Hospital Formulary and Inventory Management PDF

Module 5: **THE HOSPITAL FORMULARY AND THE FORMULARY SYSTEM** **[Hospital Formulary]** - Continually revised compilation of drug products selected by PTC. - **Complete, concise and easy to use** - Medications not included in the hospital formulary are considered **NON-FORMULARY.** **...

Module 5: **THE HOSPITAL FORMULARY AND THE FORMULARY SYSTEM** **[Hospital Formulary]** - Continually revised compilation of drug products selected by PTC. - **Complete, concise and easy to use** - Medications not included in the hospital formulary are considered **NON-FORMULARY.** **[Hospital Formulary System]** - **Evaluating, appraising and selecting drug** products available in the market place, that are considered to be the **most useful in patient care.** **[Essential Drugs List]** - National Drug Formulary - Consist of 1. core list 2. complementary list. **[Basic Terms]** 1. Generic Name or Generic Terminology 2. International Nonproprietary Name (INN) 3. Chemical Name 4. Active Ingredient 5. Brand Name **[Purpose of the Hospital Formulary System]** 1. To educate the medical staff on the available drugs. 2. Teaching aid to the interns, students and other medical staff. 3. Prevents unnecessary duplication, waste, confusion. 4. Supplies essential information to the medical/nursing staff on the multitude of available therapeutic agents. **[Hospital Formulary Content and Organization]** Provide the hospital staff with the following: 1. Information on what drug products have been approved by the PTC for patient use 2. Basic therapeutic information about each approved item 3. Information on hospital policies and procedures governing the use of drugs 4. Special information about drugs (dosing guidelines, hospital approved abbreviations, sodium content of various formulary items, etc.) Three Main Parts: **Part One** : Information on hospital policies and procedures concerning drugs **Part Two** : Drug products listing **Part Three** : Special information **[PART I]** 1. **Categories of drugs** ○ Evaluated and approved drug categories: - Formulary drug - Conditional trial period - Investigational drugs - Specialized formulary drugs - Non-formulary drug 2. Brief description of the PTC, including its membership, responsibilities and operation 3. Hospital policies governing - Prescribing - Dispensing - Administration - Company/suppliers, representatives - Standard drug administration times - Reporting of ADR and medication errors **[PART II]** - It is the heart of the formulary. Entries can be arranged in several ways: - Alphabetically, by generic name - Alphabetically, within therapeutic class - Combination of two Information to be included in each entry: - Generic name of the basic drug, dosage forms, strength, packaging and size stocked by pharmacy, formulation **2 indexes** which can be included: 1. Generic name of drug items 2. Therapeutic/Pharmacologic index **[PART III]** - List of Hospitals- approved abbreviations - Rules for calculating pediatric dosages - Table of sodium content of antacids - List of the contents of emergency cart - Dosage guides for patient with renal failure - Metric conversion scales and tables - Examples of formulary request/deletion form - Tables of drug interactions - Poison antidote charts **[Typical Format and Appearance of a Formulary]** Physically, formulary must be: 1. Visually pleasing 2. Understandable 3. Appear professional. ◎The need for proper grammar, punctuation ,correct spelling and neatness is obvious ◎ Composition: 1. Title page 2. Names and titles of the members of the PTC 3. Table of Contents 4. Information on hospital policies and procedures - Objectives and operation of the formulary system - Hospital regulations and procedures for prescribing and dispensing of drugs - Hospital pharmacy services and procedures - Directions on how to use the formulary 5. Products accepted for use at the hospital - Items added, deleted and requested for inclusion to PNDF consistent with the revision made by the NDC - Pharmacologic/Therapeutic index - Description of formulary drug products by pharmacologic/therapeutic class 6. Appendix - Rules for calculating pediatric doses - Schedule of standard drug administration times - Forms for addition to/deletion from formulary and other important forms **[Keeping the Formulary Current]** - Formulary need to be **revised annually** (addition, deletion, changes in policies will necessitate revision) - Sheet can be attached to the current edition for any changes Module 6 **PURCHASING AND INVENTORY MANAGEMENT** **[Responsibilities of Pharmacist in Inventory Management]** 1. Checking the drugs to be stocked in the hospital 2. Responsible and accountable for all drugs purchased. 3. Developing an effective system in the control of purchase, inventory and adequate maintenance of raw materials used for compounding and pharmaceuticals. **[Basic characteristics for the budget to be useful and effective:]** 1. Oriented toward achieving goals and objectives 2. Realistic 3. Implemented by the one who prepared it 4. Contain certain internal mechanisms for review and analysis 5. Use consistent measurement tools and reporting periods **[The budget for a Pharmacy Service includes:]** 1. Salaries of the pharmacist and other personnel 2. Office supplies 3. Store supplies 4. Equipment necessary in running a Pharmacy **[Inventory Management]** - Sum total of those activities necessary for acquisition, storage, sale, disposal or use of materials. **Functions of inventory management:** 1. Operational 2. Financial **The general objective of all inventory policies:** - \....must be to keep investment at the lowest level with the needs of the hospital **[In requisitioning the drug needs, a pharmacist must think in terms of:]** - the information on the balance of the revolving fund - the conditions such as seasonal, etc - transportation and delivery time problems - availability of alternate drugs - the ratio of supply and demand **[The problem of overstocking and understocking of drugs can be attributed to the following:]** 1. Ineffective purchasing administration without any control system. 2. Lack of technical requirements attached to documents. 3. Poor storage facilities. 4. Problem of availability. 5. Transportation and delivery problems, etc. 6. Geographical and climatic conditions time lag between requisition and purchase. **[Objectives and requirements of inventory management:]** 1. To have the stock available when and where needed. 2. To reduce undue strain on the government's scarce resources. 3. To maximize utilization of available storage facilities. 4. To provide area for cost reduction on drugs without compounding quality. 5. To ensure minimal waste/expired drugs through proper storage management. **[Physical inventory]** - Requirement of COA. - Ensures that the hospital's fiscal operation is properly recorded and that adequate inventory is maintained. - Spot check type inventory - Post inventory - Perpetual Inventory System - Manual System - Electronic Data System **[Drug requisitioning]** 1. Balance of the revolving fund. 2. Conditions such as seasonal, etc. 3. Transportation and delivery time problems. 4. Availability of alternative medicine. 5. Ratio of supply and demand. **[Types of purchasing]** 1. Purchase thru public bidding 2. Emergency purchase 3. Negotiated purchase 4. Procurement from duly licensed manufacturers and exclusive distributors. 5. Procurement thru the procurement service. 6. Procurement from other Philippine General agencies or foreign government. 7. Purchase thru repeat orders. **[Inventory control turn-over rate]** **[Consideration in purchase volume control]** 1. Balance of stock- Stock on Hand at the Pharmacy + Stock in the Storeroom 2. Establishment of the Ordering Point or Reorder Quality Level (RQL) 3. Dead inventory **Week 7: Patient Care Areas & Drug Distribution System** **[Patient Care Areas]** 1. In-patient care areas 2. Out-patient care areas 1. **[In-patient Care Areas]** - 2 Types: - Citical Care Units - General Care Units - Patients have great need for care ◉ Pharmacist's Role: - Make sure that patients are receiving the right drugs, in the dose that is appropriate for patient's condition. - Participates in medical rounds with the rest of the healthcare team - Patients have less need for care ◉ Pharmacist's Role: - Medication orders accurately reflect those medications being taken at home. - Discharge orders are appropriate - Patients who will be discharged will be able to continue their medications at home - Attend medical rounds - Responsible for drug distribution 2. **[Out-patient Care Areas]** - Out patient refers to patients not occupying beds in a hospital or in clinics, health centers and other places. - Out patient load into three categories. 1. Emergency 2. Tertiary Care 3. Primary Care Out-patient Care Areas ◉ Types of patient served ◉ Nature of services provided +-----------------------------------+-----------------------------------+ | **Types of Out-patients:** | **Pharmacy services:** | +===================================+===================================+ | 1. **General out-patient** | Drug distribution | +-----------------------------------+-----------------------------------+ | 2. **Special out-patient** | Medication counseling | +-----------------------------------+-----------------------------------+ | 3. **Referred out-Patient** | Drug information | +-----------------------------------+-----------------------------------+ | 4. **Emergency out-Patient** | Preparing and maintaining | | | medication profile | +-----------------------------------+-----------------------------------+ **[DRUG DISTRIBUTION SYSTEM]** - Methods by which the pharmacy department receives drug order, prepares the drug and in turn distribute the drug to the patient care area **[Principles of Good Dispensing]** 1. Interpreting the request 2. Retrieval 3. Formulation (compounding, counting, pouring) 4. Processing/ labeling 5. Delivery (distribution) **[Types of Drug Distribution System]** 1. Individual Prescription Order System 2. Complete Floor Stock System 3. Combination of Individual and Floor Stock System 4. Unit Dose Drug Distribution System 1. **[Individual prescription order system: ]** - It is a type of prescription system where the physician writes the prescription for individual patient who obtains the drug prescribed from any medical store or hospital dispensary by paying own charges. - All medication orders are directly reviewed by pharmacists. - It provides the interaction of pharmacist- doctor, nurse and the patient. - It provides clear control of inventory. - All drugs are retained in the pharmacy until receipt of the physician's initial order. - Facilitates a convenient method for instituting patient drug charges, and it provides individualized patient service. 2. **[Complete floor stock system: ]** - Under this system ,the drugs are given to the patient through the nursing station and the pharmacy supplies from the drug store of a hospital. - Drugs on the nursing station or ward may be divided into: - Medicines which are stocked on the nursing station at all times and charged to the patient's account after they have been administered to them. - Dispensing of floor stock drugs. - The patient is charged for every single dose administered to him. - Selection of these drugs in various wards is decided by PTC - Once the floor stock list is prepared ,it becomes the responsibility of the hospital pharmacist to make the drugs available - Medicaments that are placed at the nursing station for the use of all patients on the floor. - No direct charge from the patients account - 2 Methods: Drug Basket Method Mobile Dispensary Unit - ready availability of the required drugs for the patient - eliminates unused drug returned to the pharmacy - reduces the number of drug order transcriptions for the pharmacy - reduces the number of pharmacy personnel required - medication errors may increase because the pharmacist does not review the medication orders - increase drug inventory at each nursing station or other patient care area - great opportunity for pilferage of drugs - increased hazards associated with drug deterioration - additional capital funds may be necessary to provide proper storage facilities for drugs in every patient care area - Additional nurse's time required for handling drugs 3. **[Combination of Individual and Floor Stock System]** - Followed in the government and private hospitals. - Requirements of drugs/surgical items are given to the patient who purchase and deposit these items in hospital wards under the nurse supervision 4. **[Unit Dose Drug Distribution System]** - Medications are contained in, administered from, single-unit or unit-dose packages. - Medications are dispensed in ready-to-administer form, to the extent possible. - For most medications, not more than a 24- hour supply of doses is provided to or available at the patient care area at any time. - Patient medication profile is concurrently maintained in the pharmacy for each patient. - Improve pharmaceutical service 24 hours a day and are charged only for those which are administered to them. - Nurses have more time for direct patient care - creates a double check system - eliminates excessive duplication of orders and paper work at the nursing station and pharmacy - transfers IV preparations and drug reconstitution to the pharmacy - promotes more efficient utilization of professional and nonprofessional personnel - reduces revenue losses - conserves space at nursing stations by eliminating bulk floor stocks - eliminates pilferage and drug waste - extends pharmacy coverage and control throughout the hospital - communication of medication orders and delivery systems is improved **2 Types:** 1. **Central Unit Dose Drug Distribution System** - All in-patient drugs are dispensed in unit doses and all the drugs are stored in central area of the pharmacy and dispensed at the time the dose is due to be given to the patient. - Drugs re transferred from the pharmacy to the indoor patient by medication cards. 2. **Decentralized Unit Dose Drug Distribution System** - This operates through small satellite pharmacies located on each floor of the hospital. **Procedure:** - Patient profile card containing full date ,disease ,diagnosis is prepared. - Prescription are sent directly to the pharmacist witch are then entered in the patient profile card. - Pharmacist checks medication order. - Patient profile card and prescription order is filled by pharmacy technicians. - The nurses administer the drugs and make the entry in their records.  **[DISPENSING OF CONTROLLED DRUGS:]** 1. Responsibility for controlled substance in the hospital. 2. Ordering ward stock of the controlled substances from the pharmacy. 3. Doctros orders for administration of controlled drugs. - The administrative head of the hospital is responsible for the proper safeguarding and the handling of controlled substances within the hospital. 1. A requisition for ward stock controlled substances is completed by insertion a check mark opposite the name ,strength from of controlled substance desired. 2. Before any new controlled substances are issued to a ward - The fallowing information must appear on the Doctor's controlled drug order sheet". 1. Date 2. Patient's full name 3. Patient's hospital number 4. Specific description of drug ordered and strength 5. Amount to be given ***PRESCRIPTIONS:*** In dispensing of controlled substances, the following requirements should be with prescriptions: 1. Except when dispensed 2. Drugs may be dispensed on the oral prescription in an emergency situation. 3. Prescription shall be retained in conformity with the requirements of this law. 4. No prescription for a controlled substance in Schedule 2 may be refilled. 5. Controlled substances in Schedule III or IV may not be dispensed a written or oral prescription in conformity. ***Information on daily controlled drug administration sheet:*** The full information required on the Daily Controlled Drugs Administration Sheet is as follows: 1. Date. 2. Amount given. 3. Patient's full name 4. Patient's hospital number. 5. Name of doctor ordering. 6. Signature of nurse administering. 7. Frequency and route of administration ***Most Commonly Abused Rx Drugs:*** 1. **Pain relievers (opioids, narcotics)** - Oxycodone (e.g., OxyContin, Percocet), hydrocodone, codeine, and morphine 2. **Central nervous system depressants (sedatives, tranquilizers, hypnotics)** - Barbiturates (e.g., Mebaral, Nembutal) and benzodiazepines (e.g., Valium, Xanax) 3. **Stimulants (used to treat attention deficit disorders, narcolepsy, and weight loss)** - Dextroamphetamine (e.g., Dexedrine,) and methylphenidate (e.g., Ritalin,) **[Drug distribution to out-patient: ]** - No medicaments should be issued without the prescription. - After the issue has been made the quantities supplied must be recorded. - Medicines are given to the out- patients from the pharmacy situated in the out patient block. ***Location of out-patient dispensing:*** - It should be located on the ground floor of the building. - The out patient dispensing area should be provided with proper seating arrangement. - The pharmacy receives its supplies from medical stores weekly but emergency supplies can be obtained at any time. **Module 8: COMPOUNDING OF NON-STERILE PREPARATION AND PREPACKING** **[Non--Sterile Compounding: History ]** - Medicinal mixtures using plants, animals, and minerals dates back 4000 years - In 1820, 80% of prescriptions in the first U.S. Pharmacopoeia were compounds - Premade dosages do not necessarily treat everyone, are not always commercially available - Pediatric doses, hospice patients **[Use of Non--Sterile Compounding ]** - **Non--sterile compounding:** Done in vertical hood or on clean work surface as stated in USP \ - **Common items:** Creams, ointments, oral suspensions - **Less common:** Capsules, suppositories, syringe **[Reasons for Compounding ]** - No longer manufactured - Patients may be allergic to something in a drug - Specialized dosage/strength for specific patients - Increased patient compliance - Patient unable to ingest normal dosage form - Medication requires flavorings **[Equipment Used in Compounding ]** - Personal protective equipment: Gloves, goggles, gown, hair cover, lab coat, mask, shoe covers - Measuring devices: Graduated cylinders, syringes, pipettes, electronic filling machines - Measuring liquids requires reading a **[meniscus ]** - Mixing equipment: Mortar and pestle **[Weighing Equipment ]** Weighing equipment: Scales, electronic balances **Class A balance** -- Minimum of 120 mg, Sensitivity 6mg or less - Torsion balance - Pan balances such as the class A balance are standard in pharmacies. - Weights are placed on right side using tweezers/forceps **Class II** -- Analytical or digital -- 100 g - The digital balances are common and can weigh heavier amounts. **[Weighing Techniques ]** - Pharmacy balances are sensitive - **Airflow:** Keep to minimum - Glass lid cuts air currents - **Spatula:** Used to pick up small amounts; lightly tapping to flick few granules at a time - **Compounding:** Time-consuming, accuracy important **[Additional Supplies ]** - **Mold forms:** Metal and rubber - Excipients =? - Emollients =? - **Flavorings:** Added to mask bad taste of ingredients **[Completing a Compounding Sheet ]** - Clean countertops and other surfaces - Dispose of all cleaning products as soon as cleaning is complete - Damp mop the floor - Check off each activity as it is completed for each room - Prepare cleaning solutions on the day of use **[Measuring Liquids ]** **Liquids:** There are simple steps to ensure proper volume - Water molecules will cling to sides of container - Have liquid at eye level - Read at bottom of liquid line (meniscus) - Liquids can have a concave (U-shaped) meniscus, no meniscus, or a convex (domed) meniscus. The meniscus shape depends on the liquid and the container material. - Read the bottom of a convex meniscus and the top of a convex meniscus. - The liquids used in the pharmacy will almost always have a concave meniscus. For maximum accuracy in measuring liquids, use the 20% rule - 50mL graduated cylinder x 20%= 10mL - 10mL is the smallest accurate amount a 50mL graduated cylinder can measure **[Preparing Solutions ]** - Solutions comprise: - Solvent (larger part) - Solute (ingredient used in solvent) - Measure carefully and mix thoroughly - Solubility will dictate the type of dosage form that needs to be prepared - Reconstitution of premade oral suspensions may be done away from the compounding area **[Solids: Tablets, Capsules, and Lozenges ]** - Molds are used for forming these types of oral dosage forms - Molded tablets disintegrate quickly when they come into contact with moisture - Tablets or lozenges can be made one at a time or in multiple doses - **Lozenges:** Normally made with flavors to enhance their taste and sugar - Hard - Soft - Chewable **[Semisolids: Ointments, Sticks and Suppositories ]** 1. **Medication sticks:** - Applied directly to a site on the body that needs treatment 2. **Ointment: Hydrophobic base** - Petroleum jelly mixed with drug - Jars or tubes 3. Hard sticks and soft sticks 4. **Suppositories:** Oleaginous bases, water-soluble bases, glycerinated gelatins **[Terms ]** **Hydrophobic** compounds do not dissolve in water. Can you break the word hydrophobic down into its two root words? - Examples-ointments, oleagnious bases How about **hydrophilic**, which means "water soluble"? Suspensions have both hydrophilic and hydrophobic ingredients, so they must be shaken before use. **[Packaging ]** Containers must: - Be appropriate size - Protect contents - Have childproof caps (not for jars and syringes) - Have appropriate labels - Common auxiliary labels placed on medication containers: - **Suspensions:** Shake well - **Ophthalmic:** For the eye **[Storage and Stability of Compounded Drugs ]** - Consider stability of any additives - Factors affecting stability: - Amount of light and air - Temperature - pH alters longevity - Solid forms have longer shelf life than liquid forms - It is easier for a liquid product to degrade or for its components to separate **[Documentation]** - Documentation of records under quality assurance of FDA guidelines - Compounding record (CR): Log - Formulation record (FR): Recipe - Date prepared; name of ingredients; manufacturer of each ingredient; lot number and expiration date of each ingredient \[including sterile water\]; amount or weight of each ingredient; dosage form of each ingredient; pharmacy lot number assigned; pharmacy expiration date assigned; date dispensed; patient's name and medical record number - In addition, a step-by-step recipe is required, and both the pharmacist and the technician must initial the records. **[Documentation: Safety Data Sheets (SDSs) ]** - All chemicals should be stored inside cabinets or behind shelf brackets to avoid spillage - Method of cleaning and disposing of agents or any equipment used depends on the type of agents used - SDSs contain emergency contact information in case of spillage or contact. **[Professionalism and Quality Control ]** **Appearance is important** - Great care must be taken when topping off jars of creams and ointments. **Packaging affects medication inside and compliance** - Many medications can degrade with ultraviolet (UV) light exposure; therefore, they must be placed in amber-colored containers to protect the medication. - Follow all storage and labeling guidelines **[Veterinary Medications ]** - Dosage in a form that avoids stress on the animal - Medication may be mixed into a treat - Sticks to administer antibiotics to the inside of the ear - Liquids poured onto pet food - Flavorings - Bacon - Tuna **[Compounding Calculations ]** ❖ The final product may need to be prepared in a different strength or volume than what the recipe lists - Standard formulas are provided by agencies such as Professional Compounding Centers of America (PCCA). ❖ Pharmacist or technician will need to perform calculations to attain the correct weights and/or volumes for the final product