HOSPITAL PHARMACY

Mae 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

DEVELOPMENTAL HISTORY
ANCIENT PERIOD

AMERICAN ERA

DEVELOPMENTAL HISTORY
1752 Pennsylvania Hospital- first hospital in North America Jonathan Roberts- hospital pharmacist

DEVELOPMENTAL HISTORY
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

DEVELOPMENTAL HISTORY
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

DEVELOPMENT and EXPANSION

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

DEVELOPMENT and EXPANSION

TEMPLES OF AESCULAPIUS (Greek God of Medicine) TEMPLE at KOS, GREECEHippocrates practiced

DEVELOPMENT and EXPANSION

ONE DOMINANT FACTOR: RELIGIOUS INFLUENCE Doctrines of Jesus Christ intensified the emotions and virtues of love, pity and charity.

DEVELOPMENT and EXPANSION

ANOTHER FACTOR: MILITARY INFLUENCE Urgent need for care of the wounded on the battlefield.

DEVELOPMENT and EXPANSION

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

DEVELOPMENT and EXPANSION

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

DEVELOPMENT and EXPANSION

SIGNIFICANT GOVERNMENT PROGRAMS: -adoption of the HOSPITAL SURVEY AND CONSTRUCTION ACT (1946) - Commonly known as HILL BURTON PROGRAM - Provide federal funds for hospital construction

DEVELOPMENT and EXPANSION

NATIONAL PLANNING and RESOURCES DEVELOPMENT ACT (1975) Created the development of HEALTH SYSTEMS AGENCIES (HAS)

DEVELOPMENT and EXPANSION

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.

DEVELOPMENT and EXPANSION

4. Preventing unnecessary duplication of health resources.

DEVELOPMENT and EXPANSION

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 SERVICE General Hospital- provides care to patients with any type of illness Special Hospital- those which restrict the care they provide to the special conditions such as cancer, psychiatric etc

CLASSSIFICATIOS
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 50-90 beds 100-199 beds 200-299 beds 300- 399 beds

400-499 beds 500 beds and over

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 Pharmacy

Standard 1 ADMINISTRATION Standard 2 FACILITIES Standard 3 DRUG DISTRIBUTION and CONTROL Standard 4 DRUG INFORMATION

Minimum Standard for a Hospital Pharmacy

Standard 5 ASSURING RATIONAL DRUG THERAPY Standard 6 RESEARCH

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

General Requirement Order no. 56 1989

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

Abilities required for Hospital Pharmacist

1. 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.

Abilities required for Hospital Pharmacist

5. Ability to conduct teaching and in-service training programs 6. Ability to administer and manage.

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 COMMITTEE PUBLIC 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

DEPARTMENTS OF HOSPITAL
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

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

Categories
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.

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

Role of Pharmacy Technician

Assisting drug studies Taking order over the telephone Transferring prescriptions Tracking and reporting errors Tech check tech

Organizational Structure of Pharmacy

1. 2. 3. 4. 5. 6. 7. Administrative Services Division Education and Training Division Pharmaceutical Research Division In-patient Services Division Out-patient Services Division Drug Information Services Division Departmental Services Division

Organizational Structure of Pharmacy

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

Pharmacy Department
Manpower requirements and Responsibilities

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, Secretarypharmacist 3. Meetings- 6x a year or others 4x 4. Invitation to meetings 5. Agenda 6. Minutes of the meeting

PTC Organization and Operation

7. Recommendations 8. Liaison w/ other hospital committee

Functions and Scope of PTC

1. 2. 3. 4. 5. Advise on the use of drugs Drug Formulary Ensures cost effective drug therapy Educational programs QA activities ( distribution, administration, use of drugs) 6. ADR 7. Drug use review programs and studies

Functions and Scope

8. Effective drug distribution and control procedure 9. Recommends drugs to be stocked in hospital patient care areas

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

HOSPITAL FORMULARY
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

Format of the Formulary

1. 2. 3. 4. 5. 6. Title Page Names of PTC members Table of contents Policies and Procedures Drug products 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

PTC
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) 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

Guidelines for Formulary and Non-Formulary Drugs

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 patients 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.

Guidelines for Formulary and Non-Formulary 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.

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

Facilities and Equipments

---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

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

Competencies for Pharmacists

Prepare pharmaceutical products

INPATIENT PHARMACY

UNIT II

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.

Recommended Practices
5. Provisions are made to provide suitable pharmaceutical services. 6. Repacking from manufacturers original container should meet standards of good pharmacy practice. 7. Distinguishing accounting practices vs. dispensing practice.

Classification of In-patient dispensing

1. 2. 3. 4. Individual Prescription Order system Complete Floor Stock system Combination of 1 and 2. The unit dose drug distribution system

Comparisons

Individual Rx

Complete floor stock system

Combination

UD

Advantages

Reviewed by RPh
Interaction Inventory

Availability
Drug Returns Rx personnel Medication errors Pilferages Drug inventory

Disadvantages

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. 2. 3. 4. 5. 6. 24 h medicines More time of nurses for patients care Check medication order/ prescription Paper work decreased Eliminates credit ( decrease cost) Iv preparation and drug reconstitution procedures to the pharmacy 7. Profession utilization

Advantages of UD
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

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.

Unit Dose in Local Setting

5. Check medication area (specifically individual cubicle of patients 6. Note down the number of meds in the cubicle using the patients 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

Unit Dose in Local Setting

10. Endorse the medicines to the nurses. 11. Check any discrepancies (billing or lacking medicines)

COMMON ABBREVIATION

Tab Cap IVTT

tablet capsule 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 theres 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 Retail of DP/s containing Table I - Controlled Chemical/s 1 S Retail of DD/DDP/s & /or DP/s containing - Table I Controlled Chemical/s 3 S Wholesale/Distribution of DD/DDP/s/Table - 1 Controlled Chemical/s used in the 4 manufacture of drug preparation/s/ &/or their preparation/s S C Compounding/Manufacture of DD/ DDPs - &/or D P/s containing Table I Controlled 5 Chemical/s

500.00

1,000.00

3,000.00

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 DDB form 1-72.

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

date

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