6

(v.2013)


(Institutional Pharmacy Practice)
........................................................................ 4
1.

.................................................................................................................................... 5

2.

..................................................................................................................... 6

3.

................................................................................................................... 7

4.

.......................................................................................................................... 9

5.

Preceptor ...................................................................................................... 18

6.

.................................................................................... 18

7.

Preceptor ................................................................................................................... 23

8.

, .............................................................................................................. 23

9.

............................................................................................................................................ 24

...................................................................... 25
1.

.................................................................................................................................... 5

2.

..................................................................................................................... 6

3.

................................................................................................................... 7

4.

.......................................................................................................................... 9

5.

Preceptor ...................................................................................................... 18

6.

.................................................................................... 18

7.

Preceptor ................................................................................................................... 23

8.

, .............................................................................................................. 23

9.

............................................................................................................................................ 24
[2013 | ]

Page 2

[2013 | ]

Page 3

 I
(Inpatient Care Practice Experience, ICPE)

,
.

, , .

, .

(ACS: Anti coagulant Service)

.

40 5 5 200 .

200 4 .

[2013 | ]

Page 4

1.
.

) ,

,
.

) ,

, ,
.

, ,
.

,
.

,
.

) ()

, .

) (ACS, ) ()

(ACS, ]
.

, .

[2013 | ]

Page 5

2.
) 1

Hirsh J, James E, Anderson DR, Poller L, Bussey H, Ansell J, Deykin D. Oral anticoagulants:
Mechanism of Action, Clinical Effectiveness, and Optimal therapeutic Range. Chest 2001;
119(1) suppl: 8S-21S.

Gage BF, Fihn SD, White RH. Management and Dosing Warfarin Therapy. Am J Med 2000;
109(6): 481-488.

Ansell, J. Hirsh J, Dalen J, Bussey H, Anderson D, Poller L, Jacobson A, Deylin D, Matchar D.

The Pharmacology and Management of the Vitamin K Antagonists. Chest 2004; 126(3)
suppl: 204S-233S.

Beyth RJ, Quinn L, Landefeld CS. A multi-component intervention to prevent major

bleeding complications in older patients on warfarin; A randomized controlled trial. Ann

Intern Med 2000; 133(9): 687-695

Deed N, Paul D. Steine et al. Antithrombotic therapy in Valvular Heart Disease-Native and
Prosthetic. Chest 2004; 126(Supp): 457S-482S.

Levine MN, Raskob G, et al. Hemorrhageic Complications of Anticoagulant treatment.

Chest 2004; 126 (Supp): 287S-310S.

) 2

BMJ (British Medical Journal): (http://bmj.com)

Formulary (http://www.formularyjournal.com)

JAMA(The Journal of the American Medical Association) (http://jama.ama-assn.org)

Lancet (http://www.thelancet.com/journal)

NEJM(New England Journal of Medicine) (http://content.nejm.org)

) 3

Applied Therapeutics: The Clinical Use of Drugs, 9th Edition Mary A. Koda-Kimble et al.

Lippincott Williams&Wilkins. 2009

Pharmacotherapy: A Pathophysiologic Approach, 6th Edition Joseph T. Dipiro et al.

McGraw-Hill Medical. 2009

The Science and Practice of Nutrition Support: A Case-Based Core Curriculum Michele M.
Gottschlich et al.

Kendall/Hunt Publishing Company. 2000

The A.S.P.E.N. Nutrition Support Practice Manual 2nd Edition Russell Merritt et al.
AMERICAN SOCIETY FOR PARENTERALAND ENTERAL NUTRITION. 2005

Total Parenteral Nutrition: Webster's Timeline History, 1970 - 2007 Icon Group
International. 2009

Handbook on Injectable Drugs, 15th Edition Trissel, Lawrence A. et Al. American Society of
Health-System Pharmacists (ASHP). 2009.
[2013 | ]

Page 6

JPEN (Journal of Parenteral and Enteral Nutrition) : (http://pen.sagepub.com)

NCP (Nutrition in Clinical Practice) : (http://ncp.sagepub.com)

. ()&. 2002.

. . 2003.

Q&A . . 2007.

: Pharmaceutical Terminology . . 2008

[ ] .

. . 2004

- . 2009

(http://www.ashp.org)

OVID (http://www.ovid.com)

Medline (http://www.medline.com)

PubMed (http://www.pubmed.com)

(http://www.druginfo.co.kr)

KMLE (http://www.kmle.co.kr)

Micromedex (CCIS: Computerized Clinical Information System)

ASPEN (American Society for Parenteral and Enteral Nutrition)

(http://www.nutritioncare.org)

3.
)
(1)

, .

,
.

,
.

[2013 | ]

Page 7

(2)

, .

feedback .

, .

. .

, , ,

1996 ' (Health Insurance

Portability and Accountability Act; HIPAA)'
.

HIPAA ( ,
, / ) (, ,
) .

, , , , .

[2013 | ]

Page 8

4.
)

Code

ICPE1 ()

,



.

1-1
1-2
1-3
1-4
1-5
1-6
1-7
1-8

ICPE2

(/)
,


,
,

.
//

.


.

2-1
2-2
2-3
2-4

ICPE3

ICPE4

40
(1)

4-1
4-2
4-3
4-4

()

4-6
4-7

(,
)

40
(1)

3-1
3-2
3-3

4-5

ICPE5
(
,
)

intervention ()

TPN /

80
(2)

5-1
5-2
5-3

5-4
5-5
5-6

-

intervention
regimen



()


, intervention : Case
review
,





intervention ()

[2013 | ]

()

Page 9

)
(1) ()
()
Code
ICPE1-1

ICPE1-2

ICPE1-3

, .

(, , , , , )

( , , , , , )
.

(, ) (, )
.

(, ) .

. (5
)

1 (1 ) .

, .

.
ICPE1-4

ICPE1-5

/, .

.
ICPE1-6

(, ).

.
[2013 | ]

Page 10

(, )
.

,
.

, , 1 , (),
.

, ,
, .

,

, .

ICPE1-7

ICPE1-8

intervention ,

intervention .

[2013 | ]

Page 11

(2)

, ,
.

ICPE2-1

, , .

, .

, .

()

(: burrette- type, IV push, piggyback )

.

Gravity flow infusion, controllers, solution pumps, total parenteral

nutrition compounders, patient controlled infusion
.

ICPE2-2

TPN /

, .

TPN .

,
.

ICPE2-3

(, 1 , ,
) .

[2013 | ]

Page 12

(,
) .

, .

,
.

, 1 , , ,
(IM,

SC,

IV),

(),

, ,
, .

,

, .

ICPE2-4

( ) .

[2013 | ]

Page 13

(3)

,
Code

/, /, ,

.
ICPE3-1

medical chart ,
, , .

/,

/, / , ,
,
.

, ,

self-medication

(, , )
.

.
ICPE3-2

/,

/, / , ,
,
.

, ,
.

[2013 | ]

Page 14

, ,
.

ICPE3-3

medical chart
, , ,
.

/,

/, / , ,
,
.

(, ,
) .

,

( , ,
) ,
.

[2013 | ]

Page 15

(4) ()

.
ICPE4-1

, .

(, ,

ICPE4-2

) .

(,
, ) .

ICPE4-3

, -
.

ICPE4-4

Intervention

macronutrient
macronutrient
.

,
.

regimen

.
ICPE4-5

, .

Regimen

( cyclic TPN) .

( ) ,
regimen .

ICPE4-6

, ()

ICPE4-7

()

[2013 | ]

Page 16

(5) (, ) ()
(, )
,
Code

,
.

ICPE5-1

(ACS, )

, compliance .

ICPE5-2

Intervention

Warfarin/heparin .

; Case

Review

endpoint

warfarin/heparin .

,
.

endpoint

ICPE5-3

endpoint .

.
ICPE5-4

ICP5-5

intervention

) .

.
ICPE5-6

()

intervention ,

intervention .

[2013 | ]

Page 17

5. Preceptor

, .

Preceptor .

feedback .

,
.

preceptor role model .

6. ( Update )
) ()

) ,

TPN ,

) () TPN

) ()

(high-alert medication): ,

[2013 | ]

Page 18

< 1>

()

aa

ana

a.c.

ante cibum

ad

ad

ad lib.

ad libitum

agit. ante sum.

agitare ante

( )

alt. dieb

alternis diebus

alt. hor.

alternis horis

alt. noct.

alternis noctibus

aq.

aqua

aq. dest.

aqua destillata

b.i.d.

bis in die

1 2

b.i.n.

bis in nocte

c.,c

cum

Cap.

capiat

caps.

capsula

c.m.s.

cras mane sumendus

c.n.

cras nocte

c.n.s.

cras nocte sumendus

comp.

composites

Det.

detur

Dieb. tert.

diebus tertiis

dil.

dilutus

elix.

elizir

ext.

ectractum

fld.

fluidus

Ft.

fiat

Gramme

gr

granum

gt

gutta

gtt

guttae

h.

hora

h.d.

hora decubitus

h.s.

hora somni

M.

misce

m.

Minimum

mist.

mistura

non rep.

non repetatur

noct.

nocte

octarius

ol.

oleum

[2013 | ]

Page 19

o.d.

omni die

o.h.

omni hora

o.m.

omni mane

o.n.

omni nocte

os

os

oz

uncia

p.c.

post cibum

per

per

, ~

pil.

pilula

p.o.

per os

p.r.n.

pro re nata

quaque

q.d.

quaque die

q.h

quaque hora

q.2 h.

q.3. h.

q 4 h.

q.i.d.

quarter in die

1 4

q.I.

quantum libet

q.n.

quaque nocte

q.p.

quantum placeat

q.v.

quantum vis

q.s.

quantum sufficit

Rx

recipe

Rep.

repetatur

s, s

Sine

seq. luce.

sequent luce

Sig. or S.

signa

s.o.s.

si opus sit

sp.

spiritus

ss

Semis

(1/2)

stat.

statim

syr.

syrupus

t.d.s.

ter die sumendum

t.i.d.

ter in die

1 3

t.i.n.

ter in nocte

tr. or tinct.

tincture

ung.

unguentum

ut. dict.

ut dictum

vin.

vini

[2013 | ]

Page 20

< 2> SI Units and Symbols

Physical Quantity Measured

Unit

Symbol

Length

Meter

Mass

Kilogram

kg

Time

Second

Amount of substance

Mole

mol

Temperature

Kelvin

Electric current

Ampere

Luminous intensity

Candela

cd

Area

Square Meter

m2

Volume

Cubic meter

m3

Force

Newton

Pressure

Pascal

Pa

Work energy

Joule

Density

Kilogram per cubic meter

Frequency

Hertz

kg/m3
Hz

< 3> Blood Chemistry Reference Values

Laboratory Test

Normal Reference Values

Conventional Units

SI Units

ALT (SGPT)

0-35 U/L

0-0.58 kat/L

Albumin

4-6 g/dL

40-60 g/L

Alk Phos

30-120 U/L

0.5-2.0 kat/L

Amylase

35-120 U/L

0.58-2.0 kat/L

0-35 U/L

0-0.58 kat/L

Total

0.1-1 mg/dL

1.7-17.1 mol/L

Direct

0-0.2 mg/dL

0-3.4 mol/L

8-18 mg/dL

3-6.5 mmol/L

Calcium Total

8.8-10.2 mg/dL

2.20-2.55 mmol/L

Unbound

4.6-5.2 mg/dL

1.15-1.3 mmol/L

CO2 content

22-28 mEq/L

22-28 mmol/L

Chloride

95-105 mEq/L

95-105 mmol/L

Total

<200 mg/dL

<5.2 mmol/L

LDL

<130 mg/dL

<3.36 mmol/L

HDL

>45 mg/dL

>1.16 mmol/L

CK

0-150 U/L

0-2.5 kat/L

CK-MB

0-12 U/L

0-0.2 kat/L

0.6-1.2 mg/dL

50-110 mol/L

ClCr

75-125 mL/min

1.24-2.08 mL/s

GGT

0-70 U/L

0-1.17 kat/L

AST (SGOT)
Bilirubin
BUN

Cholesterol

Creatinine

[2013 | ]

Page 21

Globulin

2.3-3.5 g/dL

23-35 g/L

70-110 mg/dL

3.9-6.1 mmol/L

100-190 U/L

1.67-3.17 kat/L

0-160 U/L

0-2.67 kat/L

1.6-2.4 mEq/L Or

0.8-1.20 mmol/L

1.8-3.0 mg/dL

0.8-1.20 mmol/L

Phosphate

2.5-5 mg/dL

0.8-1.60 mmol/L

Potassium

3.5-5 mEq/L

3.5-5 mmol/L

Prealbumin

15-36 mg/dL

150-360 g/L

135-147 mEq/L

135-147 mmol/L

<160 mg/dL

<1.80 mmol/L

cTnI

<0.03 ng/ml

<0.03 g/L

cTnT

<0.2 ng/ml

<0.2 g/L

2-7 mg/dL

120-420 mol/L

Glucose (fasting)
LD (LDH)
Lipase
Magnesium

Sodium
Triglycerides (fasting)
Troponin
Uric acid

< 4> Hematologic Laboratory Values

Laboratory Test

Normal Reference Values

Conventional Units

SI Units

Male

0-20 mm/hr

0-20 mm/hr

Female

0-30 mm/hr

0-30 mm/hr

Male

39-49%

0.39-0.49 I

Female

33-43%

0.33-0.43 I

Male

14-18 g/dL

140-180 g/L

Female

12-16 g/dL

120-160 g/L

Male

80-180 g/dL

14-32 mol/L

Female

60-160 g/dL

11-29 mol/L

TIBC

250-460 g/dL

45-82 mol/L

MCH

27-33 pg/cell

27-33 pg/cell

33-37 g/dL

330-370 g/L

ESR
Hct
Hgb
Iron

MCHC

MCV

76-100 m

Platelets
RBC

Male

count Female
Reticulocyte count (adults)

76-100 fL

130-400 x 10 /mm

130-140 x 109/L

4.3-5.9 x 106/mm3

4.3-5.9 x 1012/L

3.5-5.0 x 106/mm3

3.5-5.0 x 1012/L

0.1-2.4%

0.001-0.024 I

WBC count

3.2-9.8 x 10 /mm

3.2-9.8 x 109/L

Neutrophils

54-62%

0.54-0.62 I

3-5%

0.03-0.05 I

25-33%

0.25-0.33 I

Monocytes

3-7%

0.03-0.07 I

Eosinophils

1-3%

0.01-0.03 I

Basophils

<1%

<0.01 I

Bands
Lymphocytes

[2013 | ]

Page 22

7. Preceptor

Preceptor 1:1 Case, , ,

.

preceptor 1:1 .

daily preceptor , .

, preceptor .

feedback .

8. ,
)

(ACS)

, Projects Presentations ,

(Medication-related discussion) 1

(Disease-related discussion) 1

( ) 1

( ) 1

() TPN consult 1

() ( ) 1

[2013 | ]

Page 23

9.

,
.

,
.

, .

[2013 | ]

Page 24

 II
(Ambulatory Care Practice Experience, ACPE)

II

, .

40 5 5 200 .

200 4 .

[2013 | ]

Page 25

1.
) ,

,
, .

,
.

unit dose system

autotrack .

/, , / ,
.

TDM ,
.

[2013 | ]

Page 26

2.
) 2

BMJ (British Medical Journal): (http://bmj.com)

Formulary (http://www.formularyjournal.com)

JAMA(The Journal of the American Medical Association) (http://jama.ama-assn.org)

Lancet (http://www.thelancet.com/journal)

NEJM(New England Journal of Medicine) (http://content.nejm.org)

) 3

Applied Therapeutics: The Clinical Use of Drugs, 9th Edition Mary A. Koda-Kimble et al.

Lippincott Williams&Wilkins. 2009

Pharmacotherapy: A Pathophysiologic Approach, 6th Edition Joseph T. Dipiro et al.

McGraw-Hill Medical. 2009

Applied Pharmacokinetics & Pharmacodynamics: Principles of Therapeutic Drug

Monitoring, 4th Edition Michael E. Burton et al. Lippincott Williams&Wilkins. 2005

Clinical Pharmacokinetics; Concepts and Application, 3rd Edition Malcolm Rowland et al.

Lippincott Williams&Wilkins. 1995

Basic Clinical Pharmacokinetics, 4th Edition

Michael E. Winter et

al. Lippincott

Williams&Wilkins. 2003

Drug Information; A guide for Pharmacists 3rd Edition Patrick M. Malone et al. McGraw-

Hill Medical. 2006

Interpreting the Medical Literature: Practical Epidemiology for Clinicians5th Edition

Stephen Gehlbach et al. McGraw-Hill Medical. 2006

The ICU book, 3rd Edition Paul L Marino Lippincott Williams&Wilkins. 2006

Stephens Detection of New Adverse Drug Reation, 5th Edition John Talbot et al. WILEY.
2004

. ()&. 2002.

. . 2003.

Q&A . . 2007.

: Pharmaceutical Terminology . . 2008

[ ] .

. . 2004

- . 2009

(http://www.ashp.org)

OVID (http://www.ovid.com)

Medline (http://www.medline.com)
[2013 | ]

Page 27

PubMed (http://www.pubmed.com)

(http://www.ezdrug.co.kr)

(http://www.druginfo.co.kr)

KMLE (http://www.kmle.co.kr)

Micromedex (CCIS: Computerized Clinical Information System)

3.
)
(1)

, .

,
.

,
.

(2)

, .

feedback .

, .

. .

, , ,

[2013 | ]

Page 28

1996 ' (Health Insurance

Portability and Accountability Act; HIPAA)'
.

HIPAA ( ,
, / ) (, ,
) .

, , , , .

[2013 | ]

Page 29

4.
)

Code

ACPE1

1-1

1-2

1-3

1-4

80
(2)

1-5
.

1-6
1-7
1-8
Intervention ()
1-9 ()

ACPE2

2-1

2-2

2-3

2-4

2-5

2-6

40
(1)

.
ACPE3

3-1 , ,

20

3-2

(0.5)

3-3

3-4 Q&A

3-5

3-6

monograph

3-7 ()
3-8 Journal Review ()
ACPE4

4-1

4-2

4-3

40
(1)

4-4
. 4-5
4-6
4-7 ()
ACPE5

5-1

5-2

5-3
[2013 | ]

20
(0.5)

Page 30

5-4 ,

5-5
.

,

5-6 ()
5-7 ()

ACPE6

()

. 6-2

6-1

()

6-3

6-4

6-5 ()
6-6 ()

)
(1)

Code
ACPE1-1

ACPE1-2

ACPE1-3

, .

(, , , , , ) .

( , , , , , )

(, ) (, )
.

(, ) .

. (5
)

1 (1 ) .

, .
[2013 | ]

Page 31

.
ACPE1-4

ACPE1-5

/, .

.
ACPE1-6

(, ).

(, )
.

,
.

, , 1 , (),
.

, .

, ,
, .

,

, .

ACPE1-7

ACPE1-8

()

intervention ,

intervention .

[2013 | ]

Page 32

ACPE1-9

.

.

()

( )
.

, , 1 , (),
.

, ,
.

,

, .

(2)

Code
ACPE2-1

, .

, .

ACPE2-2

ACPE2-3

ACPE2-4

ACPE2-5

ACPE2-6

(3)

[2013 | ]

Page 33


ACPE3-1

, ,

1 , 2 , 3 ,

,
.

,
.

,
.

, ,
.

ACPE3-2

, ,
.

ACPE3-3

, ,
.

ACP3-4

Q&A

ACPE3-5

(CDSS) .

monograph

ACPE3-6

, .

monograph

ACPE3-7

Newsletter ()
, , .
[2013 | ]

Page 34

, ,
.

ACPE3-8

Journal

()

Review

[2013 | ]

Page 35

(4)

Code

ACPE4-1

ACPE4-2

, .

/
.

ACPE4-3

ACPE4-4

ACPE4-5

/,

/,

/ , ,

.

,
/, /, / , ,

.
ACPE4-6

, .

ACPE4-7

, ()

.

[2013 | ]

Page 36

(5)

Code
ACPE5-1

ACPE5-2

ACPE5-3

, ,
.

(,

, ) .

ACPE5-4

WHO
.

ACPE5-5

()

ACPE5-6

ACPE5-7

()

[2013 | ]

Page 37

(6) ()

Code
ACPE6-1

,
.

, .
( )
therapeutic range .

(, , ) .

.

.

ACPE6-2

.
,
.
,
.

ACPE6-3

.
,
.
PK software
.

.

.

,
.
,
( ) .

.

.
,
.

ACPE6-4

ACPE6-5

ACPE6-6

()

.

.
, ()

.
[2013 | ]

Page 38

5. Preceptor

, .

Preceptor .

feedback .

,
.

preceptor role model .

6.
)

(high-alert medication)

, ,

(, , )

1, 2, 3

: Tacrolimus, Mycophenolic acid, Steroids, Sirolimus etc.,

: diskus , turbuhaler , MDI, spacer, nubulizer

: / ,
[2013 | ]

Page 39

:
Narango algorithm, Venulet algorithms, WHO causality term assessment criteria

) ()

: Aminoglycoides, Vancomycin

: Carbamazepine, Phenytoin, Phenobarbital, Valproic Acid

: Digoxin

: Theophylline

: Cyclosporine, Tacrolimus, Methotrexate

7. Preceptor

Preceptor 1:1 Case, , ,

.

preceptor 1:1 .

daily preceptor , .

, preceptor .

feedback .

8. ,
)

(CPCS)

, Projects Presentations ,

( ) 1

1
[2013 | ]

Page 40

worksheet 1

( 1

/ 1

() consult case 1

9.

,
.

, , .

,
/ .

[2013 | ]

Page 41