CHAPTER 16

HOSPITAL PHARMACY

CHAPTER OUTLINE

• Hospital Pharmacy• Technician Roles• Hospital Pharmacy

Areas• Hospital Formulary• Communication• Computer Systems• Medical Records• Medication Orders

• Order Processing• Inventory Control• Organization of

Medications• Unit Dose System• Sterile Products• General Hospital Issues• Calculations• Review

HOSPITAL PHARMACY

• Pharmacy technicians play an important role in the preparation, storage, and delivery of medications to patients in the hospital.

• Training requirements vary by hospital, but most are seeking technicians with certification (CPhT).

ORGANIZATION OF A HOSPITAL

• Patients with similar problems are grouped together and located on nursing units.

– Examples: Cardiac Care Unit (CCU), Obstetrics (OB)– The nurses’ station is the work station for medical

personnel on a nursing unit.

• Ancillary areas– Other areas of the hospital that provide patient care– Examples: Emergency Room, Cardiac Catheterization Lab

• The Pharmacy Department services nursing units and ancillary areas with medication.

THE HEALTHCARE TEAM

• A team of healthcare workers help provide care and medications to hospital patients.– Prescribe medications for patients• physicians, physician assistants and nurse

practitioner or advanced practice nurses

– Administer medications to patients• registered nurses, licensed practical nurses and

respiratory therapists

– Assist with getting medications to patients• pharmacists, social workers, patient care techs,

and pharmacy technicians

PHARMACY TECHNICIAN ROLES

• Front counter• Satellite pharmacies• Delivery• Outpatient pharmacy• Order processing• Compounding/Unit dosing• Monitoring drug therapy• Investigational drug service• Inventory control

•Narcotics/controlled substances•Cartfill•Automation•IV/clean room•Chemotherapy•Quality assurance•Pharmacy technician supervisor•Staff development

HOSPITAL PHARMACY AREAS

• Inpatient pharmacy – Located inside the hospital; serves only patients in the hospital and its

ancillary areas

• Pharmacy satellite – Branch of inpatient pharmacy – Responsible for preparing, dispensing, and monitoring medication for

specific patient areas– Examples: Pediatric, OR, and Oncology

• Central pharmacy – Main inpatient pharmacy (when also have satellites)– Most medications prepared and stored here – The sterile product area, or clean room, usually located here

USP <797>

• Set of regulations issued by the US Pharmacopoeia for compounding sterile products– Intended to decrease infections transmitted to

patients through drug preparation, and – better protect staff in their exposure to

pharmaceuticals.

• All hospitals accredited by The Joint Commission (TJC) must be compliant with USP 797 standards.

HOSPITAL FORMULARY• Hospital Formulary

– List of drugs stocked in the hospital and selected based on therapeutic factors as well as cost.

– The Pharmacy and Therapeutics Committee (P&T committee) adds, removes, and evaluates medications on the formulary.

• Closed formulary – Requires physicians to order only medications in the formulary.

• Non-formulary drugs – Medications not on the formulary list and not regularly stocked.

• Therapeutic interchange– Allows pharmacist to change certain non-formulary medication orders

to equivalent formulary medications.

COMMUNICATION

• Ways other areas of the hospital communicate with pharmacy:

– pneumatic tubes

– telephones

– computers

– in person at the pharmacy’s front counter

Images copyright Perspective Press and Morton Publishing Company. May not be copied, re-used, reproduced, or re-transmitted without express written permission from the publisher.

HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPPA)

• Safeguards patients’ protected health information (PHI) when it is spoken, written, or transferred electronically.

• Information in the hospital information system is highly confidential.

• Illegal to give information to any unauthorized person.

• Never look at a patient’s information unless necessary in fulfilling an assigned task.

MILITARY TIME

• Most hospitals use a 24-hour clock (also known as military time) to indicate when medications are to be given and when they expire.

12–hour clock 24–hour clock

Midnight 00:00 1 a.m. 01:00 2 a.m. 02:00 3 a.m. 03:00 4 a.m. 04:00 5 a.m. 05:00 6 a.m. 06:00 7 a.m. 07:00 8 a.m. 08:00 9 a.m. 09:00 10 a.m. 10:00 11 a.m. 11:00

12–hour clock 24–hour clock

Noon 12:00 1 p.m. 13:00 2 p.m. 14:00 3 p.m. 15:00 4 p.m. 16:00 5 p.m. 17:00 6 p.m. 18:00 7 p.m. 19:00 8 p.m. 20:00 9 p.m. 21:00 10 p.m. 22:00 11 p.m. 23:00

MEDICAL RECORDS

• Health records (aka medical records)– Detailed, chronological accounts of a patient’s medical history

• Electronic medical record (EMR) or electronic health record (EHR)– A computerized patient medical record– Allows authorized health care providers to access a patient’s medical

information from any secure location– Integrates patient medical records with billing and appointments

COMPONENTS OF A MEDICAL RECORD

DemographicsPersonal identification information

AllergiesDrug and/or food allergies and the allergic response experienced

Medical history Disease states (previous illnesses, surgeries, prescriptions, OTC and herbal medications)

Medication orders Orders written by a physician for patient’s medication

Medication administration recordTracks medications given to a patient, time they were given, and who administered them

Lab/test resultsBlood tests, X-rays, microbiology, etc. Documentation flow sheetVitals on an hourly or scheduled basis, hourly rates of IV fluids and medication drips, etc.

Progress notes Detail patient’s current progress

MEDICATION ORDERS

• All written pharmacy orders for a hospital patient are done on a medication order form.– Unit clerks, nurses, pharmacists or pharmacy technicians may be

responsible for entering these orders into the computer system before the pharmacist reviews them.

• Computerized physician order entry (CPOE) is an electronic alternative.– Physicians can enter orders directly into the computer system, decreasing

the chance of transcription errors.

TYPES OF MEDICATION ORDERS

• Standing order– Patient receives medication at scheduled intervals (e.g., 1 tablet every

8 hours)

• PRN order – Medication administered only on an as needed basis (e.g., 1 tablet

every 4 to 6 hours as needed for pain)

• STAT order – For medication to be administered immediately

Image copyright Perspective Press and Morton Publishing Company. May not be copied, re-used, reproduced, or re-transmitted without express written permission from the publisher.

TYPES OF MEDICATION ORDERS

• Restricted medications– Medication orders requiring approval by a specialty service (e.g.

Infectious Disease) prior to processing

– Some protocols also restrict which physicians or medical services can place orders for certain medications (e.g. chemotherapeutic agents)

• Stop orders– Orders limited to a certain amount of time (e.g., 7 days) after which a

new order is required to continue with the medication

MEDICATION ADMINISTRATION RECORD

Image copyright Perspective Press and Morton Publishing Company. May not be copied, re-used, reproduced, or re-transmitted without express written permission from the publisher.

ORDER PROCESSING

• The technician fills the medication order once the pharmacist has approved it.

• Many medications look similar and the same medication may come in different sizes or forms.– Be sure the correct medication, dose, and dosage

form is being filled.

• Double check the strength, quantity, expiration date, base solution, and volume (if applicable).

ORDER PROCESSING

• Missing doses– Doses that should have been delivered to the

nursing unit but cannot be located– This can be a challenge in hospitals

• There are several questions a technician should ask before refilling a missing dose.

ORDER PROCESSING

• Can be manual or automated.

• Often, it is a combination of both.

Image copyright Perspective Press and Morton Publishing Company. May not be copied, re-used, reproduced, or re-transmitted without express written permission from the publisher.

ORDER PROCESSING

Manual 1. Medication order is written in patient

chart2. Copy of medication order is removed

from chart3. Order is picked up at nursing station or

faxed or tubed to the pharmacy4. Medication order is entered into the

pharmacy computer system5. Pharmacist reviews and verifies

medication order6. Medication order is filled by a pharmacy

technician and checked by pharmacist7. Patient-specific medication is manually

delivered or tubed to nursing unit

Automated1. Physician or agent of the physician

enters medication order directly into hospital computer system which automatically communicates order to the pharmacy

2. Pharmacist reviews and verifies medication order

3. RN retrieves medication from point-of use automated medication station

4. Pharmacy technician fills inventory as medication supplies fall below par

INVENTORY CONTROL

• Inventory control responsibilities– Order medications, store and maintain par levels,

check order invoices, and deal with drug recalls and shortages

– Follow state and federal law whendealing with controlled substances

• Drug inventory is usually ordered through a program that communicates with the distributor/wholesaler.

Image copyright Perspective Press and Morton Publishing Company. May not be copied, re-used, reproduced, or re-transmitted without express written permission from the publisher.

INVENTORY MANAGEMENT

• Par– Amount of drug product that should be kept on the

shelf

• Drug recall– Voluntary or involuntary removal of a drug product by

the manufacturer– Usually pertains only to a particular shipment or lot

number

• Emergency drug procurement – Quickly obtaining a medication not currently in stock

when the drug is urgently needed

DRUGS REQUIRING REMS (RISK EVALUATION AND MITIGATION STRATEGY)

• Tracleer® (bosentan)

• Aranesp® (darbopoetin alfa)

• Tikosyn® (dofetilide)

• Epogen®/Procrit® (epoetin alffa)

• Botox/Botox Cosmetic®/(onabotulinumtoxin A)

• Thalomid® (thalidomide)

ORGANIZATION OF MEDICATIONS

• Alphabetical, using the generic drug name

• By route of administration – e.g., intravenous, oral, ophthalmic, etc.

• Narcotics and other controlled substances are often stored in a secure area of the pharmacy.

ORGANIZATION OF MEDICATIONS

• Many hospitals have a designated area for compounding oral solutions and suspensions.

• If an oral medication is needed in liquid form but is not available commercially, it may be extemporaneously compounded.

COMPOUNDING

• Bulk compounding log – Record of medications compounded in bulk

for non-specific patients– Records all the ingredients, amounts used,

manufacturer, lot numbers, and expiration dates of all ingredients used

• Reconstitute – Adding water or other diluent to commercially

made drug bottles or vials to make a solution or suspension from a pre-made powder form of the drug

• Extemporaneous compounds – Medications prepared following a specific

recipe or formula, usually because they are commercially unavailable

Images copyright Perspective Press and Morton Publishing Company. May not be copied, re-used, reproduced, or re-transmitted without express written permission from the publisher.

UNIT DOSE SYSTEM• Unit dose– Contains the amount of a drug required for one dose– Eliminates need for nurses to withdraw medication from

large bulk bottles – Decreases the chance of making an error

• Medication cart – Has an individual drawer or tray for each patient on the nursing

unit – Patient drawers are filled daily with the amount of

medication(s) required for 24 hours.

Image copyright Perspective Press and Morton Publishing Company. May not be copied, re-used, reproduced, or re-transmitted without express written permission from the publisher.

UNIT DOSE PACKAGINGPACKAGING TYPE USED FORplastic blister tablets/capsules

foil blister tablets/capsules

packet powder

tube ointment/cream

foil/plastic cup oral liquid

cartridge injection

vial injection

ampule injection

foil/plastic suppository

IV syringe injections

oral syringe oral liquids

Image copyright Perspective Press and Morton Publishing Company. May not be copied, re-used, reproduced, or re-transmitted without express written permission from the publisher.

CART FILLING

• Technicians play a large role in manually filling medication carts.

• Some hospitals have cart filling robots.

– Technicians fill and run the robot.

• Some nursing stations have automated dispensing systems (ADS).

– Pharmacy technicians stock the ADS.

Image copyright Perspective Press and Morton Publishing Company. May not be copied, re-used, reproduced, or re-transmitted without express written permission from the publisher.

UNIT DOSE SYSTEM

• Some hospital pharmacies may buy ready- to-use unit-dose packages of medications.

• Other hospitals buy bulk bottles of medication and use machines that automate unit dose packaging.

Oral liquids are drawn up in oral syringes either manually or using a special machine.

Hospital pharmacies must keep documentation logs of any medications they package.Image copyright Perspective Press and Morton Publishing Company. May not be copied, re-used, reproduced, or re-transmitted without express written permission

from the publisher.

STERILE PRODUCTS

• A large portion of hospital medications are administered intravenously.

• Requires special training:– Aseptic technique

– Correct drug, concentration, volume, base solution

– Double checking calculations

– Single vs. multi-dose vials

– SVPs, LVPs, chemotherapy, TPN

Image copyright Perspective Press and Morton Publishing Company. May not be copied, re-used, reproduced, or re-transmitted without express written permission from the publisher.

STERILE PRODUCTS – USEFUL TERMS• Total parenteral nutrition (TPN) – A type of large volume parenteral containing protein,

carbohydrates and essential nutrients given through an IV line

• Epidural – Sterile, preservative-free medication administered into a

patient’s epidural space (located near the spinal cord and backbone)

• Short stability – Medications that expire soon after preparation

(i.e., within 1–6 hours after preparation)

GENERAL HOSPITAL ISSUES• Some conditions of employment that may not be

required in other pharmacy settings:– Physical exam and drug testing– Hospital-wide orientation– Probationary period– Annual/semiannual performance review

• Regulatory agencies that oversee hospital operations:– The Joint Commission (TJC)– Centers for Medicare and Medicaid Services (CMS)– Department of Public Health (DPH)– State Board of Pharmacy (BOP)– United States Pharmacopoeia (USP)– Drug Enforcement Administration (DEA)

SAFETY• Code Cart

– Cart with medications and equipment commonly used in medical emergencies

• Universal precautions– Practices and guidelines that reduce the probability of exposure to blood-

borne pathogens– Include the use of protective barriers (gloves, gowns, masks, and

protective eyewear)• Material Safety Data Sheets (MSDS)

– Contain information for safe handling of harmful chemical substances or drugs

• Sharps container– A RED container designated for disposal of used needles or other items

that may cut or puncture the skin

Image copyright Perspective Press and Morton Publishing Company. May not be copied, re-used, reproduced, or re-transmitted without express written permission from the publisher.

CALCULATIONS

• Hospital pharmacy technicians must perform many calculations:

– Drawing up unit dose syringes

– Calculating flow rates / drip rates

– Determining time of subsequent doses

– Performing percent calculations

– Calculating the amount of drug and diluent

needed for SVPs, LVPs, and dilutions