1. © Paradigm Publishing, Inc. 1 Chapter 9 Hospital Pharmacy Practice

2. © Paradigm Publishing, Inc. 2 Hospital Organization Hospitals vary by type, size, and function. Nearly all have a hospital pharmacy. Pharmacy technicians have been employed in hospitals since the 1960s.

3. © Paradigm Publishing, Inc. 3 The Director of Pharmacy The director of pharmacy has overall responsibility for the hospital’s pharmacy services: –Managing the budget –Hiring and firing personnel –Developing a strategic vision –Ensuring compliance with state and federal laws and regulations –Developing policies and procedures

4. © Paradigm Publishing, Inc. 4 The Director of Pharmacy The director of pharmacy determines the level and scope of services offered: –Type of medication distribution systems –Hours of operation –Provision of specialty services, such as outpatient services

5. © Paradigm Publishing, Inc. 5 Hospital Pharmacy vs. Community Pharmacy The hospital pharmacy carries out many of the same services as the community pharmacy. Unlike most community pharmacies, hospital pharmacies also dispense –Parenteral drugs –Biological agents –Potentially hazardous chemotherapy medications

6. © Paradigm Publishing, Inc. 6 Inpatient Drug Distribution Systems In many hospital pharmacies, this system consists of –Unit dose –Floor stock –IV admixture –TPN service System is often highly automated, thereby –Improving quality and efficiency of services –Minimizing medication errors

7. © Paradigm Publishing, Inc. 7 Inpatient Drug Distribution Systems Medication orders Unit dose Floor stock Narcotics in a hospital pharmacy Intravenous admixture service Medication administration record

8. © Paradigm Publishing, Inc. 8 Medication Orders Prescriptions in the hospital pharmacy take the form of a medication order. There are several types: –Admitting order – written by physician when the patient is admitted –New medication order – like a new prescription in the community pharmacy –Stat order – emergency medication, receives priority attention –Continuation order – like a refill in the community pharmacy

9. © Paradigm Publishing, Inc. 9 Terms to Remember medication order a prescription written in the hospital setting admitting order a medication order written by a physician on admission of a patient to the hospital; may or may not include a medication order

10. © Paradigm Publishing, Inc. 10 Terms to Remember stat order a medication order that is to be filled and sent to the patient care unit immediately continuation order a medication order written by a physician to continue treatment; like a refill of medication

11. © Paradigm Publishing, Inc. 11 Unit Dose An amount of medication prepackaged for a single administration Systems in use since the early 1960s Increases efficiency by making the drug formulation as ready to administer as possible

12. © Paradigm Publishing, Inc. 12 Terms to Remember unit dose an amount of a drug that has been prepackaged or repackaged for a single administration to a particular patient at a particular time

13. © Paradigm Publishing, Inc. 13 Terms to Remember inpatient drug distribution system a pharmacy system to deliver all types of drugs to a patient in the hospital setting; commonly includes unit dose, repackaged medication, floor stock, and IV admixture and TPN services

14. © Paradigm Publishing, Inc. 14 Unit Dose Technician uses a fill list to add unit doses for each patient. Each patient on each care unit has a designated removable medication drawer. Drawers are delivered to each patient care unit in a unit dose cart.

15. © Paradigm Publishing, Inc. 15 Terms to Remember unit dose cart a movable storage unit that contains individual patient drawers of medication for all patients on a given nursing unit

16. Safety Note © Paradigm Publishing, Inc. 16 Unit Dose Only unopened unit doses can be returned to stock.

17. © Paradigm Publishing, Inc. 17 Unit Dose Although packaging costs are higher, unit dose system saves time and money: –Provides increased security for medications –Reduces medication errors –Reduces nursing staff time –Makes administration, charging, and crediting easier

18. © Paradigm Publishing, Inc. 18 Unit Dose Larger hospitals use automated robotic systems to fill unit dose orders. A robotic arm pulls medication and transfers it to a collection area. Pharmacy technician’s primary role is stocking the robotic system.

19. © Paradigm Publishing, Inc. 19 Unit Dose Pharmacy staff sometimes must repackage medications to achieve a unit dose: –Manufacturers do not prepare all drugs in unit dose form. –Sometimes a nonstandard dose is ordered for a patient. Single dose prepared for a specific patient is called a medication special: –Single doses are labor intensive to prepare. –They are usually the responsibility of the pharmacy technician.

20. © Paradigm Publishing, Inc. 20 Terms to Remember medication special a single dose preparation not commercially available that is repackaged and made for a particular patient

21. Safety Note © Paradigm Publishing, Inc. 21 Unit Dose Expiration dates and lot numbers must be included on all repackaged medications.

22. © Paradigm Publishing, Inc. 22 Unit Dose Repackaged medications must be carefully labeled. Pharmacy is legally required to record and document information about repackaged medications in a repackaging control log.

23. © Paradigm Publishing, Inc. 23 Terms to Remember repackaging control log a form used in the pharmacy when drugs are repackaged from manufacturer stock bottles to unit doses; the log contains the name of the drug, dose, quantity, manufacturer lot number, expiration date, and the initials of the pharmacy technician and pharmacist

24. © Paradigm Publishing, Inc. 24 Unit Dose Medication orders are filled on a regular basis (every 24 hours or less). Orders are entered into a database. Patient-specific unit dose profile is created. Printout of all unit dose profiles serves as a cart fill list.

25. © Paradigm Publishing, Inc. 25 Terms to Remember unit dose profile the documentation that provides the information necessary to prepare the unit doses, including patient name and location, medication and strength, frequency or schedule of administration, and quantity for each order

26. © Paradigm Publishing, Inc. 26 Terms to Remember cart fill list a printout of all unit dose profiles for all patients

27. © Paradigm Publishing, Inc. 27 Terms to Remember floor stock medications stocked in a secured area on each patient care unit

28. © Paradigm Publishing, Inc. 28 Floor Stock Floor stock is an inventory of frequently prescribed drugs stored on the patient care unit. Automated delivery systems can be used for floor stock: –Allow secure, locked storage –Free up nursing staff time –Capture charges for dispensed medications –Track medications by type of drug, patient, and caregiver

29. © Paradigm Publishing, Inc. 29 Floor Stock Pharmacy maintains floor stock inventory. Patient care units send reports requesting replacement inventory. Pharmacy technician inspects floor stock for –Expired drugs –Excess inventory –Proper storage

30. Safety Note © Paradigm Publishing, Inc. 30 Floor Stock No food items can be placed in a refrigerator that is dedicated to storing medications.

31. © Paradigm Publishing, Inc. 31 Narcotics in a Hospital Pharmacy Schedule II controlled substances must be secured in a locked cabinet. A careful audit trail must be kept for each medication. Complete information is kept in the Schedule II drug administration record.

32. © Paradigm Publishing, Inc. 32 Terms to Remember Schedule II drug administration record a manual or electronic form on the patient care unit to account for each dose of each narcotic administered to a patient

33. © Paradigm Publishing, Inc. 33 Intravenous Admixture Service Most hospitals provide an IV admixture service, including injectable –Antibiotics –Thrombolytics –Nutrition –Cancer chemotherapy Staffed by specially trained pharmacists and technicians

34. © Paradigm Publishing, Inc. 34 Terms to Remember IV admixture service a centralized pharmacy service that prepares IV and TPN solutions in a sterile, germ-free work environment

35. © Paradigm Publishing, Inc. 35 Intravenous Admixture Service Many hospitals also have a total parenteral nutrition (TPN) service. TPN service often consists of a specially trained or certified –Physician –Nurse –Nutritionist –Pharmacist Service provides all nutritional needs for the patient who cannot or will not eat.

36. © Paradigm Publishing, Inc. 36 Terms to Remember total parenteral nutrition (TPN) a specially formulated parenteral solution that provides nutritional needs intravenously (IV) to a patient who cannot or will not eat

37. © Paradigm Publishing, Inc. 37 Intravenous Admixture Service Larger hospital pharmacies use automation in their IV admixture and TPN services: –Allows pharmacy to operate more efficiently –Minimizes medication errors –Significantly reduces inventory

38. Safety Note © Paradigm Publishing, Inc. 38 Intravenous Admixture Service Although automation reduces errors, technical errors must still be monitored.

39. © Paradigm Publishing, Inc. 39 Medication Administration Record When any type of medication is administered, it is recorded on the medication administration record (MAR). MAR is patient specific and includes –Medication orders –Names of all drugs –Doses –Routes and times of administration –Start and stop dates –Any special instructions

40. © Paradigm Publishing, Inc. 40 Terms to Remember medication administration record (MAR) a form in the patient medical chart used by nurses to document the administration time of all drugs

41. © Paradigm Publishing, Inc. 41 Medication Administration Record Record can also be electronic (eMAR). eMAR documents the administration time of each drug to each patient. Medication orders are input into handheld computers and sent directly to pharmacy. Patient information is scanned from a barcode on the patient’s wristband. Pharmacy checks, fills, and sends medication to unit.

42. © Paradigm Publishing, Inc. 42 Terms to Remember electronic medication administration record (eMAR) documents the administration time of each drug to each patient often using bar-code technology

43. © Paradigm Publishing, Inc. 43 Hospital Committee Structure Many committees support the functions of a hospital. Those relating to pharmacy include –Pharmacy and therapeutics (P&T) –Infection control –Institutional review board (IRB) A pharmacy technician often represents the department on these committees.

44. © Paradigm Publishing, Inc. 44 Pharmacy and Therapeutics Committee Reviews, approves, and revises the hospital’s formulary Maintains hospital’s drug use policies Consists of –Medical staff –Hospital and nursing administrators –Director of pharmacy –Drug information pharmacist

45. © Paradigm Publishing, Inc. 45 Pharmacy and Therapeutics Committee Medical staff can apply to P&T committee to have a new drug added to the formulary. Cost, advantages, and disadvantages of the new drug are compared with the existing formulary drug. Full committee then considers the application.

46. © Paradigm Publishing, Inc. 46 Terms to Remember institutional review board (IRB) a committee of the hospital that ensures that appropriate protection is provided to patients using investigational drugs; sometimes referred to as the human use committee

47. © Paradigm Publishing, Inc. 47 Institutional Review Board Charged with ensuring the safety of patients in terms of investigational drugs or procedures or other clinical research studies Committee consists of a consumer representative as well as members from –Medicine –Pharmacy –Nursing –Hospital administration

48. © Paradigm Publishing, Inc. 48 Terms to Remember investigational drugs drugs used in clinical trials that have not yet been approved by the FDA for use in the general population or drugs used for nonapproved indications

49. © Paradigm Publishing, Inc. 49 Institutional Review Board Investigator or researcher submits an application to the IRB outlining the study: –Number, age, and type of subjects –Informed consent forms to be used The job of the IRB is to protect the patient by assuring adequate knowledge of risks and confidentiality of the medical information collected.

50. © Paradigm Publishing, Inc. 50 Terms to Remember informed consent written permission by the patient to participate in an IRB-approved research study in terms understandable to the lay public

51. © Paradigm Publishing, Inc. 51 Terms to Remember Joint Commission an independent, not-for-profit group that sets the standards by which safety and quality of health care are measured and accredits hospitals according to those standards; previously called the Joint Commission on Accreditation of Healthcare Organizations (JCAHO)

52. © Paradigm Publishing, Inc. 52 The Joint Commission An independent, non-profit group Sets and measures standards for quality and safety of health care Evaluates hospitals’ performance and accredits those that meet standards

53. © Paradigm Publishing, Inc. 53 The Joint Commission Requires all hospital departments to have an up-to-date policies and procedures manual Performs random and unannounced inspections Provides education and guidance to improve hospitals’ performance

54. © Paradigm Publishing, Inc. 54 Quality of Care Standards Joint Commission has National Quality Improvement Goals for select patient populations, such as those suffering from –Heart attack –Heart failure –Pneumonia –Surgical infections A hospital’s performance with these populations is compared with already accredited hospitals of similar size.

55. © Paradigm Publishing, Inc. 55 Safety-Related Standards Almost half of the Joint Commission’s standards are directly related to patient safety. For the pharmacy, these standards include –Reconciling a patient’s medical profile with subsequent medical orders –Improving the safety of medication use and drug infusion pumps

56. © Paradigm Publishing, Inc. 56 Inventory Management As much as 70% of a hospital pharmacy’s budget is spent on pharmaceuticals. Budgetary planning and accurate inventory management are crucial.

57. © Paradigm Publishing, Inc. 57 Inventory Management Purchasing Ordering Receiving and storage

58. © Paradigm Publishing, Inc. 58 Purchasing Most hospitals purchase their pharmaceuticals from a wholesaler and their IV materials directly from the manufacturer.

59. © Paradigm Publishing, Inc. 59 Purchasing In a larger hospital, an inventory control pharmacist or technician may develop specific purchasing criteria based on budget planning. Suppliers and manufacturers then compete for the hospital’s business through a confidential, sealed bid process.

60. © Paradigm Publishing, Inc. 60 Ordering An important part of the pharmacy technician’s job is the receipt, storage, and ordering of pharmaceuticals. Automation on the wholesaler’s side is making inventory management less costly and more accurate.

61. © Paradigm Publishing, Inc. 61 Receiving and Storage Once drugs are received from the wholesaler, the technician should –Verify the invoice –Inspect the shipment –Properly store the drugs –Rotate the stock on the shelves

62. © Paradigm Publishing, Inc. 62 Receiving and Storage Two types of pharmaceuticals require special procedures: –Controlled substances CSA defines inventory, filing, and recordkeeping requirements. DEA form 222 must be used. –Investigational drugs These must be maintained in a secure area. Special ordering, handling, and recordkeeping procedures are necessary.

63. © Paradigm Publishing, Inc. 63 Receiving and Storage Pharmacy technician must identify and deal with expired drugs: –Remove from storage –Return to wholesaler for credit Pharmacy technician must also properly handle manufacturer or FDA recalls: –Identify the affected lot number –Remove recalled drugs from storage –Fill out necessary paperwork –Return recalled drugs to wholesaler for credit