1 Chapter 9 Hospital Pharmacy Practice 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 ID: 779979
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© Paradigm Publishing, Inc.
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Chapter 9
Hospital Pharmacy Practice
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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.
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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
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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
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Hospital Pharmacy
vs. Community PharmacyThe 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
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Inpatient Drug Distribution Systems
In many hospital pharmacies, this system consists ofUnit dose
Floor stock
IV admixture
TPN service
System is often highly automated, thereby
Improving quality and efficiency of services
Minimizing medication errors
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Inpatient Drug Distribution Systems
Medication ordersUnit dose
Floor stock
Narcotics in a hospital pharmacy
Intravenous admixture service
Medication administration record
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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
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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
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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
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Unit Dose
An amount of medication prepackaged for a single administrationSystems in use since the early 1960s
Increases efficiency by making the drug formulation as ready to administer as possible
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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
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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
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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.
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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
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Unit Dose
Only unopened unit doses can be returned to stock.
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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
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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.
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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.
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Terms to Remember
medication special a single dose preparation not commercially available that is repackaged and made for a particular patient
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Unit Dose
Expiration dates and lot numbers must be included on all repackaged medications.
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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.
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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
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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.
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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
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Terms to Remember
cart fill list a printout of all unit dose profiles for all patients
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Terms to Remember
floor stock medications stocked in a secured area on each patient care unit
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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
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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
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Floor Stock
No food items can be placed in a refrigerator that is dedicated to storing medications.
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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.
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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
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Intravenous Admixture Service
Most hospitals provide an IV admixture service, including injectableAntibiotics
Thrombolytics
Nutrition
Cancer chemotherapy
Staffed by specially trained pharmacists and technicians
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Terms to Remember
IV admixture service a centralized pharmacy service that prepares IV and TPN solutions in a sterile, germ-free work environment
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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.
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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
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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
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Intravenous Admixture Service
Although automation reduces errors, technical errors must still be monitored.
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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
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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
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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.
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Terms to Remember
electronic medication administration record (eMAR) documents the administration time of each drug to
each patient
often using
bar-code
technology
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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.
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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
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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.
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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
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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
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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
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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.
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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
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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)
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The Joint Commission
An independent, non-profit groupSets and measures standards for quality and safety of health care
Evaluates hospitals’ performance and accredits those that meet standards
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The Joint Commission
Requires all hospital departments to have an up-to-date policies and procedures manualPerforms random and unannounced inspections
Provides education and guidance to improve hospitals’ performance
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Quality of Care Standards
Joint Commission has National Quality Improvement Goals for select patient populations, such as those suffering fromHeart attack
Heart failure
Pneumonia
Surgical infections
A hospital’s performance with these populations is compared with already accredited hospitals of similar size.
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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
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Inventory Management
As much as 70% of a hospital pharmacy’s budget is spent on pharmaceuticals.
Budgetary
planning and
accurate
inventory
management
are crucial.
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Inventory Management
PurchasingOrderingReceiving and storage
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Purchasing
Most hospitals purchase their pharmaceuticals from a wholesaler and their IV materials directly from the manufacturer.
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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.
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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.
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Receiving and Storage
Once drugs are received from the wholesaler, the technician shouldVerify the invoice
Inspect the shipment
Properly store the drugs
Rotate the stock on the shelves
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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.
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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