Pharmacy Services Management in Hospitals

INTRODUCTION
Pharmacy is one of the "big three" hospital departments, along with Radiology and the Laboratory Provides something to most patients The process of ordering and delivering medications is the single most complex process in any hospital An extraordinarily complex organizational web because of
the number of individuals involved, number of steps involved in preparing, number and location of departments and patients

Earlier pharmacy services were viewed as solely compounding and dispensing drugs Now viewed as a clinical department that can serve as a bridge between the clinical and financial aspects of drug therapy

A first referral hospital treats on an average 100 150 diseases and prescribe about 80 120 drugs About 20% of the hospital budget is accounted by the Pharmacy dept i.e. about half of the budget for Material mgt budget Availability of the right drug at the required price at the time of need is key to hospitals existence
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Delays can be disastrous as it can contribute to mortality and morbidity Properly organised pharmacy dept under a professionally competent and qualified pharmacist

Definition
Pharmacy Service is a system that integrates the application of the pharmacists specialised knowledge with the distribution of medication to assure optimal medication therapy for the patient Responsible for drug use control including purchase, storing, distributing and ensuring the optimal patient outcomes resulting from the use of medications in the hospital

History
Prior to 1947, hospital pharmacies and dispensaries were manned by dispensers and compounders, whose academic qualifications were near to non existent Pharmacy Council of India was formed in 1949 and Diploma in Pharmacy was recommended to be the minimum requisite for becoming a pharmacist

The Pharmacy act, 1948 was passed and thus the first step towards rationalizing the pharmacy service was made. The act was amended in 1959 and 1976 Objectives were:
To regulate the minimum education required to become a Pharmacist as a Central responsibility To regulate the practice of pharmacy as a state responsibility

Drug and Cosmetic Act and Rules, 1940 Publication of National formulary of India in 1960 Report of Committee on Drug Pharmaceutical Industry also known as Hathi Committee 1975
Guidelines about division of pharmacies Desirable educational qualification Pay scales of staff Quality control and methods to achieve
Proper control, supervision and recommendation that if drugs are manufactured in hospital pharmacies, conditions be stringently followed 9

Goals and Objectives

Practice of pharmacy consistent with the size, location and function of the hospital and the changing needs of the patients and the medical and nursing staff Safe, appropriate and economical medication therapy Provision of drug distribution service which ensures safe, appropriate and economical use of medications Participation with other health care team members in the assessment and medication treatment of the individual patient
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Non-personnel functions of Pharmacy

Medication Procurement and Management Order filling and Distribution Formulary Management Consultation & Education Service Monitoring Function Administrative Activities
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Medication Procurement and Management

Medication Procurement & Storage Outdated Medication Management Replenish Floor Stocks Procurement Of Non-formulary Drugs

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Order filling and Distribution

Order verification Filling prescriptions Distributing medications Preparing medications & solutions Unusual order evaluation

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Formulary Management
Formulary is a dynamic compilation of medications, information and related topics approved for use within a hospital that reflects the current clinical judgement of the medical and pharmacy staff General formulary Antibiotic Formulary

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Hospital Formulary Why ?

Too many drugs by enormous companies Many drugs useless and hazardous Need to weed out such drugs Drugs must meet the criteria:
Sound therapeutics Good benefit to risk ratio Cost effectiveness

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Promote rational therapeutics Prevent unnecessary duplication, waste and confusion Promote economies

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Consultation & Education Service

To staff and physicians Patient personal medicine identification & storage Hospital staff education Newsletter/alerts/updates Support nursing policies & procedures New product evaluation (med, solutions, etc.)

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Monitoring Function
Narcotics management Pilferage investigation & intervention Adverse drug reaction tracking Monitoring drug profiles for interactions Medication error tracking Drug sample control

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Administrative Activities
Charging/billing Computer systems maintenance Control vendor access to departments Housekeeping Utilities & compliance building code Communications systems Security

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Smaller hospitals need not have regular pharmacy department, can purchase from local pharmacist and maintain only a limited supply Larger hospitals full time pharmacist with few assistants Pharmacist must be licensed Pharmacy may manufacture certain solutions depending on hospital policy

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Relationships to Other Departments and Agencies

Interact with a wider range of departments, external businesses and agencies Clinical Departments Ancillary Departments Administrative Departments Medical Staff Outside Agencies
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Clinical Departments
Nursing services
General Nursing Units
General Medicine Orthopedics General Surgery, etc

Critical Care units Dialysis Units Emergency Services

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Ancillary Departments
Occupational Therapy Imaging Services: Cardiac Cath Lab MRI CT Scan Special Procedures Nuclear Medicine Ultrasound Laboratory Services - Microbiology

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Administrative Departments/Services
Engineering Environmental Services Quality Improvement Accounting Safety Committee Risk Management Human Resources Information Management/Data Processing
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OPD

Emergency Dept

In patient area

Patient

Research & Training

Hospital Pharmacy Services

Therapeutic Committee

Quality Control

Hospital Hospital Purchase Section

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Types of Pharmacies
Pharmacy for OPD Pharmacy for in-patients services Combination of both

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Drug Distribution System

Effective, efficient, safe and responsive system Drugs to the patients as well as other areas of the hospital like emergency room, OT, etc Drug distribution system are complex and involve interaction of many individuals in addition to pharmacy Number of distribution systems have been explored:
Floor Stock System Individual Patient Drug Order System Unit dose method

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Floor Stock System

Many pharmaceuticals in bulk bottles are kept When a drug order was written, the nurse removes the appropriate drug and administer to the patient Nurse responsible for reordering Disadvantages
Labour intensive Lack of effective control Space occupying Frequent errors Exact drug not available hence special order supplies Delay due to non availability Large uncontrolled inventories

This system, by its design was not set up to respond quickly to the patients medication needs
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Individual Patient Drug Order System

Most of the floor stock items except controlled items were removed Nurse required to write out a special request for each drug that a patient would receive and send to the pharmacist Pharmacist dispenses for multiple days to the patient care area Nurse still responsible for removing the drug from a multi dose container, preparing a patient label or identification card Medication errors Delay between 1 to 5 hrs, sometimes still more However reduced inventory Still labour intensive Did not result in good drug use control Precious nursing time lost

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Both the above system did not use personnel resources optimally
Nurses trained in patient care were busy in ordering and dispensing medications Pharmacists trained in therapeutics were busy filling orders with little or no opportunity to apply their expertise in drug use to the patient care process

Medication errors at times exceeded 10% and inventory was properly controlled Hence unit dose method was tried in 1960s
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Unit Dose Method

Pharmacist receives a direct copy of Physicians order Issues the medications packed in single use containers and dispensed in as ready to administer form as possible For most medications about 24 hrs supply is dispensed It was developed to provide safe and effective drug distribution and control This concept safe for the patient, efficient and economical and allows efficient use of professional resources
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Advantages
Reduction in incidence of medication errors Decrease in total cost of medication related activities More efficient use of nurses and pharmacists Improved drug control and drug use monitoring Greater control by the pharmacist over pharmacy work load pattern and staff scheduling Reduction in size of drug inventories located in patient care areas Greater adaptability to automation

Most hospitals do not have a pure unit drug dose distribution system

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Medication Errors
Wrong Dosage Wrong Drug Wrong Time Wrong Concentration Wrong Patient Wrong Rate Improperly Discontinued Improperly Continued Sound Alike" Drug "Look Alike" Drug Wrong Preparation (Cream Vs, Liquid...) Wrong Route (Oral, Vs. External, Vs. Iv...) Delay in Delivery of Medication
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Causes of errors
Human FactorsFailure to follow Procedures Fatigue Lack of Training Too much work (patients or orders) Inattention

Mechanical FactorsHandwriting Printer quality Poor fax quality Poor Carbon copy

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Administrative FactorsLack of commitment to Quality Inadequate oversight of staff performance Floating System for Caregivers Lack of understanding of how quality "happens"

Policies and ProceduresOutdated Incomplete Inaccurate Not distributed

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Planning Considerations

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Pharmacy service should be established within the scope of status, responsibilities, relationship and limitations A qualified and experienced Pharmacist must be in charge

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Pharmacy In Charge
Supervise and coordinate activities of personnel working in hospital pharmacy Dispense medication by means of standard physical and chemical procedures and prescription requests issued by physicians and other qualified prescribers

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Plan, organise and supervise activities in hospital pharmacy as per hospital policies, standard practices and state laws Interviews, employs and orients trained hospital pharmacists Establishes work schedules and assigns pharmacists to specified areas of responsibility in the administration, dispensing or preparation of functions
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Supervises work performance of the pharmacists and related personnel to ensure adherence to established standards Supervise and assist pharmacists in compounding and dispensing medication to fill written prescriptions and medication requests
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Reviews written prescriptions to determine that over dose or toxic compounds are not dispensed Supervise inventory of pharmacy stock periodically to determine stock needed and assure use of stock before expiration date

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Place order for supplies with the dealers Verify receipt of merchandise Approve bills for payment Maintain formularies, source of information on preparation

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Initiate, develop and carry out rules and regulations pertaining to administrative and professional policies Establish and maintain system of records and book keeping in accordance with hospital policies

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Preparation of departmental budget Dispensing of drugs, chemicals and pharmaceutical preparations Maintenance of an approved stock of antidotes and other emergency drugs Dispensing of all narcotic drugs and ensuring proper accounting systems for the same

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Specifications of all drugs, chemicals, antibiotics and pharmacological preparations Inspection of all pharmaceutical supplies at user points Establishing a system of records and book keeping in cooperation with the Accounts dept Preparing pharmacy policies and procedures in consonance with the established policies of the hospital
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Cooperating in teaching and training programmes for student nurses and interns Implementing the decisions of the therapeutics committee Preparing periodic reports and returns on the utilisation of the pharmacy service

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Drugs and Therapeutics committee

A committee that evaluates the clinical use of drugs, develops policies for managing drug use and drug administration and manages the drug formulary system. The pharmacy and Therapeutics committee recommends the standard drugs for prescription
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Drugs and Therapeutic Committee

To serve in an evaluative, educational and advisory capacity on drugs Prepare the hospital formulary of accepted drugs for use in the hospital and regular revision Selection of manufacturers and suppliers Act as an advisory group on matters pertaining to the choice of drugs to be stocked, added or deleted
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Framing of over all policy of the pharmacy service for information of all concerned and to monitor its implementation Development of drug information system Participate in quality assurance activities related to distribution, administration and use of medications Monitor and evaluate adverse drug reactions and make appropriate recommendations for preventing such occurrence

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Composition of Drugs and Therapeutic Committee

Medical superintendent Chairman Head of Medicine Head of Surgery Head of Gynae & Obs Head of Paediatrics Nursing Superintendent Chief Pharmacist Member Secretary
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The committee has to meet often in the beginning in a new hospital Later it can meet very month

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Physical facilities and Layout

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Designing
Quick and easy flow of patients and material as well as user departments Location
Accessible to OPD Convenient for dispensing Accessible to central delivery store

Traffic within department must be economical and flexible Size determined by the organisation and operational policies
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Provision for security of dangerous drugs Provision for control of fire Finishes must be impervious to acid and alkali and easy to clean Corridors should allow easy turning of wheeled vehicles

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Safe guard against misuse of the drugs, hence

Plan the rooms accordingly Alarm system to guard against intrusion and theft Space for sterile water

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Floor Area: No laid down norms

10 sq ft per bed in a 100 bedded hospital 6 sq ft per bed in a 200 bedded hospital 4-5 sq ft per bed in a larger hospital

Finishes and lighting

Floors should be resilient, smooth, easily cleaned and acid resistant Rubber or tiles or heavy linoleum Walls with smooth surface with washable paint Cabinets be white coloured wood or white enameled
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Good lighting and ventilation Venetian window blinds Dispensing windows adequate

Furniture and Equipment

Drug stock cabinets Prescription case Work tables Standard counters of 36 height, 30 depth and 74 long Acid proof sink

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Refrigerated space
8 cubic feet for 50 bedded hospital 16 cubic feet for 100 bedded hospital 32 cubic feet for 200 bedded hospital

Narcotic safe with double lock arrangement Space for records Staff room Toilets

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Staffing
Study group on Hospitals (1968)
Bed Compliment 50 beds or less Up to 100 beds Up to 200 beds Up to 300 beds Up to 400 beds Nos of Pharmacists 3 5 8 10 15

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Recommended staff for a 750 bedded teaching hospital

Chief Pharmacist Manufacturing Pharmacist Asst Chief Hosp Pharmacist Technical asst (Pharmacist) Head Pharmacists Pharmacists 1 1 1 3 2 10 18

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Managerial Issues
Control of Drug Costs
Reducing drug procurement cost Inventory management Value analysis Use of appropriate drug distribution system Computerisation Use of therapeutic equivalents

Effective staff utilisation

Appropriate mix of pharmacists, pharmacy technicians and other support staff

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Human relations
Right person for right job Workload

Consumer satisfaction
Last place to be visited by patients especially from OPD
They are tired, expect quick and courteous service

Non Availability of drugs- embarrassing Supply of sub standard drugs

Quite frequent Standard purchase practice to be followed Routine / random qualitative analytical testing Hospital therapeutic committee should supervise

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Drug pilferage
If possible, drugs with generic name be purchased After receipt, drugs to be stamped with hospital name stamp Procurement section and distribution section should be separate

Drug distribution System

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Documents to maintain
Non-expendable stores register Expendable stores register Indent file Formula file for manufacturing medicaments Costing returns Report file Stock verification returns file Hospital formulary
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Automation
Computerized pharmacy system adjunct to the HMIS
Uses the hospital main frame computer In its simplest form,
data regarding pharmacy services are entered into the main frame Reports generated usually monthly for distribution and review by the pharmacy in charge, Data like financial management data, time reporting information, reports of the number of batches by category

This system is of limited value as exclusive use of the system by only pharmacy service is not there

Dedicated system
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Dedicated system
Micro computers or mini computers are used Enables the pharmacy to tailor its computer software to its needs This has to be attached to the main frame computer as information regarding OPD attendance, admissions and discharges can be received

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Quality Assurance Process

Guideline
Patient-care indicators Medication-use indicators Operational procedures Organizational structure.

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