overview of the history of hospital pharmacy in the united states

C H A P T E R 2 : O V E R V I E W O F T H E H I S T O R Y O F H O S P I T A LP H A R M A C Y I N T H E U N I T E D S T A T E S

19

IntroductionHospitals today offer immense opportunities for phar-macists who want to practice in an environment thatdraws on the full range of their professional educationand training. It was not always so.

This chapter tells the story of how hospital pharma-cy developed in this country, analyzes the forces thatshaped the hospital pharmacy movement, and drawslessons from the changes in this area of pharmacypractice. The historical facets discussed here are high-ly selective, reflecting the author’s judgment about themost important points to cover within the limits of onechapter.

Hospital Pharmacy’s Nascencea,1–4

Hospital pharmacy practice in the United States didnot begin to develop into a significant movement untilthe 1920s. Although there were important milestonesbefore that era (including the pioneering hospital phar-macy practices of Charles Rice [1841–1901]5—seeFigure 2-1—and Martin Wilbert [1865–1916]), manyfactors kept hospital pharmacy at the fringes of thebroader development of pharmacy practice and phar-macy education.6 When the Pennsylvania Hospital (the first hospital in Colonial America) was establishedin 1752 and Jonathan Roberts was appointed as itsapothecary, medicine and pharmacy were commonlypracticed together, with drug preparation often theresponsibility of a medical apprentice.7 In 1800, with a population of 5 million, the nation had only two hos-pitals. Even by 1873, with a population of 43 million,the United States had only 178 hospitals with fewerthan 50,000 beds.2 Hospitals, which were “places of

dreaded impurity and exiled human wreckage,” anddoctors had little to do with each other.8 Hospitalsplayed a small role in health care, and pharmacistsplayed a very small role in hospitals.

In the early 1800s, drug therapy consisted of strongcathartics, emetics, and diaphoretics. From the 1830sto the 1870s, clean air and good food rather than medi-cines were the treatments emphasized in hospitals. In

Chapter 2

Overview of the History of HospitalPharmacy in the United States William A. Zellmer

a Well-documented accounts of the development of hospital pharmacy practice in the United States were published by theAmerican Society of Health-System Pharmacists (ASHP) in conjunction with anniversaries of its 1942 founding.Particularly noteworthy are the “decennial issue” of the Bulletin on the American Society of Hospital Pharmacists and articlesthat marked ASHP’s 50th anniversary.1–3 Readers who have an interest in more detail are encouraged to seek out those ref-erences and others.4 This section of the chapter is based closely on Reference 2.

Figure 2-1

Hospital Pharmacy Department,Bellevue Hospital, New York City,Late 1800sa

a The bulk medicine area, where medicines were packaged for use on the wards,at Bellevue Hospital, New York City, in the late 1800s. Standing on the right isCharles Rice, the eminent chief pharmacist at Bellevue, who headed three revi-sions of the United States Pharmacopeia.

Source: AJHP.

17283_019-032_CHAPTER 2 10/18/05 4:06 PM 9

the mid-1800s, the medical elite avoided drug use orused newer alkaloidal drugs such as morphine, strych-nine, and quinine. An organized pharmacy service wasnot seen as necessary in hospitals, except in the largestfacilities. The situation changed somewhat during theCivil War when hospital directors sought out pharma-cists for their experience in extemporaneous manufac-turing and in purchasing medical goods.2

In the 1870s and 1880s, responding to the influx ofimmigrants, the number of hospitals in cities doubled.Most immigrants in this period were Roman Catholic,and they built Catholic hospitals. This was significantfor two reasons—Catholic hospitals charged patients asmall fee (which allowed services to be improved) andthey were willing to train, or obtain training for, nunsin pharmacy. This era of hospital expansion coincidedwith reforms in nursing, development of germ theories,and the rise of scientific medicine and surgery. Thegeneral adoption of aseptic surgery in the 1890s madethe hospital the center of medical care. Advances insurgery led to growth of community hospitals, most ofwhich were small and relied on community pharmaciesto supply medicines.2

By the early twentieth century, hospitals had devel-oped to the point of having more division of labor, morespecialization in medical practice, a greater need forprofessional pharmaceutical services for handling com-plex therapies, and recognition that it was more eco-nomical to fill inpatient orders in-house. Hospitalpharmacists retained the traditional role of compound-ing, which fostered a sense of camaraderie among themand an impetus to improve product quality and stan-dardization. The advent of the hospital formulary con-cept persuaded many hospital leaders about the valueof professional pharmaceutical services. An importantreason for hiring a hospital pharmacist in the 1920swas Prohibition—alcohol was commonly prescribed,and a pharmacist was needed for both inventory controland to manufacture alcohol-containing preparations,which were expensive to obtain commercially.2

By the 1930s, pharmacy-related issues in hospitalshad coalesced to the point that the American HospitalAssociation (AHA) created a Committee of Pharmacyto analyze the problems and make recommendations.The 1937 report of that committee was considered soseminal by hospital pharmacy leaders that even adecade later they saw value in republishing it.9 Theaim of the committee was to develop minimum stan-dards for hospital pharmacy departments and to pre-pare a manual of pharmacy operations. The committee

characterized pharmacy practices in hospitals as“chaotic” and commented, “Few departments in hospi-tal performance have been given less attention by andlarge than the hospital pharmacy.” In the committee’sview, “…any hospital larger than one hundred bedswarrants the employment of a registered pharmacist….Unregistered or incompetent service should not becountenanced, not only because of legal complicationsbut to insure absolute safety to the patient.”9 The pro-liferation of unapproved and proprietary drug productsin hospitals was the target of extensive criticism by thecommittee.

A Fifty-Year Perspective There is much that can be learned by comparing con-temporary hospital pharmacy with practice of 50 yearsago. Fifty years is a comprehensible period of time formost people and, in hospital pharmacy’s case, the pasthalf century was a period of astonishing advancement.

The data sources for making such a comparison areremarkably good. A major study of hospital pharmacywas conducted between 1957 and 1960—the Audit ofPharmaceutical Services in Hospitals—under the direc-tion of Donald E. Francke and supported by a federalgrant (see Figure 2-2). The results were published in abook, Mirror to Hospital Pharmacy, which remains areference of monumental importance.10 In more recenttimes, ASHP has conducted an annual survey of hospi-tal pharmacy, yielding contemporary data for compari-son with the figures of an earlier era.

Four major themes emerge from an examination ofchanges over this period:

1. Hospitals have recognized universally that pharmacists must be in charge of drug product acquisition, distribution, and control.

2. Hospital pharmacy departments have assumed a major role in patient safety.

3. Hospital pharmacy departments have assumed a major role in promoting rational drug therapy.

4. Hospital pharmacy departments have come to see their mission as fostering optimal patient outcomes from medication use.

It is important to keep in mind what was happeningover this period in the United States as a whole. Since1950, the U.S. population has grown 86%. Expendi-tures for health care services have grown from about5% of gross domestic product to 14%. This growth hasfostered an endless stream of public and private initia-

H A N D B O O K O F I N S T I T U T I O N A L P H A R M A C Y P R A C T I C E20

17283_019-032_CHAPTER 2 10/18/05 4:06 PM 0


21

tives to curtail health care spending. Average daily hos-pital census, on a per-population basis, has declined by24% during this period as a result of public and privateinitiatives to reduce hospital use. Nonfederal, short-term general hospitals in 1950 numbered 5,031 androse to a zenith of 5,979 in 1975; in 2003 the numberstood at 4,918, nearly 18% fewer than the peak ofthree decades before. On a per-capita basis, the num-ber of inpatient hospital beds has declined 65% since1950. Since 1965 (the first year AHA reported thesedata), hospital outpatient visits have increased morethan fourfold.11

Drug Product Acquisition, Distribution, andControlFifty to sixty years ago, pharmaceutical services wereof marginal importance to hospitals. The 1949 hospitalstandards of the American College of Surgeons hadonly three questions related to pharmacy in its point-rating system, and responses to those questions con-

tributed only 10% to the overall rating. Pharmacy wasperceived as a complementary service department, notas an essential service.12

Fewer than half the hospital beds in the nation(47%) in the late 1950s were located in facilities thathad the services of a full-time pharmacist.10 Fewer thanfour out of 10 hospitals (39%) had the services of apharmacist. Hospital size was an important determi-nant of the availability of a pharmacist. All larger short-term institutions—those with 300 beds or more—employed a full-time pharmacist. This performancedeclined sharply with decreasing hospital size:

200–299 beds 96%100–199 beds 72%50–99 beds 18%under 50 beds 3.5%

Today, the vast majority of hospitals in the UnitedStates have the services of one or more pharmacists.Important exceptions are small rural hospitals that stillrely on the services of local community pharmacists.About 7% of the nation’s hospitals have fewer than 25 beds; it is not known how many of them employ apharmacist.

In 1957, the total number of hospital pharmacistswas 4,850 full time and about 1,000 part-time.10 Today,there are about 50,000 full-time equivalent pharma-cists providing inpatient services in nonfederal short-term hospitals.b,13 (Hospitals employ an equal numberof pharmacy technicians.) About one-fourth of allactively practicing pharmacists in the U.S. today are inhospitals.

Today’s hospitals employ approximately twelve full-time equivalent pharmacists per 100 occupied beds.13

The comparable figure for 1957 was approximately 0.4 FTE pharmacists per 100 occupied beds. In otherwords, pharmacist staffing in hospitals is 30-fold moreintensive today. During the same interval, the intensityof hospital staffing as a whole increased approximatelysevenfold.c

Reflective of more intensified pharmacist staffing,30% of hospitals today offer 24-hour inpatient phar-macy services. In the largest hospitals (400 beds), 95% of pharmacy departments are open around theclock.13

In the middle of the 20th century, nurses and com-munity pharmacists had significant responsibility for

bThroughout this chapter, pharmacy data from recent ASHP surveys refer to U.S. nonfederal short-term hospitals.c Calculated based on data in Reference 11.

Figure 2-2

Authors of the Mirror to HospitalPharmacya

a The authors of the Mirror to Hospital Pharmacy examining a slide containing datafrom the results of the Federal Audit of Pharmaceutical Services in Hospitals thatwas conducted in 1957. From left, Clifton J. Latiolais, Donald E. Francke, GloriaNiemeyer Francke, and Norman F. H. Ho. The results were published by ASHP inthe book, Mirror to Hospital Pharmacy, in 1964.

Source: ASHP Archives.

17283_019-032_CHAPTER 2 10/18/05 4:06 PM Page 21


hospital drug product acquisition, distribution, andcontrol. The Mirror to Hospital Pharmacy estimatedthat 4,000 nurses were engaged in pharmacy work.Here are specific data collected in 1957 showing whohandled drugs for the 2,200 hospitals that did nothave a full-time pharmacist:

Nonpharmacist personnel 45%(generally nurses)

Nonpharmacist personnel 45%plus community pharmacist

Supervision by local 9%community pharmacist

Table 2-1 shows the services hospital pharmacistswere providing in 1957–1960. Two types of services—bulk compounding and sterile solution manufactur-ing—were a major element of the hospital pharmacists’professional identity in the 1950s (Figure 2-3). Hospi-tal pharmacy leaders of the day cited the following factors in explaining the heavy involvement in manu-facturing:

■ The unsuitability of many commercially availabledosage forms for hospital use

■ The close relationship between physicians andpharmacists in hospitals

■ The opportunity to serve a need of physiciansand patients

■ The opportunity to offer a professional serviceand build interprofessional relations10

Today, bulk compounding or manufacturing is nolonger a significant activity in U.S. hospital pharma-cies. In sharp contrast to 50 years ago, hospital phar-macists now prefer to purchase commercial productswhenever they are available, in the interests of appro-priate deployment of the workforce and of using prod-ucts of standard commercial quality. Changes in thelaws and regulations that govern drug product manu-facturing and distribution, the development of a well-regulated generic pharmaceutical industry, and a shiftin the perceived mission of pharmacy practice wereamong the factors that led to the relegation of manu-facturing to hospital pharmacy’s past.

In summary, from mid-twentieth century to today,hospital pharmacy in the United States moved from anoptional service to an essential service. It used to bethat the administrator, the physicians, and the nurses inmany institutions, especially smaller facilities, believedthat they could function adequately with a drug roomcontrolled by nurses. Today it is beyond question by

anyone in the hospital field that medications need tobe controlled by a pharmacy department that is run byqualified pharmacists. Moreover, as pharmacists havebecome firmly established in hospitals, they have beenrecognized for their expertise beyond drug acquisition,distribution, and control functions, which has led togreatly intensified pharmacy staffing. The growingopportunities in hospitals have attracted more practi-tioners to the field, which has made hospital practice a major sector of the profession.

Patient SafetyThe clarion call to professionalism in hospital pharma-cy in recent times has been the patient safety impera-tive. Hospital pharmacists have made immense progressin this arena. Initially, that progress was tied to greateraccuracy in dispensing and administration of medica-tions, but it has evolved to also focus on improvingprescribing and monitoring the results of therapy. Butit all started with a desire to improve drug product dis-tribution for inpatients.

In 1957, there were two ways in which drug prod-ucts were distributed to hospital inpatients: as ward

Table 2-1

Percentage of U.S. HospitalsProviding (or Desiring to Provide)Specific Pharmacist Services,1957–1960a,10

Service Provide Would Like to Provide

Supply drugs to nursing units 97 1

Inpatient prescriptions 95 1

Prescription compounding 94 1

Interdepartmental drug needs 91 1

Drug information 84 9

Outpatient prescriptions 64 6

Formulary system 53 25

Bulk compounding program 41 12

Teaching program 28 23

Product development/research 13 23

Sterile solution manufacturing 11 15

a Hospitals with a chief pharmacist.

17283_019-032_CHAPTER 2 10/18/05 4:06 PM Page 22


23

stock or as individual prescriptions. If the patient wascharged for the medication, individual prescriptionswere generally used. Otherwise, it was most commonfor stock containers of medications to be available tothe nurse for administration to the patient as needed.10

The authors of the Mirror to Hospital Pharmacyhighlighted a critical limitation of medication systemsof that era:

“From the viewpoint of patient safety, one of themajor advances in dispensing procedures wouldbe the interpretation by the pharmacist of thephysician’s original … order for the patient. Inmany hospitals, the pharmacist never sees thephysician’s original order. In cases where thephysician does write an original prescription, hedoes so only for a limited number of drugs, theother drugs being stock items on the nursingunits. In many cases the pharmacist receives onlyan order transcribed by a nurse or even morecommonly by a lay person such as a ward clerk.As a result, errors made by the prescribing physi-cian and errors made in transcribing his orders

often go undetected, while the patient receivesthe wrong drug, the wrong dosage form, or wrongamount of the drug, or is given the drug by injec-tion when oral administration was intended, andvice versa.”14

Concerns about medication errors and about over-all efficiencies and best use of hospital personnel ledto the development of improved drug distribution sys-tems.15 Two major studies were done in the early 1960son unit dose drug distribution. At the University ofArkansas Medical Center, a centralized system wasdeveloped, and at the University of Iowa, a decentral-ized system was studied (see Figure 2-4).16,17 Both projects documented important benefits to unit dosedrug distribution, including greater nursing efficiency,better use of the pharmacist’s talents, cost savings, andimproved patient safety.

The key elements of unit dose drug distribution, asthe system has evolved from the original studies, are asfollows:

1. The pharmacist receives the physician’s original order or a direct copy of the order.

Figure 2-3

Sterile Solution Laboratory,Cardinal Glennon MemorialHospital for Children, St. Louis,Missouri, circa 1950sa

a Production of distilled water and the manufacture of large-volume sterile solutionswere major pharmacy activities in medium and large hospitals in the 1950s and1960s.

Source: ASHP Archives.Figure 2-4

Pioneers in Unit Dose DrugDistribution—William Heller (circa1965) and William Tester (circa1965)a

a The pharmacy departments led by these two prominent hospital pharmacists—William M. Heller (left), University of Arkansas Medical Center, and William W.Tester (right), University of Iowa Hospital—conducted important studies on unitdose drug distribution in the 1960s. This method of drug distribution was devisedin response to the results of medication error studies.


17283_019-032_CHAPTER 2 10/18/05 4:06 PM Page 23

2. A pharmacist reviews the medication order before the first dose is dispensed.

3. Medications are contained in single-unit packaging.

4. Medications are dispensed in as ready-to-administer form as possible.

5. Not more than a 24-hour supply of doses is delivered or available at the patient-care area at any time.

6. A patient medication profile is concurrently maintained for each patient.18

These precepts for state-of-the-art drug distributionare met widely in U.S. hospitals today. For example, ina 2002 survey, in 79% of hospitals, pharmacistsreviewed and approved all medication orders beforethe drug was administered to patients. The figure forthe largest hospitals (≥400 beds) was 92%.19

There has been much debate in hospital pharmacyover the years about the virtues of centralized versusdecentralized drug distribution. With a decentralizedsystem, pharmacists come in contact more regularlywith physicians, nurses, and patients, which is consis-tent with contemporary views about how the professionshould be practiced. Among all hospitals, 20% use adecentralized system; the figure is 41% for the largesthospitals.19 Many hospitals indicate that they wouldlike to move toward decentralized pharmacy services inthe future (see Table 2-2).

U.S. hospitals have shown a remarkable rate ofadoption of point-of-use automated storage and distri-bution devices, which are now used to some extent in58% of facilities. Point-of-use dispensing is now theprimary method of dose delivery in about one-fourth of U.S. hospitals.19

Pharmacy-based IV admixture services have beenwidely adopted by U.S. hospitals. Development of suchservices, as a professional imperative, was a topic ofintense interest in the 1960s.20 For short-term hospitals

as a whole, ASHP estimates that about 80% of IVadmixtures are now prepared by the pharmacy depart-ment.19

ASHP’s 2002 survey showed that most hospitalsregularly engage in a number of programs designed toincrease the safety of injectable medications, includingeducational programs on IV administration equipment(82%), administration and precautions associated withhigh-risk therapies (71%), and administration of IVpush medications (62%); promulgating lists of approvedIV push medications (57%); and affixing supplementallabels for IV push medications (53%).19

There is immense interest in U.S. hospitals inapplying computer technology to improve the safety ofmedication prescribing, dispensing, and administration.Computer-generated medication administration recordsare used in 64% of all hospitals and in 75% of thelargest hospitals.19 The foregoing data notwithstanding,the cost of such technology is having a decided moder-ating effect on the rate of adoption. For example, in2002, only about 2% of hospitals used computer-readable coding technology to improve accuracy ofmedication administration, and, in 2004, only about3% of hospitals used a computerized prescriber orderentry system that was linked to a decision support sys-tem.13,19

Because of the concerns of groups such as theInstitute of Medicine and various federal agencies,improving patient safety is now a major national priori-ty.21 When that general interest in patient safetyembraces medication-use safety, hospital pharmacistshave cheered and felt “it’s about time!” Further break-through advances in medication-use safety will dependon a fundamental reengineering of the entire medica-tion-use process, a shift toward a true team culture inproviding care, and wider application of computertechnology.22 As new technologies or new patterns ofhealth professional behavior evolve, history suggeststhat hospital pharmacists will be at the leading edge ofthose advances.

Promoting Rational Drug Use In U.S. hospitals, the concept of a pharmacy and thera-peutics (P&T) committee, as a formal mechanism forthe pharmacy department and the medical staff tocommunicate on drug-use issues, was first promulgatedin 1936 by Edward Spease (dean of the School ofPharmacy at Western Reserve University) (Figure 2-5)and Robert Porter (chief pharmacist at the University’s


Table 2-2

Hospitals with Decentralized DrugProduct Distribution19

Year 2002 Future Desire

All hospitals 20% 44%Largest hospitals (≥400 beds) 41% 56%

17283_019-032_CHAPTER 2 10/18/05 4:06 PM Page 24


25

hospitals).23 Subsequently, the American HospitalAssociation and the American Society of HospitalPharmacists jointly developed guidance on the P&Tcommittee and on the operation of a hospital formula-ry system. The formulary system is a method wherebythe medical staff of a hospital, working through theP&T committee, evaluates, appraises, and selects fromamong the drug products available those that are con-sidered most useful in patient care. The formulary sys-tem is also the framework in which a hospital’s medi-cation-use policies are established and implemented.

A major imperative for the advocates of the formu-lary system in the mid-1900s was to manage the proli-feration of drug products. The number of new marketentries for just one year, 1951, were as follows:

New drug products, 332New drug entities, 35Duplications of drug entities, 74Combination products, 22124

In 1957, slightly more than half of all hospitalsoperated under the formulary system.10 Today, essen-tially all hospitals do so.13

In 1957, 58% of hospitals had an active P&T com-mittee, and a similar percentage of hospitals had a formulary or approved drug list. However, about onefourth of the P&T committees were inactive.10 Today,nearly all hospitals in the U.S. have an active P&Tcommittee that meets an average of seven times ayear.13

In the late 1950s, the functions of P&T committeesfocused on very basic activities such as delegating tothe chief pharmacist responsibility for preparing prod-uct specifications and selecting sources of supply (66% of committees) and approving drugs by nonpro-prietary name (50%).10 In most hospitals today, theP&T committee has authorized pharmacists to trackand assess adverse drug events (ADEs), conduct retro-spective drug-use evaluations, and identify and moni-tor patients on high-risk therapies.13

In summary, concepts first advanced in the 1930sregarding a formal communications linkage betweenthe hospital pharmacy department and the medicalstaff with respect to drug-use policy have taken holdfirmly. Hospital pharmacists are heavily engaged inhelping the medical staff establish drug-use policies, inimplementing those policies, in monitoring compliancewith those policies, and in taking corrective action. Theinvention of the pharmacy and therapeutics committeeand the hospital formulary system has facilitated thedeep involvement of pharmacists in promoting rationaldrug use in hospitals.

Fostering Optimal Patient OutcomesU.S. hospital pharmacists have evolved markedly intheir self-concept over the past 50 years. As recently as20 years ago, the traditional pharmacist mission pre-vailed, a mission that was captured in the words, rightdrug, right patient, right time, connoting a drug-product-handling function. Right drug in this contextmeant whatever the physician ordered. Today’s philos-ophy about the mission of pharmacists focuses onachieving optimal outcomes from medication use. Theoverarching question for the hospital pharmacist iswhether the right drug is being used in the first place.A popular phrase used to summarize this philosophyis, “The mission of pharmacists is to help people makethe best use of medicines.” These words reflect a pro-found paradigm shift with respect to the primary pur-pose of pharmacy practice.25,26

In the 1950s, hospital pharmacy’s Spartan staffinglevels did not leave much time for work beyond the

Figure 2-5

Advocate of the Pharmacy andTherapeutics Committee—EdwardSpease (1883–1957), circa 1952a

a Edward Spease established one of the first college courses in hospital pharmacyand developed the Minimum Standards for Hospital Pharmacies for the AmericanCollege of Surgeons in 1936. At the time, Spease was dean and professor atCleveland’s Western Reserve University School of Pharmacy.


17283_019-032_CHAPTER 2 10/18/05 4:06 PM Page 25

basics of acquiring, storing, compounding, and distri-buting medications. Nevertheless, chief pharmacists ofthe time were called upon frequently by physicians andnurses to answer drug information questions related todosage, dosage forms, and pharmacology. Somewhatless frequently, pharmacists were asked for advice onadverse drug reactions and clinical comparisons ofproducts. In analyzing pharmacist consultations, theauthors of the Mirror to Hospital Pharmacy suggestedthat both weakness in the pharmacist’s scientific know-ledge and lack of time contributed to limited progressin this realm.

The transformation of the hospital pharmacydepartment from a product orientation to a clinicalorientation was stimulated by active consensus-build-ing efforts by hospital pharmacy leaders. One impor-tant example of such efforts was the ASHP Head con-ference.25

Hilton Head refers to a consensus-seeking invita-tional conference conducted in 1985 in Hilton Head,South Carolina, officially designated as an invitationalconference on Directions for Clinical Practice in Phar-macy (see Figure 2-6). The purpose of the meeting wasto assess the progress of hospital pharmacy departmentsin implementing clinical pharmacy. What emergedfrom the event was the idea that clinical pharmacyshould not be thought of as something separate frompharmacy practice as a whole. Rather, hospital phar-macies should function as clinical departments with amission of fostering the appropriate use of medicines.This was a very important idea because most hospitalpharmacists thought in terms of adding discrete clini-cal services (such as pharmacokinetic monitoring)rather than conceptualizing the totality of the depart-ment’s work as a clinical enterprise.

Working through its affiliated state societies, ASHPsupported repetitions of the conference on a regionalbasis. ASHP leaders spoke at meetings around thecountry about the ideas of Hilton Head, and the Ameri-can Journal of Hospital Pharmacy published numerouspapers on the subject.

As a result, many individual pharmacy departmentsbegan to hold retreats of their staffs to reassess thefundamental mission of their work. It was common fordepartments to adopt mission statements that, for thefirst time, framed their work not in terms of drug dis-tribution but in terms of achieving optimal patient out-comes from the use of medicines.

The most important indirect indicators of hospitalpharmacist clinical activity in the current era are

shown in Table 2-3. There is a growing body of scien-tific evidence, published in both the medical and phar-macy literature, about the positive outcomes achievedthrough pharmacist involvement in direct patientcare.27–30

In summary, U.S. hospital pharmacists today areengaged in extensive clinical activity, which is a majorchange from practice of 50 years ago. We are not yetat the point where a majority of hospital patients whoare on medication therapy receive the benefit of clini-cal oversight by the pharmacist, but progress in thisdirection continues to be made.

Recap of Major ThemesThus we have a picture of the major thrust of changesin hospital pharmacy over the past 50 years. The fourmajor themes have been, first, the universal recogni-tion by hospitals that pharmacists must be in charge ofdrug product acquisition, distribution, and control;second, hospital pharmacy departments have assumeda major role in patient safety; third, pharmacy depart-ments have assumed a major role in promoting ration-al drug therapy; and, finally, pharmacy departments


Figure 2-6

Hilton Head Conference, 1985a

a A workshop session at ASHP’s Hilton Head conference in 1985. This invitationalconsensus-seeking program was designed to assess the progress of hospitalpharmacy departments in implementing clinical pharmacy; as a result of the dis-cussions, many hospital pharmacy departments began to conceptualize their mission in terms of fostering appropriate use of medicines. Standing at the flipchart at one of the break-out sessions is Henri R. Manasse, Jr., at the time deanof the School of Pharmacy, University of Illinois at Chicago


17283_019-032_CHAPTER 2 10/18/05 4:06 PM Page 26


27

have defined their mission in terms of optimal patientoutcomes from medication use. Taken together, thesechanges signify that pharmacy practice in U.S. hospi-tals over the past 50 years has become more intensivein its professional staffing, more directly focused onpatient care, and more directly influential on the quali-ty and outcome of patient care. In short, hospital phar-macy has been transformed from a marginal, optionalactivity into a vital profession contributing immenselyto the health and well being of patients and to the sta-bility of the institutions that employ them.

Explaining the TransformationA combination of indirect and direct factors helpsexplain this transformation in hospital pharmacy.Indirect factors are those forces external to hospitalpharmacy that fostered development of the field. Thesefactors include the following:

■ Shift of national resources into health care,especially hospital care (stimulated immenselyby implementation of Medicare in 1965 andexpansion of other health insurance coverage).

■ Expanded clinical research and drug productdevelopment.

■ Greater complexity and cost of drug therapyaccompanied by sophisticated pharmaceuticalproduct marketing.

■ Growing interest in improving the quality ofhealth care services.

More important for this chapter’s discussion are theinternal factors within hospital pharmacy that precipi-tated the changes discussed above. In this category,five points merit discussion:

1. Visionary leadership

2. Professional associations

3. Pharmacy education

4. Postgraduate residency education and training

5. Practice standards

Visionary LeadershipOne cannot read the early literature of hospital phar-macy in the U.S. without being impressed by the cleararticulation of an exciting, uplifting vision by that era’spractice leaders. These views were being expressed at atime when pharmacy was a marginal profession in theU.S.; when most pharmacists were engaged primarilyin retail, mercantile activities; when hospital pharmacyhad little visibility and respect; and when hospitalpharmacy was a refuge for pharmacists who preferredminimal interactions with the public. Out of this envi-ronment emerged a number of hospital pharmacists,many of them at university teaching hospitals, whoexpressed an inspiring vision about the development ofhospital pharmacy and about the role of hospital phar-macy in elevating the status of pharmacy as a whole.

These were leaders such as Arthur Purdum,Edward Spease, Harvey A. K. Whitney, and Donald E.Francke (to mention only a few) who were familiarwith the history of pharmacy and had a sense of phar-macy’s unfulfilled potential. Many of them had seenEuropean pharmacy firsthand and decried the immensegap in professional status and scope of practicebetween the two continents.

A sense of the deep feelings of these leaders may begained from the following comment by Edward Spease,a retired pharmacy dean speaking in 1952 about hisinitial exploration of hospital pharmacy 40 years earlier:

“I expected to see true professional pharmacy inhospitals and was much disappointed that it didnot exist there. The more I observed and heardabout the growing tendency towards commercial-

Table 2-3

Indicators of ContemporaryHospital Pharmacist ClinicalActivity

All LargestHospitals Hospitals

(≥400 beds)

Hospitals with decentralized pharmacists29% 82%

(1999 data)a

Percentage of decentralized pharmacists time spent on clinical activities (1999) 59% -

Pharmacists have authority to initiate52% 62%

medication orders (2001)

Pharmacists attend rounds (2004) 35% 79%

Pharmacists provide drug information 90% -

consultations (2004)

Pharmacists monitor prescriber 81% 92%compliance with medication-use

policies (2004)

a All data are from ASHP national surveys of the year shown.

17283_019-032_CHAPTER 2 10/18/05 4:06 PM Page 27

ism in drugstores, the more I felt that if profes-sional pharmacy was to exist, let alone grow to anideal state, it would have to be in the hospitalwhere the health professions were trained….Good pharmacy is as important in hospitals awayfrom teaching centers as it is in the teaching andresearch hospital. It can be developed to a highdegree of perfection there, too, if the pharmacistcan get the picture in his mind.” (Emphasisadded.)31

“…if the pharmacist can get the picture in hismind.” Those are key words that reflect that early hos-pital pharmacy leaders were trying to create a newmodel for pharmacy practice in hospitals and not allowthis practice setting to become an extension of the typeof practice that prevailed in community pharmacies.These leaders were change agents with a missionaryzeal, and they were blessed with the ability to infectothers with their passion.

It is noteworthy that the Mirror to Hospital Phar-macy framed the entire Audit project in the context ofprofessional advancement. The report laid out theessential characteristics of a profession and articulatedgoals for hospital pharmacy that would bring pharmacyas a whole into better alignment with those character-istics.

Professional AssociationsThe national organization of hospital pharmacists—the American Society of Health-System Pharmacists(ASHP)—has had a profound effect on the advance-ment of the field. The visionary hospital pharmacistsof the early 1900s focused much of their energies onthe creation of an organizational structure for hospitalpharmacy. One landmark event was the creation of theHospital Pharmacy Association of Southern Californiain 1925. On a national level, organizational effortswere funneled through the American PharmaceuticalAssociation (APhA), the oldest national pharmacistorganization in the country. For years, hospital phar-macists participated in various committee activities ofAPhA focused on their particular interest. Then, in1936, a formal APhA subsection on hospital pharmacywas created. This modest achievement evolved to thecreation of ASHP in 1942 as an independent organiza-tion affiliated with APhA32 (see Figure 2-7).

There are two essential things that ASHP has donefor the advancement of hospital pharmacy. One is toserve as a vehicle for the nurturing, expression, and

actualization of the professional ideals and aspirationsof hospital pharmacists. In its early years, ASHP con-ducted a series of educational institutes that were veryinfluential in enhancing knowledge and skills and inbuilding esprit de corps among hospital pharmacists.33

Also noteworthy, especially as the organization hasgrown in size and diversity, is ASHP’s efforts to devel-op consensus about the direction of practice.25,26

The second essential act of ASHP has been its cre-ations of resources to assist practitioners in fosteringthe development of hospital pharmacy practice. Oneexample is the AHFS Drug Information reference book(and, in recent times, electronic versions for centralinformation systems, desktop computers, and hand-held devices), which is the most widely used independ-ent source of drug information in U.S. hospitals.Another example is the American Journal of Health-


Figure 2-7

A Leading Force in the Creation ofASHP—Harvey A. K. Whitney(1894–1957) circa, 1940a

a Harvey A. K. Whitney took the lead in organizing hospital pharmacists in theUnited States. He was chief pharmacist at the University of Michigan Hospitalswhen he became ASHP’s first chairman (president) in 1942. Whitney was alsoa pioneer in developing postgraduate training in hospital pharmacy.


17283_019-032_CHAPTER 2 10/18/05 4:06 PM Page 28


29

System Pharmacy. These two publications, and otherASHP activities such as the Midyear Clinical Meeting,have produced a source of funds beyond membershipdues that ASHP has used to develop a broad array ofservices that help members advance practice.

The original objectives of ASHP were as follows:■ Establish minimum standards of pharmaceutical

service in hospitals■ Ensure an adequate supply of qualified hospital

pharmacists by providing standardized hospitalpharmacy training for four-year pharmacy graduates

■ Arrange for interchange of information amonghospital pharmacists

■ Aid the medical profession in the economic and rational use of medicines

The core strengths of ASHP today are as follows:■ Practice standards and professional policy■ Advocacy (government affairs and public

relations)■ Residency and technician training accreditation■ Drug information■ Practitioner education■ Publications and communications

One of the reasons for ASHP’s success has been itsclarity about objectives and its concentrated focus on a limited number of goals. It is a testament to the wis-dom of ASHP’s early leaders that the goals expressedin 1942 still serve to guide the organization, althoughdifferent words are used today to express the sameideas, and some other points have been added. Theorganization continues as a powerful force in theongoing efforts to align pharmacists with the needsthat patients, health professionals, and administratorsin hospitals have related to the appropriate use ofmedicines.

Pharmacy EducationThere are three important points about the role ofpharmacy education in transforming hospital pharmacy.First, as pharmacy education as a whole has beenupgraded over the years, hospital pharmacy has bene-fited by gaining practitioners who are better educatedand better prepared to meet the demands in hospitalpractice. Second, hospital pharmacy leaders have putconsiderable pressure on pharmacy educators to up-

grade the pharmacy curriculum, to make it more con-sistent with the needs in hospital practice. This is sig-nificant because practice demands have always beenfar more intense in hospitals than in community phar-macy, so pressure to meet the demands in hospitalsserved to elevate education for all pharmacists. Also,beginning in the 1970s, corresponding with increasedemphasis on clinical pharmacy in the curriculum, hos-pital pharmacies played a much larger role in pharma-cy education as clerkship rotation sites for pharmacystudents. Third, in the early days of clinical education,faculty members from schools of pharmacy beganestablishing practice sites in hospitals, which often hada large impact on the nature of the hospital’s pharmacyservice.

Table 2-4 shows how the minimum requirementsfor pharmacy education have evolved over the years. Ittook a very long time for pharmacy in the U.S. to set-tle on the Pharm.D. as the sole degree for pharmacypractice. Many bitter fights—between educators,between practitioners, among educators and practition-ers, and among educators and the retail employers ofpharmacists—occurred over this issue. Now that thematter is settled, everyone seems to be moving on withthe intention of making the best application of thepharmacist’s excellent education.

Over the past 20 years, pharmacy education in theU.S. has been transformed completely from teachingprimarily about the science of drug products to teach-ing primarily about the science of drug therapy. Trans-

Table 2-4

Evolution of MinimumRequirements for PharmacistEducation in the United States

Year Minimum Requirement (Length of Curriculum and Degree Awarded)

1907 2 years (Graduate in Pharmacy)

1925 3 years (Graduate in Pharmacy or Pharmaceutical Chemist)

1932 4 years (B.S. or B.S. in Pharmacy)

1960 5 years (B.S. or B.S. in Pharmacy)a

2004 6 years (Pharm.D.)

a Transition period; some schools offered only the B.S. or the Pharm.D. degree; manyschools offered both degrees, with the Pharm.D. considered an advanced degree.

17283_019-032_CHAPTER 2 10/18/05 4:06 PM Page 29


formation of hospital pharmacy practice from a prod-uct orientation to a patient orientation could not haveoccurred without this change in education.

Postgraduate Residency Education andTrainingStemming from its early concerns about the inadequa-cy of pharmacy education for hospital practice, ASHPleaders advocated internships in hospitals and workedfor years to establish standards for such training. Thisled to the concept of residency training in hospitalpharmacy and a related ASHP accreditation pro-gram.33–35

Early hospital pharmacy leaders noted the followingimperatives for hospital pharmacy residency training36:

■ Hospitals were expanding, thereby creating agrowing unmet need for pharmacists who hadbeen educated and trained in hospital pharmacy.

■ Pharmaceutical education was out of touch withthe needs in hospital pharmacy.

■ The internship training required by state boardsfor licensure was not adequate preparation for acareer in hospital pharmacy practice.

■ Hospital pharmacists required specialized train-ing in manufacturing, sterile solutions, and phar-macy department administration.

■ Organized effort was needed to achieve improve-ments in hospital pharmacy internships or resi-dencies.

There are well over 10,000 pharmacists in practicewho have completed accredited residency training.These individuals have been trained as change agentsand practice leaders. Early in their careers, they cameto understand the complexity of hospital pharmacy,including inpatient operations, outpatient services,drug product technology and quality, and medication-use policy. Residency training is the height of mentor-ship in professionalism in American pharmacy. Dreamsare fostered in residency training—dreams of the pro-fession becoming an ever more vital force in healthcare; dreams of patients improving their health statusmore readily because pharmacists are there to helpthem.

Practice StandardsNumerous legal and quasi-legal requirements affecthospital pharmacy practice. On the legal end of the

spectrum are various federal laws governing drug prod-ucts and state practice acts governing how the phar-macist behaves and how pharmacies are operated. Atthe opposite end of the spectrum are voluntary practicestandards promulgated by organizations such as ASHP.

A practice standard is an authoritative advisorydocument, issued by an expert body, that offers adviceon the minimum requirements or optimal method foraddressing an important issue or problem. A practicestandard does not generally have the force of law.Methods used to foster compliance with practice stan-dards include education and peer pressure. ASHP’spractice standards have been very important in elevat-ing hospital pharmacy in the United States.

The origins of hospital pharmacy practice standardsgo back to 1936 when the American College ofSurgeons adopted the Minimum Standard for Pharma-cies in Hospitals. This document was semidormant fora number of years, but it served as a rallying point forhospital pharmacists and revision and promulgation ofthe Standard became a priority for ASHP.37

The revision pursued by ASHP in the 1940s speci-fied the following minimum requirements:

■ An organized pharmacy department under thedirection of a professionally competent, legallyqualified pharmacist

■ Pharmacist authority to develop administrativepolicies for the department

■ Development of professional policies for thedepartment with the approval of the pharmacyand therapeutics committee

■ Ample number of qualified personnel in thedepartment

■ Adequate facilities■ Expanded scope of pharmacist’s responsibilities:

- Maintain a drug information service- Nurse and physician teaching- File periodic progress reports with

administrator■ P&T committee must establish a formulary

From this modest beginning, ASHP has developedmore than 60 practice standards that deal with mostaspects of hospital pharmacy operations and severalmajor controversies in therapeutics.38

ASHP practice standards have been used effectivelyover the years as a lever for raising the quality of hos-pital pharmacy services. The standards have been usedin the following ways:

17283_019-032_CHAPTER 2 10/18/05 4:06 PM Page 30


31

■ Requirements for pharmacy practice sites thatconduct accredited residency programs

■ Guidance to practitioners who desire to volun-tarily comply with national standards

■ Guidance to the Joint Commission on Accredi-tation of Healthcare Organizations in developingstandards for pharmacy and the medication-useprocess

■ Tools for pharmacy directors who are seekingadministrative approval for practice changes

■ Guidance to regulatory bodies and courts of law■ Guidance to curriculum committees of schools

of pharmacy

Summary of Internal FactorsIn summary, five internal factors have played a largerole in transforming U.S. hospital pharmacy over thepast 50 years: (1) visionary leadership, (2) a strongprofessional society, (3) reforms in pharmacy educa-tion, (4) residency training, and (5) practice standards.The common element among these forces has beendissatisfaction with the status quo and burning desireto bring hospital pharmacy in better alignment withthe needs of patients and the needs of physicians,nurses, other health professionals, and administratorsin hospitals.

SummaryFrom the author’s perspective, clouded to be sure byparticipation in the hospital pharmacy movement formany years, four tentative lessons may be drawn fromthe history of U.S. hospital pharmacy:

1. Fundamental change of complex endeavorsrequires leadership and time. Hospital pharma-cists are sometimes frustrated by the slow paceof change. Wider study of history might help practitioners dissolve that discouragement.

2. It is important to engage as many practitioners as possible in assessing hospital pharmacy’s problems and identifying solutions, so that a large number of individuals identify with the final plan and are committed to pursuing it.

3. It is critical to recognize and capitalize on changes in the environment that may make conditions more favorable to the advancement of hospital pharmacy. This requires curiosity about the world at large.

4. It is important to regularly and honestly assessprogress and embark on a new approach if theexisting plan for constructive change is notworking or has run its course. This requiresopen-mindedness and a good sense of timing.

Today’s challenges in hospital pharmacy are nomore daunting than those that faced hospital pharma-cy’s leaders and innovators in the past. Fortunately,hospital pharmacy is imbued with a culture of takingstock, setting goals, making and executing plans, meas-uring results, and refining plans. If hospital pharmacysticks to this time-tested formula, it will continue to bea beacon for the profession as a whole.

References1. Niemeyer G, Berman A, Francke DE. Ten years of the

American Society of Hospital Pharmacists, 1942–1952.Bull Am Soc Hosp Pharm. 1952;9:279–421.

2. Higby G. American hospital pharmacy from the colonialperiod to the 1930s. Am J Hosp Pharm. 1994;51:2817–23.

3. Harris RR, McConnell WE. The American Society ofHospital Pharmacists: a history. Am J Hosp Pharm.1993;50(suppl 2):S3–S45.

4. Berman A. Historical currents in American hospitalpharmacy. Drug Intell Clin Pharm. 1972;6:441–7.

5. Wolfe HG. Charles Rice (1841–1901), an immigrantin pharmacy. Am J Pharm Educ. 1950;14:285–305.

6. Burkholder DF. Martin Inventius Wilbert(1865–1916): hospital pharmacist, historian, and sci-entist. Am J Hosp Pharm. 1968;25:330–43.

7. Williams WH. Pharmacists at America’s first hospital,1752–1841. Am J Hosp Pharm. 1976;33:804–7.

8. Starr P. The reconstitution of the hospital. In: Starr P.The Social Transformation of American Medicine.New York: Basic Books; 1982:145–79.

9. Hayhow EC, Amberg G, Dooley MS, et al. Report ofcommittee on pharmacy, American Hospital Associa-tion, 1937. Bull Am Soc Hosp Pharm. 1948;5:89–96.

10. Francke DE, Latiolais CJ, Francke GN, et al. Mirror toHospital Pharmacy—A Report of the Audit of Pharma-ceutical Services in Hospitals. Washington: AmericanSociety of Hospital Pharmacists; 1964.

11. AHA Hospital Statistics, 2005. Chicago: Health Forum;2005.

12. Purdum WA. Minimum standards and the future. BullAm Soc Hosp Pharm. 1951;8:114–7.

13. Pedersen CA, Schneider PJ, Scheckelhoff DJ. ASHPnational survey of pharmacy practice in hospital set-tings: prescribing and transcribing—2004. Am JHealth-Syst Pharm. 2005;62:378–90.

14. Francke DE, Latiolais CJ, Francke GN, op. cit. p 115.

17283_019-032_CHAPTER 2 10/18/05 4:06 PM Page 31

15. Barker KN, McConnell WE. The problems of detectingmedication errors in hospitals. Am J Hosp Pharm.1962;19:361–9.

16. Barker KN, Heller WM. The development of a central-ized unit dose dispensing system, part one: descriptionof the UAMC experimental system. Am J Hosp Pharm.1963;20:568–79.

17. Black HJ, Tester WW. Decentralized pharmacy opera-tions utilizing the unit dose concept. Am J Hosp Pharm.1964;21:344–50.

18. ASHP technical assistance bulletin on hospital drugdistribution and control. Am J Hosp Pharm.1980;37:1097–103.

19. Pedersen CA, Schneider PJ, Scheckelhoff DJ. ASHPnational survey of pharmacy practice in hospital set-tings: dispensing and administration—2002. Am JHealth-Syst Pharm. 2003;60:52–68.

20. Holysko Sr, MN, Ravin RL. A pharmacy centralizedintravenous additive service. Am J Hosp Pharm.1965;22:266–71.

21. Committee on Quality of Health Care in America(Institute of Medicine). Crossing the Quality Chasm—A New Health System for the 21st Century. Washington:National Academy Press; 2001.

22. Re-engineering the medication-use system—proceed-ings of a national interdisciplinary conference conduct-ed by the Joint Commission of Pharmacy Practitioners.Am J Health-Syst Pharm. 2000;57:537–601.

23. Francke DE, Latiolais CJ, Francke GN, op. cit. p 139.24. Francke DE. Hospital pharmacy looks to the future.

In: Harvey A. K. Whitney Award Lectures (1950–2003).Bethesda, MD: ASHP Research and EducationFoundation; 2004:19–25.

25. Directions for clinical practice in pharmacy—proceed-ings of an invitational conference conducted by theASHP Research and Education Foundation and theFebruary 10–13, 1985, Hilton Head Island, SouthCarolina. Am J Hosp Pharm. 1985;42:1287–342.

26. Implementing pharmaceutical care. Proceedings of aninvitational conference conducted by the AmericanSociety of Hospital Pharmacists and the ASHPResearch and Education Foundation. Am J HospPharm. 1993;50:1585–656.

27. Leape LL, Cullen DJ, Clapp MD, et al. Pharmacistparticipation on physician rounds and adverse drugevents in the intensive care unit. JAMA.1999;282:267–70.

28. Kucukarslan SN, Peters M, Mlynarek M, et al.Pharmacists on rounding teams reduce preventableadverse drug events in hospital general medicine units.Arch Intern Med. 2003;163:2014–8.

29. Boyko WL, Yurkowski PJ, Ivey MF, et al. Pharmacistinfluence on economic and morbidity outcomes in atertiary care teaching hospital. Am J Health-SystPharm. 1997;54:1591–5.

30. Bjornson DC, Hiner WO, Potyk RP, et al. Effect ofpharmacists on health care outcomes in hospitalizedpatients. Am J Hosp Pharm. 1993;1875–84.

31. Spease E. Background to progress. Bull Am Soc HospPharm. 1953;10:362–4.

32. Niemeyer G. Founding and growth. Bull Am Soc HospPharm. 1952;9:299–338.

33. Niemeyer G. Education and training. Bull Am SocHosp Pharm. 1952;9:363–75.

34. Francke DE. Contributions of residency training toinstitutional pharmacy practice. Am J Hosp Pharm.1967; 24:193–203.

35. ASHP residency and accreditation information.Available at: http://www.ashp.org/rtp/index.cfm?cfid=4992632&CFToken=35717293. Accessed February 1,2005.

36. Francke DE, Latiolais CJ, Francke GN, op. cit. p 157–67.

37. Niemeyer G. Establishment of minimum standard.Bull Am Soc Hosp Pharm. 1952;9:339–46.

38. ASHP policy positions, statements, and guidelines.Available at: http://www.ashp.org/bestpractices/index.cfm?cfid=4992632&CFToken=35717293.Accessed February 1, 2005.


17283_019-032_CHAPTER 2 10/18/05 4:06 PM Page 32

overview of the history of hospital pharmacy in the united states

Documents