1. Hospital Pharmacy © Paradigm Publishing, Inc.

2. Chapter Topics Hospital functions and organization Hospital pharmacy department Hospital pharmacy personnel Inventory management Hospital medication orders and order entry Hospital pharmacy inpatient drug distribution systems Nursing unit drug administration and documentation Hospital accreditation © Paradigm Publishing, Inc.

3. Learning Objectives Describe the classifications and functions of a hospital and its organizational framework. Identify the roles of major hospital committees that impact pharmacy. Describe the role of the Institutional Review Board. Explain the functions of the hospital pharmacy department. Describe the roles and responsibilities of the director of pharmacy, pharmacist, and pharmacy technician. Describe the types of medication orders and order entry system. Understand the unit dose system and unit dose cart. Identify the advantages and disadvantages of a unit dose vs. a robotic drug distribution system. © Paradigm Publishing, Inc.

4. Learning Objectives (continued) Explain the proper procedure for preparing, labeling, and repackaging of medications. Identify the process of medication filling and dispensing in a hospital pharmacy. Describe specialty services, such as intravenous admixtures and parenteral nutrition. Discuss the advantages of an automated floor stock system for medication, including narcotics. Describe the purpose and advantages of an electronic medication administration record. Discuss the role of automation and inventory control in the hospital. Understand inventory management of pharmaceuticals, including drug-bidding, ordering, receiving, and storage processes. Explain the major role of the Joint Commission in establishing accreditation standards for hospitals. © Paradigm Publishing, Inc.

5. Hospital Functions and Organization Hospitals classified according to certain characteristics: – Bed capacity – Patient population – Type of service – Affiliation – Ownership – Length of stay – Financial status © Paradigm Publishing, Inc.

6. Hospital Functions and Organization (continued) Functions of a hospital: – Diagnosis and testing – Treatment and therapy – Patient processing – Public health and wellness – Preventive health initiatives – Training healthcare professionals – Conducting research © Paradigm Publishing, Inc.

7. Hospital Functions and Organization (continued) Board of Directors CEO (Chief Executive Officer) CEO (Chief Executive Officer) Vice present of patient care Pharmacy Rehabilitation Vice president of nursing Nursing Sample Organization Chart © Paradigm Publishing, Inc.

8. Hospital Functions and Organization (continued) Hospital committee structure – Pharmacy and Therapeutics (P&T) Committee Reviews, approves, and revises the hospital’s drug formulary Maintains the drug use policies of the hospital Reviews studies on appropriate use of drugs within the hospital Studies investigational drugs for hospital use Monitors medication error reports © Paradigm Publishing, Inc.

9. Hospital Functions and Organization (continued) Hospital committee structure – Pharmacy and Therapeutics (P & T) Committee Representatives from medical staff, hospital and nursing administration Director of pharmacy – Acts as secretary – Records and disseminates meeting minutes Drug information pharmacist – Researches and makes unbiased drug formulary recommendations Pharmacy technician – Collects data and performs audits for the drug information pharmacist © Paradigm Publishing, Inc.

10. Hospital Functions and Organization (continued) Hospital committee structure – Pharmacy and Therapeutics (P&T) Committee Drug formulary – List of drugs approved for use in the hospital – Provides the most effective medications while limiting costs – If a physician wants to add a medication to formulary, needs to submit a medication application form – Drug information pharmacist reviews the literature and compares costs, advantages, and disadvantages to existing formulary drug. – Formulary approval sometimes restricted to a specific medical service. – If physician writes for nonformulary drug, may need to justify its use to the P&T committee or to an attending physician. © Paradigm Publishing, Inc.

11. Hospital Functions and Organization (continued) Hospital committee structure – Pharmacy and Therapeutics (P&T) Committee Medication error reports – Drug information pharmacist collects and analyses reports from pharmacy, nursing, and medicine. – Adverse drug events tabulated – Focus is to identify and correct the system’s problem so error does not recur. © Paradigm Publishing, Inc.

12. Hospital Functions and Organization (continued) Hospital committee structure – Institutional Review Board (IRB) Reviews the use of investigational drugs or procedures in the hospital Investigational drug–drug being used in clinical trials that hasn’t been approved by the FDA Committee consists of representatives from medicine, pharmacy, nursing, and hospital administration as well as a member of the public. © Paradigm Publishing, Inc.

13. Hospital Functions and Organization (continued) Hospital committee structure – Institutional Review Board (IRB) Clinical research investigational study – Requires IRB approval before it can begin – Investigator submits application and informed consent – Informed consent–a document written in understandable language about the study IRB protects the patient by ensuring adequate knowledge of study risks and confidentiality of medical information. © Paradigm Publishing, Inc.

14. Hospital Pharmacy Department Physical layout and hours – Designated areas such as unit dose cart fill, repackaging, narcotic and investigational drug storage, preparation of sterile products – Typically staffed 24 hours a day, 7 days a week Services – Medication preparation and delivery – IV additive program – Investigational drug storage and control – Drug information center © Paradigm Publishing, Inc.

15. Hospital Pharmacy Personnel Director of Pharmacy responsibilities – The pharmacist-in-charge who oversees the day- to-day operations – Determines the level and scope of pharmacy services – Plans and monitors the budget – Develops the Policy & Procedure Manual © Paradigm Publishing, Inc.

16. Hospital Pharmacy Personnel (continued) Responsibilities of a Hospital Pharmacist Entering medication orders into the computer Assisting in medication cart fills and the preparation of sterile products Monitoring narcotic usage Ordering pharmaceuticals, products, and supplies Checking all pharmacy technician work Providing drug information to physicians and nurses Monitoring and maintaining automated systems Assisting in cardiopulmonary resuscitation (CPR) codes Dispensing investigational drugs Completing medication histories Providing medication counseling for patients to be discharged from the hospital Investigating medication error reports Representing pharmacy department on committees © Paradigm Publishing, Inc.

17. Hospital Pharmacy Personnel (continued) Hospital pharmacy technician responsibilities – Filling the unit dose cart A cart that supplies medications to nursing units Medications dispensed as unit doses in a patient-specific drawer of a cart Supply of medication dispensed for a 12- to 72-hour window – Stocking the medication dispensing units Located on each nursing unit Checking for expired drugs, adjusting inventory levels, transporting necessary medications to the nursing unit © Paradigm Publishing, Inc.

18. Hospital Pharmacy Personnel (continued) Hospital pharmacy technician responsibilities – Preparing IV admixtures Includes TPN and hazardous drugs Must comply with USP Chapter standards – Monitoring inventory and narcotic control Ordering, receiving, storing medications – Filling the crash cart A mobile cart that holds necessary drugs for an emergency code © Paradigm Publishing, Inc.

19. In the Know: True or False The P&T Committee is the Pharmacist and Technician Committee. false The formulary is the recipe for making a sterile product. false One responsibility of a pharmacy technician is to stock the medication dispensing units. true © Paradigm Publishing, Inc.

20. Inventory Management Inventory – Up to 70% of a hospital pharmacy budget is spent on pharmaceuticals. – The inventory budget includes IV solutions, sets, pumps, and other medical supplies. – The buyer in a hospital pharmacy manages inventory. – The buyer is often a senior pharmacy technician. – Works under the direct supervision of the director of pharmacy. © Paradigm Publishing, Inc.

21. Inventory Management (continued) Bidding and purchasing – Confidential process by which the pharmacy “locks in” medication costs from a prime wholesale vendor for one year – Pharmacy also bids with manufacturers of drugs and IV solutions, with longer contracts (about 5 years) – Need an accurate estimation of formulary medication use for the next calendar year © Paradigm Publishing, Inc.

22. Inventory Management (continued) Ordering – Pharmaceuticals are ordered from wholesalers such as McKesson Provider Technologies or Cardinal Health. – IV solutions are ordered from a medical device company such as Baxter or Hospira. – Procedures for ordering nonformulary drugs and borrowing from other facilities vary from hospital to hospital. © Paradigm Publishing, Inc.

23. Inventory Management (continued) Receiving and storage – An order must be checked against the invoice when received. – Discrepancies must be resolved. – An order should be checked for damaged goods. – Pharmaceuticals should be placed on inventory shelves or in the refrigerator. – Storage guidelines for products are available in package inserts or some reference texts. © Paradigm Publishing, Inc. Pharmacy refrigerators are designated for medication storage. No food items are allowed to be stored alongside these medications.

24. Inventory Management (continued) Special handling of certain pharmaceuticals – Controlled substances Schedule II drugs must be ordered on a DEA 222 form. Physical inventory of Schedule II drugs is required every two years. Destruction of Schedule II drugs must be witnessed and documented. – Investigational drugs A separate, secure area of the pharmacy is used to store investigational drugs. Investigational drugs are not usually labeled with name and strength. The package is labeled with the lot number and expiration date. © Paradigm Publishing, Inc.

25. Inventory Management (continued) Performing daily inventory duties – Rotating inventory Place drugs on shelves so that products expiring first will be used first. Document the inspection of expired drugs. – Processing returned unit dose cart Check and empty all patient cassette drawers. Credit returned medications back to patient. Investigate any medications remaining in drawer to find out why they were not given. © Paradigm Publishing, Inc.

26. Inventory Management (continued) Performing daily inventory duties – Restocking automated equipment Pharmacy technicians restock robots or automated medication dispensing systems (AMDS). Joint Commission holds pharmacy responsible for safety, security, and inventory of the AMDS. – Checking for drug recalls Recall notices may come from wholesalers. Compare the lot number of the drug in the recall notice with the inventory in pharmacy storage. Complete form indicating drug, strength, amount, and lot number. Sign and return form to the wholesaler. © Paradigm Publishing, Inc.

27. Inventory Management (continued) Performing daily inventory duties – Transporting and tracking of narcotics Technicians are often responsible for transporting narcotics to the nursing unit. Narcotics exchanged from pharmacy technicians to nursing units require the documentation of names and narcotics being delivered. Pharmacy technicians are responsible for reporting unusual increases in the use of controlled substances on any nursing unit. Pharmacists are responsible for checking and reconciling narcotic inventory records. Discrepancies should be resolved by the end of the shift. © Paradigm Publishing, Inc.

28. Inventory Management (continued) Role of automation in inventory management: – Helps the pharmacy department in meeting and adjusting budgetary goals – Simplifies ordering and receiving with bar-code scanners – Provides alerts regarding lot numbers of medications soon to be out-of-date – Sends out-of-stock reports to the pharmacy from the patient care units – Simplifies narcotic inventory and tracking © Paradigm Publishing, Inc.

29. In the Know: True or False Hospital pharmacies lock in medication cost from a wholesaler for one year. true Investigational drugs may be stored together with the other medications. false When narcotics are delivered to the nursing units, the signatures of the pharmacy technicians and nurses are required. true © Paradigm Publishing, Inc.

30. Hospital Medication Orders and Order Entry Medication order – Ordered by the prescriber for a patient – Received electronically, by fax, pneumatic tube, phone, or hand delivery – Written in the medical chart – Entered (most often) by the hospital pharmacist © Paradigm Publishing, Inc.

31. Hospital Medication Orders and Order Entry (continued) Types of Medication Orders Admitting orderOrders written upon admission. Includes suspected diagnoses, orders for lab tests, diet, nursing, medications (includes those taken at home and those started upon admission), and notation of drug allergies. Stat orderAn emergency order that is typically called in or sent electronically. It must receive priority attention. Daily orderA new medication order written daily by a physician after every patient examination. Continuation order Continuation orders are written when patients transfer from one unit to another or when a physician reviews and rewrites all orders periodically. Standing orderIn certain cases, the same set of medications and treatments applies for each patient receiving the same surgery or procedure. Discharge orderAn order that provides take-home instructions for a patient who is being discharged from the hospital. © Paradigm Publishing, Inc.

32. Hospital Medication Orders and Order Entry (continued) Inputting of hospital medication orders – Handwritten orders Reviewed by a pharmacist or experienced pharmacy technician reviews Input by pharmacist or technician into the pharmacy computer database Verified for accuracy by the pharmacist if the pharmacy technician has entered the order – Computerized prescriber order entry (CPOE) Prescriber directly enters order into the electronic health record (EHR) Pharmacist checks and verifies the order © Paradigm Publishing, Inc.

33. Hospital Medication Orders and Order Entry (continued) Inputting of hospital medication orders – Advantages of CPOE Provides efficient medication order completion Allows for prescriber entry off-site Simplifies inventory ordering and posting of patient hospital charges Improves medication safety – Reduces transcription errors – Includes safeguards that identify duplicate drugs, incorrect doses, and laboratory test results that may affect drug or dose © Paradigm Publishing, Inc. All computerized software, including CPOE, EHRs, and eMARs, must protect patient privacy.

34. Hospital Pharmacy Inpatient Drug Distribution Systems Definitions Inpatient drug distribution system A pharmacy system to deliver all types of drugs to patients in a hospital setting, including unit dose, IV admixture, and TPN services Unit doseA dose of a drug repackaged for a single administration to a particular patient at a particular time Unit dose cart A movable cart that contains removable cassette drawers that house the medications for all patients on a nursing unit © Paradigm Publishing, Inc.

35. Hospital Pharmacy Inpatient Drug Distribution Systems (continued) Order entered into the computer Patient-specific unit dose label created Medication filled at a pick station Sufficient supply of medication provided until next cart exchange © Paradigm Publishing, Inc. Procedure for Filling Medication Order Procedure for Filling Medication Order

36. Hospital Pharmacy Inpatient Drug Distribution Systems (continued) Each drawer of cart labeled with patient’s name and room number Daily cart fill list is printed (patient profiles) Technician takes cart to pick station for filling Technician determines how many doses of each drug to put in drawer Cart is delivered to nursing unit Nurse verifies the medication before administration © Paradigm Publishing, Inc. Procedure for Filling Unit Dose Cart Procedure for Filling Unit Dose Cart

37. In the Know: True or False A prescription in the hospital setting is referred to as a medication order. true A standing order must be administered when the patient is in the upright position. false A unit dose is an amount of drug repackaged for a single administration to a particular patient at a particular time. true Each drawer of a unit dose cart is assigned to a particular medication. false © Paradigm Publishing, Inc.

38. Hospital Pharmacy Inpatient Drug Distribution Systems (continued) Robotic dispensing system – Picks, counts, packages, labels, stores, and dispenses medication using bar- code technology – Medication dispensing process Selected by robotic arm Transferred to a collection area Put into an envelope Labeled with the patient’s name, drug name, dose, administration time, and bar code Checked (bar code scanned) by technician Added to the unit dose cart by technician Checked (bar code scanned) by nurse prior to administration © Paradigm Publishing, Inc.

39. Hospital Pharmacy Inpatient Drug Distribution Systems (continued) Unit dose systemRobotic dispensing system AdvantagesStreamlined workflow process Further decrease in medication errors Decreased medication errorsReduced pharmacy workload Increased medication security Increased long-term cost savings Reduced medication wastage Increased cost-effectiveness DisadvantagesNot automatedShort-term costs © Paradigm Publishing, Inc.

40. Hospital Pharmacy Inpatient Drug Distribution Systems (continued) Repackaging medications into unit doses – Not all drugs and doses are commercially available in unit dose form. – Repackaged medications must be labeled carefully. – Information about repackaged medication must be documented in a repackaging control log. – Both the technician who repackages and the pharmacist who checks must initial the log. © Paradigm Publishing, Inc. Expiration dates and lot numbers must be included on all repackaged medications.

41. Hospital Pharmacy Inpatient Drug Distribution Systems (continued) © Paradigm Publishing, Inc. As in the community pharmacy, the technician in the hospital pharmacy works under the direct supervision of the pharmacist.

42. Hospital Pharmacy Inpatient Drug Distribution Systems (continued) Intravenous admixture service – The service is responsible for the safe and accurate preparation of parenteral medications. – Admixtures are prepared in a sterile “clean room.” – Sterile garb and aseptic technique is followed as outlined in USP Chapter. – A horizontal laminar airflow hood is used for most products. – A vertical laminar airflow hood is used for chemotherapy. © Paradigm Publishing, Inc.

43. Hospital Pharmacy Inpatient Drug Distribution Systems (continued) Total parenteral nutrition (TPN) service – Provides nutritional needs intravenously for patients who cannot or will not eat – Automated compounding device (ACD) prepares TPN solutions. – ACD reduces medication errors and contamination. – Hospital pharmacy must ensure accuracy and precision of ACDs. – Smaller hospitals may outsource their TPNs. © Paradigm Publishing, Inc. The accuracy of the ACD must be continually monitored by both the technician and the pharmacist.

44. Nursing Unit Drug Administration and Documentation Automated medication dispensing system (AMDS) – Secure, locked cabinet of designated drugs on a nursing unit – Extension of the unit dose delivery system – Touch screen technology – Each dose matched with a patient’s medication order – Interfaces with the pharmacy’s computer information system © Paradigm Publishing, Inc.

45. Nursing Unit Drug Administration and Documentation (continued) Advantages of automated medication dispensing system (AMDS) – Decreased medication errors Each dose accounted for each time by the nurse – Secure medication storage Deterrent to diversion and theft of controlled substances – Streamlined work flow Most frequently used medications available on the unit Medications administered on schedule Fewer phone calls to pharmacy – Improved tracking of medications Captures the distribution and charges of all medications Audit trail deters and detects potential drug diversion © Paradigm Publishing, Inc.

46. Nursing Unit Drug Administration and Documentation (continued) Medication administration record (MAR) – Documents the administration times of all drugs – Used by nurses Electronic medication administration record (eMAR) – A record of the administration time of each drug – Uses bar-code technology – Reduces medication errors – Increases nurse productivity © Paradigm Publishing, Inc.

47. Nursing Unit Drug Administration and Documentation (continued) Benefits of eMAR – Enhances communication among healthcare team members – Reduces medication errors – Provides a way to meet documentation guidelines © Paradigm Publishing, Inc.

48. Hospital Accreditation Joint Commission – Standards for quality and safety of healthcare are enforced through accreditation. – Hospital’s performance is compared with defined standards, and accreditation is awarded if the hospital meets or exceeds these standards. – The survey team performs unannounced, multiday, on-site surveys. – The survey team evaluates the hospital’s performance, reviews the P&P manual, and interviews hospital personnel. – A summary report of the survey is given to hospital administrative staff. – Final report available for the public to review online. © Paradigm Publishing, Inc.

49. In the Know: True or False When repackaging a medication, only the pharmacist must sign the log. false TPN stands for total parenteral nutrition. true The organization which accredits hospitals based on quality and safety standards is the Joint Commission. true © Paradigm Publishing, Inc.

50. Chapter Summary The P&T Committee makes final decisions on medication included in the hospital’s drug formulary. The IRB is responsible for protecting the patient in investigational studies undertaken in the hospital. The director of pharmacy is responsible for safe and efficient pharmacy operation. Automation is widely used in the hospital pharmacy. The pharmacy technician assists in ordering, purchasing, and receiving medications. Hospital pharmacies carry out a number of unique activities. In the hospital, a prescription is called a medication order. Technology has significantly reduced the risk of medication errors. A unit dose drug distribution system saves money and reduces the chance of medication errors. © Paradigm Publishing, Inc.

51. Chapter Summary (continued) A cart fill list is used by the technician to fill medication needs for a hospitalized patient. Repackaged units of medications are prepared if medication is not commercially available in unit dose packaging. Most hospitals today have an automated floor stock dispensing system. An IV admixture service may reduce risks of errors and product contamination. Many hospital pharmacies have a centralized TPN service. An eMAR is used to document the administration time of each medication to each patient. The Joint Commission sets and measures the standards for quality and safety of health care through an accreditation process. © Paradigm Publishing, Inc.