Hospital Pharmacy Procedural

Manual- Devyani Joshi

Mission and motto of Hospital

Excellence in health care service

Guidelines of the manual focus on professional attitude, ethics, knowledge, commitments, responsibilities and skills for provision of total health care facilities.

Definition Hospital Pharmacy Procedural Manual

contains a series of administrative and professional policies which are formulated to provide guidelines for development and execution of efficient and safe pharmaceutical services at the hospital.

It is a document intended to encourage national pharmaceutical organizations to focus attention of pharmacist in the community and hospital pharmacy sector.

It provides a framework according to which each hospital will decide reasonable aspirations and proceed to set its own standards.

Hospital in general and pharmacy in particular should develop written policies for number of

reasons: They serve as a guide for training of new

employees. They prevent errors resulting from verbal

transmission of the policy from one employee to another.

They ensure that same policy applies in all similar situations.

They serve as control tool in ensuring a defined procedure for transforming a task eliminating wastage through error or carelessness.

In hands of the supervisor, they serve as means of evaluation job performance.

In the legal case, they serve as the important element in hospital’s defence of an action resulting in loss arising out of an error caused by the pharmacy department.

Hospital pharmacy procedural manual is aimed at providing

efficient and economical drug services.

The Joint Commission on accreditation of hospitals has created a standard for pharmaceutical services which mandates for the preparation of written policies and procedures that pertain to the intrahospital drug distribution systems

The interpretation of this standard provides the hospital pharmacist an appropriate guideline as to what must be included in the procedural manual in order to make the hospital accredited.

Scope First operational manual must contain the

recorded development from its very beginning, its objectives, philosophy, motivation, policies, regulations, departmental procedures, staffing pattern, job specifications, organizational plans and charts, description of the department, listing of physical facilities and library holdings.

It also includes inter and intra departmental relationships, description of formulary system, pharmacy and therapeutic committee and its activities.

Contents and Format The procedural manual is usually

divided into policies related to the following sections.

○Organizational policies○Facilities and procedures○Personnel guidelines ○Services and activities offered by pharmacy department

Organization Organization of the hospitals Organization of the pharmacy department Objectives and functions of pharmacy

services Responsibilities of pharmacy department Services offered by pharmacy department Inter and intradepartmental relationships Pharmacy and Therapeutics committee Pharmacy licensing policies and regulatory

requirements

Equipment and Physical Plant General policies relating to use, maintenance

and repairs of pharmacy equipments The distilled water still, Ointment mill, High

speed mixer, Capsule filling machine, Homogenizer etc

Policies and procedures governing the loan of pharmacy equipments

Obtaining engineering department services for the pharmacy like air conditioners

Policies governing the use of laboratory equipments in a controlled manner.

Personnel policies Job descriptions Sick leave Vacation period Holidays and on call services Emergency duty Attending training programmes,

seminars etc

Services and activitiesAdministrative policies Professional policies

Policies of pharmacy department

Personnel recruitment Hours of operation Performance evaluation Purchasing procedures Refund policy Handling of cash receipt Requisition of charge and non

charge floor stock drugs Inventory taking and records of

stock control Compounding and dispensing

records

Drug distribution system for inpatients

Distribution of ward stock drugs and emergency drugs

Verification of medication order Employee prescriptions Narcotic regulations Use of research and

investigational drugs The formulary system Sterile compounding Bulk compounding procedures Drug information services

Pharmacy communications and bulletins

o Selection of Titleo It should be specific and short

o Contentso Editorial- by chief pharmacisto New drug sectiono Abstract of pharmacy committee meetingso Lead articles by prominent members of the medical

staffo Format or Duplication

o DistributionoMembers of medical staff, library,

administration, nursing services and laboratories are sent a copy of pharmacy publication

o AdvantagesoBetter means of communication

compared to telephonic or verbal conversation

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