TEAM PHARMACY

HOSPITAL MISSION

To provide world class multi-specialty

tertiary care services at an affordable
cost in a safe, patient centered
environment conforming to ethical
standards with commitment to social
responsibility.
(purpose of a company ) (overall goal, provide a path, and guide )(Our plan to get
there) ( define the key measures of the organization's success)( describes what the
company wants now )(A Mission statement talks about HOW you will get to where
you want to be.)
 HOSPITAL VISION
Be a centre of Healthcare Excellence with
commitment to promote, sustain and exceed
international healthcare standards
Be a Global leader in super specialty, multi organ
transplant using cutting edge technology
Be a preferred employer for healthcare
professionals
Be a leading provider of professional education,
training, research and Regenerative Medicine that
foster innovation and growth.
Deliver increasing value to stakeholders
A Vision statement outlines where you want to be in future.
Communicates both the purpose and values of your business.
The values, vision and mission statements identify what the
business is and what it stands for, how it wants to be seen, and
how it wants to go forward
 SPECIALTY PHARMACY

Now the bowl represents a medicinal potion, and the

snake represents healing. Healing through medicine
is precisely why pharmacy has adopted the Bowl of
Hygeia symbol.
 HYGEIA was the goddess
of good health. She was a
daughter and attendant of
the medicine-god
Asklepios, and a
companion of the goddess
Aphrodite.

Hygieia and her five sisters each

performed a facet of Apollo's art:
Hygieia ("Hygiene" the
goddess/personification of health,
cleanliness, and sanitation), Panacea
(the goddess of Universal remedy),
Iaso (the goddess of recuperation
from illness), Aceso (the goddess of
the healing process), and Agla/gle
(the goddess of beauty, splendor,
glory, magnificence, and adornment).
 Pharmacy
Pharmacy is the science and technique of preparing as
well as dispensing drugs and medicines. It is a
health profession and aims to ensure the safe and
effective use of pharmaceutical drugs.
Pharmacy practice also includes more modern services
related to health care, including clinical services,
reviewing medications for safety and efficacy, and
providing drug information. Pharmacists, therefore, are
the experts on drug therapy and are the primary health
professionals who optimize use of medication for the
benefit of the patients.
Staff members involved in the medication-use
process are safety conscious, Accurate, and
productive.
 Pharmacy Mission

To provide high quality pharmacy services that

result in optimal medication outcomes. We are
committed to meeting or exceeding the needs of our
patients and customers by providing efficient,
caring, professional and cost-effective services in
an environment that encourages excellence,
teamwork, innovation and continuous improvement.
 Pharmacy Vision

The vision of the Department of Pharmacy

is to be a nationally recognized leader in the
provision of pharmacy patient care services
across the healthcare continuum.

Vision and Mission Statements are the inspiring words chosen by

successful leaders to clearly and concisely convey the direction of
the organization.
 Pharmacy Values
Integrity We adhere to high moral principles and
professional standards by a commitment to honesty,
confidentiality, trust, respect and transparency.
Teamwork Our words and actions reflect our commitment to
work together to achieve the best individual and collective
outcomes.
Excellence Our words and actions demonstrate a culture of
exceptional service and the highest quality of care
Associate Development --support personal growth and
achievements, where they can reach their fullest potential.
Passion -- being passionately committed to our
profession
Innovation. We welcome change, encourage invention and
continually seek better, more efficient ways to achieve our
goals.

companys ethical and moral "guiding principles"

 Performance assessment factors
Personality Factors

1. Team Spirit ,Interpersonal

&Communication skills,
2. Initiative , Creativity & Enthusiasm
3. Problem analysis & Decision Making
4. Self involvement & Dedication
5. Pleasant personality
 Job performance
Job knowledge & Skills
Quantity &Quality of work
Cost Consciousness
Safety Consciousness
Maintenance of Records (Documentation)
Attendance & Punctuality .
Reliability, Dependability.
Pharmacy logo design in India
"A customer is the most important visitor on our
premises. he is not dependent on us. We are
dependent on him. He is not an interruption in our
work. He is the purpose of it. He is not an outsider in
our business. He is part of it. We are not doing him a
favour by serving him. He is doing us a favour by giving
us an opportunity to do so."
 QUALITY
excellence of
The degree of
something.

A state of being free from

defects, deficiencies.

Doing things right the first

time and doing it better every
time.
 What does the customer look for?
Fitness for purpose
 NABH

NATIONAL
ACCREDITATION
BOARD FOR
HOSPITALS & HEALTH
CARE PROVIDERS
 Focus of standards
Patient Safety

Staff and employee safety

Environment and community safety

Information Education and Communication

Accreditation is a Journey.
Not a Destination
 NABH Standards for Hospitals

10 Chapters

102 Standards

636 Objective Elements

A standard is a statement that defines the structures and

processes that must be substantially in place in an
organization to achieve outcome and enhance the quality
of care
 Patient-Centered Standards

Chapter Access, Assessment and Continuity of

1 Care (AAC)
Chapter
2 Patients Rights and Education (PRE)
Chapter
3 Management of Medications (MOM)
Chapter
4 Care of Patients (COP)
Chapter
5 Hospital Infection Control (HIC)
 Management-Centered Standards
Continuous Quality Improvement
Chapter 6 (CQI)
Responsibilities of Management
Chapter 7 (ROM)
Facility Management & Safety
Chapter 8 (FMS)
Human Resource Management
Chapter 9 (HRM)
Chapter Information Management Systems
10 (IMS)
 (MOM) MANAGEMENT OF MEDICATION
mom 1 Chapter 3

There is a documented policy and

procedure for pharmacy services and
medication usage.
These comply with the applicable laws
and regulations.
A multidisciplinary committee guides the
formulation and implementation of these
policies and procedures.
 Hospital Drug Formulary
mom-2
The Formulary is the list of
pharmaceutical products and
preparations available in the hospital.
A list of medications appropriate for the
patients and as per the scope of the
organizations clinical services is
developed by P & T committee based
on need, efficacy, risk and cost.
The formulary is available for clinicians to refer
and adhere to.
 medication procurement
All drugs shall be purchased from authorised
dealers possessing GMP (Good Manufacturing
Practices) certificate.
All drugs before purchasing shall be checked for

Bioavailability and
Bioequivalence
Policy For Existing Items
Based on the inventory levels and consumption
pattern materials will be purchased from the
nominated vendors.
Purchase order to be raised for each and every
supply.
PROCEDURE FOR PROCUREMENT OF DRUGS WHICH

ARE NOT INCLUDED IN HOSPITAL FORMULARY

When a Non-Formulary medication is

ordered by the physician for emergency
need , these drugs are locally
purchased by the pharmacist.
 PROCEDURE TO INCLUDED NEW DRUG INTO THE

HOSPITAL FORMULARY

Doctor shall give the detailed description

of the drug that need to be added to the
formulary
It need to be justified on the usage and the
frequency of usage of such drug
This requisition would be put forth to the
P&T committee and the decision would be
taken collaboratively
(Material management ) INVENTORY CONTROL
In health care system, material management is
concerned with providing the drugs, supplies and
equipment needed by health personnel to deliver
health services.
The right drugs, supplies and equipment must be at
the right place, at the right time, and in the right
quantity in order that health personnel deliver
health services.
Inventory control it is an important aspect of
material management.
Inventory control is a scientific system which
indicates as to what to order, when to order, and
how much to order, and how much to stock so that
purchasing costs and storing costs are kept as low
as possible.
 ABC Analysis (Always Better Control)
Analysis of the store items based on cost criteria.

Class Number of items Rupee value in items

A 10% of total items 70%
B 20% of total items 20%
C 70% of total items 10%

A Items represent the high cost centre, B items represent the

immediate cost centres, and C- items represent low cost centres

FSN Analysis (Fast, Slow moving and Non-moving

(based on consumption of the items).

SDE Analysis (Scarce, Difficult, Easy)

VED Analysis (Vital, Essential, Desirable
(analysis based on their criticality of the item)
Vital: items without which treatment comes to standstill: i.e. non-
availability can not be tolerated.
Essential: items whose non availability can be tolerated for
some time (hours), because similar or alternative items are
available.
Desirable: items whose non availability can be tolerated for a
long period. Although the proportion of vital, essential and
desirable items varies from hospital to hospital depending on the
type and quantity of workload

Maximum, Minimum and Reorder level is maintained for

all items in in all pharmacies. This is developed by
averaging 3 months for slow moving items and one-month
sale for fast moving items.
If Actual Demand > Expected, we Stock Out
Order
Quantity

Stockout
Point
Inventory

Time

Lead Time Unfilled demand

Place Receive
order order
 FIFO

First in First Out shall be applied for

consumption of the drugs. Another method
that is followed is according to the date of
expiry. All items getting soon will be
consumed first. This is checked in the HIS
and issued accordingly
 STORAGE OF MEDICATION (mom-3 )
Medications are stored in the pharmacy in
designated areas which are sufficient to ensure
proper sanitation, temperature, light, ventilation,
moisture control, segregation, and security. according
to the manufacturer's recommendation.

Medications are readily available and accessible to

meet patient needs within safety and security
controls.

Drugs shall be stored in the area accessible to only

designated and authorized persons.
Emergency medications are replenished in a timely
manner when used and are available all the time.
CENTRAL PHARMACY
INCHARGE STOCK
DOCUMENTATION
 Arrange stocks neatly in alphabetical
order & category wise.
Sound alike and look
alike medications are identified and
stored separately.
Fragile items shall not be stored
near edges of shelves. Heavy items
to be placed in lower shelves
Expired, Near expiry & breakage drugs
are stored in a separate designated
area.
 Sound inventory control practices
guide storage of the medications.
Drugs available with proper purchase
reference shall only be stored in the
pharmacy premises.
All stock of narcotic drugs is kept in
double lock & Key. Key of the locked
compartment shall be available with senior
pharmacists nominated for handling
narcotic.
 Items requiring refrigeration will be
stored appropriately. Refrigerators shall
be maintained at the require
temperatures. This shall be ensured by
continuous temperature charting in each
shift
All refrigerated medicines are dispensed
with ice packs.
Food items shall not be stored in
Refrigerator containing drugs and other
such items.
All medication refrigerators shall be
clean and free of excess frost
Storage Temperature of medicines
Proper storage of medication ensures efficacy,
stability and safety
Store frozen : Minus -- 200c
Cold : 20c - 8*c
Cool : 8*c - 25*c
Room temperature : 15*c - 30*c
Warm : 30*c - 40*c
Excessive Heat : 40*c Above
 All drugs, which require light protection while
in storage, remain in the original package, until
the time of patient administration. If a
medication comes in a non-light protected
package, the product is stored in an amber bag.
High alert medications will be identified by
specialty labels and stored in special storage
location.
Disinfectants and drugs for external use will be
stored separately from internal and injectable
medications.
Pests control to be taken care off.
Investigational drugs are stored in locked,
segregated cabinets under the supervision of
designated pharmacy personnel.
 Storage of Cytotoxic ,Flammable,
Hazardous Materials:
To prevent accidental contamination
resulting in exposure of personnel to
cytotoxic and hazardous drugs are stored
in segregated &secure areas which are
clearly labeled, with access limited to
authorized personnel.
Adequate ventilation &fire fighting
arrangements needed.
 Check For Expiry
Expiry date will be checked at the beginning
of every month.
All such drugs, which will be likely to be
expired within 3 months, will be removed
form the shelves. Locations other than Main
pharmacy will be returned to the Main stores
pharmacy.
The HIS generates a list of all such drugs in
the pharmacy.
 All drugs received form location in the hospital as well
as in the Main stores will be accumulated and returned
back to the suppliers/manufacturer for credit or
replacement.
Expired Cut tablets & suppliers rejected stock will be
listed out, after getting authorized Signatures , this
stock will be sent for condemnation , may be stock
write off in HIS.
All pharmacy will be routinely inspected for
discontinued, outdated, defective or deteriorated drugs
and containers with worn, illegible, or missing labels.
These drugs will be returned to the Pharmacy
Storeroom where they will be kept in a segregated
area for return or destruction.
 Prescription of medications
mom-4
Latin "recipe"

written clearly and legibly (Prefer CAPITAL LETTERS)

and that the same are dated, timed, named and legibly
signed.
Doctors are authorized to use only those drugs listed in
the hospital Formulary except in specific instances.
Patients name and Registration number, Patient
demographics
the drug name (generic name) dosage, the route of
administration, the frequency and duration of
administration.
Abbreviations for drug names are not written.
OP PHARMACY
 Safe Dispensing of medications
(mom-5 )
Drugs shall be dispensed only by the authorized
person registered with state pharmacy council.
Drugs shall be dispensed only on production of
valid prescription from those authorized by the
hospital to do so.
Prescriptions/Indent shall be read carefully.
In case of non clarity in the prescription
(including mistakes of dose of drug/duration/
timings/ spellings), the duty pharmacist contacts
the prescriber for clarifications before
dispensing.
Ensure the correct drug and dose form for the
specific patient.
IP PHARMACY
 Drug ordered shall be billed with
correct name, strength, dose form
and quantity, quality,MRP,batch no,
EXP date & check items with bill
before dispatch.

The following details shall be labeled on all cut

tablets/capsules strip or loose tablets dispensed for
inpatient:

1. Name of the medicine

2. Strength and form of medicine
3. Quantity of medicine
4. Exp date

Name of patient shall be confirmed before issuing

medicines
IP PHARMACY STOCK DISTRIBUTION
 Check all items for expiry dates before dispensing,
Drugs issued shall have expiry date not less than
three months.
High-risk medication orders are verified & Double
Check prior to dispensing
Stat doses and discharge medications will be
given first priority for dispensing.
Patient and family are being educated & counseled
about drug-drug and food-drug interactions, if any
and on the effective use of their medications.
Maintain prescription bounce register compulsory.
Sign on dispensed column after dispensing.
All documents pertaining to
purchases/issues/returns shall be retained for a
minimum period
 There are documented policies and
procedures for medication management.
(mom 6 )
Prescription
Patient identification
Correct medicine , dose , route , time.
Medication Preparation / dilution
Multiple dose drugs(Inj. heparin ,Lox ,Medaz)
Open vials should be date,Inspected before each use for
contamination. Discard after 28 days
Patients medications brought from outside the
organization.
Self medication will be only advised at the time of
discharge.
 Omitting Medication

Medication omission due to unusual or unexpected

occurrences, such as patient refusal to take prescribed
medication, shall be reported to the responsible for the patient
and to the patient's doctor.

Patients are monitored after

medication administration. ( Mom-7 )
Monitoring the patients response to the
medication.
Educate the patient about medicine.
Monitor Drug interactions, allergies
Near misses, Medication errors and Adverse drug
events are reported and analyzed.MOM-8

An ADR is a harmful reaction to a medication

that is unexpected, unintended, unusual, or
previously unreported and occurs when the
medication is prescribed and administered
properly.
Staff notify prescriber and resident doctor
immediately if the event is significant or may
alter the patient's plan of care.
 Reporting an ADE :
Staff completes the Incident reporting form immediately
or not later than 24 hours of the ADE identification.
Forms are sent, confidentially to the Manager Quality,
either as hard copy or via email.

Reviewing ADEs:
Supervisor/manager completes timely evaluation of the
circumstances surrounding the event.

Root cause analysis :

The Drugs and Therapeutic Committee reviews the monthly
report, significant events, results of root cause analysis and
makes recommendations for improvements to the
medication use process.
Reporting and Categorization due to medication Errors:
Category Description Effect
Category A An error occurred that may have the capacity to No Error
cause error
Category B An Error occurred but the error did not reach the Error, but No Harm
patient
Category C An Error occurred that reached the patient but did Error, but No Harm
not cause patient harm
Category D An error occurred that reached the patient and Error, but No Harm
required monitoring to confirm that it resulted in no
harm to the patient and / or required intervention to
preclude harm
Category E An Error occurred that may have contributed to or Error + Harm
resulted in temporary harm to the patient and
required intervention
Category F An error occurred that may have contributed to or Error + Harm
resulted in temporary harm to the patient and
required initial or prolonged hospitalization

Category G An error occurred that may have contributed to or Error + Harm

resulted in permanent patient harm
Category H An error occurred that required intervention Error + Harm
necessary to sustain life
Category I An error occurred that may have contributed to or Error + Death
 DRUG RECALL PROCEDURE

To ensure the safety and quality of

pharmaceutical products, questionable quality
shall be immediately removed from the Pharmacy
and all the Patient care areas with proper
documentation.
The pharmacy will obtain notification of drug
recalls from a variety of sources including;
Pharmaceutical manufacturers and
Pharmaceutical distributors or by the Government
some times, internally observed problems like
colour changes, cluster formation, Turbidity may
lead the pharmacist to determine that certain drug
has been contaminated , or possibly
contaminated, and should be removed from
inventory.
 The pharmacist, may fill a drug recall form
and then approved by MEDICAL DIRECTOR.
The drug recall form circulated to all the
patient care areas, pharmacy sub stores.
The stocks are immediately sent to the
pharmacy (within 24 hrs) from the
pharmacy it will send to the distributors.
(Labeled as RECALL DRUG).
 DRUG RECALL FORM
Call No: (To be filled by the office)
Ward:
Date:
Time:
Name of the Drug:
Unit of issue/dose:
Reason for return:
Unused
Out dated/ Short Expiry
Damaged/ Broken
Explanation:

Patient Medication
Name of the Patient :
UHID :
Name of the drug :
Unit of issue/dose :
Reason for return :

Authorized by:
Ward In charge Nursing Supervisor Medical Director
 *DRUG
1. Unused (Unauthorized) 2. Out dated/ Short Expiry 3. Damaged/
Broken
FOR OFFICE USE ONLY

Received the drugs at pharmacy : Yes No

Name of the drug :
Unit of issue/dose :
Date & Time :
Name / Signature of the pharmacist:

Replaced drugs to ward nurse : Yes No

Name of the drug :
Unit of issue/dose :
Date & Time :
Name / Signature of the Nurse :
 Use of narcotic drugs and psychotropic
substances. MOM- 9 )
The hospital has a policy to treat the Narcotics
and Psychotropic drugs with extra precaution
to prevent any misuse
Appropriate license is obtained and renewed
every year before procuring Narcotic drugs
All Narcotics and Psychotropic Drugs shall be
stored under Secured double door Locks both
in pharmacy and in nursing stations under the
supervision of a nominated person.
Every prescription for narcotic drug contains
prescribers name, date, reg. no. along with the
name & doses of drug.
Narcotic stock is issued against the Narcotic
Prescription form with empty ampoules.
 Necessary entry in the stock register is made
which include the name of doctor, name of the
drug, batch no., date of issue, remaining stock
balance.
All such Logbooks will contain Seal:
Government, Drug Control Administration. Such
Records will be sent to Office of Drug Control
Administration for Seal. After obtaining the seal
such logbooks shall be used for documenting
the Receipts and issued
Information regarding losses, theft or any
breakage is given in writing to Medical director &
Can be written in incident register.
 Usage of chemotherapeutic
agents.MOM-10
Chemotherapeutic drugs shall be
dispensed only if prescribed by a
consultant authorized by the hospital to
do so.
Chemotherapy is administered by
qualified personnel.
Chemotherapy drugs are disposed off in
accordance with legal requirement.
 Usage of radioactive drugs.MOM-11

the safe storage, preparation, handling,

distribution, and disposal of radioactive
drugs.
Staff, patients and visitors are educated
on safety precautions.
 Use of implantable prosthesis and
medical devices. (MOM-12)
Usage of implantable prosthesis and medical devices is
guided by scientific criteria for each individual item and
national/international recognized guidelines/approvals
for such specificitem(s).
Documented policies and procedures govern
procurement, storage/stocking, issuance and usage of
implantable prosthesis and medical devices
incorporating manufacturer'srecommendation(s).
The implants are pre approved by the Clinical Head of
the user department.
The batch and serial number of the implantable
prosthesis and medical devices are recorded in the
patients medical record and the master master log
book.
OT PHARMACY
 Use of Medical Gases supplies
and consumables.mom-13
Medical gas procurement / Handling
Distribution
Safety & security
No Smoking zone
Preventive maintenance
 DRUG USAGE INSTRUCTIONS

1 - 1 -1 Review after 1 month

1 - 0 -1
0 - 0 -1

TID For 1 week next

BID For 4 days next
OD For 10 days

Monthly once
Alternative day

20 mg for 1 week next 10 mg for 1 month

 AMP: AMPULE
B.I.D: TWICE A DAY
CAP.: CAPSULE
G OR GM: GRAM
H.: HOUR
H.S: AT BEDTIME
IM: INTRAMUSCULAR
IV: INTRAVENOUS
M2: METER SQUARED
MG: MILLIGRAM
ML: MILLILITER
Q.I.D: FOUR TIMES A DAY
OD: ONCE A DAY.
STAT: IMMEDIATELY
SOS: As & When required.
SUBQ, SQ, SC, SUBCUT: SUBCUTANEOUS
SUSP.: SUSPENSION
T.I.D.: THREE TIMES A DAY
TAB: TABLET
TBSP.: TABLESPOON (15 ML)
TSP.: TEASPOON (5 ML)
WISH YOU ALL THE BEST FOR YOUR BRIGHT FUTURE
WISH HAPPY MOVEMENTS ALWAYS WITH
PHARMACY TEAM
Wish you healthy life