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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: 600529

publishing paradigm medication pharmacy paradigm publishing pharmacy medication unit patient dose terms hospital remember drugs drug administration order stock service floor medications

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Slide1

© Paradigm Publishing, Inc.

1

Chapter 9

Hospital Pharmacy PracticeSlide2

© 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.Slide3

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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 proceduresSlide4

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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

servicesSlide5

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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 medicationsSlide6

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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 errorsSlide7

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Inpatient Drug Distribution Systems

Medication ordersUnit dose

Floor stock

Narcotics in a hospital pharmacy

Intravenous admixture service

Medication administration recordSlide8

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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 pharmacySlide9

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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 orderSlide10

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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 medicationSlide11

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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 possibleSlide12

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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 timeSlide13

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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 servicesSlide14

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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.Slide15

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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 unitSlide16

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Unit Dose

Only unopened unit doses can be returned to stock.Slide17

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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 easierSlide18

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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.Slide19

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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.Slide20

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Terms to Remember

medication special a single dose preparation not commercially available that is repackaged and made for a particular patientSlide21

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Unit Dose

Expiration dates and lot numbers must be included on all repackaged medications.Slide22

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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.Slide23

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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 pharmacistSlide24

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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.Slide25

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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 orderSlide26

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Terms to Remember

cart fill list a printout of all unit dose profiles for all patientsSlide27

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Terms to Remember

floor stock medications stocked in a secured area on each patient care unitSlide28

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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 caregiverSlide29

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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 storageSlide30

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Floor Stock

No food items can be placed in a refrigerator that is dedicated to storing medications.Slide31

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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.Slide32

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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 patientSlide33

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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 techniciansSlide34

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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 environmentSlide35

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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.Slide36

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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 eatSlide37

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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 inventorySlide38

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Intravenous Admixture Service

Although automation reduces errors, technical errors must still be monitored.Slide39

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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 instructionsSlide40

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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 drugsSlide41

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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.Slide42

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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

technologySlide43

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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.Slide44

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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

pharmacistSlide45

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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.Slide46

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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 committeeSlide47

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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 administrationSlide48

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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 indicationsSlide49

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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.Slide50

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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 publicSlide51

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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)Slide52

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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 standardsSlide53

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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’ performanceSlide54

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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.Slide55

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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 pumpsSlide56

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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.Slide57

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Inventory Management

PurchasingOrderingReceiving and storageSlide58

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Purchasing

Most hospitals purchase their pharmaceuticals from a wholesaler and their IV materials directly from the manufacturer.Slide59

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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.Slide60

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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.Slide61

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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 shelvesSlide62

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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.Slide63

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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