hospital pharmacy Prepared by Nehad Jaser Ahmed
Introduction to hospital pharmacy • A hospital pharmacy is concerned with pharmacy service to all types of hospital and differs considerably from a community pharmacy . • Some pharmacists in hospital pharmacies may have more complex clinical medication management issues whereas pharmacists in community pharmacies often have more complex business and customer relations issues.
Because of the complexity of the medication use system, many pharmacists practicing in hospitals gain more education and training after pharmacy school through a pharmacy practice residency and sometimes followed by another residency in a specific area.
Hospital pharmacies can usually be found within the premises of the hospital. Hospital pharmacies usually stock a larger range of medications, including more specialized and investigational medications (medicines that are being studied, but have not yet been approved), than would be feasible in the community setting.
Hospital pharmacies typically provide medications for the hospitalized patients only, and are not retail establishments. They typically do not provide prescription service to the public. • Some hospitals do have retail pharmacies within them, which sell over-the counter as well as prescription medications to the public, but these are not the actual hospital pharmacy.
Director of pharmaceutical services is in charge of : • financial management • purchasing drugs and equipment inter-departmental affairs • quality assurance • provision of professional services.
Purchasing of equipment • Enteral and parenteral infusion pumps (e.g. patient-controlled analgesia pump) • Computer systems • Refrigerator and narcotic cupboards • Counting systems, tablet counter, containers
Laminar airflow hoods • Gloves • Balance.
Considerations when purchasing equipment • Specifications, functionality • Reliability of the equipment • Personnel training • Cost
Maintenance • User-friendliness • Portability • Lease vs purchase.
Professional hospital pharmacy services • Medicines supply to inpatients and outpatients • Clinical pharmacy • Drug information service • Drug and therapeutics committee • Infection control committee • Medical gases
Cytotoxic dispensing • Specials (e.g. total parenteral nutrition, extemporaneous preparation) • Developing systems of seamless care: integrating community and hospital pharmaceutical services.
Inpatient pharmacy • An inpatient pharmacy specifically fills prescriptions for people who are hospitalized. • The inpatient pharmacy is often in a different area of the hospital than the outpatient pharmacy, and it may only be open to authorized personnel, with doctors and nurses picking up prescriptions for their patients.
This pharmacy also synchronizes its records with the outpatient pharmacy to ensure that the patient's data is always up to date
Medicines supply to inpatients Pharmacist could be involved in: • prescription sheet design to ensure an easy-to follow documentation of medicines to be administered • medicines storage and medicine stock levels at ward level.
Dispensing medicines for the wards • List of ward stock items maintained updated • Topping up of ward stock: maintain practical stock levels to ensure that wards have the required medicines in the appropriate amounts and avoid stock wastage • Consider unit-dose dispensing
Unit Dose • A unit dose is a method of preparing medications in which individual doses of patient medications are prepared by the pharmacy and delivered in individual labelled packets to the patient's unit to be administered by the nurses on an ordered schedule.
Unit-dose packaging is the packaging of a single dose in a non-reusable container. It is increasingly used in hospitals, nursing homes , etc. Medications in unit-dose packaging are easily identifiable and can be returned to the pharmacy if the medication is discontinued
Unit-dose dispensing may lead to increased pharmacist time during dispensing of medicines to wards but it is an efficient system that reduces medication errors. Cost-effectiveness of the system employed needs to be assessed.
Definition of ward stock • Medicines where at least five or six patients are receiving it at the same time • Products should not be expensive • Products should have a good shelf-life • No major contraindications to their use and no requirements for specialist care and supervision
Include commonly used items (e.g. paracetamol tablets) • Label: name of drug, strength, instructions for use (e.g. dilution/reconstitution), storage requirements, no dosage instructions and patient names • Items used without prescription (e.g. disinfectants, antiseptics).
Controlled drugs • Stock record Medicines are kept. Unused stock of these Medicines should be kept in a secure place. • Medicines stored in a locked box on ward • Signature upon receipt of stock and when administering drug doses.
Ward drug storage areas • Controlled drugs cupboard • Cupboard for medicines intended for internal use • Cupboard for medicines intended for external use • Area to store disinfectants
Refrigerator to store drugs: temperature controlled with thermometer being used • Clean area for intravenous fluids.
Monitoring ward stocks • Pharmacy staff should establish a working relationship with nurses and ward manager • Ensure cleanliness and hygiene • Advise on appropriate storage conditions • Remind ward staff to carry out stock rotation when new stock is received
Correct stock levels • Ensure appropriate monitoring of refrigerators • Check controlled drugs cupboard.
Sterile production • Hospital pharmacists and trained pharmacy technicians compound sterile products for patients including total parenteral nutrition (TPN), and other medications given intravenously e.g.nenatal antibiotics and chemotherapy.
This is a complex process that requires adequate training of personnel, quality assurance of products, and adequate facilities. Some hospital pharmacies have decided to outsource high-risk preparations and some other compounding functions to companies that specialize in compounding.
Drug and therapeutics committee Aims are: • to maintain a hospital formulary • to develop and implement policies on drug use including, for example, generic substitution, therapeutic guidelines and cost-containment policies.
Infections control committee Aims are: • to review use of anti-infective agents • to develop and implement policies and guidelines regarding the use of anti-infective agents • to develop policies for wound management.
Drug information services Aims are • to respond to queries from different departments and other care settings • to evaluate drug usage • to investigate drug activity and coordinate clinical trials activity (this activity may be shared with the quality assurance unit) • to coordinate reporting programmes for adverse drug reactions and medication errors Hospital pharmacy services
Drugs to be stored in a refrigerator include total parenteral nutrition (TPN) solutions, reconstituted antibacterial suspensions and cytotoxic drugs, insulin, vaccines • Items and drugs that are not to be stored in refrigerator include heparin, blood and urine specimens, food, inflammables
A good procedure is to prepare a list on the door of the refrigerator of all the items that require storage in a refrigerator • Check that all items in the refrigerator require to be stored in a refrigerator (usually between 2 and 8 ° C).
Pharmacists’ actions in the development of protocols to standardise practical nursing techniques on the wards • Blood sugar monitoring technique • Use of patients’ own medicines • Administration of injections • Intravenous additives • Medicines administration
Nebuliser therapy • Urine testing • Ordering and storage of medicines. • to provide poison information • to produce publications • to educate and provide professional development for professionals.
Wound management committee Aims are: • to design protocols for wound management • to liaise with the infections control committee to identify antibacterial agents that are less likely to develop bacterial resistance • to use proper wound treatment and appropriate dressings
to keep wound treatment cost-effective • to address factors precipitating wound development (e.g. uncontrolled diabetes).
Clinical pharmacy services • Pharmacists should use their professional knowledge to foster the safe and appropriate use of drugs by patients in a teamwork approach. They should also aim to solve medication errors, detect drug–drug interactions and identify drug-induced disease.
Services provided include: • therapeutic drug monitoring • pharmacokinetic dosing • patient education • medication counselling • drug utilisation review • participation in pharmacotherapy decision making and in patient follow-up.
Pharmaceutical care should also: • focus on patient outcomes • identify potential and actual drug-related problems • resolve actual drug-related problems • prevent potential drug-related problems.
Documentation of pharmacist actions in pharmacy held patient records should contain information on: • age, weight and height • medical history • allergic or adverse drug reaction history • renal function • hepatic function.
Outpatient pharmacy • an outpatient pharmacy can usually handle written prescriptions as well as prescriptions which are phoned in. • Due to the need to compound complex drugs in a hospital facility, outpatient pharmacies may also be able to offer specialty drugs and preparations to their patients, rather than having to special-order them.
There are several advantages for patients who use an outpatient pharmacy as opposed to a regular pharmacy. The first is that the pharmacy is on the same site where they receive medical treatment, so they do not need to make an extra trip to the pharmacy to pick up prescriptions.
The second is that the pharmacy staff is usually very knowledgeable about the patient's condition, and the staff can quickly catch potential drug conflicts and other issues which may arise. The outpatient pharmacy may also offer discounts on prescriptions.
Hospital staffs may also take advantage of outpatient pharmacy services, picking up the prescriptions they need at work. • Pharmacy services may also be a part of employee benefits, with employees receiving prescriptions at reduced cost as part of their health plans.
Employees who choose to fill prescriptions elsewhere may certainly do so, but they may be obliged to pay full cost for the drugs.
Drug Utilization Reviews (DUR) • Drug Utilization Reviews (DUR), also referred to as Drug Utilization Evaluations (DUE) or Medication Utilization Evaluations (MUE), are defined as an authorized, structured, ongoing review of healthcare provider prescribing, pharmacist dispensing, and patient use of medication.
DURs involve a comprehensive review of patients' prescription and medication data before, during, and after dispensing to ensure appropriate medication decision making and positive patient outcomes.
DURs are classified into three categories: • Prospective - evaluation of a patient's therapy before medication is dispensed • Concurrent - ongoing monitoring of drug therapy during the course of treatment • Retrospective - review of therapy after the patient has received the medication
Why DURs are important • DUR programs play a key role in helping managed health care systems understand, interpret, and improve the prescribing, administration, and use of medications.