hospital pharmacyhospital pharmacy

Prepared byPrepared by

Nehad Jaser AhmedNehad Jaser Ahmed

Introduction to hospital pharmacyIntroduction to hospital pharmacy

• A hospital pharmacy is concerned with pharmacy A hospital pharmacy is concerned with pharmacy service to all types of hospital and differs service to all types of hospital and differs considerably from a community pharmacy .considerably from a community pharmacy .

• Some pharmacists in hospital pharmacies may Some pharmacists in hospital pharmacies may have more complex clinical medication have more complex clinical medication management issues whereas pharmacists in management issues whereas pharmacists in community pharmacies often have more complex community pharmacies often have more complex business and customer relations issues. business and customer relations issues.

• Because of the complexity of the Because of the complexity of the medication use system, many pharmacists medication use system, many pharmacists practicing in hospitals gain more practicing in hospitals gain more education and training after pharmacy education and training after pharmacy school through a pharmacy practice school through a pharmacy practice residency and sometimes followed by residency and sometimes followed by another residency in a specific area.another residency in a specific area.

• Hospital pharmacies can usually be found Hospital pharmacies can usually be found within the premises of the hospital. within the premises of the hospital. Hospital pharmacies usually stock a larger Hospital pharmacies usually stock a larger range of medications, including more range of medications, including more specialized and investigational specialized and investigational medications (medicines that are being medications (medicines that are being studied, but have not yet been approved), studied, but have not yet been approved), than would be feasible in the community than would be feasible in the community setting. setting.

• Hospital pharmacies typically provide Hospital pharmacies typically provide medications for the hospitalized patients only, medications for the hospitalized patients only, and are not retail establishments. They and are not retail establishments. They typically do not provide prescription service to typically do not provide prescription service to the public. the public.

• Some hospitals do have retail pharmacies Some hospitals do have retail pharmacies within them, which sell over-the counter as within them, which sell over-the counter as well as prescription medications to the public, well as prescription medications to the public, but these are not the actual hospital but these are not the actual hospital pharmacy.pharmacy.

Director of pharmaceutical services is Director of pharmaceutical services is in charge of :in charge of :

• financial managementfinancial management

• purchasing drugs and equipment inter-purchasing drugs and equipment inter-departmental affairsdepartmental affairs

• quality assurancequality assurance

• provision of professional services.provision of professional services.

Purchasing of equipmentPurchasing of equipment

• Enteral and parenteral infusion pumps Enteral and parenteral infusion pumps (e.g. patient-controlled analgesia pump)(e.g. patient-controlled analgesia pump)

• Computer systemsComputer systems

• Refrigerator and narcotic cupboardsRefrigerator and narcotic cupboards

• Counting systems, tablet counter, Counting systems, tablet counter, containerscontainers

• Laminar airflow hoodsLaminar airflow hoods

• GlovesGloves

• Balance.Balance.

Considerations when purchasing Considerations when purchasing equipmentequipment

• Specifications, functionalitySpecifications, functionality

• Reliability of the equipmentReliability of the equipment

• Personnel trainingPersonnel training

• CostCost

• MaintenanceMaintenance

• User-friendlinessUser-friendliness

• PortabilityPortability

• Lease vs purchase.Lease vs purchase.

Professional hospital pharmacy Professional hospital pharmacy servicesservices

• Medicines supply to inpatients and Medicines supply to inpatients and outpatientsoutpatients

• Clinical pharmacyClinical pharmacy• Drug information serviceDrug information service• Drug and therapeutics committeeDrug and therapeutics committee• Infection control committeeInfection control committee• Medical gasesMedical gases

• Cytotoxic dispensingCytotoxic dispensing

• Specials (e.g. total parenteral nutrition, Specials (e.g. total parenteral nutrition, extemporaneous preparation)extemporaneous preparation)

• Developing systems of seamless care: Developing systems of seamless care: integrating community and hospital integrating community and hospital pharmaceutical services.pharmaceutical services.

Inpatient pharmacyInpatient pharmacy

• An inpatient pharmacy specifically fills An inpatient pharmacy specifically fills prescriptions for people who are hospitalized. prescriptions for people who are hospitalized.

• The inpatient pharmacy is often in a different The inpatient pharmacy is often in a different area of the hospital than the outpatient area of the hospital than the outpatient pharmacy, and it may only be open to authorized pharmacy, and it may only be open to authorized personnel, with doctors and nurses picking up personnel, with doctors and nurses picking up prescriptions for their patients. prescriptions for their patients.

• This pharmacy also synchronizes its This pharmacy also synchronizes its records with the outpatient pharmacy to records with the outpatient pharmacy to ensure that the patient's data is always up ensure that the patient's data is always up to date to date

Medicines supply to inpatientsMedicines supply to inpatients

Pharmacist could be involved in:Pharmacist could be involved in:

• prescription sheet design to ensure an prescription sheet design to ensure an easy-to follow documentation of medicines easy-to follow documentation of medicines to be administeredto be administered

• medicines storage and medicine stock medicines storage and medicine stock levels at ward level.levels at ward level.

Dispensing medicines for the Dispensing medicines for the wardswards

• List of ward stock items maintained updatedList of ward stock items maintained updated

• Topping up of ward stock: maintain practical Topping up of ward stock: maintain practical stock levels to ensure that wards have the stock levels to ensure that wards have the required medicines in the appropriate required medicines in the appropriate amounts and avoid stock wastageamounts and avoid stock wastage

• Consider unit-dose dispensingConsider unit-dose dispensing

Unit DoseUnit Dose

• A unit dose is A unit dose is a method of preparing a method of preparing medications in which individual doses of medications in which individual doses of patient medications are prepared by the patient medications are prepared by the pharmacy and delivered in individual pharmacy and delivered in individual labelled packets to the patient's unit to be labelled packets to the patient's unit to be administered by the nurses on an ordered administered by the nurses on an ordered schedule. schedule.

• Unit-dose packaging is the packaging of a Unit-dose packaging is the packaging of a single dose in a non-reusable container. It single dose in a non-reusable container. It is increasingly used in hospitals, nursing is increasingly used in hospitals, nursing homes , etc. Medications in unit-dose homes , etc. Medications in unit-dose packaging are easily identifiable and can packaging are easily identifiable and can be returned to the pharmacy if the be returned to the pharmacy if the medication is discontinuedmedication is discontinued

• UUnit-dose dispensing may lead to nit-dose dispensing may lead to increased pharmacist time during increased pharmacist time during dispensing of medicines to wards but it is dispensing of medicines to wards but it is an efficient system that reduces an efficient system that reduces medication errors. Cost-effectiveness of medication errors. Cost-effectiveness of the system employed needs to be the system employed needs to be assessed.assessed.

Definition of ward stockDefinition of ward stock

• Medicines where at least five or six patients Medicines where at least five or six patients are receiving it at the same timeare receiving it at the same time

• Products should not be expensiveProducts should not be expensive

• Products should have a good shelf-lifeProducts should have a good shelf-life

• No major contraindications to their use and no No major contraindications to their use and no requirements for specialist care and requirements for specialist care and supervisionsupervision

• Include commonly used items (e.g. Include commonly used items (e.g. paracetamol tablets)paracetamol tablets)

• Label: name of drug, strength, instructions Label: name of drug, strength, instructions for use (e.g. dilution/reconstitution), for use (e.g. dilution/reconstitution), storage requirements, no dosage storage requirements, no dosage instructions and patient namesinstructions and patient names

• Items used without prescription (e.g. Items used without prescription (e.g. disinfectants, antiseptics).disinfectants, antiseptics).

Controlled drugsControlled drugs

• Stock record Medicines are kept. Unused Stock record Medicines are kept. Unused stock of these Medicines should be kept in stock of these Medicines should be kept in a secure place.a secure place.

• Medicines stored in a locked box on wardMedicines stored in a locked box on ward

• Signature upon receipt of stock and when Signature upon receipt of stock and when administering drug doses.administering drug doses.

Ward drug storage areasWard drug storage areas

• Controlled drugs cupboardControlled drugs cupboard

• Cupboard for medicines intended for internal useCupboard for medicines intended for internal use

• Cupboard for medicines intended for external useCupboard for medicines intended for external use

• Area to store disinfectantsArea to store disinfectants

• Refrigerator to store drugs: temperature Refrigerator to store drugs: temperature controlled with thermometer being usedcontrolled with thermometer being used

• Clean area for intravenous fluids.Clean area for intravenous fluids.

Monitoring ward stocksMonitoring ward stocks

• Pharmacy staff should establish a working Pharmacy staff should establish a working relationship with nurses and ward managerrelationship with nurses and ward manager

• Ensure cleanliness and hygieneEnsure cleanliness and hygiene

• Advise on appropriate storage conditionsAdvise on appropriate storage conditions

• Remind ward staff to carry out stock rotation Remind ward staff to carry out stock rotation when new stock is receivedwhen new stock is received

• Correct stock levelsCorrect stock levels

• Ensure appropriate monitoring of Ensure appropriate monitoring of refrigeratorsrefrigerators

• Check controlled drugs cupboard. Check controlled drugs cupboard.

Sterile productionSterile production

• Hospital pharmacists and trained Hospital pharmacists and trained pharmacy technicians compound sterile pharmacy technicians compound sterile products for patients including total products for patients including total parenteral nutrition (TPN), and other parenteral nutrition (TPN), and other medications given intravenously medications given intravenously e.g.nenatal antibiotics and chemotherapy. e.g.nenatal antibiotics and chemotherapy.

• This is a complex process that requires This is a complex process that requires adequate training of personnel, quality adequate training of personnel, quality assurance of products, and adequate assurance of products, and adequate facilities. Some hospital pharmacies have facilities. Some hospital pharmacies have decided to outsource high-risk decided to outsource high-risk preparations and some other preparations and some other compounding functions to companies that compounding functions to companies that specialize in compounding. specialize in compounding.

Drug and therapeutics Drug and therapeutics committeecommittee

Aims are:Aims are:

• to maintain a hospital formularyto maintain a hospital formulary

• to develop and implement policies on drug to develop and implement policies on drug use including, for example, generic use including, for example, generic substitution, therapeutic guidelines and substitution, therapeutic guidelines and cost-containment policies.cost-containment policies.

Infections control committeeInfections control committee

Aims are:Aims are:

• to review use of anti-infective agentsto review use of anti-infective agents

• to develop and implement policies and to develop and implement policies and guidelines regarding the use of anti-guidelines regarding the use of anti-infective agentsinfective agents

• to develop policies for wound management.to develop policies for wound management.

Drug information servicesDrug information services

Aims areAims are

• to respond to queries from different departments and other to respond to queries from different departments and other care settingscare settings

• to evaluate drug usageto evaluate drug usage

• to investigate drug activity and coordinate clinical trials to investigate drug activity and coordinate clinical trials activity (this activity may be shared with the quality activity (this activity may be shared with the quality assurance unit)assurance unit)

• to coordinate reporting programmes for adverse drug to coordinate reporting programmes for adverse drug reactions and medication errors Hospital pharmacy services reactions and medication errors Hospital pharmacy services

• Drugs to be stored in a refrigerator include Drugs to be stored in a refrigerator include total parenteral nutrition (TPN) solutions, total parenteral nutrition (TPN) solutions, reconstituted antibacterial suspensions reconstituted antibacterial suspensions and cytotoxic drugs, insulin, vaccinesand cytotoxic drugs, insulin, vaccines

• Items and drugs that are not to be stored Items and drugs that are not to be stored in refrigerator include heparin, blood and in refrigerator include heparin, blood and urine specimens, food, inflammablesurine specimens, food, inflammables

• A good procedure is to prepare a list on A good procedure is to prepare a list on the door of the refrigerator of all the items the door of the refrigerator of all the items that require storage in a refrigeratorthat require storage in a refrigerator

• Check that all items in the refrigerator Check that all items in the refrigerator require to be stored in a refrigerator require to be stored in a refrigerator (usually between 2 and 8 ° C).(usually between 2 and 8 ° C).

Pharmacists’ actions in the Pharmacists’ actions in the development of protocols to development of protocols to standardise practical nursing standardise practical nursing techniques on the wardstechniques on the wards

• Blood sugar monitoring techniqueBlood sugar monitoring technique

• Use of patients’ own medicinesUse of patients’ own medicines

• Administration of injectionsAdministration of injections

• Intravenous additivesIntravenous additives

• Medicines administrationMedicines administration

• Nebuliser therapyNebuliser therapy

• Urine testingUrine testing

• Ordering and storage of medicines.Ordering and storage of medicines.

• to provide poison informationto provide poison information

• to produce publicationsto produce publications

• to educate and provide professional to educate and provide professional development for professionals.development for professionals.

Wound management committeeWound management committee

Aims are:Aims are:• to design protocols for wound managementto design protocols for wound management

• to liaise with the infections control committee to liaise with the infections control committee to identify antibacterial agents that are less to identify antibacterial agents that are less likely to develop bacterial resistancelikely to develop bacterial resistance

• to use proper wound treatment and to use proper wound treatment and appropriate dressingsappropriate dressings

• to keep wound treatment cost-effectiveto keep wound treatment cost-effective

• to address factors precipitating wound to address factors precipitating wound development (e.g. uncontrolled diabetes).development (e.g. uncontrolled diabetes).

Clinical pharmacy servicesClinical pharmacy services

• Pharmacists should use their professional Pharmacists should use their professional knowledge to foster the safe and knowledge to foster the safe and appropriate use of drugs by patients in a appropriate use of drugs by patients in a teamwork approach. They should also aim teamwork approach. They should also aim to solve medication errors, detect drug–to solve medication errors, detect drug–drug interactions and identify drug-drug interactions and identify drug-induced disease.induced disease.

Services provided include:Services provided include:

• therapeutic drug monitoringtherapeutic drug monitoring

• pharmacokinetic dosingpharmacokinetic dosing

• patient educationpatient education

• medication counsellingmedication counselling

• drug utilisation reviewdrug utilisation review

• participation in pharmacotherapy decision participation in pharmacotherapy decision making and in patient follow-up.making and in patient follow-up.

Pharmaceutical care should also:Pharmaceutical care should also:

• focus on patient outcomesfocus on patient outcomes

• identify potential and actual drug-related identify potential and actual drug-related problemsproblems

• resolve actual drug-related problemsresolve actual drug-related problems

• prevent potential drug-related problems.prevent potential drug-related problems.

Documentation of pharmacist actions in Documentation of pharmacist actions in pharmacy held patient records should pharmacy held patient records should contain information on:contain information on:

• age, weight and heightage, weight and height

• medical historymedical history

• allergic or adverse drug reaction allergic or adverse drug reaction historyhistory

• renal functionrenal function

• hepatic function.hepatic function.

Outpatient pharmacyOutpatient pharmacy

• an outpatient pharmacy can usually handle an outpatient pharmacy can usually handle written prescriptions as well as prescriptions written prescriptions as well as prescriptions which are phoned in. which are phoned in.

• Due to the need to compound complex drugs Due to the need to compound complex drugs in a hospital facility, outpatient pharmacies in a hospital facility, outpatient pharmacies may also be able to offer specialty drugs and may also be able to offer specialty drugs and preparations to their patients, rather than preparations to their patients, rather than having to special-order them.having to special-order them.

• There are several advantages for patients There are several advantages for patients who use an outpatient pharmacy as who use an outpatient pharmacy as opposed to a regular pharmacy. The first is opposed to a regular pharmacy. The first is that the pharmacy is on the same site that the pharmacy is on the same site where they receive medical treatment, so where they receive medical treatment, so they do not need to make an extra trip to they do not need to make an extra trip to the pharmacy to pick up prescriptions. the pharmacy to pick up prescriptions.

• The second is that the pharmacy staff is The second is that the pharmacy staff is usually very knowledgeable about the usually very knowledgeable about the patient's condition, and the staff can patient's condition, and the staff can quickly catch potential drug conflicts and quickly catch potential drug conflicts and other issues which may arise. The other issues which may arise. The outpatient pharmacy may also offer outpatient pharmacy may also offer discounts on prescriptions.discounts on prescriptions.

• Hospital staffs may also take advantage of Hospital staffs may also take advantage of outpatient pharmacy services, picking up outpatient pharmacy services, picking up the prescriptions they need at work. the prescriptions they need at work.

• Pharmacy services may also be a part of Pharmacy services may also be a part of employee benefits, with employees employee benefits, with employees receiving prescriptions at reduced cost as receiving prescriptions at reduced cost as part of their health plans. part of their health plans.

• Employees who choose to fill prescriptions Employees who choose to fill prescriptions elsewhere may certainly do so, but they elsewhere may certainly do so, but they may be obliged to pay full cost for the may be obliged to pay full cost for the drugs. drugs.

Drug Utilization Reviews (DUR)Drug Utilization Reviews (DUR)

• Drug Utilization Reviews (DUR), also Drug Utilization Reviews (DUR), also referred to as Drug Utilization Evaluations referred to as Drug Utilization Evaluations (DUE) or Medication Utilization Evaluations (DUE) or Medication Utilization Evaluations (MUE), are defined as an authorized, (MUE), are defined as an authorized, structured, ongoing review of healthcare structured, ongoing review of healthcare provider prescribing, pharmacist provider prescribing, pharmacist dispensing, and patient use of medication. dispensing, and patient use of medication.

• DURs involve a comprehensive review of DURs involve a comprehensive review of patients' prescription and medication data patients' prescription and medication data before, during, and after dispensing to before, during, and after dispensing to ensure appropriate medication decision ensure appropriate medication decision making and positive patient outcomes.making and positive patient outcomes.

DURs are classified into three DURs are classified into three categories:categories:

• Prospective - evaluation of a patient's Prospective - evaluation of a patient's therapy before medication is dispensedtherapy before medication is dispensed

• Concurrent - ongoing monitoring of drug Concurrent - ongoing monitoring of drug therapy during the course of treatmenttherapy during the course of treatment

• Retrospective - review of therapy after Retrospective - review of therapy after the patient has received the medicationthe patient has received the medication

Why DURs are importantWhy DURs are important

• DUR programs play a key role in helping DUR programs play a key role in helping managed health care systems understand, managed health care systems understand, interpret, and improve the prescribing, interpret, and improve the prescribing, administration, and use of medications. administration, and use of medications.

• Employers and health plans find DUR Employers and health plans find DUR programs valuable because the results are programs valuable because the results are used to foster more efficient use of scarce used to foster more efficient use of scarce health care resources. health care resources.

• Pharmacists play a key role in this process Pharmacists play a key role in this process because of their expertise in the area of because of their expertise in the area of pharmaceutical care.pharmaceutical care.

• DURs afford the managed care pharmacist the DURs afford the managed care pharmacist the opportunity to identify trends in prescribing opportunity to identify trends in prescribing within groups of patients such as those with within groups of patients such as those with asthma, diabetes, or high blood pressure. asthma, diabetes, or high blood pressure.

• Pharmacists can then, in collaboration with Pharmacists can then, in collaboration with other members of the health care team, other members of the health care team, initiate action to improve drug therapy for initiate action to improve drug therapy for both individual patients and covered both individual patients and covered populations. populations.

• DURs serve as a means of improving the DURs serve as a means of improving the quality of patient care, enhancing quality of patient care, enhancing therapeutic outcomes, and reducing therapeutic outcomes, and reducing inappropriate pharmaceutical inappropriate pharmaceutical expenditures, thus reducing overall health expenditures, thus reducing overall health care costs.care costs.

Practice summaryPractice summary

• Pharmacy services are provided to support the Pharmacy services are provided to support the rational and safe use of medicines and to ensure rational and safe use of medicines and to ensure teamwork in the therapeutic process.teamwork in the therapeutic process.

• Pharmacists can give advice on storage of Pharmacists can give advice on storage of medicines, stock levels for ward stock, medicines, stock levels for ward stock, information on methods of drug use and drug information on methods of drug use and drug administration, participate in development of administration, participate in development of therapeutic protocols and in clinical trials, and therapeutic protocols and in clinical trials, and participate in patient care and patient monitoring.participate in patient care and patient monitoring.

• Pharmacists practising in a hospital Pharmacists practising in a hospital involved in the clinical pharmacy services involved in the clinical pharmacy services are in a position to promote seamless care are in a position to promote seamless care when the patient is transferred back to the when the patient is transferred back to the primary care level.primary care level.

• Pharmacists in the hospital setting should Pharmacists in the hospital setting should be involved in the wards and outpatient be involved in the wards and outpatient clinics to establish collaboration with the clinics to establish collaboration with the prescribers and nursing staff so as to liaise prescribers and nursing staff so as to liaise with them as a team when providing the with them as a team when providing the pharmacy professional services.pharmacy professional services.

• Pharmacists practising in a hospital Pharmacists practising in a hospital involved in the clinical pharmacy services involved in the clinical pharmacy services are in a position to promote seamless care are in a position to promote seamless care when the patient is transferred back to the when the patient is transferred back to the primary care level.primary care level.

• Pharmacists in the hospital setting should Pharmacists in the hospital setting should be involved in the wards and outpatient be involved in the wards and outpatient clinics to establish collaboration with the clinics to establish collaboration with the prescribers and nursing staff so as to liaise prescribers and nursing staff so as to liaise with them as a team when providing the with them as a team when providing the pharmacy professional services.pharmacy professional services.

Formulary systemFormulary system

• A formulary is a continually updated list of A formulary is a continually updated list of medications and related information, medications and related information, representing the clinical judgement of representing the clinical judgement of physicians, pharmacists and other experts physicians, pharmacists and other experts in the diagnosis, prophylaxis or treatment in the diagnosis, prophylaxis or treatment of disease and promotion of health. of disease and promotion of health.

• A formulary includes, but is not limited to, A formulary includes, but is not limited to, a list of medications and medication-a list of medications and medication-associated products or devices, associated products or devices, medication-use policies, important medication-use policies, important ancillary drug information, decision-ancillary drug information, decision-support tools, and organizational support tools, and organizational guidelines.guidelines.

Selection of drugs for Selection of drugs for inclusion in a formularyinclusion in a formulary

Drugs are selected for inclusion on the basis Drugs are selected for inclusion on the basis of their:of their:

• efficacyefficacy

• safetysafety

• patient acceptabilitypatient acceptability

• cost.cost.

Reasons to develop formulary Reasons to develop formulary systemsystem

To ensure quality and appropriateness of To ensure quality and appropriateness of drug use in a particular practicedrug use in a particular practice

• To teach appropriate drug therapy To teach appropriate drug therapy especially relevant for junior doctorsespecially relevant for junior doctors

• To promote evidence-based and cost-To promote evidence-based and cost-effective drug therapyeffective drug therapy

• To cut down on the range of drugs in useTo cut down on the range of drugs in use

• To encourage the use of therapeutic To encourage the use of therapeutic protocols.protocols.

Benefits of a formularyBenefits of a formulary

• Cost-effective prescribingCost-effective prescribing• Rational prescribingRational prescribing• Use of a restricted range of drugs results Use of a restricted range of drugs results

in better knowledge of drug usein better knowledge of drug use• Better stock managementBetter stock management

• Improvement in communication between Improvement in communication between prescribers and pharmacistsprescribers and pharmacists

• Promotes seamless care between hospital Promotes seamless care between hospital practitioners and primary care practitioners and primary care practitioners.practitioners.

Content of a formularyContent of a formulary

• IntroductionIntroduction• Follow a basic drug information system Follow a basic drug information system

(e.g. reference to (e.g. reference to British National British National FormularyFormulary))

• Use a classification system (e.g. Use a classification system (e.g. pharmacological or symptomatic)pharmacological or symptomatic)

• Include drug costs and cost of treatmentInclude drug costs and cost of treatment• Notes on inclusion criteria and selection of Notes on inclusion criteria and selection of

drugs.drugs.

Formulary management Formulary management systemsystem

• Has to be flexible and dynamicHas to be flexible and dynamic

• Regular updates to reflect current practice Regular updates to reflect current practice (e.g. biannual or annual editions)(e.g. biannual or annual editions)

• Inclusion of new drugs released on the Inclusion of new drugs released on the market: consider issue of safety, cost, market: consider issue of safety, cost, indications.indications.

• Withdrawing drugs: discontinued drugs, Withdrawing drugs: discontinued drugs, drugs no longer prescribeddrugs no longer prescribed

• Procedure to meet non-formulary Procedure to meet non-formulary requests.requests.

Formulary system summaryFormulary system summary

• A formulary provides information on the A formulary provides information on the drugs and medical devices that are used in drugs and medical devices that are used in a particular institution.a particular institution.

• For successful implementation, the For successful implementation, the formulary requires regular updating, and formulary requires regular updating, and participation of different members of the participation of different members of the health professions in decisions relating to its health professions in decisions relating to its development and maintenance.development and maintenance.

• Presentation of the formulary should be Presentation of the formulary should be easy to use and follow, and attractive. easy to use and follow, and attractive. Electronic access to the formulary should Electronic access to the formulary should be supportedbe supported

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