug regimens. PMP enables the pharmacists to detect over or under utilization of medications based on refill frequency. Hospital Formulary Definition of formulary and formulary system: the formulary is a continually revised compilation of pharmaceutical (plus important ancillary information) that reflect the current clinical judgment of medical staff. The formulary system: is a method whereby the medical staff of an institution working through the pharmacy and therapeutic committee, evaluations, and selects from the numerous available drug entities and drug products those that are considered most useful in patient care. The 14 formulary system is an important tool for assuring the quality of drug use and controlling it cost. The formulary system provides for procuring, prescribing, dispensing and administering of drugs is under either their non proprietary or proprietary name in instances where drugs have both names. Formulary content and organization The primary objective of the formulary is to provide the hospitals staff with: 1. Information on what drug products have been approved for use by the pharmacy and therapeutic committee. 2. Basic therapeutic information about each approved item. 3. Information on about hospital policies and procedures governing the use of drugs. 4. Special information about drugs, such as drug dosing rules, hospital approved abbreviations, sodium content of various formulary items. Contents of the formulary Formulary should consist of three main parts: Part one; Information on hospital policies and procedures concerning drugs. Part two: Drug products listing Part three: Special information about three drugs. E, respect to part one the following items may be included: 1. Formulary policies and procedures including such items as restrictions on drug use (if any) and procedures for requesting that a drug be added to the formulary. 15 2. Brief description of the pharmacy and therapeutics committee, including its membership, responsibilities and operation. 3. Hospital regulations governing the prescribing, dispensing and administration of drugs, including the writing of drug orders and prescription. 4. Pharmacy operating procedures as hours of services out patient prescription policies, pharmacy changing system prescription labeling and packaging practices, impatient drug distribution procedures the handling of drug information requests and specialized services of the pharmacy. (e.g. patient education programs, pharmacy bulletins). 5. Information on using the formulary, including how the formulary entries are arranged, the information contained in each entry and the procedure for looking up a given drug product. References to sources of detailed information on formulary drugs (e.g, American hospital formulary service, pharmacy drug information service etc.) should be included here. Part two drug product listing. it is the heart of the formulary and consist of one or more descriptive entries for each formulary item plus one or more indexes to facilitate use of the formulary. Formulary item entries The entries can be arranged in several ways: 1. alphabetically by generic name, 2. Alphabetically within therapeutic class usually following the American Hospital formulary service (AHFS) classification scheme. 3. A combination of the two systems where by the bulk of the drugs are contained (alphabetically in a general section w, is 16 supplemented by several special sections such as ophtantmic otic drugs dermatogicials and diagnostic agents. The type of information in each entry will vary at a minimum each entry must include: a. Generic name of the basic drug entity or product, combination products may be listed by generic common lf trade name. b. Common synonym (s) and trade name(s) there should be a note in the direction for use. c. Dosage form, strength, packaging and size stocked by the pharmacy. d. Formulation (active ingredients) of a combination product and e. AHFS category number Additional information that can be included: 1. Usual adult or pediatric dosage ranges or both. 2. Special cautions and notes such as, do not administer IV, or refrigerate. 3. Controlled substances symbol. 4. Cost information, this generally will be the most useful where the therapeutic classification is used. Or alternatively, lists of similar drugs (e.g. oral steroids) may be prescribed relative cost data. Indexers to the drug products listing There are tow indexes which will facilitate the use of the formulary. They are: 1. Generic name Brand, synonym cross index. The proper page no. reference should be included in each entity. An example of this type index is: Ophtaine : brand of propara carine P114 17 Ophtetic : brand of propara caine P114 Opium tincture, campholated synonym for paregolie, P103 paragoric :P103 This index also could be integrated into the drug products listing rather than being a separate entity. the listing in this event, must be arranged alphabetically. 2. Therapeutic (pharmacologic index) It is useful in ascertaining what therapeutic alternatives exist for a given situation as patient allergy to a particular drug. And e.g. of this type of index is : 4.00 Antihistamine drug Bromphniramine maleate, P14 Chlorpheniramine maleaste, P14 Diphenhydramine HCl, P14 Promethazine HCl, P20 The enteries should include the AHFS code no. Special Information Examples of the type of items often found in the special information section of hospital formularies are: 1. Nutritional product list. 2. Tables of equivalent dosage of suimialr drugs. 3. List of hospital approved abbreviations. 4. rules for calculating pediatric dosage. 5. Table of the sodium content o f antacids. 6. List of content of emergency carts. 7. List of sugar free drug products. 8. Pharmacokienetic dosing and monitoring information. 9. Metric conversation scale and tables. 10.List of dialyzable poisons. 18 11.Table of drug interactions, drug interference e, diagnostic tests and parenteral drug in compatablities and poison control information. 12.Examples of blank or completed hospitals forms such as prescription. Distribution of the Formulary Copies of the formulary should be placed at each patient care unit, including clinics and other outpatients care areas such as the emergency room. Each division of the pharmacy (in pt, out pt, dispensing, drug information service etc) should receive a copy heads of departments providing direct patient care should receive a copy as should hospital administration each member of the medical staff should receive a copy of it. The necessary steps shod be taken to ensure that the nursing and medical staff are familiar the formulary and know how to use it. Keeping the formulary current The formulary will need to revised annually addition and deletions to the formulary changes in drug products, removal of the drug from the market place and changes in hospital policies and procedures all will necessitate periodic revision of the formulary. There should be a system for including between revision changes in the current edition for the formulary on method, is to attach formulary supplement sheet to the inside back covers of the formulary books use of non formulary drugs. In many institution a non formulary drug will not be dispensed from the out patient pharmacy with respect to inpatients, a physician is allowed to order a non formulary drug to a specific patient by the use of a special non formulary drug request. Chart B. 19 Formulary Vs drug catalogue or list Too many people use the terms formulary and drug list interchangeably. There is a big difference in the scope and preparation of a formulary over a drug list. A formulary usually consist of therapeutic agents by their genetic names followed by information on strength, from, toxicology use and recommended quantity to be dispensed, where as drug list usually consists of listing of therapeutic agents by their generic names followed by the data on strength and form there may or may not be any addition information. The formulary is the more information type of publication and may exert an important rule in the education aspects of drug therapy particularly in hospital with an active intern and training program and school of nursing. If a formulary type of publication is desirable, then the committee has the option of either preparing a private formulary for the hospital or to subscribe to a drug monograph service such as the American hospital formulary service, a publication of the American society of hospital pharmacists. Either of their will provide the hospital with adequate information concerning drugs each has its own advantages. Hospital Pharmacy II PHT 453 Dispensing to inpatients A great deal of nursing time was consumed by frequent trip to the pharmacy to obtain medications and other ancillary supplies. As a result new systems for the distribution and dispensing of drugs are developed. One such approach was the stocking of drugs on the nursing station in bulk quantities, thereby eliminating the pharmacists control for here the physician prescribed and the use dispensed and administered. But it has stated that drug administration is a nursing act which consists of the removal or with drawl of a single dose from a drug container and its 20 administration to a patient on the order of a physician or dentist. But dispensing is a pharmacy act and consists of the pharmacist removing two or more doses from a bulk drug container and placing them in another container for subsequent use. So nurses are not authorized to dispense drugs. A mole rational approach, might be the installation of a messenger service between pharmacy and the nursing stations, installation of mechanical covenyor systems or pneumatic tube systems or to develop emergency boxes or the placing of charge floor stock drug on the pavilion after a limited selection of drugs for this use has been made by the PTC. Many examples are recorded in the literature that illustrate the relationship between a drug distribution system and the nursing system. Studies show that 22% increase in the amount of time nurses were able to spend at the patient’s bedside as a result of changing the drug dispensing system. The following are guidelines for planning and evaluating hospital drug distribution systems. 1. before the initial dose of medication is administrated the pharmacist should review the prescriber’s original order or a direct copy. 2. Drugs dispensed should bear adequate identification including, name of names of drugs, strength or potency, route (s) of administration, expiration date, control No., and such other special instructions. 3. Facilities and equipment used to store drugs should be designed that the drugs are accessible only to medical practitioners authorized to prescribe, to pharmacists authorized to dispense to nurses authorized to administer such drugs. 21 4. Facilities and equipment used to store drugs should be designed to facilitates routine inspection of the drug prior to the time of administration. 5. Mechanical or electronic drug storage and dispensing device as require or encourage the repackage of drug dosage forms from the manufacture’s original container should permit and facilitate. The use of a new package which will assure the stability of each drug and meet u.s.p standards for the packaging and storing drugs and all other standard of GMP. 6. In considering automated devices as pharmaceutical tools, the distinction between the accuracy required in accounting practices versus that required in dispensing practices should be clearly distinguished. 22