hospital pharmacy lecture

HOSPITAL PHARMACYMae Quenie A. Tiro, RPh

UNIT I

Hospital Pharmacy

• Such practice traditionally involves:

Supplying medicines for In patient and outpatient

Preparing of sterile medications

Bulk compounding

Pre-packing

Drug formulation

Hospital Pharmacy

• Research

• Drug therapy information

Words to know:• Procurement• Manufacturing• Storage• Compounding• Packaging• Controlling• Assaying• Dispensing• Distribution and drug monitoring

Definition

• The practice of pharmacy in a hospital setting including its organizationally related facilities or services.

• Maybe defined according to its form; physical make-up, quantitative nature of service

• Maybe also define according to its purpose/ mission

Hospital Pharmacy

“It serves as a focal point for the coordination and delivery of

patient care to its community”

DEVELOPMENTAL HISTORY

• Urdang (hospital pharmacist)

-first recognized representative of the pharmaceutical profession

-were employed in the hospitals which were a part of many early monasteries

-Description” “apothecary shop” and its garden for the cultivation of medicinal herbs

ANCIENT PERIOD

AMERICAN ERA


• 1752

• Pennsylvania Hospital- first hospital in North America

• Jonathan Roberts- hospital pharmacist


• 1565- Hospital Militar, cebu

• 1571- Hospital Militar, Manila

• 1577- Hospital de San Juan de Dios

• 1577- Hospital de San Lazaro

• 1588- Hospital de San Gabriel

• 1891- Chinese general Hospital

• 1911- Philippine general Hospital


• 1957- Government Hospital Association

• 1960- Private Hospital Pharmacist Association

Philippine Society of Hospital Pharmacist (PSHP)


DEVELOPMENT and EXPANSION

• Origin: Indian and Egyptian culture-6th century BC

• Some hospitals were developed thru religious and divine motives

• Temples of the gods in early Greek and Roman civilization

• Healing-divine power

• Continued illness or death-lack of purity

• Greek temples- forerunners of the modern hospital in the sense that they provided a refuge and treatment for the sick and also provided the teaching of medical students


• TEMPLES OF AESCULAPIUS

(Greek God of Medicine)

TEMPLE at KOS, GREECE-

Hippocrates practiced


• ONE DOMINANT FACTOR: RELIGIOUS INFLUENCE

• Doctrines of Jesus Christ intensified the emotions and virtues of love, pity and charity.


ANOTHER FACTOR: MILITARY INFLUENCE

Urgent need for care of the wounded on the battlefield.


• OTHER FACTORS:1. FLEXNER REPORT on medical education

Caused revolutionary developments in medical education and medical internship training.

2. ACTIVITIES OF FLORENCE OF NIGHTINGALE

Quality of NURSING CARE/ nursing school


• 3. THE PUBLIC INTEREST in HOSPITALS- led to production of finances for further development, expansion and improvement.


• SIGNIFICANT GOVERNMENT PROGRAMS:

-adoption of the HOSPITAL SURVEY AND CONSTRUCTION ACT (1946)

- Commonly known as HILL BURTON PROGRAM

- Provide federal funds for hospital construction


• NATIONAL PLANNING and RESOURCES DEVELOPMENT ACT (1975)

• Created the development of HEALTH SYSTEMS AGENCIES (HAS)


• Responsibilities of HAS

1. Improving the health of residents of its health service area

2. Increasing the accessibility, acceptability, continuity and quality of services provided.

3. Restraining increase in the cost of these services.


• 4. Preventing unnecessary duplication of health resources.


• Beyond the 3 basic essentials of human existence (food, clothing and shelter), the hospital has become a neccessary instrument for the fourth basic element of survival- HEALTH.


CLASSSIFICATIOS

1. TYPE OF SERVICEGeneral Hospital- provides care to

patients with any type of illnessSpecial Hospital- those which restrict the

care they provide to the special conditions such as cancer, psychiatric etc

2. LENGTH OF STAY

-Short term hospital (less than 30 days)

-Long term hospital (30 days or longer)

3. OWNERSHIP

-Government hospitals

a. Federal (armed forces, public health services)

b. State

c. County

CLASSSIFICATIOS

d. City ( Municipality)

e. City county

f. District

-NON-GOVERNMENT HOSPITALS

a. Non-profit

b. For profit

CLASSSIFICATIOS

4. BY BED CAPACITY

Pattern

Under 50 beds 400-499 beds

50-90 beds 500 beds and over

100-199 beds

200-299 beds

300- 399 beds

CLASSSIFICATIOS

FUNCTIONS of Hospitals

1. PATIENT CARE

Diagnosis, preventive and treatment, rehab, dental, personalized serices.

2. EDUCATION- Patient and colleagues

3. RESEARCH

-advancement of medical knowledge against disease

-improvement of hospital services

4. ADMINISTRATION

Minimum Standard for a Hospital PharmacyStandard 1ADMINISTRATIONStandard 2FACILITIESStandard 3DRUG DISTRIBUTION and CONTROLStandard 4DRUG INFORMATION

Standard 5

ASSURING RATIONAL DRUG THERAPY

Standard 6

RESEARCH

Minimum Standard for a Hospital Pharmacy

General Requirement Order no. 56 1989

• Standard petition form• Proof of registration as an establishment• Valid certificate of registration• Certificate of attendance to a BFAS

sponsored seminar on Licensing of Drug Outlets

• Affidavit of undertaking• Tentative list of products to be sold using

GN with BN

• Authenticated photocopy of contract of Lease of space to be occupied if renting

General Requirement Order no. 56 1989

Abilities required for Hospital Pharmacist1. Thorough knowledge of drugs and their

actions.

2. Ability to develop and conduct a pharmaceutical manufacturing program.

3. An intimate knowledge of control procedures.

4. Ability to conduct and participate in research.

5. Ability to conduct teaching and in-service training programs

6. Ability to administer and manage.

Abilities required for Hospital Pharmacist

GOVERNING BODY

• Administrator• Director• Superintendent• Medical Director• Chief Administrative Officer

- Selection of personnel, control funds, supervision of physical plant

Standing Committees

• EXECUTIVE COMMITTEE

• HOSPITAL COMMITTEE

• FINANCE COMMITTEEPUBLIC RELATIONS COMMITTEE

Infection Control committee

Pharmacy and Therapeutics committee

DEPARTMENTS OF HOSPITAL

A. Departments which the services involve primarily the professional care of the patient.

-Ambulatory care, Anaesthesia, Blood Bank, Central Sterile supply, Clinical laboratory, Dental Service, Dietary & Nutrition service, ECG, ER, Medical library, Medical records, Medical social service, nuclear medicine, nursing service, OT, Pharmacy, Physical Medicine, Radiology and X-ray therapy. Respiratory therapy

B. Departments which deal with the business management or administrative side of the Hospital

-accounting, admitting, biomedical engineering, business office, cafeteria and coffee shop, central transportation, credit and collection, computer services, engg and maintenance, housekeeping, information service, personnel and payroll, post office, purchase and store room, telephone switchboard, volunteer service

DEPARTMENTS OF HOSPITAL

MEDICAL STAFF

Duties

Providing professional care of the sicj and injured in the hospital

Maintaining its own efficiency

Participating in the educational program of the hospital

Categories

• Honorary staff

Composed of physicians who have been active in the hospital but who are retired and those to whom it is desired to do honor because of outstanding contribution

• Consulting Medical staff

Consist of specialists who are recognized as such by right of passing specialty boards or belonging to the rational organization of their specialty, and who serve as consultants to other members of the medical staff.

Categories

• Active or attending Medical staff

The group primarily concerned with regular patient care. It is the group most actively involved in the hospital.

Categories

• Associate Medical Staff

Composed of junior or less experienced members

Categories

• Courtesy medical staff

Consists of physicians who desire the privilege of attending.

Categories

• Resident Medical staff

Composed of residents who are full time employees of the hospital. Provides specific services, for which they receive education and experiences.

Categories

Role of Pharmacy Technician

• Receives written prescriptions or refills

• Verify info on the prescription

• Counting, weighing, measuring and mixing medication

• Preparing prescription labels

• Establishing and maintaining patient profiles

• Order and stocking

• Assisting drug studies

• Taking order over the telephone

• Transferring prescriptions

• Tracking and reporting errors

• Tech check tech

Role of Pharmacy Technician

Organizational Structure of Pharmacy1. Administrative Services Division

2. Education and Training Division

3. Pharmaceutical Research Division

4. In-patient Services Division

5. Out-patient Services Division

6. Drug Information Services Division

7. Departmental Services Division

8. Purchasing and Inventory Control Division

9. Central Supply Services Division

10. Assay and Quality Control Division

11. Manufacturing and Packaging Division

12. Sterile Products Division

13. Radiopharmaceutical Services Division

14. Intravenous Admixture Division

Organizational Structure of Pharmacy

Manpower requirements and Responsibilities

Pharmacy Department

PHARMACY and THERAPEUTICS Committee

It is a policy-recommending body to the medical staff and the administration of the hospital on matters related to the therapeutic use of drugs.

1. ADVISORY

2. EDUCATIONAL

PTC Organization and Operation

1. Composed of Physicians, pharmacist, nurses and administrator

2. Chairman-physician, Secretary-pharmacist

3. Meetings- 6x a year or others 4x

4. Invitation to meetings

5. Agenda

6. Minutes of the meeting

7. Recommendations

8. Liaison w/ other hospital committee

PTC Organization and Operation

Functions and Scope of PTC

1. Advise on the use of drugs2. Drug Formulary3. Ensures cost effective drug therapy4. Educational programs5. QA activities ( distribution,

administration, use of drugs)6. ADR7. Drug use review programs and studies

8. Effective drug distribution and control procedure

9. Recommends drugs to be stocked in hospital patient care areas

Functions and Scope

HOSPITAL FORMULARY

Formulary

- Continually revised compilation of pharmaceuticals that reflects the current clinical judgement of the medical staff.

Formulary system

Is a method whereby the medical staff of an institution, working through the PTC, evaluates, appraises, and selects from among the numerous available drug entities and drug products those that are considered most useful in patient care

HOSPITAL FORMULARY

Potential benefits

1. Therapeutic

2. Economic

3. Educational

HOSPITAL FORMULARY

Format of the Formulary

1. Title Page

2. Names of PTC members

3. Table of contents

4. Policies and Procedures

5. Drug products

6. Appendix

Appearance of the Formulary

1. Different color of the paper (recommended)

2. Using and edge index

3. Pocket size (4 x & cm)

4. Generic name in BOLD

FIVE RIGHTS for RATIONAL DRUG THERAPY

• Right Patient

• Right Drug

• Right Strength

• Right Route

• Right Time

Steps to be followed for DRUG INCLUSION in the HOSPITAL

FORMULARY 1. Pharmaceutical representatives obtain

application form and list of requirements from the PTC Secretary

2. Completed requirements submitted to the PTC Secretary on or before the deadline set which is one (1) month before the next scheduled PTC meeting

3. All applications with complete documents endorsed to and reviewed by the PTC members

Drugs Approved

Drug Inclusion in the Hospital Formulary

Stock donations to precede regular stocking

Regular evaluation & review every 3 months during PTC meeting (history of drug adverse events/ reactions, sales movement)

PTC

Drugs Not Approved

Lack essential documents & other

considerations

Waiting List (Full 5 brand

listing)

Re-application (submission of letter of Re-application

with completed requirements)

Drug review on PTC Meeting

Drug Approved

Process of DRUG DELETION from the FORMULARY

Slow-moving Drugs Non-moving Drugs

List presented to the PTC during the regular Meeting

Involved companies are informed in writing regarding the status of their drugs. A grace period of 3 months

is given to allow for improvement in sales.

NO IMPROVEMENT

Formal deletion from the Formulary on the next PTC meeting

All stakeholders (drug companies/proponent physicians/ concerned medical staff) are informed through letters, postings at Pharmacy

Bulletin Board, information provided at Nurses’ Stations

•Only one brand shall be carried per generic of a dangerous drug at a time.Attending physicians are encouraged to utilize the formulary drugs.

•Non-formulary drugs are purchased upon request of the attending physicians when as the following have been made or approved:

•When referrals for available formulary drugs have been made to attending physicians who still opt to use the specific non-formulary drug of their choice.

•Non-formulary form is completely filled up and passed to the pharmacy. Indicating the concrete advantage the drug has over the available formulary drugs we have in the pharmacy.

Guidelines for Formulary and Non-Formulary

Drugs

•The Pharmacy will not cater herbal supplements and preparation of no therapeutic claims.

•All procured Non-formulary drugs will automatically charged to the patient’s account and cannot be returned to the Pharmacy.

All drugs must undergo Drug evaluation by the Pharmacy and Therapeutics committee before it can become a formulary drug.

•Formulary Drugs are the only drugs that can be stocked in the Pharmacy.

•A maximum of 5 brands per generic entity excluding the innovator brand can be included in the Formulary Drug list.


Drugs

Drugs that are in the list are subject for deletion if deemed to be slow moving even after 3 months grace period given for the company to promote the specific drug.

•Deleted drugs are required to undergo similar process and pass all requirements again if the company wishes to re-apply for product inclusion.

•A different dose and preparation of an existing brand in the pharmacy need not apply but required to submit Certificate of Analysis, Product registration and their stock donation.

•Endorsements from different medical departments will no longer be entertained if the maximum slot has been filled. If a drug is deleted in the same category, the slot shall be open.


Drugs

Facilities and Equipments

• Smaller hospitals- one room- one pharmacist

• Sterile products- separate room or area

• Hospitals with more than 200 beds

---separate area for in patient and unit dose dispensing

--chief pharmacist (office)

--compounding ,pre packaging, labelling

---a storeroom, sterile products and IV admixture room

--- drug info service room

Hospitals of more than 500 or 1000 beds

--increase space requirements for pharmaceutical services

Facilities and Equipments

Other requirements for a Hospital Pharmacy• Books• Laboratory apparatus• Office supplies• Biological refrigerator• Laminar flow hood• Telephones/ shelves• Internet service• Computer

Staffing

• 100 beds- 1 pharmacist

• 300 beds- director, assistant director, 7-12 staff pharmacist, 5-15 non-pharmacist, secretary

• 700 beds- director, assistant director (2 or more), supervisor pharmacist (2 or more), 40-60 staff pharmacist

Competencies of Pharmacist

Competencies for Pharmacists

• Practice pharmacy in a professional and cultural manner

• Contribute to the quality use of medicines

• Provide primary health care

• Apply management and organizational skills

• Research and provide information\

• Dispense Medicines

• Prepare pharmaceutical products

Competencies for Pharmacists

UNIT IIINPATIENT PHARMACY

Recommended Practices

1. RPh reviews M.D order before initial administration.

2. Ready to use medications to be administered.

3. Facilities & equipment accessible only to medical practitioners.

4. Facilities & equipment designed for routine inspections.

5. Provisions are made to provide suitable pharmaceutical services.

6. Repacking from manufacturer’s original container should meet standards of good pharmacy practice.

7. Distinguishing accounting practices vs. dispensing practice.

Recommended Practices

Classification of In-patient dispensing1. Individual Prescription Order system

2. Complete Floor Stock system

3. Combination of 1 and 2.

4. The unit dose drug distribution system

Comparisons Individual Rx

Complete floor stock

system

Combination UD

Advantages Reviewed by RPh

Interaction

Inventory

AvailabilityDrug

Returns

Rx personnel

Disadvantages Medication errors

Pilferages

Drug inventory

UNIT DOSE DRUG DISTRIBUTION SYSTEM

“Those medications which are ordered and packaged, handled, administered and

charged in multiples of single dose units containing pre-determined amount of

drugs or supply sufficient for one regular dose application or use”

Advantages of UD

1. 24 h medicines2. More time of nurses for patient’s care3. Check medication order/ prescription4. Paper work decreased5. Eliminates credit ( decrease cost)6. Iv preparation and drug reconstitution

procedures to the pharmacy7. Profession utilization

8. Prevents revenue losses

9. Nursing units conserved

10. Eliminates pilferages and drug waste

11. Extends pharmacy coverage

12. Communication of medication order

Improved

13. Drug consultants

Advantages of UD

EXEMPTED in UD

• IV Fluids

• Ointment

• gargle ( without definite dose or cc )

• PRN Medications

• Dangerous Drugs

• TPN ( esp. large volume TPN )

• Once a week refrigerated drug

Procedures in UDDDS

• Px entered into the system• Medication order sent to pharmacist• Pharmacist check drug order• Dosing schedule• Dispensing medicines• Medication carts• Pharmacist check carts• Nurse administers the drug then log• Cart is rechecked

Unit Dose in Local Setting

1. Assignation of station of Unit Dose Pharmacists

2. Know the patients for UD

3. Prepare Patient Profile sheets.

Discharged patients- disregard and file

Transferred patients- endorse to other RPh

4. Read medication orders from 10 am or to the last order written by the pharmacist.

5. Check medication area (specifically individual cubicle of patients

6. Note down the number of meds in the cubicle using the patient’s profile

7. Charge medicines in a 24h consumption.8. Dispense the medicines and prepare for

individual packaging.9. Re-check your dispensed medicines

ready for distribution


10. Endorse the medicines to the nurses.

11. Check any discrepancies (billing or lacking medicines)


COMMON ABBREVIATION• Tab tablet• Cap capsule• IVTT intravenous thru

tubing• IM intramuscular• SQ subcutaneous• OD once daily• QO_OD every other day• Bid twice daily• Tid three times a day• Qid four times a day• 5x a day five times a day• Q4hrtc every four hours

round the clock

• Q4hprn every four hours as

needed• Q6h every six hours• Q8h every eight hours• Q12h every twelve

hours

• T/C to consider• //t/c to consume• //d/c discontinue meds• //DC discharge• //shift is use when a

previous order in IV and changed into oral

• //revise is use if there’s a change in meds with same therapeutic

//complete used to indicate a completed regimen

• //filled used to indicate if the ordered med has been fully dispensed

• MGH may go home• Arrow up increase• Arrow down decrease

SAMPLE UNIT DOSE

Dispensing of controlled substances

ADDICT

S-1

Retail of DP/s containing Table I Controlled Chemical/s

500.00

S-3

Retail of DD/DDP/s & /or DP/s containing Table I Controlled Chemical/s

1,000.00

S-4

Wholesale/Distribution of DD/DDP/s/Table 1 Controlled Chemical/s used in the manufacture of drug preparation/s/ &/or their preparation/s

3,000.00

S-5

C Compounding/Manufacture of DD/ DDPs &/or D P/s containing Table I Controlled Chemical/s

5,000.00

S-2 License to prescribe DD/DDPs, &/or DP/s containing Table I Controlled Chemical/s

IN-Patient Prescription

Annex for dangerous and regulated

Out-patient Prescription

• The official prescription form comes in 3 copies. This is called The official prescription form comes in 3 copies. This is called the DDB form 1-72.the DDB form 1-72.

Original (Yellow) – shall be retained by the Drugstore/ Original (Yellow) – shall be retained by the Drugstore/ Hospital Pharmacist for a period of Hospital Pharmacist for a period of 1 yr.1 yr. From the From the date of date of sole or delivery.sole or delivery.

Duplicate (Yellow) – shall be retained by the buyer or by Duplicate (Yellow) – shall be retained by the buyer or by the person to whom the drug is delivered until such the person to whom the drug is delivered until such drug is drug is consumed.consumed.Triplicate (Blue) – shall be retained by the person issuing Triplicate (Blue) – shall be retained by the person issuing the prescription.the prescription.

hospital pharmacy lecture

Documents

general requirement

unit dose

medical staff

organizational

hospital militar

minimum standard

controlled

therapeutics