Chapter 9

Hospital Pharmacy Practice

Learning Objectives
Describe the various inpatient drug distribution systems. Explain the proper procedure for repackaging of medications. Identify the process of medication dispensing. Describe specialty services such as intravenous admixtures and total parenteral nutrition.

Learning Objectives
Identify the various roles of clinically trained pharmacists in the hospital. Describe the functions of a drug information center. Discuss the origins and purpose of the hospital formulary. Discuss the role of automation and inventory control in the hospital.

Learning Objectives
Describe the classifications and functions of a hospital. Identify the roles of major hospital committees. List common universal precautions to protect hospital employees.

HOSPITAL PHARMACY SERVICES

Inpatient Drug Distribution Systems:
Hospital pharmacies carry out a number of unique activities such as unit dose drug distribution system, repackaging, floor stock, and an IV admixture/TPN service. Also, a unit dose drug distribution system saves money and reduces the chance of medication errors.

Functions of a Hospital
1. Diagnosis and testing

Table 9.1

Functions of a Hospital
2. Treatment and therapy

Table 9.1

Functions of a Hospital
3. Public processing (including admissions, record keeping, billing, and planning for post-release patient care)

Table 9.1

Functions of a Hospital
4. Public health education and promotion, done through a variety of programs, including smoking cessation programs, weight loss programs, support group programs, and screening of community members (including mammographies and testing of blood pressure and cholesterol) Table 9.1

Functions of a Hospital
5. Teaching (i.e., training health professionals)

Table 9.1

Functions of a Hospital
6. Research (i.e., carrying out programs that add to the sum of medical knowledge)

Table 9.1

Hospital Pharmacy Issues

Safety Note!
Only unopened unit doses can be returned to stock.

Hospital Pharmacy Services

Services Similar to Community Pharmacy Services

1. Maintaining drug treatment records

Table 9.2

Hospital Pharmacy Services

Services Similar to Community Pharmacy Services

2. Ordering and stocking medications and medical supplies

Table 9.2

Hospital Pharmacy Services

Services Similar to Community Pharmacy Services

3. Repackaging medications

Table 9.2

Hospital Pharmacy Services

Services Similar to Community Pharmacy Services

4. Dispensing medications

Table 9.2

Hospital Pharmacy Services

Services Similar to Community Pharmacy Services

5. Providing information about the proper use of medications

Table 9.2

Hospital Pharmacy Services

Services Similar to Community Pharmacy Services

6. Collecting and evaluating information about adverse drug reactions and interactions

Table 9.2

Hospital Pharmacy Services

Services Similar to Community Pharmacy Services

7. Preparing medications in various dose forms for dispensing

Table 9.2

Hospital Pharmacy Services

Services Similar to Community Pharmacy Services

8. Educating and counseling patients about their drug therapies

Table 9.2

Hospital Pharmacy Services

Services Similar to Community Pharmacy Services

9. Preventing, identifying, and resolving medication-related problems

Table 9.2

Hospital Pharmacy Services

Services Provided by a Hospital Pharmacy

1. Preparing and maintaining a formulary

Table 9.2

Hospital Pharmacy Services

Services Provided by a Hospital Pharmacy

2. Conducting drug use evaluations

Table 9.2

Hospital Pharmacy Services

Services Provided by a Hospital Pharmacy

3. Following universal precautions

Table 9.2

Hospital Pharmacy Services

Services Provided by a Hospital Pharmacy

4. Preparing products using aseptic techniques

Table 9.2

Hospital Pharmacy Services

Services Provided by a Hospital Pharmacy

5. Ensuring that hazardous agents are handled and disposed of properly

Table 9.2

Hospital Pharmacy Services

Services Provided by a Hospital Pharmacy

6. Filling medication orders (as opposed to prescriptions)

Table 9.2

Hospital Pharmacy Services

Services Provided by a Hospital Pharmacy

7. Routinely preparing 24-hour supplies of patient medications in a form appropriate for a single administration to a patient (as opposed to a 30- or 90-day supply)

Table 9.2

Hospital Pharmacy Services

Services Provided by a Hospital Pharmacy

8. Stocking nursing stations with medications and supplies

Table 9.2

Hospital Pharmacy Services

Services Provided by a Hospital Pharmacy

9. Delivering medications to patients rooms

Table 9.2

Hospital Pharmacy Services

Services Provided by a Hospital Pharmacy

10. Maintaining a drug information service, and providing drug information to the other healthcare professionals in the institution

Table 9.2

Hospital Pharmacy Services

Services Provided by a Hospital Pharmacy

11. Educating and counseling inpatients and outpatients about their drug therapies

Table 9.2

Hospital Pharmacy Services

Services Provided by a Hospital Pharmacy

12. Monitoring patient outcomes

Table 9.2

Hospital Pharmacy Services

Services Provided by a Hospital Pharmacy

13. Preventing, identifying, and resolving medication-related problems

Table 9.2

Hospital Pharmacy Services

Services Provided by a Hospital Pharmacy

14. Participating in clinical drug investigations and research

Table 9.2

Hospital Pharmacy Services

Services Provided by a Hospital Pharmacy

15. Providing in-service drug-related education

Table 9.2

Hospital Pharmacy Services

Services Provided by a Hospital Pharmacy

16. Reviewing or auditing prescription services for evaluation of service accuracy and quality

Table 9.2

Hospital Pharmacy Services

Services Provided by a Hospital Pharmacy

17. Providing expert consultations in such areas as pediatric pharmacology, nutritional support, and pharmacokinetics

Table 9.2

Hospital Pharmacy Issues

Safety Note!
As in the community pharmacy, in the hospital pharmacy the technician works under the direct supervision of the pharmacist.

Figure 9.1

Figure 9.2

Figure 9.3

HOSPITAL PHARMACY SERVICES

Clinical Services: Many hospitals offer clinical
and consultative services such as nutrition support, pharmacokinetics, critical care, and other specialties.

Drug Information Services: Most hospitals

have a drug information service that is primarily responsible for making recommendations on a drug formulary. A hospital pharmacy may maintain a drug information center, containing reference works, including books, periodicals, microfilm, CDs, DVDs, and access to computerized or Internet databases.

HOSPITAL PHARMACY SERVICES

Outpatient Pharmacy Services: Many large hospitals operate an outpatient pharmacy to serve the medication needs of patients discharged from the hospital, as well as for those patients who are seen in the emergency room or other ambulatory clinics adjoining the hospital.

Terms to Remember
unit dose medication fill list unit dose profile floor stock Total parenteral nutrition (TPN) satellite pharmacy protocol formulary

AUTOMATION IN THE HOSPITAL PHARMACY

Technology is used in the hospital pharmacy to increase accuracy and improve efficiency and quality of pharmacy services. Automated pharmacy services are replacing some of the routine, time-consuming filling procedures. For instance, large automated robots are now being used to perform some of the filling procedures with near 100% accuracy

Hospital Pharmacy Issues

Safety Note!
All computer systems must protect patient privacy.

Hospital Pharmacy Issues

Safety Note!
Although automation reduces errors, technical errors must still be monitored.

Hospital Pharmacy Issues

Safety Note!
Expiration dates must be included on all repackaged medications.

Terms to Remember
stat medications

INVENTORY MANAGEMENT
An important part of the technicians position is the receipt, storage, and ordering of pharmaceuticals; discrepancies in the order from the wholesaler or pharmaceutical manufacturer should be resolved. Automation from the pharmacy wholesalers is making inventory management more accurate and less costly.

Terms to Remember
Investigational drugs

ORGANIZATION OF THE HOSPITAL

Pharmacy Administration: The director of
pharmacy is the pharmacist-in-charge, with overall responsibility for the hospitals pharmacy services. Depending on the hospital size, additional assistant or associate directors may work under the director. In small rural hospitals, only one or two pharmacists may make up the pharmacy staff.

ORGANIZATION OF THE HOSPITAL

Joint Commission on Accreditation of Healthcare Organizations: The JCAHO is
an independent, non-profit group that sets the standards by which quality of healthcare is measured. The primary mission of JCAHO is to ensure quality care and patient safety in the hospitals that are accredited. They evaluate levels of safety and the quality of care in more than 15,000 healthcare organizations.

Hospital Pharmacy Issues

Safety Note!
Almost 50% of JCAHO standards relate directly to safety.

ORGANIZATION OF THE HOSPITAL

Pharmacy and Therapeutics Committee:
The P&T committee is primarily responsible for making the final decision on drug formulary decisions.

Infection Control Committee: The major

role of the infection control committee (ICC) is the prevention of nosocomial infections in the hospital. Universal precautions are used to prevent infection when a hospital worker comes into contact with blood or other bodily fluids.

ORGANIZATION OF THE HOSPITAL

Institutional Review Board: The IRB is responsible for protecting the patient in investigational studies undertaken in the hospital.

Universal Precaution Guidelines

1. Universal precautions apply to all persons within the hospital.

Table 9.3

Universal Precaution Guidelines

2. Universal precautions apply to all contact or potential contact with blood, other bodily fluids, or body substances.

Table 9.3

Universal Precaution Guidelines

3. Disposable latex gloves must be worn when contact with blood or other bodily fluids is anticipated or possible.

Table 9.3

Universal Precaution Guidelines

4. Hands must be washed thoroughly after removing the latex gloves.

Table 9.3

Universal Precaution Guidelines

5. Blood-soaked or contaminated materials, such as gloves, towels, or bandages, must be disposed of in a wastebasket lined with a plastic bag.

Table 9.3

Universal Precaution Guidelines

6. Properly trained custodial personnel must be called if cleanup or removal of contaminated waste is necessary.

Table 9.3

Universal Precaution Guidelines

7. Contaminated materials such as needles, syringes, swabs, and catheters must be placed into red plastic containers labeled for disposal of biohazardous materials. Proper institutional procedures generally involve incineration.
Table 9.3

Universal Precaution Guidelines

8. A first-aid kit must be kept on hand in any area in which contact with blood or other bodily fluids is possible. The kit should contain, at minimum, the following items: adhesive bandages for covering small
wounds
Table 9.3

Universal Precaution Guidelines

alcohol
antiseptic/disinfectant bottle of bleach, which will be diluted at time of use to create a solution containing 1 part bleach to 10 parts water, for use in cleaning up blood spills box of disposable latex gloves disposable towels
Table 9.3

Universal Precaution Guidelines

medical tape
plastic bag or container for contaminated waste disposal sterile gauze for covering large wounds

Table 9.3

Terms to Remember
Joint Commission on Accreditation of Healthcare Organizations (JCAHO) accreditation pharmacy and therapeutics (P&T) committee infection control committee (ICC) nosocomial infection

Terms to Remember
sharps universal precautions institutional review board (IRB) informed consent

Discussion
Communicating in the hospital setting often means working with a wide variety of other healthcare providers. Understanding what role they play in the patients healthcare is essential to effective communication. What duties do each of the following have? g. social services aide or
primary care physician
anesthesiologist registered nurse practical nurse nurses aide housekeeping aide worker h. i. j. k. l. respiratory therapist phlebotomist medical lab technician pharmacist pharmacy technician

a.
b. c. d. e. f.

Discussion
Write out a complete description, not using abbreviations, of the medication orders given in Figure 9.2 and Figure 9.3.