Pharmacy Practice

By Dr. ABDRHMAN GAMIL

Associate Professor of Pharmaceutics
Al-Neelain University - Khartoum
Institutional Pharmacy

Hospital Pharmacy
Definition
 Practice of pharmacy in a hospital setting including it organizational related facilities or
services.

 It is that department or division of the hospital wherein the procurement, storage,

compounding, manufacturing, packaging, controlling, assaying, dispensing, distribution
and monitoring of medicines through the drug therapy management for hospitalized and
ambulatory patients are performed by a legally qualified, professionally competent
pharmacist.

 It includes responsibility for the safe and appropriate use of drugs.

Rational selection, monitoring, dosing and overall control of the

therapy program
 Uniqueness of
hospital pharmacy
 Functions of hospital pharmacy
To provide and evaluate service in support of medical care
pursuant to the objectives and policies of the hospital.

To implement for departmental services the philosophy,

objectives, policies and standards of the hospital.

To provide and implement a plan with clear responsibilities

and duties of the personnel.

To participate in all functions of all other departments and

services of the hospital.
Functions of hospital pharmacy

To estimate the requirements for the department and to recommend and

implement policies and procedures to maintain adequate competent staff.

To provide methods by which personnel can work with other groups to

interpreting the objectives of the hospital to the patient and community.

To develop and maintain an effective system for clinical and administrative

records and reports.

To estimate needs for facilities, supplies and equipment and to implement a

system for evaluation, control and maintenance.
Functions of hospital pharmacy

Research activities.

Continuous education for the staff.

Educational program for the students.

To adhere to the safety program of the hospital.

Comprehensive pharmaceutical service of high quality coordinated to

meet the needs of diagnostic and therapeutic department as well as
nursing service to provide better patient care.
 Routine contacts of hospital pharmacist
 Physician specialists ( PTC), clinical round, all matters related to drug therapy)
 Nursing professionals.
 Microbiologists.
 Biochemists.
 Physicists and radiologist
 Clinical pharmacologist
 Medical sociologist
 Medical dietetics
 Engineering
 Administrative staff
Group practice

 There is a need for a number of hospital pharmacists of variety of clinical

pharmacy specialists to assist in the rational selection and use of drug
therapy.
 This will strengthen the professional role of the hospital pharmacist and
give them entry to the group of professionals who make up the health
care team.
 Organizational Structure
 The head department reports to the hospital administrator.
 Formulates and implements administrative and professional polices of the
pharmacy subject to the approval of the administrator.
 Professional and clinical policies which have direct relationship to the
medical staff, are formulated and developed through the pharmacy and
therapeutics committee and are subject to administrative approval.

Comprehensive job description and responsibilities in pharmacy

activities and in clinical functions
 Hospital Administrator

Department of Pharmacy Director

Executive and administrative operations

Professional and clinical services Educational and technical services Research and support services

Nuclear pharmacy division Drug information division Research division

Unit dose dispensing division Education& training division Assay & QC division

Ambulatory &home care Professional development Kinetic & bioavailability lab

I.V admixture division Residency training program Manufacturing & packaging

Sterile products division Computerized operations Purchasing&inventory control

Drug administration division Dept services division

Clinical pharmacy division Investigation division

 Pharmacist Responsibilities – Director

 Determine the level and scope of pharmacy services.

Planning and monitoring the budget.
GENERAL

Developing the policy and procedures manual.

 Pharmacist Responsibilities – Central Pharmacist
1. Ensures that established policies and procedures are followed.
2. Check for accuracy of doses prepared, IV or unit dose.
3. Proper drug control, investigational drugs, laws are followed.
Dispensing Area

4. Good techniques are used in compounding

5. Proper record keeping and billing
 Patient medication records.
 Extemporaneous compounding records.
 IV admixture records.
 Investigational drug records.
 Monthly workload reports.

6. Maintain professional competence; drug stability & incompatibilities and drug information.
7. Ensures that personnel are well trained on policies and procedures.
8. Coordinate and evaluate the personnel activities.
9. Keep the dispensing area neat, clean and orderly organized.
10. Coordinate with the patient-care area.
 Pharmacist Responsibilities – Central Pharmacist
1. Supervision of drug administration:
 Review and interprets each unit-dose and IV admixture medication order to ensure that it is entered
accurately into the system.
Patient - care Area

 Review each patient´s drug administration form ( missed doses, review drug charges)
 Confirm that administered doses are noted correctly in patient chart.( sign)
 Ensures that records for controlled drugs are correctly kept.
 Ensures that proper drug administration techniques are used.
 Acts as liaison between the pharmacist and nursing and medical staff.
 Communicate with nurses and physicians concerning medication problems.
 Periodically inspects the medication area on the nursing units to ensure that adequate levels of floor
stock are maintained.
 Ensures that drugs are procured from the dispensing area as required.
 Coordinate all pharmacy services on the nursing units level.
 Ensures that the area is neat, orderly and appropriate security levels are maintained.
 Pharmacist Responsibilities – Central Pharmacist
2. Direct Patient care:
 Identify drugs brought by the patient.
Obtain patient medication histories.
Patient - care Area

 Assist in drug-product selection

 Assist physician in selecting dosage regimens and schedules, then assigns administration times.
 Monitors patient total therapy ( effectiveness, side effects, toxicity, allergic reactions, drug
interaction, therapeutic outcome)
 Patient counseling.
 Participate in cardiopulmonary emergencies.
3. General responsibilities:
 Education to personnel staff, students, medical and nursing students.
 Provides drug information to the health care personnel.
 Pharmacist Responsibilities – Ambulatory Pharmacist
1. Ensures that established policies and procedures are followed.
2. Checks for the accuracy of supportive personnel.
Dispensing Area

3. Ensures that proper techniques are used in compounding.

4. Adequate record keeping ( patient medication records,
investigational drug records, outpatient billing, reports and
prescription files)
5. Maintain professional COMPETENCE.
6. Training for the new personnel.
7. Coordinate the activities of the area.
8. Keep the area neat, clean and orderly organized.
 Pharmacist Responsibilities – Ambulatory Pharmacist
1. Inspect the medication area at the nursing unit to ensure an adequate supply
of stock and proper storage.
2. Identifies drugs brought by the patient into the clinic.
Patient care Area

3. Obtain patient medication records and provided to the physician.

4. Assist in drug-product and entity selection.
5. Assist the physician in dosage regimen and schedules.
6. Monitors patient total therapy ( effectiveness, side effects, toxicity, allergic
reactions, drug interaction, therapeutic outcome)
7. Patient counseling
8. Prepare medications for intravenous administration.
9. Provides medications for patient home care.
 Pharmacist Responsibilities – Ambulatory Pharmacist
1. Provide drug information to staff , nursing and medical staff.
General Responsibilities

2. Coordinate activities and needs within the area,

3. Provide adequate control and proper handling following the laws.

4. Maintain professional competence.

5. Participate in cardiopulmonary emergencies.

6. Provides education on service to staff, nursing and medical students.

Pharmacy staff

 Director of the pharmacy.

 7 – 12 pharmacists to each 300 beds hospital.
 5- 15 technicians, helpers, clerical staff.
 Full-time secretary.
Administrative aids:
 Functional organization charts.
 Operation manual
 Job description.
 Policy and procedures manual
 Facilities
 The space varies according to the hospital size.
Example; hospital of 200 beds requires:
 Office for chief pharmacist.
 Separate area for inpatient and unit-dose dispensing.
 Outpatient services.
 Compounding area.
 Sterile admixture area.
 Store room.
 Departmental computer.
 Space for drug information service.
 Controlled medicines.
 Clinical pharmacy services.
 Pharmacy & Therapeutics Committee
The American society of health system pharmacists state
that “ the multiplicity of drugs available and the
complexities surrounding their safe and effective use
make it necessary for hospital to have organized, sound
program for maximizing rational use of drug”. The
pharmacy and therapeutic committee, or equivalent, is
the organizational keystone for this program“ Health system
pharmacists”.
 Pharmacy and Therapeutic Committee:-
 Objectives:-
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 1- Developing and implementing professional policies on drug
selection, procurement, evaluation, safe use and drug
information.
 2- Assisting in the formulation of educational programs
designed to meet the needs of the staff for drug related
practices.
 The formulary and therapeutic committee is the authoritative
body who formulates the drug list circulating in that facility,
and regulates the intervention concerning drug. The P&TC
should have a regulatory power and activity.
 The committee should be launched by the first post in the
organization. His first deputy, normally, is the chairman of the
committee. The committee should be permanent and the
order should point to the members and functions and
activities regulating its work.
 Members: -
 Chairman – usually a physician representing the headquarter. 23
 Secretary – pharmacist; senior or drug information centre or pharmacologist.
 Head of main clinical department.
 Hospital pharmacist.
 Authoritative physician and specialist.
 Invited specialists to participate in certain issues, also nurses when needed with
no voting privileges.
 -Decisions should be made by vote.
 -Members should not have any business relationship with pharmaceutical
distributors or manufactures.
 - Members should not be more than ten.
 - One at least should attend continuing course in clinical pharmacology.
 Pharmacy & Therapeutic Committee
Subcommittees
 Subcommittee on Antineoplastic Agents.
 Subcommittee on Anti-infective Agents.
 Subcommittee on GIT Agents.
 Subcommittee on Cardiovascular Agents.
 Subcommittee on CNS Agents.
 Subcommittee on Endocrinology Agents.
 etc.
 Functions of Formulary & Therapeutic Committee: -
 1- Developing criteria for evaluation of drugs to be included in the drug hospital list,
preparing and maintaining the formulary list. 25
 2- Developing policies and procedures for selection, procurement and use of drugs..
 3- Criteria for additions and deletions from the formulary list.
 4- Conducting monitoring and evaluation programs for use of drugs, management
and dispensing practices.
 5- Maintain an emergency drug list, approve standard ward stock list.
 6- Standardizing prescribing practices through preparation of treatment guidelines.
 7- Provide unbiased drug information through the development of a formulary
manual.
 8- Coordinate drug supply for special ongoing programs.
 9- Review the leveling of drugs utilization.
 10- Conduct training programs.
 11- Represent the facility to drug companies’ representatives.
 12- Describe the inpatient and outpatient drug schemes.
 13- Coordinate drug reimbursement with the health insurance program.
 Policies to be developed: -
 Policies empower the committee to implement decisions.
 Firstly, polices developed should be approved by the chair administrator.
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 To request medical staff compliance.
 To organize its work and activities.
 he criteria of formulary drug selections.
 The addition and deletion procedures.
 Meetings; on call and periodical meetings.
 The use of generic names.
 Prescribing requirement and ideal prescription.
 Substitution policy. Generically equivalent or therapeutically alternatives.
 Non-.formulary drugs, allowed or not, reimbursed or not.
 Rules governing the formulary and revising period.
 Drug use evaluation and investigational regulations.
 Drug promotion and company representative guidelines.
Formulary System

 Increasing number of drugs being marketed.

 High competitive marketing practices

 Increasing influence of biased advertising literature.

 Increasing complexities untoward of the newer more

potent drugs.
 Hospital drug formulary: “ Hospital level selection”
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 The key factor for the optimum therapeutic benefit of the public sector expenditure
is the rational selection of drugs.

 At the hospital level this may involve forming a hospital therapeutic and formulary
committee. The result of such selection is developing a hospital formulary list which
differs from that of the national level in being restrictive to be used within that given
hospital .The hospital formulary becomes the basis of developing a hospital
formulary manual which is a concise reference book containing the basic drug
information facilitating the rationality of prescribing, dispensing, patient and staff
education to rationalize drug use.
• The Formulary : A continually revised compilation of pharmaceuticals plus
ancillary information that reflects the current clinical judgement of the medical
staff.

• The formulary System: is a method whereby the medical staff of an institution

working through the P&T committee, evaluates, appraises and selects from
among the numerous available drug entities and drug products those that are
considered most useful in patient care.

 Only those selected are routinely available from the pharmacy

It is a control for drug cost and use.
It provides for the procurement, prescribing, dispensing and administration of
drugs in their nonproprietary or proprietary names.
Principles in utilizing Formulary system
1. Appointment of pharmacy and therapeutic committee.

2. Medical staff on recommendation of P&T should be sponsored of the formulary.

3. written procedures governing polices from the P&T committee.

4. Drugs in generic names and prescribers should comply.

5. Limited number sustain the patient care and give financial benefits.

6. Polices governing purchasing, prescribing , dispensing and administration.

7. Formulary system should be available to all medical staff.

8. Quantity and quality are the pharmacist responsibility.

Formulating the list:-
1-Classification method: 31
Therapeutic and pharmacological actions, anatomical, chemical classification or
alphabetical arrangement could be chosen..
2-Data collection: Concerning annual morbidity report and the statistical information
available.
3-Drug information available, e.g. essential list of drugs.
4- Drug consumption.
5- Analyze the data:
6- Arranging orderly the prevalent diseases.
7-Define the drug of choice for each disease. The dosage pattern.
8-Calculate the quantity of each drug required.
9-Setting priorities according to ABC / VEN. ( Vital, Essential ,Non-essential)
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10-Conduct drug class reviews and draft the formulary:

11-Classify the drugs obtained.

12- Implement the formulary either class by class or totally.

After finishing selection, drafting the formulary and widely disseminated, the
deleted drugs could be eliminated and the new drugs could be added.

13-Reviewing the formulary periodically and cautiously. Evaluation and monitoring

of drugs by group facilitates the improvement.

14-Endorsement by the chief of the organization.

Methods to promote formulary adherence:-
33
16- Take action on non-formulary drugs available

17- Provide easy access to the formulary list.

18- Involve the medical staff in preparing the list and committee decisions.

19- Provide lists for therapeutic substitution when a prescribed drug is out of stock.

20- Design a request form for the use and addition of the drugs out of the list.

21-Prohibiting the distribution of drug samples of non-formulary drugs.

22- Filing the committee activities.

23- Shortly disseminate and develop the hospital drug manual.

24- The list should be open for additions and deletions

Results required from the formulary: -
 The formulary should be designed to maximize the use of resources. Limited to conserve resource, as
there is no way to stock all drug in the national formulary. Therefore the number of drugs34 is limited.
 Formulary in generic names, rationalize the practice, concentrate on drug of choice for prevalent
diseases, assures the balance of safety, toxicity, effectiveness and cost of a chosen drug and avoids
duplication of unnecessary alternatives.
 A formulary classified in therapeutic groups allow formulary manual development to provide
unbiased information resulting in improved prescribing, dispensing and appropriate use of drugs .
 Provide good quality drugs and eliminate unsafe and ineffective drug and newly introduced drugs of
questionable efficacy drugs.
 Decrease the inpatient hospital stay .
 Leveling the list by medical occupation position, allow improved prescribing and restriction and
limitation of use of certain drugs to certain specialties and certain wards and professional level verify
the patient safety and health.
 Excluded approved products may be supplied to meet exceptional needs.
 The formulary should provide an important objective of selection in establishing a drug supply system
that satisfies the health needs of certain community and respond positively to the exceptional
circumstances.( Taylor & Harding-2001 ) .
 Inventory management
 Generally assigned to senior pharmacy technician.
 Every hospital pharmacy should maintain sufficient inventory without shortage.
 Purchasing
 Ordering
 Receiving and storage.
 Daily monitoring
 Special handling of certain substances.
Purchasing The goal is to obtain high quality at the lowest cost.

The specifications and standards for all requirements should

be established by the pharmacist and approved by the FTC.
Competitive bidding is the professional practice.
o Manufacturer .
o Whole seller
o Prime vendor
IV solutions may have special supply procedures.
 Contracts
ordering

 Ordering may be according to

the stock using a software
computer program.
 Using a bar-cod scanner
Receiving and storage

 Once the order received it should be checked against the invoice.

 Any discrepancies should be noted and solved.
 Then the inventory control technician cam make the entry to the
records.
 The stock is then stored in shelves or refrigerator according to the
storage conditions stated.

Food material should no be kept aside

Daily monitoring

 Storage conditions. Checked and documented.

 Storage area; clean and dust-free.
 Out-of-stocks.
 Checking expiration date of the rotating inventory as FEFO.
 Checking the unit dose cart.
 Checking the nurse stock.
 Software computer program and out-of-stock reports.
 Checking and Monitoring the narcotics and control drugs.
 Checking for drug recalls.
Hospital Medication Order ( Prescription) and order Entry.
 Medication order is a format that differs from the
common prescription.
 Could be delivered to the pharmacy via nurse,
personal, computer system, pneumatic tube or fax.
 All medication orders entered into the computer
by the hospital pharmacist.

Types of medication orders:

• Admitting order.
• Stat order
• Daily and continuation order.
• Standing order.
• Discharge order.
Admitting order
• Written by the physician upon patient admission and it contains:
- Name and demographic data.
- Medications taken before.
- Diagnosis.
- Request for laboratory investigations.
- Radiological examination.
- Instructions for the nursing staff.
- Medication order including dose, dose intervals and administration.
- Dietary requirements.
- Allergies.
- Home med and bedside medications.
Stat order ( Emergency order)

• An order being sent electronically to the pharmacy.

• It should have the priority in dispensing.
• Delivered to the patient by the pharmacy technician.
Daily and continuation order

 Written by the physician in daily or at least weekly basis

Standing order

 The same set of medications for each patient who receives a

similar treatment or surgery.

 Physician may sign this preprinted order and may add or

delete some items.

 Postoperative orders are good example.

Discharge order

 Order including all medications, doses and instructions to

take-home.

 May continue for one week or maximum one month until

follow-up visit.
Computerized Prescriber Order Entry CPOE
Benefits
- Immediate access to patient medical records.
- Streamlined work-flow process.
- Enhance coordination of patient care.
- Clear communication with other health care professionals.
- End result improves patient care and safety.
Drawbacks:
- High initial cost.
- Need time for training.
- Resistance from the prescribers to embrace changes.
CPOE – cont.
For the pharmacy:
- Efficient medication order completion.

- Simplification of inventory ordering and posting of patient

charges.

- Improvement of medication safety

- Safeguard medication filling and dispensing.

- Error checking functions, duplication, incorrect doses

- Reduce medication errors.

 Inpatient Distribution Systems

1- A complete floor-stock System.

2- Individual prescription medication for each patient.

3- Combination of 1 & 2.

4- Unit-dose dispensing system.

Floor-stock
 Floor-stock is an inventory of frequently prescribed drugs that is stored on
the patient care unit rather than delivered by a unit dose cart.

 May be free or charge.

 Predetermined list kept on each nursing unit.

 Topping-up by the pharmacy and record the consumption and cost.

 For more expensive drug the charge may be via bar-code, removable label
or pre-stamped pharmacy requisition form.
Individual Patient Medications

 All medications dispensed by the pharmacy, kept in the nurse

cabinet and administered to each patient in doses as instructed by

the physician.

 Control through pharmacy prepackaged form.

Mixed system

 Floor-stock is carried out and the charges were included in the nursing and

other services charges.

 Individual patient drugs kept in the nursing cabinet and charges are recorded

in the pharmacy upon dispensing.

 Control and follow-up of storage conditions are the pharmacy responsibility.

Unit Dose Distribution System
 It is the standard practice in developed hospitals

 12 – 72 hours supply prepacked for each patient-care unit.

 Then administered by the nurse to the patient.

 Inpatient distribution system is composed of:

- Unit dose.

- IV admixture.

- TPN services.

The pharmacist maintain the inventory of the floor stock drugs and narcotic sent to
each unit.
Unit dose –cont.

 Definition:

An amount of a drug prepackaged for a single administration. That is

to say an amount of a medication in a particular dosage form that is

ready for administration to a particular patient at a particular time.

 Unit dose cont.
 General information on the label:

- Generic or brand name of the drug

- Strength of the dose.

- Bar code of the product

- Manufacturer name and lot number.

- Expiration date.
Unit dose cont.
 Unit dose cart:

 A movable cart that contains removable

cassette drawers that house medications.

 Each cassette drawer is labeled with specific

patient, patient bar code and room number.

 Medications are generally for 24 hours -

exchange in the morning by pharmacy.
Unit dose –cont.
 Benefits:

 Streamlined work flow.

 Decreased medication errors.

 Increased medication security.

 Reduced medication wastage.

 increased cost effectiveness.

Unit dose –cont.
 Repackaging medication into unit dose
1- heat-sealed ziplock bags.
2- adhesive sealed bottles.

3- blister pack.

4- heat- sealed strips.

5- Plastic or glass cups.

6- heat-sealed aluminum cups.

7- plastic syringes for liquids labelled for oral use only.

Unit dose cont.
 Processing medication order: