Hospital Pharmacists and Responsibilities

Hospital Pharmacists

• Responsible for ensuring the 7 "rights" of medication administration are respected
• The 7 rights include: right patient, right dose, right route, right time, right drug, right information, and right documentation

Hospital Pharmacy Staff

• Pharmacists
• Pharmacy Technicians
• Nurses
• Students
• Storekeepers
• Porters
• Administrative and Clerical Staff
• Domestic Staff

Hospital Pharmacist Responsibilities

• Possess the knowledge and clinical skills that make them an authoritative source of drug information for physicians, nurses, and patients
• Responsible for systems controlling drug distribution
• Systems are designed to assure each patient receives the appropriate medication, in the correct form, dosage, and at the correct time
• Pharmacists maintain records on each patient to fill medication orders and to screen for drug allergies and adverse drug effects

Pharmacy Director Responsibilities

• Maintaining an adequate drug supply
• Participating in the pharmacy and therapeutics committee to develop and update a current hospital formulary of the drug list
• Presenting the drug list to the medical staff for approval
• Attending all meetings of the pharmacy and therapeutics committee
• Implementing committee decisions throughout the hospital
• Establishing specifications for the procurement of drugs
• Taking responsibility for any pharmaceuticals manufactured within the hospital
• Taking responsibility for emergency drugs and antidotes
• Maintaining confidentiality of information relating to patients and staff
• Cooperating in any hospital teaching of research programs
• Responsibilities for drug monitoring
• Establishing drug information services

Staff Pharmacist Responsibilities

• Have daily responsibilities for the pharmacy's distributive duties of physician order review and filling
• Performing unit dose cart checking and parenteral admixtures
• Monitoring drug-drug interactions and adverse drug effects
• Playing a major role in therapeutic drug monitoring and evaluating drug therapy

Pharmacy and Therapeutics Committee (P&T)

• Composed of at least 3 physicians, a pharmacist, and a representative of the nursing staff
• The committee should invite persons within or outside the hospital who can contribute specialized or unique knowledge, skills, and judgments to its meetings

P&T Committee Advisory Purpose

• Recommends the adoption or assists in the formulation of broad professional policies regarding evaluation, selection, and therapeutic use of drugs

P&T Committee Educational Purpose

• Recommends or assists in the formulation of programs designed to meet the needs of the professional staff for complete current knowledge on matters related to drugs

Hospital Classifications

• Hospitals can be classified by:
  • Ownership (Government, Private)
  • Mosque or Church Operated/Affiliated, Corporation
  • Not-for-Profit or For-Profit
  • Types of Care (Primary, Secondary, Tertiary)
  • Acute or Chronic
  • General or Specialty
  • Teaching Affiliation

Organizational Structure of a Hospital

• Organizational structure refers to levels of management within a hospital
• Efficient management of hospital departments is enabled by these levels
• Understanding the hospital's chain of command is facilitated by the structure
• Organizational structure varies from hospital to hospital
• Large hospitals have complex organizational structures
• Smaller hospitals tend to have simpler organizational structures

Grouping of Hospital Departments

• Grouping is done to promote the efficiency of hospital facilities
• Generally done according to the similarity of duties

Common Categorical Grouping of Hospital Departments

• Administrative Services
• Informational Services
• Therapeutic Services
• Diagnostic Services
• Support Services

Administrative Services

• Hospital administrators include: chief executive officer (CEO), vice president(s), executive assistants, and department heads
• Business people who "run the hospital"
• Supervise budgeting and finance
• Establish hospital policies and procedures and often perform public relation duties

Informational Services

• Include: admissions, billing & collection, medical records, computer information systems, health education, and human resources
• Document and process information

Therapeutic Services:

• Provide treatment to patients
• Includes:
  • Physical Therapy (PT): Treatment to improve large muscle mobility
  • Occupational Therapy (OT): Treatment goal is to help the patient regain fine motor skills
  • Speech/Language Pathology: Identify, evaluate, and treat speech/language disorders
  • Respiratory Therapy: Treat patients with heart & lung disease
  • Medical Psychology: Concerned with the mental well-being of patients
  • Social Services: Connect patients with community resources (financial aid, etc.)
  • Pharmacy: Dispense medications
  • Dietary: Maintain nutritionally sound diets for patients
  • Sports Medicine: Provide rehabilitative services to athletes
  • Nursing: Provide care for patients

Diagnostic Services

• Medical Laboratory: Studies body tissues
• Medical Imaging: Radiology, MRI, CT, Ultra Sound
• Emergency Medicine: Provides emergency diagnoses & treatment
• Determines the cause(s) of illness or injury

Support Services

• Provide support for the entire hospital
• Central Supply: Orders, receives, stocks & distributes equipment & supplies
• Biomedical Technology: Design, build repair, medical equipment
• Housekeeping & Maintenance: Maintain safe, clean environment

Hospital Pharmacy Facilities: Pharmacy Location

• Should be located in an area which is convenient for providing services to many departments
• Should be convenient for personnel who make daily use of the pharmacy
• Should be near elevators, outpatient services, and the center of activities of the hospital

Hospital Pharmacy Facilities: Area

• There should be adequate floor space for all pharmacy operations
• There is great variation in floor space devoted to the pharmacy in hospitals of the same size and type
• Variations have a direct relation to the scope of services provided by the pharmacy
• In 50 Bed hospitals: The pharmacy requires one room in which a combination of dispensing, manufacturing, administration, and other pharmaceutical services are done.
• If sterile products are to be prepared, a separate room should be present, no less than 25 m2
• In 100 Bed Hospitals: There would be 3 rooms, one for administration, dispensing and manufacturing, a separate room for parenteral preparations and store room
• In 200 Bed Hospitals or Larger: There should be: Separate area for out-patient service, an office for the chief pharmacist, a manufacturing room, a storeroom, a sterile products room, a drug information center, and a separate area for inpatient service
• As the hospital size advances to 500, 1000 or more beds, there should be: a waiting room, store room, an office for the chief pharmacist, and an office for the secretary and bookkeeper
• 500-1000 beds or more areas also including an outpatient dispensing laboratory & consultation area, inpatient dispensing laboratory, library and drug information center
• 500-1000 beds or more areas also including a manufacturing laboratory, formulation, control & research laboratory, radiopharmaceutical laboratory, analytical & QC laboratory, prepackaging and labeling laboratory, sterile products laboratory
• Alcohol and volatile liquid room, narcotics, investigational drugs and controlled drugs, and additional bulk storage facilities

Hospital Pharmacy Facilities: Storage Area

• Storage of pharmaceuticals should be a satisfactory location and provided with proper lighting and ventilation
• Drugs must be stored under proper conditions of: Sanitation, Temperature, Light, Moisture, Ventilation, Segregation, Security
• Normal storage area: Contains the largest portion of the pharmacy such as liquids, tablets, capsules, and injections at a temperature of about 25°C
• Refrigerated Storage: Large hospital should have a walk-in refrigeration, with a separate freezing compartment to house biologicals and other drugs which must be stored at temperature below freezing
• Automated systems are now used to monitor refrigerators where these refrigerators are connected to alarm systems to easily discover their failure

Hospital Pharmacy Facilities: Storage Area

• Antiseptics: Other drugs for external use and disinfectants are stored separately from internal and injectable medications
• Narcotics: Should be stored according to the national regulatory standards (locked)
• Flammable storage: Some hospitals construct an underground bunker outside the hospital to store flammable products (chemicals, acetone, alcohol containing products)
• Outdated or unstable drugs: Drugs should be identified, and their distribution and administration should be prevented
• Emergency drugs: Must be in adequate and proper supply within the pharmacy and in designated hospital areas
• Investigational drugs: In use must be properly stored, distributed, and controlled

Hospital Pharmacy Facilities: Security

• Documentation is needed to minimize any misappropriation opportunity
• Signature of nurses are asked by some department for deliveries to ensure there is an audit trail from the point of ordering to the point of delivery to wards

Hospital Pharmacy Facilities: Ventilation

• Air conditioning of the pharmacy is desirable for the following:
  • Prevents contamination with dust or dirt upon opening windows or doors
  • Reduces temperature that may rise due to various autoclaves, ovens, and steam jacketed kettles
  • Permits the maintenance of a temperature, which is compatible with the official storage requirements for drugs on a year round
  • Helps for security of the pharmacy

Hospital Pharmacy Facilities: Electric Lighting

• Sufficient lighting must be provided for the various work area as well as the library

Hospital Pharmacy Facilities: Parenteral Admixture Preparation Area

• There should be a suitable area for the parenteral
• When laminar airflow hoods are used, quality requirements shall include cleaning of the equipment used, microbiological monitoring and periodic checks for operational efficiency at least every 12 hours

Hospital Pharmacy Facilities: Pneumatic Tube System

• Modern engineering technology has made available a means of transporting nearly every item from the pharmacy to its hospital destination

Hospital Pharmacy Facilities: Additional Areas

• Consultation Area
• Drug information resources and Library: To make information for drugs available to both pharmacists and physicians
• Planning a hospital pharmacy should include a library
• Specially locked spaces: For narcotics, controlled drugs and alcohol
• Necessary equipment: For the compounding, dispensing and manufacturing of pharmaceuticals and parenteral preparations
• Refrigerator for thermolabile products
• Office for the director of pharmaceutical services
• Bookkeeping supplies and related materials and equipment necessary for proper administration.
• Metric – Apothecaries: Weight and measure conversion charts should be available to professional individuals who may require them

Refrigerator for Thermolabile Products: Complete List of Storage Temperature Terms

• Cold place: A temperature not exceeding 8 °C
• Refrigerator: A cold place in which temperature is held between 2° and 8 °C
• Freezer: Temperature between – 20° and – 10°C
• Cool place: A temperature controlled between 8 °C and 15°C
• Room Temperature: Between 15° and 30° С
• Excessive Heat: Temperature above 40°C
• Large hospitals require a construction of room with regulated temperature from 12-15°C
• Regular checks of temperature are performed with a thermometer

The Formulary

• Is a list of drugs (and associated information) which are recommended or approved for use by a group of practitioners in an organized healthcare setting (e.g., a hospital, managed care or home-care operation)
• There should be a program of objective evaluation, selection, and use of medicinal agents in the hospital for better patient care
• This program is the basis of rational drug therapy
• The hospital formulary concept is a method of providing such a program in the hospital

Formulary System

• Uses various techniques to ensure high-quality and cost-effective drug therapy
• Drugs are selected for inclusion on the basis of efficacy, safety, Patient acceptability, and cost
• A formulary may be thought of as a prescribing policy since it lists which drugs are recommended

Formulary Management:

• Development, maintenance and approval of the formulary are the responsibilities of the P&T committee, or its equivalent, which exists as a committee of the medical staff
• The three key elements for establishing and maintaining a credible formulary are:
  • A collaborative work relationship among healthcare professionals
  • A defined medical staff (or physician-provider network) that practices within that healthcare setting
  • An interdisciplinary P&T committee as a committee of the medical staff

Importance of the Formulary

• It lists drugs, dosage forms, package sizes, and drug strengths stocked by the Hospital and Pharmacies, establishing standards concerning the use and control of drugs
• Formularies serve as an advisory group to the hospital medical staff
• They provide information on the cost of products to help users become cost-conscious
• They make recommendations concerning drugs to be stocked, prevent unnecessary duplication in stocking drugs and drugs in combination
• Develop and review procedures to control the use of dangerous and toxic drugs
• Develop a procedure for handling and controlling drugs brought by patients
• Evaluate clinical data concerning new drugs or preparations requested by the hospital
• Review the appropriateness of the empiric and therapeutic use of drugs through the analysis of individual or aggregate patterns of drug practice
• Develop policies and procedures relating to the selection, distribution, handling, use and administration of drugs and diagnostic testing materials
• Review all significant adverse drug reactions

The Formulary is Generally Divided Into General Sections:

• Introduction
• Therapeutic Index
• Drug Monographs (Official, non-proprietary or generic name, Trade name, Category, and Dosage Form available in the market)
• General Reference Section
• Formulary appendices
• Index listing the medications alphabetically

The Therapeutic Index

• Is a listing by pharmacological or therapeutic category of those drugs which are carried in one or more dosage forms, by the Pharmacy
• Listing is alphabetical by generic name under each category

Drug Monograph

• Is an alphabetical listing of both generic and trade names
• The trade name will be cross-referenced to the generic name under which the complete information will be found
• Each monograph will contain:
  • Generic name, Official, non-proprietary
  • Trade name: Common trade or proprietary names, which refer to the generic drug
  • Listing of trade names doesn't necessarily mean that it's stocked as such
  • Category: Relates to the information in the Therapeutic Section of the Formulary
  • Includes information regarding strength, toxicology, use and recommended quantities to be dispensed
  • Dosage Form: This lists all the dosage forms available in the Pharmacy

The General Reference Section

• Contains information and aids which are used in patient care
• Contains dosing formula conversion tables for weight, measures and temperature, as well as guidelines for use of certain drugs as adopted by P&T committee

Formulary Appendices

• Contain: drug-drug interactions, drugs contraindicated in liver disease, renal diseases, in pregnancy and lactation, tables of metric weights and apothecary and household equivalents, tables of common laboratory values, and calculation of dosage for children based on established rules and by use of the body surface methods

Index Listing

• At the end of the Formulary is an index listing the medications alphabetically with the corresponding chapter number where other medications in that class can be found

Drug Product Selection

• Pharmacists and prescribers must understand the concept of therapeutic equivalence to ensure proper application of generic substitution and therapeutic interchange principles
• Pharmacists should assume a leadership role in drug product selection by proposing opportunities for drug product selection
• This includes evaluation and assessment of bioequivalence data; storage, dispensing, and administration; cost; and other relevant information
• Pharmacists must ensure that products of adequate quality are obtained

Therapeutic Equivalence

• Products can be expected to produce the same therapeutic outcome and toxicity
• Both generic substitution and therapeutic interchange should be safe and effective if the therapeutic equivalence of products to be exchanged has been established
• The use of therapeutically equivalent products can contribute to improve the drug use by maintaining a high quality of therapy in the most cost-effective manner

Generic Substitution

• It is the substitution of drug products that contain the same active ingredient(s) and are chemically identical in strength, concentration, dosage form and route of administration to the drug product prescribed
• These are “pharmaceutical equivalents"
• These products can also be termed “generic equivalents,” and should display therapeutic equivalence
• The key word in this definition is “identical”
• The substitution of one brand of propranolol tablets for another represents the application of generic substitution if the strength of the active ingredients and the dosage form are identical
• The substitution of purified animal insulin for human insulin is not generic substitution, because the products are not chemically identical
• The interchangeability of purified animal insulin for human insulin may be acceptable under the principle of therapeutic interchange, if therapeutic equivalence can be ensured
• Prescribers have the right to override a generic substitution
• In some cases, a patient preference may negate an otherwise acceptable generic substitution
• he P&T committee is responsible for determining which drugs are acceptable for generic substitution

Therapeutic Interchange

• The interchange of various therapeutically equivalent drug products by pharmacists under arrangements between pharmacist and authorized prescriber who have previously established and agreed on conditions for interchanges
• Therapeutic interchange occurs pursuant to development of agreements between pharmacists and prescribers
• Implies that there is appropriate and timely communication between them
• Therapeutic interchange agreements can vary from simple understandings to complex protocols
• Therapeutic interchange agreements permitting interchange between cephradine and cephalexin may be a simple arrangement if the dose and dosage form of the two drugs are equivalent, and the drugs can be interchanged in the treatment of any disease for which the drugs are indicated
• A therapeutic interchange arrangement that permits the interchangeability of different colony-stimulating factors in treating a specific diagnosis pursuant to specific protocols might be more complex
• he P&T committee acts on behalf of the medical staff to develop and approve arrangements
• In some settings, all drugs that may be therapeutically interchanged are acceptable to the formulary and the pharmacy is authorized to purchase and dispense the most cost-effective products
• In other settings, certain drug products are considered interchangeable, but the P&T committee designates a preferred product and approves it for formulary addition
• The other equivalent drugs or products are deleted from the formulary
• To remain effective over time, therapeutic interchange decisions should be routinely reviewed and revised as appropriate
• Therapeutic interchange may not be appropriate for all patients
• Professional judgment must be exercised by the pharmacist and the prescriber
• Consultation with the prescriber and the patient may be necessary
• Prescribers have the prerogative to override a therapeutic interchange

Pharmaceutical Services of Hospital Pharmacists

• In-patient pharmacy services
• Out-patient pharmacy services
• Pharmaceutical procurement and control services
• Drug information services
• Pharmaceutical development services
• Clinical pharmacy services
• Rational use of drugs and essential drug list services
• Educational and training services
• Drug-drug interactions
• Handling of cytotoxic drugs

In-Patient Pharmacy Services

• Drug Distribution systems
• Intravenous admixture and Total Parental Nutrition (TPN)
• Drug monitoring

Drug Distribution Systems

• Floor or Ward Stock System
• Individual Prescription order system
• Combined Stock individual Prescription order system
• Unit Dose Distribution System

Floor or Ward Stock System

• Successfully operated in some hospitals as a decentralized pharmacy under the direct supervision of a pharmacist

Floor or Ward Stock System Advantages

• Ready availability of the required medication
• Elimination of drug returns
• Reduction of drug order transcriptions for the pharmacy
• Reduction in the number of personnel required

Floor or Ward Stock System Disadvantages

• Medication errors resulting from lack of review by a pharmacist for each patient order
• Increased drug inventory on the pavilions
• Financial loss due to greater chance for pilferage
• Limited capacity for proper storage facilities in nursing units
• Increased danger of unnoticed drug deterioration that threatens patient's safety

Individual Prescription Order System

• Traditionally used method in the small and/or private hospitals
• All medications are dispensed by the pharmacist on individual prescription orders after the prescription orders are sent to the pharmacy
• Medications are labeled with the patient's name and the instructions for dosage

Individual Prescription Order System Advantages

• All prescriptions are directly reviewed by the pharmacist
• A chance for close connection between the pharmacist, nurse and physicians in pharmaceutical matters
• Facilitates charging of private patients
• Enables investigation of possible medication errors in prescriptions
• Name of medicine appearing on the patient's treatment to avoid confusion of nursing staff
• Limiting the supply in each bottle where the pharmacist ensures that treatment is not continued indefinitely without review

Individual Prescription Order System Disadvantages

• Increased potential for errors due to lack of checks in distribution of medication and administration
• Consumption of excessive nursing manpower in the preparation of doses and in conducting other medication-related activities
• Increase potential for drug loss due to waste and deterioration
• Since the nurse may administer the medication to the patient without any reference to the prescription sheet, any changes or cancellation on this document may not be seen

Combined Stock Individual Prescription Order System

• Medicines are supplied as ward stocks, for those drugs in frequent use and individually dispensed items for all others
• The aim is to provide the maximum number of treatments as individually dispensed items
• In the combined system, a positive decision is made to restrict these, usually to minimize pharmacy load
• The extent of the ward stock varies considerably in applying this system to different hospitals

Unit Dose Distribution System

• A pharmacy-coordinated method of dispensing and controlling medications in healthcare hospitals
• Unit dose medications have been defined as medications that are ordered, packaged, handled, administered, and charged in multiples of single dose unit containing a predetermined amount of drug or supply sufficient for one regular dose, or use
• For most medications, not more than 24 hours supply of doses is delivered to or available at the patient care area at any time

Unit Dose Distribution System Advantages

• Safe for the patient
• More efficient & economical for the hospital
• More effective method for utilizing professional resources
• A reduction in the incidences of medication errors
• A decrease in the total cost of medication - related activities
• More efficient usage of pharmacy and nursing personnel
• Improved overall drug control and drug use monitoring
• More accurate patient billings for drugs
• Greater control by the pharmacist over pharmacy work
• A reduction in the size of drug inventories located in patient care areas

In-Patient Prescription Labels

• Should bear at a minimum: patient name, non-proprietary and/or proprietary name of the drug actually dispensed, strength of medication dispensed, date of issue, and name or initial of dispensing pharmacist

The Prescription (or In-Patient Order)

• Should have at the time dispensed: the source and batch identifying number of the medication and the initial of the dispenser

Outpatient Services

• Dispense medications to ambulatory patients
• Ambulatory care generally refers to providing healthcare services to patients who are not restricted to beds
• The outpatient pharmacy dispensing area should be located somewhere along the normal patient traffic flow
• The services can be provided from: a separate outpatient pharmacy, a combined inpatient and outpatient unit service provided from separate windows, or a combined inpatient and outpatient unit service provided from the same window

Minimum Practice Standards for Outpatient Services

• The ambulatory care pharmacy must be directed by a qualified pharmacist
• The appropriateness of the choice of drug and its dosage form, route of administration and amount must be verified by the pharmacist
• All medication dispensed to the patient should be correctly labeled and packaged in accordance with all applicable regulations and accepted standards of practice
• On dispensing a new medication to the patient, the pharmacist will ensure that patient or his representative receive and understand all information required for proper use of drug
• Proper control of all drug in the ambulatory care service areas

The Dispensing Routine

• The pattern involved in providing medications to clinic patients and patients being discharged with "take home drugs" is identical with that carried on by community pharmacy
• In both cases, the prescription is written by the physician, and the patient takes it to the pharmacy where it is compounded
• If there is a waiting period, the pharmacist will make use of a prescription call check, which numerically identifies the patient, and the finished prescriptions
• Once in the hands of the pharmacist, the prescription and label are numbered
• The directions and other information are placed on the label, ancillary labels are affixed, the proper medications then placed in the container, a check for accuracy is conducted, and finally the prepared prescription is wrapped and dispensed

Labeling for Outpatient Prescriptions should include:

• Patient's full name
• The prescription identification number
• Specific direction for use and date of issue
• The dispenser's and prescriber's name
• Where physician request or hospital policy dictates, identity and strength should be on the label
• Warning to keep out of reach of children
• The name, address and telephone number of hospital
• The source and batch identifying number of the medication and the initials of the dispenser should be noted
• Establish a system for identification of outpatients
• Drugs that require an expiration date should show it on the immediate container and carton