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Chapter 9
Hospital Pharmacy
Practice
© Paradigm Publishing, Inc.
1
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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2
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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3
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 Pharmacy
• The 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 of
–
–
–
–
Unit 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 orders
Unit 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
administration
• Systems 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
Safety Note
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
Safety Note
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
Safety Note
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 injectable
– Antibiotics
– 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
Safety Note
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 group
• Sets 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 manual
• Performs 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 from
–
–
–
–
Heart 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
• Purchasing
• Ordering
• Receiving 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 should
– Verify 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
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