Institutional Pharmacy Practice

1. Institutional Pharmacy Practice Chapter 9

2. The Hospital Pharmacy Environment Define the most common tasks performed by hospital pharmacy technicians. Identify different types of hospital pharmacy settings. Discuss different hospital pharmacy standards and procedures. Identify the difference between formulary and non-formulary medication lists. Explain the importance of a good relationship between the pharmacy and the nursing staff. Lesson 9.1

3. The Hospital Pharmacy Environment Identify different regulatory agencies that govern the operations of hospitals, including pharmacies in the hospital. List various ways orders are processed by the pharmacy. Identify the difference between stat, ASAP, and standing orders. Describe how POE, CPOE, BPOE, and CADM systems are used in medication ordering. Lesson 9.1

4. Introduction • Hospital pharmacy: Most common institutional setting and most challenging area to work • Fewer job openings for technicians • More highly skilled technicians required • Multitasking and more complicated tasks • Tasks include: • Preparing intravenous (IV) medications and loading patient medication drawers • Entering data into pharmacy computer system

5. Types of Hospitals • Size of hospital: Depends on number of patient beds available • Small: 50 beds or fewer • Large: 50 to 250 beds or more • Other differences: Capabilities in diagnosis, surgery, and outpatient services

6. Hospital Pharmacy Settings • Differences: Layout of pharmacies • Older hospitals: Central inpatient pharmacy • Larger, newer hospitals: Central and satellite pharmacies • Teaching hospitals: Pediatrics, burn units, intensive care units (ICUs), cancer units • Satellite pharmacies: Specialty pharmacies that supply a clinic • Discharge pharmacies: Fulfill the same duties as a community pharmacy

7. Policies and Standard Operating Procedures • Policies and Procedures (P&P) manual is found in all pharmacies • Outlines facility’s rules • Rules apply to all employees • Information concerns daily work activities, benefits, emergency situations, mandatory training

8. Hospital Protocol • Protocol: Defines the guidelines for a particular facility • Determines which medications are formulary drugs (approved for use) and which are non-formulary drugs (not approved for use) • Purpose: To choose best medicines for patients

9. Formulary Versus Non-Formulary Medications • Formulary medications: Approved for use by a particular health care entity • Non-formulary medications: Not approved for use by a particular health care entity • Formularies are developed by a group of specialty physicians and pharmacists • Drugs are evaluated based on cost, effectiveness/safety, and patient demographics

10. Pharmacy and Nursing Staff Relationship • Nurses are the pharmacy’s primary customers; they should receive the highest level of support • Nurses depend on the pharmacy for all medications • Nurses often make inquiries to pharmacies, including: • Patient medication status and drug interaction • Dosing ranges and pharmacy calculations • “Where are the medications I ordered?” (most common) • Collaboration prevents medication errors

11. Regulatory Agencies • Hospitals all must meet federal and state guidelines • Department of Public Health sets standards of safe operation • State board of pharmacy inspects facilities and ensures that personnel are working within guidelines

12. Regulatory Agencies • Agencies that govern operations: • The Joint Commission (TJC): Accreditation and inspection • Centers for Medicare and Medicaid Services (CMS) • Department of Health and Human Services (HHS) • Department of Public Health (DPH) • State Board of Pharmacy (BOP)

13. Flow of Orders • Prescriber visits patient in hospital and writes a medication order (equivalent to a prescription) • Medication order is written on the prescriber’s order sheet and placed in the patient’s record (chart) • Unit clerk checks chart and sends new orders to appropriate department

14. Flow of Orders • Patient information: • Full name • Date of birth • Medical record number • Room number • Diagnosis, weight • Drug allergies

15. Flow of Orders • Orders arrive in the pharmacy around the clock, 365 days a year • Various methods are used to send orders: Pneumatic tube system, computerized physician order entry, fax machine, staff member • As orders are entered, labels are produced • Name alert stickers are used when two patients with same last name are on same the floor • Technician pulls labels off printer and fills order • Labels are placed on small zippered baggies for delivery

16. Different Types of Orders • Stat (meaning “at once”): Order must be delivered within minutes; takes precedence over all orders • ASAP (meaning “as soon as possible”): Not as urgent as stat, but filled before new orders • Standing order: Written protocol to be used in specific situations • Emergency situation: Order is filled immediately

17. Computerized Physician Order Entry (CPOE) • Electronic systems that can quickly and clearly transfer patient orders and information to and from the pharmacy • Provide electronic access to medical information and drug information data, limiting errors of transcription

18. Computerized Prescriber Order Entry • Medication orders can be clearly identified, and the computer systems check new medications against current medications for interactions or contraindications • Health care providers can enter all lab results, dietary requirements, medications, and special notes into the computer

19. Bar Code Point of Entry (BPOE) • Each unit of medication is bar coded and can be scanned with a handheld device • Nurse is notified of any warnings or special notes • Orders are sent in “real time” • Nurse must verify order before administering the drug

20. Computerized Adverse Drug Event Monitoring (CADM) • Computerized systems can detect and monitor adverse drug events • Pharmacies must make sure all medications are bar coded for identification. • The information in the computer must accurately reflect the way the dosage form is to be given

21. The Various Responsibilities of the Institutional Pharmacy Technician Identify the responsibilities of an institutional pharmacy technician. Describe the technician’s role in the IND process. Describe the advantages of using automated dispensing systems (ADS). Explain the importance of counting, dispensing, and tracking controlled substances. Explain what PAR levels are and who is responsible for maintaining them. Identify the difference between hazardous and non-hazardous IV preparation. Lesson 9.2

22. The Various Responsibilities of the Institutional Pharmacy Technician Explain the importance of aseptic technique for the technician preparing compounded sterile preparations (CSPs). Identify the duties involved in ordering and maintaining the stock levels of the pharmacy. Recognize the differences in floor stock, depending on the area of the hospital. Identify specialty areas of the hospital for which the pharmacy stocks or orders medication. Describe the importance of ongoing technician education and identify professional organizations that institutional technicians can join. Lesson 9.2

23. Institutional Pharmacy Technicians • Flexibility needed to work all shifts; technician must be multifunctional for all shifts • IV room • Chemotherapy, controlled substances, and patient medication • Medication preparation and inventory • Miscellaneous duties • Specialty tasks: Clinical duties and anticoagulant therapy tasks, preparing nuclear medications

24. Technician’s Role in the Investigational New Drug (IND) Process • Investigational drug technicians • Prehuman and human testing phases • Clinical trials • Investigational drugs go to the central pharmacy; these are separated from other drugs • Often used in hospitals, but under strict regulations • Every drug has a logbook

25. Patient Cassette Drawers and Pyxis • Loading patient cassette drawers from a pick station is a long-standing daily task of the hospital pharmacy technician • Medications needed for the next day must be loaded in a cassette drawer • Automated floor dispensing systems: Pyxis, SureMed

26. Patient Cassette Drawers • Held in large push carts so they may be delivered to the floor each day • Robot dispensing machine: Fills each patient’s medication cassette with 99% accuracy as the cassette moves along a conveyer belt • Speeds up delivery of medication and helps ensure accuracy

27. Automated Dispensing Systems • Pyxis MedStation • Uses fingerprint scanners for verification • Touch screen for medication removal • Drawer opens for removal, then closes and records the removal

28. Unit Dose Medications/Liquids • Important daily task of pharmacy technicians: Preparation of unit dose medications not available from the manufacturer or stocked by the pharmacy • Pharmacist performs the final check • Unit dose liquids • TJC now requires hospitals to make all medications patient-dose specific • Every liquid dose is prepared in a unit dose package and labeled

29. Controlled Substances • Counting, dispensing, and tracking narcotics is a critical job • Each hospital conducts an actual count of controlled substances by two nurses every shift • All controlled substances are counted three times daily • Periodic automatic replenishment (PAR) levels: Amounts of medications kept on floors at all times • Controlled substances are kept in a locked room in the pharmacy at all times

30. Controlled Substances • After confirmation of the daily narcotic count, the technician signs out each drug onto a dispensing sheet, which is used to deliver medications • Controlled substances must be kept unidentifiable during delivery • They are placed in stapled brown bags • Technician should never let these out of sight

31. Controlled Substances • Counting of narcotics is done by a nurse and technician • Return of controlled substances to the pharmacy is validated in the pharmacy • Registered nurses (RNs), not licensed practical nurses (LPNs), must sign for controlled substances • Make sure all numbers are correct

32. Intravenous Preparations • Printing of IV labels • Keeping up with changes in patient status • Reconstituting and preparing all IV medications in a horizontal flow hood • Delivery of medications to nursing floors

33. Aseptic Technique • Method used to prevent contamination of an object by microorganisms • Extremely important in the preparation of all IV medications, chemotherapy, and ophthalmics • Samples are periodically tested for microbial contamination

34. Non-Hazardous IV Preparation • Parenteral medications: Meant for quick action • Some must be prepared with additives • Prepared in a laminar flow hood, in a clean room outside the compounding area

35. USP <797> Regulations and Standards • Enforceable USP regulations for facilities that prepare sterile products, both non-hazardous and hazardous (such as chemotherapeutic drugs) • Compounding must be done only in a clean room rated ISO Class 8 or better • Glove box isolators can be added

36. IV Therapy and Chemotherapy Preparation • Technician is responsible for preparation of IV therapies and chemotherapies • Horizontal flow hood: Used to prepare IV medications • Orientation of hands must not block flow of air • Vertical flow hood: Used to prepare chemotherapeutic drugs • Technician must wear gown and double gloves • Hands must not move over the top of any vial, needle, or IV bag

37. Horizontal and Vertical Flow Hoods Courtesy NuAire, Plymouth, Minn.

38. Labeling • Proper placement of labels ensures visibility of the solution and contents • Technician must initial all medications • Pharmacist checks each prepared medication before delivery to floors • Use of light-protected bags for light sensitive drugs • Refrigerated drugs • Storage requirements • Medication stabilities

39. Supplying Specialty Areas • Floor stock: Supplies kept on hand in units • Pharmacies supply special preprinted forms with descriptions of commonly used drugs for specialty areas • Outdated medications must be checked monthly • Outdated medications are returned to the pharmacy if expiration is within 3 months • Manufacturer will credit • Outside company is contracted to do drug inventory on expired medications

40. Floor Stock by Department • OR, PACU, wards, clinics stocked with own type of medications • ED, OR, ICU stock many drugs in injectable form, also oral and injectable controlled substances

41. Floor Stock by Department • Pediatrics: Medications in lower doses and in suspension form • Labor and delivery: Injectables meant for labor, contractions, and cesarean births • Technician collects and fills all floor stock medications • Crash cart and OR trays, boxes, or carts • Central supply

42. Special Departments Stocked by the Pharmacy • Anesthesia • Respiratory • Injection clinic • Radiology

43. Future of Institutional Pharmacy Technicians • American Society of Health-System Pharmacists (ASHP) recognizes trained technicians as the cornerstone to the future • Graduating from an ASHP-accredited program ensures the basic level of knowledge needed to gain employment in an institutional setting • Increased education to prepare for expanded roles • Increased job satisfaction

44. Questions?