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The Impact-full Role of Hospital Pharmacists in the Profession Moving Forward Amrahi Buang Deputy Director (Professional) University Malaya Medical Centre MPS Seminar - Amrahi - 23.5.15 1 The Role of the Pharmacist in a Health Care system 4.3 Hospital pharmacy Hospitals and other institutions and facilities, such as outpatient clinics, drug-dependency treatment facilities, poison control centres, drug information centres, and long-term care facilities, may be operated by the government or privately. While many of the pharmacist’s activities in such facilities may be similar to those performed by community pharmacists, they differ in a number of ways. Additionally, the hospital or institutional pharmacist: • has more opportunity to interact closely with the prescriber and, therefore, to promote the rational prescribing and use of drugs; • in larger hospital and institutional pharmacies, is usually one of several pharmacists, and thus has a greater opportunity to interact with others, to specialize and to gain greater expertise; MPS Seminar - Amrahi - 23.5.15 2 The Role of the Pharmacist in a Health Care system • having access to medical records, is in a position to influence the selection of drugs and dosage regimens, to monitor patient compliance and therapeutic response to drugs, and to recognize and report adverse drug reactions; • can more easily than the community pharmacist assess and monitor patterns of drug usage and thus recommend changes where necessary; • serves as a member of policy-making committees, including those concerned with drug selection, the use of antibiotics, and hospital infections (Drug and Therapeutics Committee) and thereby influences the preparation and composition of an essential-drug list or formulary; MPS Seminar - Amrahi - 23.5.15 3 The Role of the Pharmacist in a Health Care system • is in a better position to educate other health professionals about the rational use of drugs; • more easily participates in studies to determine the beneficial or adverse effects of drugs, and is involved in the analysis of drugs in body fluids; • can control hospital manufacture and procurement of drugs to ensure the supply of high-quality products; • takes part in the planning and implementation of clinical trials. MPS Seminar - Amrahi - 23.5.15 4 In 2011, FIP and WHO adopted an updated version of Good Pharmacy Practice entitled "Joint FIP/WHO guidelines on good pharmacy practice: standards for quality of pharmacy services“. GPP are organised around 4 major roles for pharmacists Role 1: Prepare, obtain, store, secure, distribute, administer, dispense and dispose of medical products Role 2: Provide effective medication therapy management Role 3: Maintain and improve professional performance Role 4: Contribute to improve effectiveness of the health-care system and public health MPS Seminar - Amrahi - 23.5.15 5 MPS Seminar - Amrahi - 23.5.15 6 SCOPE OF SERVICES Non-Clinical Clinical Pharmacy logistics Dispensing of drugs Preparation of sterile & non-sterile drugs Drug information service Medication counseling Pharmacy ward rounds Clinical pharmacokinetic service Specialised services CDR PN 80s MPS Seminar - Amrahi - 23.5.15 90s New Millennium 7 2010 2015 Pharmacy Leadership Provide leadership to steer the pharmacy department in line with hospital’s mission and vision Leader in all matters concerning medicines management and use Formulating policies and procedures Sit in powerful decision making committees Provision of excellent facilities Optimising resources Healthcare technology MPS Seminar - Amrahi - 23.5.15 8 COMMITTEES 1. 2. 3. 4. 5. 6. Drug & Therapeutics Medication safety Medical Advisory Medical Ethics Drug Technical Evaluation Infection Control & Antibiotics MPS Seminar - Amrahi - 23.5.15 7. 8. Risk Management Quality Management System & Accreditation 9. Occupational Safety, Health & Environment 10. Credentialing & Privileging 11. PharmUMMC 9 Healthcare Technology Pharmacy Information System Closed Loop system MPS Seminar - Amrahi - 23.5.15 10 Pharmacy Integrated System (PIS) Integrate all activities in pharmacy Patient medical record (PMR) Clinical screening Dispensing label Inventory control References - eBNF MPS Seminar - Amrahi - 23.5.15 11 Farmasi Pesakit Luar (Outpatient Pharmacy) Stor Farmasi (Pharmacy Store) Sistem Bersepadu PIS Integrated System Kedai PharmUMMC (Retail Pharmacy) Pusat Maklumat Ubat-ubaatan (Drug Information Centre) Pengeluaran (Production) MPS Seminar - Amrahi - 23.5.15 Farmasi Pesakit Dalam (Inpatient Pharmacy) 12 Pharmacy Integrated System (PIS) IMPACT Dispensing Reduction of potential medication errors Enhancement of patient safety MPS Seminar - Amrahi - 23.5.15 Quality Assurance 13 The METRO 26 June 2006 MPS Seminar - Amrahi - 23.5.15 14 Closed Loop Medication Management System PCMC Journey & Milestones Closed Loop Medication Administrati on System Advance CPOE Medication Reconciliation Bar Coded Medication Administration (BCMA) Barcoded Unit Dose System Go-Live – Fully Integrated PIS, Unit Dose System, CPOE, eMAR, CDSS 2007 MPS Seminar - Amrahi - 23.5.15 2008 2011 2011 15 2012 2012 Closed Loop Medication Management System in PCMC Closed Loop Medication Management System is a system that is designed to feed data and outcomes from the various medication processes back into the system that will support future improvements and changes providing patient care to eliminate gaps in information to smoothen handovers, reduce handoffs to minimise healthcare professionals interventions to automate the repetitive tasks MPS Seminar - Amrahi - 23.5.15 16 Closed Loop Medication Management System in PCMC PATIENT INFO Name: Mary Jones Age: 67 Problem: Congestive Heart Failure Medications: Digoxin Allergies: No Known Allergies ASSESS Doctor ADMINISTER ORDER THIS Nurse Doctor DISPENSE (Verification) Pharmacist MPS Seminar - Amrahi - 23.5.15 17 Healthcare Technologies in PCMC Computerized physician order entry (CPOE) Clinical Decision Support System (CDSS) Pharmacy Information System (PIS) Pharmacy Unit Dose System (UDDDS) Electronic medication administration record (eMAR) integrated with CPOE and pharmacy system Bedside Bar-Code Medication Administration (BCMA) MPS Seminar - Amrahi - 23.5.15 18 Pharmacy Logistics Quality, safety and efficacy of medicines Availability of medicines at all times Accountability Proper storage – cytotoxic drugs, cold chain items, dangerous drugs, psychotropic Proper transportation of medicines Expired items Proper disposal MPS Seminar - Amrahi - 23.5.15 19 Alarm for power failure Monitoring panel for cold room Electrical trip --> security will call Pharmacist oncall who will check coldchain items Thermoguard for all chillers & freezers MPS Seminar - Amrahi - 23.5.15 20 Cold chain item monitoring Logtag MPS Seminar - Amrahi - 23.5.15 21 Outpatient Dispensing 24 hour service Main and satellite pharmacies Acceptable patient waiting time Supply of long term medications Medication Therapy Adherence Clinic (MTAC) Use of high technology MPS Seminar - Amrahi - 23.5.15 22 PROCESS Model of Good Care - Dispensing •Screening •Keying-in •Packing IMPACT • Systematic framework • Promote medication safety • Catch near misses • Prevent error •Checking •Dispensing MPS Seminar - Amrahi - 23.5.15 Enhancement of patient safety 23 HUMANWARE Pharmacy Preceptorship Program • • • • CPD program Train → verification → re-verification Dispensing process Keying-in & packing process MPS Seminar - Amrahi - 23.5.15 24 HUMANWARE Pharmacy Preceptorship Program IMPACT • Address competency of staff • Competency profiling Enhancement of patient safety & care MPS Seminar - Amrahi - 23.5.15 25 PharmCARE Counter service Medication counseling By-Post Drive-Thru MPS Seminar - Amrahi - 23.5.15 SERVICE DELIVERY 26 PharmCARE SERVICE DELIVERY IMPACT • • • “PharmCARE is the most efficient and friendliest in the hospital..” MPS Seminar - Amrahi - 23.5.15 27 Promote medication safety Medication counseling sessions Total number of PharmCARE patients: Counter: 2440/month Drive-thru: 120/mth By-Post: 60/mth Enhancement of patient safety & care Berita Harian 11 September 2008 Berita Harian July 2007 MPS Seminar - Amrahi - 23.5.15 Harian Metro 14 May 2010 28 Pharmaceutical Manufacturing Non-sterile Sterile – special speciality MPS Seminar - Amrahi - 23.5.15 29 Sterile Complex Inventory control includes referring to expiry dates & cold chain document Model of Good Care for aseptic dispensing as framework Use PPEs in sterile complex & general lab MPS Seminar - Amrahi - 23.5.15 30 RECONSTITUTION OF CYTOTOXIC DRUGS Protocols (from wards/cli nics) sent to Inpatient Pharmac y • Protocols are checked • Prescriber confirmation on whether to proceed with chemotherapy is obtained For tracking purposes, worksheet is initialed by pharmacy assistant Protocols sent to Sterile Complex via the passthrough hatch Products sent out from the clean room via the passthrough hatch Products are attached Labelling with purple Packagin of cytotoxic g of products stickers- and products MPS Seminar Amrahi - 23.5.15 other anxillary labels Protocols inserted into individual plastic folders • Reconstitu tion is in accordanc e with written standard operating procedure s • Using aseptic technique The product is placed into a clear, impervious plastic bag & heat sealed Generati on of workshe ets & product labels Reconstit ution of cytotoxic drugs by trained and validated personnel Products placed into opaque bags • Doses are calculated to reconfirm • Labels are computergenerated The identity, strength, quantity & expiry date of the materials are checked by pharmacy assistant • Bags labeled with name, ward, storage condition, expiry & warnings 31 • Intrathecal products in green bags; Crosschecking of protocol with generate d labels Crosschecking of materials with the reconstitu tion label Finished products sent out from Sterile Complex Labels & worksheets are checked by pharmacist Trays are sent in one by one • Products given a final check by pharmacis t • Protocol is initialed Details entered into the cytotoxi c product register Items sent to the cytotoxic clean rooms via passthrough hatch Products stored at Inpatien t Pharmac y • Patient’s name • Ward • Name, strength & quantity of products • Batch number Each tray contains equipment & material for one cytotoxic product Products are placed in designated bins awaiting collection Packing of raw materials , diluents & syringes PREPARATION OF TPN BAXA M 24 MPS Seminar - Amrahi - 23.5.15 32 HIGH TECHNOLOGY EQUIPMENT BAXA MM12 IV STATION Laminar Flow Hood MPS Seminar - Amrahi - 23.5.15 33 Clinical Pharmacy Services Collaborative work with doctors, nurses and other allied healthcare professionals Ward pharmacists Specialised areas MPS Seminar - Amrahi - 23.5.15 34 PAU KIEW BING LAU CHEE LAN FARAH WAHEEDA TAJARUDIN LOONG LY SIA YIN MEI KUAN KONG SHUE HONG GHAN SHEAH LIN LAI YIN KEY NUR JANNAH BINTI AZMAN 35 Our team - 11 Clinical Pharmacists MPS Seminar - Amrahi - 23.5.15 SARAH ANNE ROBERT LYDIA GAN LAY YEN Introduction Wards that we cover: Adult Medical Wards 1-6 • Intensive wards General Intensive Care Unit (GICU), Coronary Care Unit (CCU), Cardiac Rehabilitation Ward (CRW), Bone Marrow Transplant (BMT) ward, Neonatal Intensive Unit (NICU) • Orthopaedic wards (male & female), Surgical wards 1- 8, Psychiatric wards (male & female) • Also receive referrals from other wards for counseling, Therapeutic Drug Monitoring (TDM) and other services MPS Seminar - Amrahi - 23.5.15 36 CLINICAL PHARMACY SERVICES OTHERS: 1. Neuro team meeting 2. Multi-disciplinary patient management programme 3. Training/ education 4. Clinical practice pathways 5. Patient’s own drug (POD) 6. Ward Check 7. Infectious control committee, UKMMC 8. Publications 9. Research projects 10. Counseling week (annually) CORE SERVICES: A) PATIENT MONITORING B) VERIFICATION C) ANSWERING QUERIES FROM DOCTORS/ NURSES D) PATIENT COUNSELLING E) THERAPEUTIC DRUG MONITORING F) CLINICS Services accredited by ISO 9001:2000 Quality Objective: 80% of patients in primary wards with Clinical Pharmacists are to be monitored MPS Seminar - Amrahi - 23.5.15 37 3. TRAINING/EDUCATION 3.1 CONTINUOUS NURSES’ EDUCATION (CNE) • Hold CNE sessions for nurses from time to time • Topics usually relevant to nurses such as Insulin Therapy, High alert medications, Drug Administrations and Dilution, TDM etc MPS Seminar - Amrahi - 23.5.15 Provision of Clinical Pharmacy Service July 2010 – Dec 2010 – Preparation work •Recruitment of clinical pharmacists •Hospital demographic study •Survey to selected consultants •Policy and SOP related to clinical pharmacy Year 2011 – Stroke Interest Group Member in SIG to set up allied health support to stroke cases. Year 2011 Monash Student attachment MOA agreement for yearly pharmacy student attachment Dec 2010 – Pilot service • Review prescription for in-patients admitted under 1 consultant March 2011 – Coverage of 1 ward • Expanded service to cover inpatients admitted / transferred in to 1 Medical / Surgical ward Jan 2012 – Coverage of 2 wards Expanded service to cover in-patients admitted / transferred in to 2 Medical / Surgical wards 2014 Year 2012 – 2013 – Clinical initiatives & Publications •Reconstitution and Administration Guideline for Injectable Anti-infectives •Understanding Tuberculosis and Your Treatment •Guideline for dilution and administration of IV Pantoprazole •Guideline for dilution and administration of IV Amiodarone Introduction of Pharmacy Referral Form to all wards. 2015 Expansion to Oncology & Critical Care areas The proposal and recommendations contained herewith remain the sole property of Sunway Group. Any unauthorized duplication or content use without consent of authority from Sunway Group, is deemed as breach of copyright. Antibiotic Stewardship Activities Conducted 6 months survey on reasons for prescribing carbapenems in inpatients Survey results summarized in write-up that was circulated in-house Poster was accepted for presentation at 15th Asia Pacific Congress of Clinical Microbiology and Infection The proposal and recommendations contained herewith remain the sole property of Sunway Group. Any unauthorized duplication or content use without consent of authority from Sunway Group, is deemed as breach of copyright. MPS Seminar - Amrahi - 23.5.15 41 SERVICES RENDERED Ambulatory Drug Distribution OUT-PATIENT EMERGENCY / TRAUMA Unit Dose Drug Distribution for inpatients Clinical Pharmacy Services Intensive Care (ICU, CCU, SICU, Neuro ICU) Medical Pain Management Hematology RESEARCH DRUG USE EVALUATIONS / REVIEWS Drug counseling In-patient / Discharges Out-patient Medication Adherence Programme DIABETES WARFARIN MPS Seminar Amrahi(Chronic - 23.5.15 Kidney Disease) -CKD Total Parenteral Nutrition IV Admixtures Cytotoxic Drug Reconstitution Pharmaceutical / Galenicals Radiopharmacy Therapeutic Drug Monitoring Dissemination of Drug Information Investigational Drug Services Procurement of Drugs & Disposables Store & Inventory for Pharmaceuticals and Disposables 42 ACHIEVEMENTS @ FARMASI MAKMAL PENDISPENSAN ASEPTIK •Counseling for Cancer Patients RADIOFARMASI •PREPARATIONS •Diagnostic •Treatment •QUALITY CONTROL •COUNSELING •PUPIL TRAINING •SAMARIUM THERAPY PEMONITORAN DRUG TERAPEUTIK •Steroid •Best Lab 2007 •Best Lab Runner-up 2015 MPS Seminar - Amrahi - 23.5.15 43 ACHIEVEMENTS @ FARMASI PESAKIT DALAM FARMASI SATELIT FARMASI KLINIKAL • Unit Dose Drug Distribution • COMING SOON: In-patient Prescription On Line System (i-POLS) under simulation…….. •Critical Care : ICU, CCU, SICU,Neuro-ICU •Hematology •Pain Management •Medical •HUSM Formulary On-Line / Mobile •Develop/implementing 5 Counselling Modules for CKD-MAP@Nephrology KAJIAN & •Co-ordination of Investigational Drug Services MAKLUMAT DRUG •Multicentered Sponsor-Initiated Clinical Studies •Local Studies •Drug Use Evaluations/Reviews MPS Seminar - Amrahi - 23.5.15 44 Drug Information Services Pharmacy bulletin & newsletters Drug formulary – hard copy and on-line Secretariat to Drugs & Therapeutics committee Samples Clinical trials MPS Seminar - Amrahi - 23.5.15 45 MPS Seminar - Amrahi - 23.5.15 46 Improving Management of Allergy Documentation Allergy screening service provided by Pharmacists Issuing of Drug Allergy Card to patients Documentation in hospital HIS system The proposal and recommendations contained herewith remain the sole property of Sunway Group. Any unauthorized duplication or content use without consent of authority from Sunway Group, is deemed as breach of copyright. Screening of Medications for Enteral Tube Feeding Development of in-house reference database on suitability to crush medications for patients on tube feeding Screening of suitability by Pharmacists Provision of administration guide to nurses to educate on correct administration method The proposal and recommendations contained herewith remain the sole property of Sunway Group. Any unauthorized duplication or content use without consent of authority from Sunway Group, is deemed as breach of copyright. Development of In-House Reference Guidelines The proposal and recommendations contained herewith remain the sole property of Sunway Group. Any unauthorized duplication or content use without consent of authority from Sunway Group, is deemed as breach of copyright. Development of In-House Reference Guidelines The proposal and recommendations contained herewith remain the sole property of Sunway Group. Any unauthorized duplication or content use without consent of authority from Sunway Group, is deemed as breach of copyright. Development of In-House Patient Education Materials The proposal and recommendations contained herewith remain the sole property of Sunway Group. Any unauthorized duplication or content use without consent of authority from Sunway Group, is deemed as breach of copyright. Development of In-House Patient Education Materials The proposal and recommendations contained herewith remain the sole property of Sunway Group. Any unauthorized duplication or content use without consent of authority from Sunway Group, is deemed as breach of copyright. Publication of In-House Pharmacy Bulletin Platform for sharing of information & alerts on medication safety, updates on policies, amendments to hospital drug formulary The proposal and recommendations contained herewith remain the sole property of Sunway Group. Any unauthorized duplication or content use without consent of authority from Sunway Group, is deemed as breach of copyright. Medication Safety On-line incident reporting system Root cause analysis Patient safety solutions Reporting of Medication Errors (ME) Reporting of Adversed Drug Reactions (ADR) MPS Seminar - Amrahi - 23.5.15 54 MPS Seminar - Amrahi - 23.5.15 55 Improving Safety of High Risk Medications Dedicated shelf for identified High Risk Medications Labelling of each ampoule & vial to alert users to double check The proposal and recommendations contained herewith remain the sole property of Sunway Group. Any unauthorized duplication or content use without consent of authority from Sunway Group, is deemed as breach of copyright. Increasing Awareness of Look-Alike Sound-Alike (LASA) Drugs Increase awareness of LASA drugs via posters, drug container colour coding, bulletin article The proposal and recommendations contained herewith remain the sole property of Sunway Group. Any unauthorized duplication or content use without consent of authority from Sunway Group, is deemed as breach of copyright. Transportation Special container for fridge items Controlled drugs use locked luggage MPS Seminar - Amrahi - 23.5.15 58 Colour-coded syringes. Morphine and Epidural Cocktail look alike could lead to possible handling errors as both syringes are prepared by the Sterile Unit, and normally ordered for the same indication ie ‘pain’. Therefore an initiative to colourcode the stoppers and labels were initiated. Combi Blue and Combi Red Stoppers were purchased as below. Apart from that, Preparation of PCA Morphine and Epidural Cocktail done different days to avoid confusion. MPS Seminar - Amrahi - 23.5.15 59 Screening Detects prescribing errors MPS Seminar - Amrahi - 23.5.15 60 Packing Alerts for packers – LASA, multiple strength, different dosage forms/preparations Separate oral & IV preparations Separate LASA & multiple strength MPS Seminar - Amrahi - 23.5.15 61 Checking Compare Rx with medication & labels Record near misses to study causes MPS Seminar - Amrahi - 23.5.15 62 Dispensing Two patient identifiers Provide verbal instructions Partition between dispensing counter and the rest of pharmacy area functions to minimize distractions of staff MPS Seminar - Amrahi - 23.5.15 63 Separation/segregation Improvement on separation and segregation on LASA (Looks Alike and Sound Alike) medication in the pharmacy MPS Seminar - Amrahi - 23.5.15 64 DifferentiationUse techniques such as boldface or color codes MPS Seminar - Amrahi - 23.5.15 65 1.13 High alert labels and date of opened labels These high alert labels help to alert nurses regarding drugs with high hazard levels if administered wrongly. Labels of ‘date of opening’ helps to reduce administration of expired drugs. MPS Seminar - Amrahi - 23.5.15 66 PATIENT SAFETY SOLUTIONS Look-alike/sound-alike drugs (LASA) MPS Seminar - Amrahi - 23.5.15 67 1.7 Use of ‘Tall Man Letters’ and Alert Labels for Lookalike or Sound-Alike medications Previous Selection errors had occurred before for this drug as AKURIT and AKURIT-4 soundalike. So the Outpatient Pharmacy took the initiatives to utilise ‘Tall Man Letters’ in medication labelling and also by adding additional labels to alert pharmacy assistants about the difference strengths available for certain selected drugs. ( As Shown) MPS Seminar - Amrahi - 23.5.15 68 Tallman lettering MPS Seminar - Amrahi - 23.5.15 69 Example of Tallman lettering on label MPS Seminar - Amrahi - 23.5.15 70 Improvement in resuscitation and anesthetic box supply Before MPS Seminar - Amrahi - 23.5.15 After 71 Guidelines on the handling GTN on the wards Step 1 MPS Seminar - Amrahi - 23.5.15 Step 3 Step 2 72 Step 4 Coloured boxes for storing HCE MPS Seminar - Amrahi - 23.5.15 73 Continuous Improvement Activities MPS Seminar - Amrahi - 23.5.15 74 Putting red tag at patient notes for allergic sign for patient who allergic to any medication Allergy Sticker MPS Seminar - Amrahi - 23.5.15 75 Tablet Cutter Tablet Crusher MPS Seminar - Amrahi - 23.5.15 76 Medication nurse serving medications MPS Seminar - Amrahi - 23.5.15 77 Oral Medication Syringe MPS Seminar - Amrahi - 23.5.15 78 SOP Prescribing and SOP Administration Registered 2012 Collaboration between Clinician, Pharmacy and Nursing MPS Seminar - Amrahi - 23.5.15 79 Medication Error Reporting MPS Seminar - Amrahi - 23.5.15 80 Adverse Drug Reaction Reporting • Malaysia ADR Advisory Committee (MADRAC) MPS Seminar - Amrahi - 23.5.15 81 Pharmacy Automation Automated Dispensing Cabinet Automated Dispensing robot Automated IV station MPS Seminar - Amrahi - 23.5.15 82 Usage of Automated Dispensing Cabinets in Wards 12 automated dispensing cabinets used hospital-wide including medical, surgical, paediatric, critical care wards Improve in inpatient medication supply efficiency Secured & orderly storage of medications in cabinets, accessed by authorized nurses & pharmacy staffs only Nurses remove medications only after medication order is reviewed by Pharmacy The proposal and recommendations contained herewith remain the sole property of Sunway Group. Any unauthorized duplication or content use without consent of authority from Sunway Group, is deemed as breach of copyright. MPS Seminar - Amrahi - 23.5.15 84 Pharmself24 automated dispensing unit Tuanku Mizan Military Hospital Kuala Lumpur MPS Seminar - Amrahi - 23.5.15 85 Thank You Special thanks to MPS Hospital Pharmacy Chapter for sharing their experiences and achievements MPS Seminar - Amrahi - 23.5.15 86