HOSPITAL PHARMACY

Prepared by:
Dr. Farman Ali Bozdar
Pharm-D, M.A Sociology,(MPhil)

CONTENTS
UNIT -I

Introduction to hospital pharmacy

1. Definition of Hospital and Hospital Pharmacy
--------------------------- 5
2. Goals for Hospital
Pharmacy------------------------------------------------ 6
3. Minimum Standard for Hospital Pharmacy
------------------------------- 8
3-1Administration ------------------------------------------------------ 6
3-2 Facilities -------------------------------------------------------------7
3-3 Drug distribution and control
-------------------------------------- 8
3-4 Drug information
---------------------------------------------------- 8

3-5 Rational drug

therapy------------------------------------------------ 9
3-6 Research -------------------------------------------------------------9
4. Role of Pharmacy Technician in Pharmaceutical
Services -------------12
5. Organizational Structure of Pharmacy Department
---------------------13
6. Pharmacy and Therapeutics Committee
----------------------------------20
6-1 Role or purposes of committee
-----------------------------------20
6-2 Organizations and Operation ------------------------------------21
6-3 Functions and Scope ---- -----------------------------------------22
7. The Hospital Formulary
-----------------------------------------------------23
7-1 Definition of formulary and formulary system --------------- 23
7-2 Benefits of the formulary system
---------------------------------23
7-3 Format and appearance of formulary
-----------------------------24

8. The five rights for correct drug administration

------------------------26
9. Unit review
--------------------------------------------------------------------28
UNIT II

Inpatient Pharmacy
1. Hospital Drug Distribution System
--------------------------------------- 30
1-1 Individual prescription order system
------------------------------ 32
1-2 Complete floor stock system
--------------------------------------- 33
1-3 Charge floor stock drugs and non-charge floor stock
drugs --- 34
1-4 Combination of Individual prescription order system
and
Complete floor stock system ---------------------------------------35
1-5 Unit dose system
----------------------------------------------------- 35
1-6 Unit dose dispensing procedure
------------------------------------ 37
2.Drug Distribution and Control (unit dose section)
--------------------- 40

2-1 Elements of distribution

------------------------------------------- 40
2-2 Writing the Order
---------------------------------------------------- 42
2-3 Medication Order Sheets ------------------------------------------ 43
2-4 Special Orders
------------------------------------------------------- 44
3.Dispensing of Controlled Substances
------------------------------------- 46
3-1 Definition of addict, administer, control substances,
depressant -and stimulant substances, narcotic drugs
------------ 46
3-2 Schedules for Controlled Substances
---------------------------- 48
Hospital Pharmacy
3
3-3 Prescriptions
--------------------------------------------------------- 49
4. Regulation of Hospital Controlled Substances
-------------------------- 50
4-1 Registration of doctors who can prescribe
------------------------ 50

4-2 Responsibility for controlled substances

-------------------------- 51
4-3 Preparation of orders, telephone and verbal orders
------------ 51
4-4 Information on daily controlled drug administration
sheet - ---- 51
4-5 Prescribing controlled drug in out patient department
----------- 52
4-6 Dispensing controlled drugs for home use
------------------------ 52
4-7 Procedure in case of waste, destruction,
contamination etc ----- 53
5. Prepacking
-------------------------------------------------------------------- 55
5-1 Definition and advantages of Prepacking
------------------------- 55
5-2 Factors considered in prepacking
--------------------------56
6. Sterile medication doses and I.V nutrition
------------------------------- 57
6-1Parenteral Hyperalimentation
---------------------------------------- 57
6-2 Intravenous additive program
--------------------------------------- 58

6-3 Preparation of I.V additive

solutions----------------------------- -- 59
6-4 Laminar flow hoods
-----------------------------------------------60
7. Emergency medication
----------------------------------------------------- 63
8. Unit review
------------------------------------------------------------------ 65
UNIT III

Out Patient Pharmacy

1- Definition of ambulatory-care, primary care, tertiary
care and
emergency care
----------------------------------------------------------------- 67
2- Minimum standard for ambulatory-care pharmaceutical
services ---- 69
3- Location of out-patient dispensing area
---------------------------------- 70
4-Types of prescriptions
received-------------------------------------------- 71
5-Dispensing routine
---------------------------------------------------------- 72
6- Inventory Control
----------------------------------------------------------- 77

7. Unit
review----------------------------------------------------------------------------- 80
References
------------------------------------------------------------------ 81
Hospital Pharmacy
4
UNIT -1
INTRODUCTION
TO HOSPITAL PHARMACY
Hospital Pharmacy
5
DEFINITION OF HOSPITAL AND HOSPITAL PHARMACY
Hospital
The hospital is a complex organization utilizing
combination of intricate,
specialized scientific equipment, and functioning
through a corps of
trained people educated to the problem of modern
medical science. These
are all welded together in the common purpose of
restoration and
maintenance of good health

Hospital Pharmacy
The department or service in a hospital which is under
the direction of a
professionally competent, legally qualified pharmacist,
and from which
all medications are supplied to the nursing units and
other services, where
special prescriptions are filled for patients in the
hospital, where
prescriptions are filled for ambulatory patients and
out-patients, where
pharmaceuticals are manufactured in bulk, where
narcotic and other
prescribed drugs are dispensed, where injectable
preparations should be
prepared and sterilized, and where professional supplies
are often stocked
and dispensed.
The computerization of the pharmacy department
makes it possible for
the staff to participate in patient education
programs, poison control
center activities, preparation of patient drug use
profiles, parenteral

nutrition program participation, cooperating in the

teaching and research
programs of the hospital, communicating new product
information to
nursing service and other hospital personnel and
dispensing
radiopharmaceuticals
Hospital Pharmacy
6
GOALS FOR HOSPITAL PHARMACY
Just as any organization must have long-range goals
toward which
its daily activities are directed, so must a profession,
its members, and
their representative societies. For example the
American Society of
Hospital Pharmacists, in its Constitution and Bylaws,
sets forth the
following objectives:
1. To provide the benefits of a qualified hospital
pharmacist to patients
and health care institutions, to the allied health
professions, and to the

profession of pharmacy.
2. To assist in providing an adequate supply of such
qualified hospital
pharmacists.
3. To assure a high quality of professional practice
through the
establishment and maintenance of standards of
professional ethics,
education, and attainments and through the
promotion of economic
welfare.
4. To promote research in hospital pharmacy practices
and in the
pharmaceutical sciences in general.
5. To disseminate pharmaceutical knowledge by providing
for
interchange of information among hospital pharmacists
and with
members of allied specialties and professions.
More broadly, the Society's primary purpose is the
advancement of
rational, patient-oriented drug therapy in hospitals
and other organized

health care settings.

Hospital Pharmacy
7
To the preceding can be added the following objectives:
1. To expand and strengthen institutional pharmacists'
abilities to:
(a) Effectively manage an organized pharmaceutical
service.
(b) Develop and provide clinical services.
(c) Conduct and participate in clinical and
pharmaceutical
research
(d) Conduct and participate in educational programs for
health
practitioners, students, and the public.
2. To increase the knowledge and understanding of
contemporary
institutional pharmacy practice by the public,
government,
pharmaceutical industry, and other health care
professionals.
3. To promote compensation and benefits
commensurate with

pharmacists responsibilities and contributions to patient

care.
4. To help provide an adequate supply of qualified
supportive personnel
for institutional pharmacy services.
5. To help ensure that health care reimbursement and
payment systems
do not inhibit the implementation of innovative
pharmaceutical
services or adversely reflect on institutional pharmacy
practice.
6. To assist in the development and advancement of
the pharmacy
profession.
The foregoing serves as a collective statement of goals of
the Society and
its constituency. Transforming these goals into realities
will require the
dedicated efforts of all institutional pharmacists, both as
individuals and
as members of the Society.
Hospital Pharmacy
8

MINIMUM STANDARD FOR HOSPITAL PHARMACY

Pharmaceutical services in institutions have numerous
components,
the most prominent being
(1) The procurement, distribution, and control of all
pharmaceuticals used within the facility.
(2) The evaluation and dissemination of
comprehensive
information about drugs and their use to the
institution's staff and
patients.
(3) The monitoring, evaluation, and assurance of the
quality of
drug use.
These functions are carried out in cooperation with
other
institutional departments and programs.
The primary function of this document is to serve as a
guide for the
development and provision of pharmaceutical services
in institutions. It
will also be useful in evaluating the scope and quality of
these services. It

does not, however, provide detailed instructions for

operating a
pharmacyother Society publications serve this function.
Standard 1: Administration
The pharmaceutical service shall be directed by a
professionally
competent, legally qualified pharmacist. He or she must
be on the same
level within the institution's administrative structure as
directors of other
clinical services. The director of pharmaceutical
services is responsible
for:
(1) Setting the long- and short-range goals of the
pharmacy based on
developments and trends in health care and
institutional pharmacy
practice and the specific needs of the institution.
(2) Developing a plan and schedule for achieving these
goals.
Hospital Pharmacy
9

(3) Supervising the implementation of the plan and

the day-to-day
activities associated with it.
(4) Determining if the goals and schedule are being met
and instituting
corrective actions where necessary.
The director of pharmaceutical services, in carrying out
these tasks,
shall employ an adequate number of completent and
qualified personnel
Standard II: Facilities
There shall be adequate space, equipment, and
supplies for the
professional and administrative functions of the
pharmacy.
The pharmacy shall be located in an area (or areas)
that facilitate (s)
the provision of services to patients. It must be integrated
with the
facility's communication and transportation systems.
Space and equipment, in an amount and type to
provide secure,
environmentally controlled storage of drugs, shall be
available.

There shall be designated space and equipment

suitable for the
preparation of sterile products and other drug
compounding and
packaging operations.
The pharmacy should have a private area for
pharmacist-patient
consultations. The director of pharmaceutical services
should also
have a private office or area.
Current drug information resources must be available.
These should
include appropriate pharmacy and medical journals and
texts and
drug literature search and retrieval resources.
Hospital Pharmacy
10
Standard III: Drug Distribution and Control
The pharmacy shall be responsible for the
procurement,
distribution, and control of all drugs used within the
institution. This

responsibility extends to drugs and related services

provided to
ambulatory patients. Policies and procedures
governing these functions
shall be developed by the pharmacist with input
from other involved
hospital staff (e.g. nurses) and committees (pharmacy
and therapeutics
committee, patient-care committee, etc.). In doing so, it
is essential that
the pharmacist routinely be present in all patientcare areas, establish
rapport with the personnel, and become familiar with
and contribute to
medical and nursing procedures relating to drugs.
Standard IV: Drug Information
The pharmacy is responsible for providing the institution's
staff and
patients with accurate, comprehensive information about
drugs and their
use and shall serve as its center for drug information.
Hospital Pharmacy
11

Standard V: Assuring Rational Drug Therapy

An important aspect of pharmaceutical services is
that of
maximizing rational drug use. In this regard, the
pharmacist, in concert
with the medical staff, must develop policies and
procedures for assuring
the quality of drug therapy.
Standard VI: Research
The pharmacist should conduct, participate in, and
support medical and
pharmaceutical research appropriate to the goals,
objectives, and
resources of the pharmacy and the institution.
Hospital Pharmacy
12
ROLE OF PHARMACY TECHNICIANS IN THE
PHARMACEUTICAL SERVICES
The pharmacist and pharmacy technician are important
professionals on
the healthcare team. The primary responsibility of the
pharmacist is to see

that drugs are dispensed properly and used appropriately.

The technician
assists the pharmacist in this endeavor. It has
become increasingly
important for pharmacist to focus their expertise and
judgment on direct
patient care and counseling. Accordingly,
responsibilities related to
dispensing have shifted to the pharmacy technician.
A pharmacy
technician is defined as an individual working in a
pharmacy who, under
the supervision of a licensed pharmacist, assists in
activities not requiring
the professional judgment of a pharmacist. The rules and
regulations that
set limits on the roles and responsibilities vary from
country to country.
Technicians are involved in all faces of drug distribution. A
few of their
responsibilities include:
receiving written prescriptions or requests for
prescription refills
from patients or their caregivers.

 verifying that the information on the prescription is

complete and
accurate.
counting, weighing, measuring, and mixing the
medication
preparing prescription labels and selecting the
container
establishing and maintaining patient profiles
ordering and stocking prescription and over-thecounter
medications
assisting with drug studies
taking prescriptions over the telephone
transferring prescriptions
tracking and reporting errors
tech check tech in preparation of medicine carts
Hospital Pharmacy
13
ORGANIZATIONAL STRUCTURE OF PHARMACY
DEPARTMENT
With the selection and categorizing of the
employees, it now

becomes essential to develop a chart showing the flow of

administrative
authority. Obviously, in the very small departments,
this is usually
generally understood and no problems arise. However, in
the large units
with assistant chief pharmacists, supervisors, and lay
personnel, authority
must be delegated by the chief pharmacist.
Sample distributions are depicted in Figures (1-1) and (12). Clearly this
can and should be tailored to meet the specific
requirements of the
department and hospital. Once prepared and
approved, it should be
conspicuously posted for each of the departmental
employees to read and
adhere to.
In large hospitals, departments of pharmacy have a
more complex
organization. Note for example, the Ohio State
University Hospital's
Department of Pharmacy organizational chart. It should
seem obvious to

the student that each of the subdivisions of the

department are assigned
specific responsibilities. The following are some of the
responsibilities of
each division.
Hospital Pharmacy
14
OUTPATIENT
DISPENSING
SUPERVISOR
MANUFACTURING
AND CONTROL
SUPERVISOR
INPATIENT
DISPENSING
SUPERVISOR
MESSENGER
ASSISTANT PHARMACIST IN-CHIEF
SECRETARU
CLERK
PHARMACY

RESIDENTS
PHARMACIST IN-CHIEF
ASSOCIATE DIRECTOR
Fig (1-1). Departmental organization
Hospital Pharmacy
15
ADMINISTRATIVE SERVICES
DIVISION
UNIT DOSE DISPENSING
AND
ADMINSTRATION
EDUCATION & TRANING
DIVISION
ASSOCIATE
DIRECTOR OF PHARMACY
DIRECTOR OF PHARMACY
PHARMMCEUTICAL
RESEARCH DIVISIONS
RESEARCH
PHARMACIST
RADIOPHARMACEUTICAL

DIVISIONS
PHARMACIST
SPECIALIST
RADIOPHARMACEUTICAL
DIVISIONS
DRUG INFORMATION
SERVICES
ASSISTANT
DIRECTOR OF PHARMACY
ASSAY & QUALITY
CONTROL DIVISION
DRUG INFORMATION
SERVICES
CENTRAL SUPPLY
DIVISION
ASSISTANT
DIRECTOR OF PHARMACY
IN-PATIENT SERVICES
DIVISION
OUT-PATIENT SERVICES
DIVISION

INTRAVENOUS
ADMIXTURE DIVISION
ASSISTANT
DIRECTOR OF PHARMACY
DEPARTMENTAL
SERVICES
PURCHASE AND
INVENTORY CONTROL
MANUFACTURING AND
PACKAGING
Fig (1-2). Departmental organization in a large university
hospital pharmacy operation
Hospital Pharmacy
16
Administrative Services Division
1. Plan and coordinate departmental activities.
2. Develop policies.
3. Schedule personnel and provide supervision.
4. Coordinate administrative needs of the Pharmacy and
Therapeutics
Committee.

5. Supervise departmental office staff.

Education and Training Division
1. Coordinate programs of undergraduate and
graduate pharmacy
students.
2. Participate in hospital-wide educational programs
involving nurses,
doctors etc.
3. Train newly employed pharmacy department
personnel.
Pharmaceutical Research Division
1. Develop new formulations of drugs, especially
dosage forms not
commercially available, and of research drugs.
2. Improve formulations of existing products.
3. Cooperate with the medical research staff of
projects involving
drugs.
In-Patient Services Division
1. Provide medications for all in-patients of the hospital
on a 24-hour
per day basis.

2. Inspection and control of drugs on all treatment areas.

3. Cooperate with medical drug research.
Hospital Pharmacy
17
Out-Patient Services Division
1. Compound and dispense out-patient prescriptions.
2. Inspect and control all clinic and emergency
service medication
stations.
3. Maintain prescription records.
4. Provide drug consultation services to staff and medical
students.
Drug Information Services Division
1. Provide drug information on drugs and drug
therapy to doctors,
nurses, medical and nursing students and the house staff.
2. Maintain the drug information center.
3. Prepare the hospital's pharmacy newsletter.
4. Maintain literature files.
Departmental Services Division
1. Control and dispense intravenous fluids.

2. Control and dispense controlled substances.

3. Coordinate and control all drug delivery and
distribution systems.
Purchasing and Inventory Control Division
1. Maintain drug inventory control.
2. Purchase all drugs.
3. Receive, store and distribute drugs.
4. Interview medical service representatives.
Hospital Pharmacy
18
Central Supply Services Division
1. Develop and coordinate distribution of medical
supplies and
irrigating fluids.
Assay and Quality Control Division
1. Perform analyses on products manufacturered and
purchased.
2. Develop and revise assay procedures.
3. Assist research division in special formulations.
Manufacturing and Packaging Division
1. Manufacture wide variety of items in common use at
the hospital.

2. Operate an overall drug packaging and prepackaging

program.
3. Undertake program in product development.
4. Maintain a unit dose program.
Sterile Products Division
1. Produce small volume parenterals.
2. Manufacture sterile ophthalmologic, irrigating solutions
etc.
3. Prepare aseptic dilution of lyophylizal and other
"unstable" sterile
injections for administration to patients.
Radiopharmaceutical Services division
1. Centralize the procurement, storage and dispensing
of radioisotopes
used in clinical practice.
Hospital Pharmacy
19
Intravenous Admixture Division
1. Centralize the preparation of intravenous solution
admixture.
2. Review each 1.V. admixture for physio-chemical
incompatibilities.

Hospital Pharmacy
20
PHARMACY AND THERAPEUTICS COMMITTEE
The multiplicity of drugs available and the
complexities surrounding
their safe and effective use make it necessary for
hospitals to have an
organized, sound program for maximizing rational
drug use. The
pharmacy and therapeutics committee, or its
equivalent, is the
organizational keystone of the program.
The pharmacy and therapeutics committee is an advisory
group of the
medical staff and serves as the organizational line of
communication
between the medical staff and pharmacy department.
This committee is
composed of physicians, pharmacists, and other
health professionals
selected with the guidance of the medical staff. It is
a policyrecommending body to the medical staff and the
administration of the

hospital on matters related to the therapeutic use of

drugs.
Role or purposes of committee
The primary purposes of the pharmacy and therapeutics
committee are
as specified in the following:
1. Advisory. The committee recommends the adoption
of, or assists in
the formulation of, policies regarding evaluation,
selection, and
therapeutic use of drugs in hospitals
2. Educational. The committee recommends or assists in
the formulation
of programs designed to meet the needs of the
professional staff
(physicians, nurses, pharmacists, and other health-care
practitioners)
for complete current knowledge on matters related to
drugs and drug
use.
Hospital Pharmacy
21
Organization and Operation

While the composition and operation of the pharmacy and

therapeutics
committee might vary from hospital to hospital, the
following generally
will apply:
1. The pharmacy and therapeutics committee should be
composed of
at least three physicians, a pharmacist, a nurse, and
an
administrator. Committee members are appointed by a
governing
unit or elected official of the organized medical staff.
2. A chairman from among the physician
representatives should be
appointed. A pharmacist usually is designated as
secretary.
3. The committee should meet regularly, at least six
times per year,
and more often when necessary.
4. The committee should invite to its meetings
persons within or
outside the hospital who can contribute specialized
or unique
knowledge, skills, and judgments.

5. An agenda and supplementary materials (including

minutes of the
previous meeting) should be prepared by the
secretary and
submitted to the committee member's insufficient time
before the
meeting for them to properly review the material.
6. Minutes of the committee meetings should be
prepared by the
secretary and maintained in the permanent records of the
hospital.
7. Recommendations of the committee shall be
presented to the
medical staff or its appropriate committee for
adoption or
recommendation.
8. Liaison with other hospital committees concerned
with drug use
(e.g., infection control, medical audit) shall be
maintained.
Hospital Pharmacy
22
Functions and Scope

The basic organization of the hospital and medical staffs

will determine
the functions and scope of the pharmacy and
therapeutics committee.
The following list of committee functions is offered as a
guide:
1. To service in an advisory capacity to the medical staff
and hospital
administration in all matters pertaining to the use of
drugs
(including investigational drugs).
2. To develop a formulary of drugs accepted for use in the
hospital
and provide for its constant revision. The selection of
items to be
included in the formulary will be based on objective
evaluation of
their relative therapeutic merits, safety, and cost. The
committee
should minimize duplication of the same basic drug
type drug
entity, or drug product.
3. To establish programs and procedures that help
ensure costeffective drug therapy.

4. To establish or plan suitable educational, programs

for the
hospital's professional staff on matters related to drug
use.
5. To participate in quality-assurance activities related
to the
distribution, administration, and use of medications.
6. To review adverse drug reaction occurring the hospital.
7. To initiate (or both) drug-use review programs and
studies and
review the results of such activities.
8. To advise the pharmacy in the implementation of
effective drug
distribution and control procedures.
9. To make recommendations concerning drugs to be
stocked in
hospital patient-care areas.
Hospital Pharmacy
23
THE HOSPITAL FORMULARY
Definition of formulary and formulary system
The formularyis a continually revised compilation of
pharmaceuticals

(plus important ancillary information) that reflects the

current clinical
judgment of the medical staff.
The formulary system is a method whereby the
medical staff of an
institution, working through the pharmacy and
therapeutics committee,
evaluates, appraises, and selects from among the
numerous available drug
entities and drug products those that are considered most
useful in patient
care. Only those so selected are routinely available from
the pharmacy.
The formulary system is thus an important tool for
assuring the quality of
drug use and controlling its cost.
The formulary system provides for the procuring,
prescribing,
dispensing, and administering of drugs under either their
nonproprietary
or proprietary names in instances where drugs have both
names
Benefits of the formulary system

The potential benefits of a formulary system are

threefold:
(l) Therapeutic. (2) Economic. (3) Educational.
The therapeutic aspect of a formulary system
provides the greatest
benefit to the patient and physician in that only the
most efficient
products are listed and available.
The economic merit also has a double benefit in that
the formulary
eliminates duplication thus reducing inventory
duplication and the
opportunity for volume purchasing means lower charges
to the patient.
The educational benefit is also significant for the resident
staff, nurses
and medical students because many good formularies
contain various
prescribing tips and additional drug information of
educational value.
Hospital Pharmacy
24
Format and appearance of the formulary

The physical appearance and structure of the formulary is

an important
influence on its use. Although elaborate and
expensive artwork and
materials are unnecessary, the formulary should be
visually pleasing,
easily readable, and professional in appearance.
The need for proper grammar, punctuation, correct
spelling, and
neatness is obvious. There is no one single format
or arrangement
which ail formularies must follow.
A typical formulary must have the following composition:
1. Title page
2. Names and titles of the members of the pharmacy and
therapeutics
committee
3. Table of contents
4. Information on hospital policies and procedures
concerning drugs
4.1 The pharmacy and therapeutics committee of XYZ
hospital
4.2 Objectives and operation of the formulary system

4.3 Hospital regulations and procedures for prescribing

and
dispensing drugs
4.4 Hospital pharmacy services and procedures
4.5 How to use the formulary
5. Products accepted for use at XYZ hospital
5.1 Items added and deleted since the previous edition
5.2 Generic-brand name cross reference list
5.3 Pharmacological/therapeutic index with relative cost
codes.
5.4 Descriptions of formulary drug products by
pharmacology
therapeutic class
Hospital Pharmacy
25
6. Appendix
6.1 Central service equipment and supply list
6.2 Rules for calculating pediatric doses
6.3 Nomogram for estimating body surface area
6-4 Schedule of standard drug administration times
Several techniques can be used to improve the
appearance and ease of

use of the formulary. Among these are:

1. Using a different color paper for each section of the
formulary,
2. Using an edge index,
3. Making the formulary pocket size (approximately 4" x
7") and
4. Printing the generic name heading of each drug entry
in boldface
type or using some other methods for making it stand out
from the rest
of the entry.
Hospital Pharmacy
26
THE FIVE RIGHTS FOR CORRECT DRUG ADMINISTRATION
There are five rights of medication administration
that offer useful
guidelines when filling prescriptions for patient
medications. These
concepts have been widely used to avoid medication
errors. A drug
misadventure occurs whenever these are not followed
correctly.

Figure (1-3) illustrates the concepts, and the five

rights are
overviewed below.
Right PatientAlways verify the patient name before
dispensing
medicines
Right Drug Always check the medication against
the original
prescription and the patients disease state. The
medication label
contains important information about the drug that
will be
dispensed to the patient.
Right Strength Check the original prescription for
this
information and pay attention to the age of the patient.
Pediatric or
elderly patient can easily get the wrong dose.
Right Route Check that the physicians order agrees
with the
drugs specified route of administration. Many
medications can be
given by a variety of routes and the route of
administration can

affect the medications absorption.

Right Time Check the prescription to determine the
appropriate
time for the medication to be administrated. Some
medications
must be taken on an empty stomach (one hour before or
two hours
after a meal) while others should be taken with food.
Sometimes, a
certain time span is needed between doses to
maintain a
therapeutically effective blood level.
Hospital Pharmacy
27
Figure (1-3). The five rights for correct drug
administration
Hospital Pharmacy
28
Unit review
1- Define Pharmacy Technician
-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

------------------------2- Briefly discuss, Role of Pharmacy

Technician in Pharmaceutical
Services
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------3- What are the main goals
for hospital pharmacy?
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------4- What is the role of
Therapeutics Committee?
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------5- What Hospital Formulary?
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------6- Explain, the Organizational Structure of
Pharmacy Department
-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

------------------------7- What areThe Five Rights for Correct

Drug Administration?
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------Hospital Pharmacy
29
UNIT - II
IN-PATIENT PHARMACY
Hospital Pharmacy
30
HOSPITAL DRUG DISTRIBUTION SYSTEM
Traditional methods of distributing drugs in hospitals are
now undergoing
reevaluation, and considerable thought and activity is
being directed
toward the development of new and improved drug
distribution systems.
Some of the newer concepts and ideas in connection with
hospital drug
distribution systems are centralized or decentralized
(single, or unit-dose)

dispending, automated (mechanical and/or electronic)

processing of
medication orders and inventory control, and
automated (mechanical
and/or electronic) storage and delivery devices. Several
investigators are
at work in each of these areas, and the results of their
studies may greatly
alter current practices and procedures.
Because of the present state of uncertainty regarding
the proper
scope and optimum design of drug distribution
systems for the modern
hospital, and as an aid to pharmacists, nurses,
physicians, and
administrators who are faced with making decisions
concerning drug
distribution systems during this period of change, the
following
guidelines for evaluating proposed changes or new ideas
or equipments
are presented.
Though some of the practices recommended may not
be

widespread at the present, the adoption of these

practices is believed to be
a desirable and practical goal. Therefore, it is urged
that they be given
prime consideration in the design of new drug distribution
systems and in
modifications of existing ones (particularly where
such changes would
commit a hospital to a considerable financial investment
in a system not
including, or not easily altered to include, the
recommended practices).
1. Before the initial dose of medication is administered
the pharmacist
should review the prescribers original order or a direct
copy.
Hospital Pharmacy
31
2. Drugs dispensed should be as ready for
administration to the
patient as the current status of pharmaceutical
technology will
permit, and must bear adequate identification
including (but not

limited to); name or names of drug, strength or potency,

routes(s)
of administration, expiration date, control number, and
such other
special instructions as may be indicated.
3. Facilities and equipment used to store drugs should be
so designed
that the drugs are accessible only to medical
practitioners
authorized to prescribe, to pharmacists authorized to
dispense, or to
nurses authorized to administer such drugs.
4. Facilities and equipment used to store drugs should be
designed to
facilitate routine inspection of the drug prior to the
time of
administration.
5. When utilizing automated (mechanical and/or
electronic) devices
as pharmaceutical tools, it is mandatory that provision be
made to
provide suitable pharmaceutical services in the event of
failure of
the device.

6. Such mechanical or electronic drug storage and

dispensing devices,
as require or encourage the repackaging of drug dosage
forms from
the manufacturers original container, should permit and
facilitate
the use of new package, which will assure the stability of
each drug
and meet the standards for the packaging and storing of
drugs, in
addition to meeting all other standards of good pharmacy
practice.
7. In considering automated (mechanical and/or
electronic) devices as
pharmaceutical tools, the distinction between the
accuracy required
in accounting practices versus that required in dispensing
practices
should be clearly distinguished.
Hospital Pharmacy
32
There are four systems in general use for dispensing
drugs for inpatients.
They may be classified as follows:

(i) Individual Prescription Order System.

(ii) Complete Floor Stock System.
(iii) Combination of (i) and (ii).
(iv) The unit dose method.
Individual prescription order system
As has been previously stated, this system is generally
used by the small
and/or private hospital because of the reduced manpower
requirement and
the desirability for individualized service.
Inherent in this system is the possible delay in
obtaining the required
medication and the increase in cost to the patient.
Advantages of this system:
(i) All medication orders are directly reviewed by the
pharmacist.
(ii) Provides for the interaction of pharmacist, doctor,
nurse and
patient.
(iii) Provides closer control of inventory.
Hospital Pharmacy
33

Complete floor stock system

Under this system, the nursing station pharmacy
carries both charge
and non-charge patient medications. Rarely used or
particularly
expensive drugs are omitted from floor stock but are
dispensed upon the
receipt of a prescription or medication order for the
individual patient.
Although this system is used most often in
governmental and other
hospitals in which charges are not made to the patient
or when the allinclusive rate is used for charging, it
does have applicability to the
general hospital. Obviously, there are both advantages
and disadvantages
to the complete floor stock system.
Advantages of complete floor stock system:
(i) Ready availability of the required drugs.
(ii) Elimination of drug returns.
(iii) Reduction in the number of drug order transcriptions
for the
pharmacy.

(iv) Reduction in the number of pharmacy personnel

required.
Disadvantages of complete floor stock system:
(i) Medication errors may increase because the
review of
medication orders is eliminated.
(ii) Increased drug inventory on the pavilions.
(iii) Greater opportunity for pilferage.
(iv) Increased hazards associated with drug deterioration.
(v) Lack of proper storage facilities on the ward may
require
capital outlay to provide them.
(vi) Greater inroads are made upon the nurse's time.
To be borne in mind by the student is the fact that in
some hospitals the
complete floor stock system is successfully operated
as a decentralized
pharmacy under the directsupervision of a pharmacist.
Hospital Pharmacy
34
Obviously, when this occurs, many of the disadvantages
associated with

such a system disappear. In addition, the use of the

decentralized
pharmacy concept provides for a "home base" for the
clinically oriented
pharmacist.
In the past, floor stock containers were pre-labeled
multiple dose units.
Today, the floor stock is in unit-of-use packaging thereby
assuring better
packaging, control and identity of the medication.
Charge floor stock drugs and non-charge floor stock drugs
Each pavilion in the hospital, regardless of its size or
specialty
care, has a supply of drugs stored in the medicine cabinet
even though the
nursing unit is serviced by a unit dose system. However,
the use of floor
stock medications should be minimized. In addition,
research has shown
that the system of drug distribution has an effect upon
the incidence of
adverse drug reactions. These medications may be
classified under two

separate headings, each of which serves a specific

purpose. Drugs on the
nursing station may be divided into charge floor stock
drugs and noncharge floor stock drugs.
Definitions
Charge floor stock drugsmay be defined as those
medications that are
stocked on the nursing station.
Charge floor stock drugs represent that group of
medications that are
placed at the nursing station.
It is the responsibility of the hospital pharmacist,
working in
cooperation with the nursing service, to develop
ways and means
whereby adequate supplies of each are always on hand
and, in appropriate
situation that proper charges are made to the patients
account.
Hospital Pharmacy
35
Combination of Individual prescription order system and
complete

floor stock system

Falling into this category are those hospitals which
use the individual
prescription or medication order system as their
primary means of
dispensing, but also utilize a limited floor stock. This
combination system
is probably the most commonly used in hospitals today
and is modified to
include the use of unit dose medications.
Unit dose system
Unit-dose medications have been defined as:
Those medications which are ordered, packaged,
handled, administered
and charged in multiples of single dose units containing a
predetermined
amount of drugs or supply sufficient for one regular dose
application or
use.
Advantages of unit dose system:
(1) Patients receive improved pharmaceutical service
24 hours a
day and are charged for only those doses, which are

administered to them.
(2) All doses of medication required at the nursing
station are
prepared by the pharmacy thus allowing the nurse
more time
for direct patient care.
(3) Allow the pharmacists to interpret or check a
copy of the
physicians original order thus reducing medication
errors.
(4) Elimination excessive duplication of orders and paper
work at
the nursing station and pharmacy.
(5) Eliminates credits.
(6) Transfers intravenous preparation and drug
reconstitution
procedures to the pharmacy.
Hospital Pharmacy
36
(7) Promotes more efficient utilization of professional
and nonprofessional personnel.
(8) Reduces revenue losses.

(9) Conserves space in nursing units by eliminating

bulky floor
stock.
(10) Eliminates pilferage and drug waste.
(11) Extends pharmacy coverage and control
throughout the
hospital from the time the physician writes the order to
the time
the patient receives the unit-dose.
(12) Communication of medication orders and delivery
systems
are improved.
(13) The pharmacists can get out of the pharmacy
and onto the
wards where they can perform their intended function as
drug
consultants and help provide the team effort that is
needed for
better patient care.
Fig (2-1) A full range of unit dose packaging equipment
Hospital Pharmacy
37
Unit dose dispensing procedure

The characteristic features of centralized unit-dose

dispending are that all
in-patient drugs are dispensed in unit-doses and all the
drugs are stored in
a central area pharmacy and dispensed at the time the
dose is due to be
given to the patient. To operate the system
effectively, electronic data
processing equipment is not required, however delivery,
systems such as
medication carts and dumbwaiters are needed to get the
unit-doses to the
patients; also suction tube system (called pneumatic
tube) or other means
are required to send a copy of the physicians original
medication order to
the pharmacy for direct interpretation and filling.
The decentralized unit-dose system, unlike the
centralized system,
operates through small satellite pharmacies located on
each floor of the
hospital. The main pharmacy in this system becomes
a procurement,

storage, manufacturing and packaging center serving all

the satellites.
The delivery system is accomplished by the use of
medication carts.
This type of system can be used for a hospital with
separate buildings or
old delivery systems.
Fig (2-2) nursing cart for use in unit dose system
Hospital Pharmacy
38
Although each hospital introduces variations, the
following is a step-bystep outline of the procedure
entailed in a decentralized unit-dose system:
1-Upon admission to the hospital, the patient is entered
into the system.
Diagnosis, allergies and other pertinent data are entered
on to the Patient
Profile card.
2-Direct copies of medication orders are sent to the
pharmacist.
3-The medications ordered are entered on to the Patient
Profile card.
4-Pharmacist chicks medication order for allergies,
drug interactions,

drug-laboratory test effects and rationale of therapy.

5- Dosage scheduled is coordinated with the nursing
station.
6- Pharmacy technician picks medication orders. Placing
drugs in bins of
a- Transfer cart per dosage schedule fig. (2-2) and (2-3).
7- Medication cart is filled for particular dosage schedule
delivery.
8- Pharmacist checks cart prior to release.
9-The nurse administers the medication and makes
appropriate entry on
her medication record.
10-Upon returns to the pharmacy, the cart is rechecked.
11-Throughout the entire sequence, the pharmacist is
available for
consultation by the doctors and nurses. In addition
he is maintaining
surveillance for discontinued orders.
Hospital Pharmacy
39
Fig (2-3) Nursing cart for use in unit dose system
Hospital Pharmacy

40
DRUG DISTRIBUTION AND CONTROL
(UNIT DOSE SECTION)
Medication distribution is the responsibility of the
pharmacy. The
pharmacist, with the assistance of the pharmacy and
therapeutics
committee and the department of nursing, must
develop comprehensive
policies and procedures that provider for the safe
distribution of all
medications and related supplies to inpatients and
outpatients.
For reasons of safety and economy, the preferred
method to distribute
drugs in institutions is the unit dose system. Though the
unit dose system
may differ in form depending on the specific needs,
resources, and
characteristics of each institution, for elements are
common to all.
Elements of unit dose distribution:
(1) Medications are contained in, and administered
from, single unit or

unit-dose packages
(2) Medications are dispensed in ready-to-administer
form, to the extent
possible
(3) For most medications, not more than a 24-hour
supply of doses is
provided to or available at the patient care area at any
time
(4) A patient medication profile is concurrently
maintained in the
pharmacy for each patient. Floor stocks of drugs are
minimized and
limited to drugs for emergency use and routinely used
safe items such
mouthwash and antiseptic solutions.
Hospital Pharmacy
41
Fig (2-4). Daily controlled drugs administration form
Hospital Pharmacy
42
Writing the Order:
Medications should be given (with certain specified
exceptions) only on

the writtenorder of a qualified physician or other

authorized prescriber.
Allowable exceptions to this rule (i.e., telephoned or
verbal orders)
should be put in written form immediately and the
prescriber should
countersign the nurses or pharmacists signed record
of these orders
within 48 (preferably 24) hours. Only a pharmacist or
registered nurse
should accept such orders. Provision should be made to
place physicians
order in the patients chart, and a method for sending this
information to
the pharmacy should be developed.
Prescribers should specify the date and time
medication orders are
written.
Medication orders should be written legibly in ink and
should include:
Patients name and location (unless clearly indicated on
the
order sheet).
Name (Generic) of medication.

Dosage expressed in the metric system, except in

instances
where dosage must be expressed otherwise (i.e., units,
etc)
Frequency of administration.
Route of administration.
Signature of the physician.
Date and hour the order was written.
Any abbreviations used in medication orders should
be agreed to and
jointly adopted by the medical, nursing, pharmacy, and
medical records
staff of the institution.
Any questions arising from a medication order,
including the
interpretation of an illegible order, should be refer to
the ordering
Hospital Pharmacy
43
physician. It is desirable for the pharmacist to make
(appropriate) entries
in the patients medical chart pertinent to the patients
drug therapy. Also,

a duplicate record of the entry can be maintained in the

pharmacy profile.
In computerized patient data systems, each prescriber
should be assigned
a unique identifier; this number should be included
in all medication
orders. Unauthorized personnel should not be able to
gain assess to the
system.
Medication Order Sheets:
The pharmacist (except in emergency situations)
must receive the
physicians original order or a direct copy of the order
before the drug is
dispensed. This permits the pharmacist to resolve
questions or problems
with drug order before the drug is dispensed and
administered. It also
eliminates errors, which may arise when drug orders are
transcribed onto
another form for use by the pharmacy. Several
methods by which the
pharmacy may receive physicians original orders or
direct copies are:

1. Self-copying order forms. The physicians order

form is
designed to make a direct copy (carbon or NCR), which is
sent to
the pharmacy. This method provides the pharmacist
with a
duplicate copy of the order and does not require special
equipment.
There are two basic formats:
a. Orders for medications included among treatment
orders.
Use of this form allows the physician to continue
writing his
orders on the chart as he has been accustomed in
the past,
leaving all other details to hospital personnel.
b. Medication orders separated from other treatment
orders on
the order form. The separation of drug orders makes it
easier for
the pharmacist to review the order sheet.
Hospital Pharmacy
44

2. Electromechanical. Copying machines or similar

devices may be
used to produce and exact copy of the physicians order.
Provision
should be made to transmit physicians orders to the
pharmacy in
the event of mechanical failure.
3. Computerized. Computer systems in which the
physician enters
orders into a computer, which then stores and prints out
the order
in the pharmacy or elsewhere, are used in some
institutions. Any
such system should provide for the pharmacists
verification of any
drug orders entered into the system by anyone other
than an
authorized prescriber.
Special Orders:
Special Orders (i.e., stat and emergency orders,
and those for
nonformulary drugs, investigational drugs, restricteduse drugs or

controlled substances) should be processed according to

specific written
procedures meeting all applicable regulations and
requirements.
Hospital Pharmacy
45
Fig. (2-5). Monthly controlled drug inventory form
Hospital Pharmacy
46
DISPENSING OF CONTROLED SUBSTANCES
Definitions:
Addict:Any individual who habitually uses any narcotic
drug so as
to endanger the public morals, health, safety or welfare,
or who is so far
addicted to the use of narcotic drugs as to have lost
the power or selfcontrol with reference to his addiction.
Administer:The direct application of a controlled
substances to the
body of a patient or research subject by a practitioner or
his agent or by
the patient or research subject at the direction and in the
presence of the

practitioner.
Controlled Substances: A drug or other substance, or
immediate
precursor, included in schedule I, II, III, IV or V of Part B of
this title.
The term dose not includes distilled spirits, wine,
malt beverages or
tobacco.
Depressant Or Stimulant Substance:
[A] a drug which contain any quantity of (1) barbituric
acid or any of the
salts of barbituric acid; or (2) any derivative of barbituric
acid ;or
[B] a drug which contains any quantity of (1)
amphetamine or any of its
optical isomers; (2) any salt of amphetamine or any
salt of an optical
isomer of amphetamine; or (3) any substance which
the Attorney
General, after investigation, has found to be, and by
regulation designated
as habit-forming because of its stimulant effect on
the central nervous
system; or

[C] Lysergic acid diethylamide; or

[D] any drug which contains any quantity of a
substance which the
Attorney General, after investigation, has found to
have, and by
regulation designated as having, a potential for
abuse because of its
depressant or stimulant effect on the central nervous
system or its
hallucinogenic effect.
Hospital Pharmacy
47
Narcotic Drug:means any of the following, whether
produced
directly or indirectly by extraction from substances of
vegetable origin, or
independently by means of chemical synthesis, or by
a combination of
extraction and chemical synthesis.
[A] Opium, coca leaves and opiates.
[B] A compound, manufacture, salt, derivative, or
preparation of opium,
coca leaves or opiates.

[C] A substance (any compound, manufacture, salt,

derivative, or
preparation thereof) which is chemically identical with
any substance
referred to in [A] or [B] above. Excluded are decocainized
coca leaves or
extracts of coca leaves, which do not contain cocaine or
ecgonine.
Hospital Pharmacy
48
SCHEDULES FOR CONTROLLED SUBSTANCES
(1) SCHEDULE I
[A] The drug or other substance has a high potential for
abuse.
[B] The drug or other substance has no currently
accepted medical use in
treatment in the (United States).
[C] There is a lack of accepted safety for use of the
drug or other
substance under medical supervision.
(2) SCHEDULE II
[A] The drug or other substance has a high potential for
abuse.

[B] The drug or other substance has recurrently accepted

medical use in
treatment in the (United States) or a currently accepted
medical use with
severe restrictions.
[C] Abuse of the drug or other substances may lead
to severe
psychological or physical dependence.
(3) SCHEDULE III
[A] The drug or other substance has a potential for
abuse less than the
drug or other substances in schedules I and II.
[B] The drug or other substance has a currently accepted
medical use in
treatment in the (United States).
[C] Abuse of the drug or other substances may lead to
moderate or low
physical dependence or high psychological dependence.
(4) SCHEDULE IV
[A] The drug or other substance has a low potential for
abuse relative to
the drug or other substances in schedules III.

[B] The drug or other substance has a currently accepted

medical use in
treatment in the (United States).
[C] Abuse of the drug or other substances may lead to
limited physical
dependence or psychological dependence relative to
the drugs or other
substances in schedule III.
(5) SCHEDULE V
[A] The drug or other substance has a low potential for
abuse relative to
the drugs or other substances in schedules IV.
[B] The drug or other substance has a currently accepted
medical use in
treatment in the (United States).
[C] Abuse of the drug or other substances may lead to
limited physical
dependence or psychological dependence relative to
the drugs or other
substances in schedule IV.
Hospital Pharmacy
49
PRESCRIPTIONS

In dispensing of controlled substances, the following

requirements should
be considered with prescriptions:
1. Except when dispensed
2. Drugs may be dispensed on the oral prescription
in an emergency
situation.
3. Prescription shall be retained in conformity with the
requirements of
this law.
4. No prescription for a controlled substance in
Schedule II may be
refilled.
5. Controlled substances in Schedule III or IV may
not be dispensed
without a written or oral prescription in conformity.
6. Such prescriptions may not be filled or refilled
more than 6 months
after the date thereof or be refilled more than 5 times
after the date of the
prescription unless renewed by the practitioner.
7. No controlled substance in Schedule V that is a
drug may be

distributed or dispensed other than for a medical

purpose.
Prescriptions filled with controlled substances in
Schedule II may be
written in ink or indelible pencil and must be signed by
the practitioner
issuing them. Prescriptions for narcotic substances in
Schedules III, IV
and V, must be kept in a separate file.
Hospital Pharmacy
50
REGULATIONS OF HOSPITAL CONTROLLED SUBSTANCES
Definitions:
1. Order: The direction for the drug, strength and
frequency of
administration as written on the Doctors Order Sheet
of the patients
Medical Record.
2. Prescription:The direction for the drug, strength,
quantity, and
frequency of administration as written on a prescription
blank by a doctor
for dispensing by the Pharmacy.

3. Administer:The word administer is employed

when a nurse or
other properly qualified individual gives medication to a
patient, pursuant
to the order of a qualified practitioner.
4. Dispense:The word dispense is employed when
a pharmacist
gives medication to a nurse or other properly
qualified individual in
accord with the directions of a properly written
prescription.
5. Doctor:This term is herein employed to indicate and
individual who
has qualified for and has received a number from the
Drug Enforcement
Agency.
Registration of doctors who can prescribe
Doctors (Practitioners), in order to prescribe narcotics
for or order
administered (dispensed) to their patients in the hospital,
must be licensed
to practice under the laws of the (state) and must be duly
registered with
the DEA.

INTERNS and RESIDENTS

Registration requirements were waived to allow interns
and residents
to dispense and prescribe controlled substances under
the registration of
the hospital by which they are employed.
Hospital Pharmacy
51
Responsibility for controlled substances
The administrative head of the hospital is responsible
for the proper
safeguarding and the handling of controlled
substances within the
hospital. Responsibility for the purchase, storage,
accountability and
proper dispensing of bulk controlled substances within
the hospital is
delegated to the Pharmacist-in-Chief. The Head Nurse of a
nursing unit is
responsible for the proper storage and use of the nursing
units controlled
substances.
Preparation of orders

All controlled substances orders and records must be

typed or written
in ink or indelible pencil and signed in ink or indelible
pencil.
Telephone orders
A doctor may order a controlled drug by telephone in
case of necessity.
The nurse will write the order on the doctor's order sheet,
stating that it is
a telephone order and will sign the doctor's name and her
own initials.
The controlled drug may then be administered at once.
The order must
then be signer by the doctor with either his signature or
his initials within
24 hours.
Verbal orders
A verbal order may be given by a doctor in an extreme
emergency where
time does not permit writing the order. The nurse must
write the order on
the doctors order sheet. The doctor must sign the order
with either his
signature or his initials within 24 hours.

Information on daily controlled drug administration sheet

The full information required on the Daily Controlled
Drugs
Administration Sheet is as follows:
1. Date.
2. Amount given.
3. Patients full name
4. Patients hospital number.
5. Name of doctor ordering.
6. Signature of nurse administering.
The following information is requested for auditing
purposes and is not
required by Federal law:
1. Number of tablets or ml administered
2. Filing out inventory column (to be retained for
Pharmacy).
Hospital Pharmacy
52
Prescribing controlled drug in out patient department
Prescriptions for Schedule II and other controlled
substances drugs

may be dispensed from Pharmacy and must include the

following
information.
a. Patient s full name
b. Patients address or hospital number
c. Date
d. Name and strength of drug prescribed.
e. Quantity of drug to be dispensed
f. DEA number and signature of physician
g. Frequency and route of administration
The prescription must be written in ink or indelible pencil
and shall not
bear cross outs or erasures. Discharge prescriptions for
Schedule II drugs
must be picked up by a registered nurse.
Dispensing controlled drugs for home use
Occasionally patients who require drugs for use at
home are
discharged from the hospital or released from The
Emergency Ward
during hours when the Pharmacy is closed. Whenever
possible, a

prescription signed by a member of the staff who

has a License to
practice medicine and a DEA number should be obtained.
A staff physician whose DEA number is issued to an
outside office
should use his own prescription blank. If this is not
available, then he
must insert his office address on the hospital prescription
blank. This will
permit the patent or his relative to purchase the
drugs at an outside
pharmacy. If no physician is available, or during
hours when the local
pharmacies are closed, the following procedure is
allowed, but only as an
EMERGENCY MEASURE:
Hospital Pharmacy
53
The attending doctor will calculate the smallest
amount of the drug
necessary to treat the patient until the Pharmacy opens.
He will write a
prescription for this amount and the nurse may dispense
the medication

from her stock supply. The prescription will be presented

to the pharmacy
the following morning for replacement of stock.
Procedure in case of waste, destruction, contamination
etc
1. Aliquot Part of Narcotic Solutions Used for Dose:
The nurse shall use the proper number of tablets or
ampoules from
nursing stock. She shall record the number of tablets or
ampoules used
and the dose given in the proper columns on Daily
Controlled Drugs
Administration Form. She shall, in arriving at the
proper aliquot part,
expel into the sink that portion of the solution that is not
used.
2. Prepared Dose refused by Patient or Cancelled by
Doctor:
When a dose has been prepared for a patient but
not used, due to a
refused by the patient or because of cancellation by the
doctor, the nurse
shall expel the solution into the sink and record why
the drug was not

administered. Examples: "Discarded," "Refused by

patient" or "order
cancelled by Dr. _____." The head nurse of the unit shall
countersign the
statement.
3. Accidental Destruction and Contamination of Drugs:
When a solution, ampoule, tablet etc., is accidentally
destroyed or
contaminated on a Nursing Unit, The person responsible
shall indicate the
loss on figure (2-4).
Hospital Pharmacy
54
Fig (2-6). Controlled Substance Loss or Form
Hospital Pharmacy
55
PREPACKING
Prepackaging of drugs is not a new concept to the
profession of
pharmacy. It has been in practice since the apothecary of
old grew
his own herbs and drugs and harvested and
packaged them for

sale. Many retail pharmacies purchase various overthe-counter

tablets and syrups in bulk quantities and prepackage the
material
in smaller-sized containers.
In the hospital pharmacy, the concept of prepackaging is
utilized
in both the large and the small hospital for it is,
oftentimes, the
means of coping with the periods of peak demand
for
pharmaceutical service. In the small hospital, the
pharmacist may
prepackage only those items which he considers require
too much
time if filled only when called for. In some hospital
pharmacies,
items, which fall into this category, are narcotics,
barbiturates oily
products, heavy syrups or magmas.
Most large hospitals have found it economical to
prepackage all
ward stock items as well as the often-prescribed tablets;
capsules,

syrups, ointments and creams used both by the inpatients as well

as the outpatient clinics. Because of the scope of thus
phase of a
large hospital pharmacy operation, it often requires a
separate
work force, special equipment, and detailed control
procedures to
ensure against the possibility of errors.
Hospital Pharmacy
56
Factors considered in prepacking
a. Demand for the product.
Is it a year 'round demand or is it a seasonal demand?
Is the demand one, which originates from the clinics or
the pavilions?
Can this product be purchased in quantities to meet the
demand,
yet have it packaged in small units by the manufacturer
at a price
lower than the hospital cost to prepackage the same
item in a
similar container?

b. What size units shouldbe packaged? How many of each

size?
c. What type of containers and closures must be used in
order to
maintain therapeutic integrity?
d. What special labeling will be required?
e. Can the item be machine packaged or must
handcounting be
resorted to?
f.What is the stability of the product? Is it dated?
g.What will the unit cost of prepackaging amount to?
Who
should pay it?
Hospital Pharmacy
57
STERILE MEDICATION DOSES AND I.V NUTRITION
Parenteral Hyperalimentation
Parenteral hyperalimentation is the intravenous
administration of
sufficient nutrients above the usual basal
requirements to achieve
tissue synthesis, positive nitrogen balance and anabolisin.

0
The preparation of parenteral hyperalimentation
solutions must be
considered as an integral part of the pharmacy
department's manufacturing program irrespective of
its size. The procedures employed are
not unduly complicated and do not require extensive
capital outlay for
equipment.
Most hospital pharmacists prepare these solutions by
using a technique
described as the "wet method" through the
extemporaneous compounding techniques of an
intravenous admixture program.
10
This consists of mixing the dextrose solution from
one flask with the fibrin
hydrolysate solution in anotherflask utilizing a solution
transfer set. In
the "dry method" the pharmacist adds the
appropriate amount of
anhydrous glucose to the fibrin hydrolysate solution.
Both
methods must be carried out under a laminar flow hood.

Because of the nature of these products, the pharmacy

must have
available appropriate refrigeration equipment and the
pharmacist
must become familiar with membrane filtration processes
in view
of the fact that the heat associated with the normal
sterilization
process will cause caramelization of the dextrose
contained in
each formula.
Hospital Pharmacy
58
Intravenous additive program
One writer has stated that an intravenous additive
program
and an intravenous additive service may not be the
same. The
differentiation cited is that an IV additive program
consists of
policies and procedures for both the preparation and
administration of intravenous fluids to which drugs
are to be

added under aseptic conditions, on an around-the-clock

basis, and
controlled as to location and person preparing the
product. On the
other hand, the IV additive service usually refers
only to the
preparation of the product by individuals who may
not necessarily be the same as those who will administer
them and assume
the responsibility for the monitoring of its clinical
effects. The
conclusionarrivedat is that an IV additive service is a part
of an
IV additive program.
Through the implementation of an IV service, the
hospital
pharmacist might be expected to achieve the following
objectives:
A- Thatthe preparation of the final product be
accomplished
under aseptic condition
B- Thatthe drug interactions be avoided through the
judicious
choice of additive and mixing techniques

C- Thatthe final product is appropriated labeled,

dispensed and
stored.
In the not too distant past, the preparation of
intravenous
solutions with their additives was a task performed on the
nursing
floor by nurses or interns and residents. The concept
that the
preparation of these products requires the skills of a
pharmacist
has raised many other questions not the least of
which is
availability of the product at odd hours particularly if the
site of
preparation is moved to the main pharmacy. Thus, has
evolved
Hospital Pharmacy
59
the satellite pharmacy, staffed by a clinical
pharmacist and
pharmacy technicians. On final analysis, itis irrelevant
where the

additives are added so long as definite policies are

formulated
which spell out responsibilities. In addition, it is
imperative that
the pharmacist becomes involved in the preparation
of these
products in an environment conducive to the efficient
and safe
preparation of them.
Preparation of I.V additive solutions
In the preparation of these solutions, the pharmacist
should
work from the physician's original order sheet or from
a direct
copy. Upon receipt of the order, a pressure-sensitive label
must
be prepared which provides the following information:
(a) Patient identification
(b) Patient location
(c) Physicians name
(d) Name of drugs with quantities added
(e) Date of compounding
(f) Expiration date

(g) Identification ofthe pharmacist preparing the product.

If necessary, any ancillary labeling should also be
prepared at
this time. When applying the label to the container,
it must be
positioned in an upside down order to facilitate
reading when the
container is hung from an intravenous solution pole
on the patient's
bed.
Preparation of the solution should always take place
under a
laminar flow hood using sterile needles and syringes or
double-ended
transfer needles. In some instances, a Cornwall
syringe is useful in
reconstitution procedures.
Hospital Pharmacy
60
Once the transfer is made, the metal disc must be
replaced and a
new seal crimped on to the container. As a safety
device, a different

colored seal should be used in view of the fact that it

warns individuals
that drugs have been added.
Before permitting the admixture to leave his control,
the
pharmacist must carry out a final inspection of the
product. The
inspection should include a review of the label, clarity of
the solution,
and the mathematics involved in the preparation.
Laminar flow hoods
Although many hospitals have abandoned the
preparation of large
volume, sterile intravenous fluids, a large number
have commenced
other programs, such as the intravenous solutions
additive procedure,
which require sterile techniques to be performed in an
atmosphere of
micro-filtered air.
In order to create such an atmosphere, various
manufacturers of hoods
have incorporated into them the laminar flow principle.

Laminar airflow is defined as:

"Airflow in which the entire body of air within a confined
area moves
with uniform velocity along parallel flow lines, with a
minimum of
eddies."
By providing a constant outward flow of micro-filtered
air over the
entire face of the hood's work area opening, dust
particles may be kept
from enteringthe work area from the ambient
atmosphere.
Hospital Pharmacy
61
Fig (2-7) Horizontal laminar airflow unit fig (2-8) Vertical
laminar airflow unit
Hospital pharmacists who plan to commence
intravenous solutions
additive programs or those who are called upon to
produce
special sterile research products should investigate
the
possibilities, which such an installation offers.

Pharmacy-Central Sterile Supply Rooms that still

produce
parenteral fluids should install laminar flow hoods in
order to
ensure safe, sterile products.
Hospital Pharmacy
62
Fig (2-9) laminar airflow unit
Hospital Pharmacy
63
Emergency medications
Because in most true emergencies time is of the essence,
it is imperative
that emergency drug or Stat boxes containing drugs
and supplies be
readily available for use by the bedside. The
pharmacy and therapeutic
committee should develop a list of supplies and drugs,
which ought to be
in an emergency box and instruct the pharmacist
and nursing service
supervisors of their joint responsibility to have the box
ready for use at all

times.
Once the content of the box has been established and the
responsibility
for its stocking assigned, the units should be prepared
and placed on each
pavilion, in the clinic, in the emergency ward and in
the special
procedures room of the department of radiology.
After the emergency boxes have been placed on the
ward, it is mandatory
that a program be developed whereby they are checked
daily either by the
hospital pharmacist or by the nursing supervisor
responsible for the ward.
The following list of contents is provided to serve as a
guide.
Hospital Pharmacy
64
Hospital Pharmacy
65
Unit Review
1- What are the four classes of drug distribution systems?

a------------------------------------------- b-------------------------------------c----------------------------------------- d-------------------------------------2-Discus, advantages and

disadvantages of unit dose system.
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------3- What are the main
elements of unit dose distribution?
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------4- What is the difference between U.D.S
and C.F.S.S.?
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------4- Define the following:
A- Addict:
---------------------------------------------------------------------------BControlled Substances:
--------------------------------------------------------C- Narcotic Drug:
------------------------------------------------------------------5- What is
laminar flow hood?

--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------6- If a doctor needs to write (Pethadine)

injection he must use:
a- Narcotic prescription
b- Normal prescription
c- Flour stock request
d- All of the above
7- The arrangement of the drugs in hospital pharmacy is
done by the
following methods except:
a- Alphabetical method
b- Therapeutic category
c- Dosage form
d- Arranged according to company name
Hospital Pharmacy
66
UNIT III
OUT-PATIET PHARMACY
Hospital Pharmacy
67
DISPENSING TO AMBULATORY PATIENTS

DEFINITIONS:
Ambulatory care, primary care, tertiary care, emergency
care
"Ambulatory" refers to patients not occupying beds in
hospitals
or other in patient settings, and to care given in
physicians' offices,
clinics, health centers, and other places where
ambulatory patients
usually go for health care. Today hospitals break
down their
ambulatory patient load into three categories
emergency, referral or
tertiary care and primary care. The term emergency
care is self
explanatory and tertiary caremeans care beyond that of
primary care.
Stated simply, primary health care is what most people
use most of the
time for most of their health problems. Primary care is
majority care.
It describes a range of services adequate for meeting the
great majority

of daily personal health needs. This majority includes

the need for
preventive health maintenance and for the evaluation
and management
on a continuing basis of general discomfort, early
complaints,
symptoms, problems, and chronic intractable aspects of
disease.
Most primary care is used by patients who are
ambulatory, and
most, but not all, ambulatory care is primary care.
Primary care does
not include service that is intensive, or very specialized,
or both. These
characteristics describe other levels of comprehensive
health care.
In an organizational sense, primary health care describes
a locus
which should serve the patient as an entry point into a
comprehensive
health care system. Once entry is madeand initial care
needed at the
time of entry giventhe primary care locus or
program should be

responsible for assuring continuity of all the care the

patient may
subsequently need.
Hospital Pharmacy
68
The growth of ambulatory care clinics may be attributed
to
the following:
A. The need of the hospital to supplement its in-patient
teaching
program.
B. The demand by the community lay as well as
professional, for
comprehensive diagnostic and treatment centers.
C. The new philosophy of hospitalsto take a more active
role in
the community health programs.
D. The need of the hospital and physician to exercise
greater
control over patients receiving investigational use drugs.
E. The lack of a sufficient number of physicians in some
areas,

thereby causing the population to travel to the medical

center for
comprehensive care.
F. The fact that the emergency service of a hospital
is always
available, whereas a physician, in some rural areas,
may not
always be available.
Because of this volume and the prospect of growing
larger
within the next 20 years, many community pharmacists
have
been quick to cite the economic hardship this trend may
create in the community. Although this is an important
factor
to be considered, it would appear that the crux of the
problem is the lack of understanding by the community
practitioner of the purpose and scope of a complete or
comprehensive ambulatory service.
Hospital Pharmacy
69
MINIMUM STANDARD FOR AMBULATORY-CARE

PHARMACEUTICAL SERVICES
Services to ambulatory patients are an important
part of many
institutional pharmacy programs. The need for such
services probably
will increase substantially in the 1980s.
The Society has identified 12 activities in which
institutional
pharmacists will be involved in the ambulatory-care
setting. However,
providing all these services in all institutions at all times
is not feasible.
At a minimum, ambulatory patients require certain
critical
pharmaceutical services. The essential elements of any
ambulatory-care
pharmaceutical service program are as follows:
1. The ambulatory-care pharmacy program must be
directed by a
qualified pharmacist.
2. The appropriateness of the choice of drug and its
dosage, route of
administration, and amount must be verified by the
pharmacist. This

will require the maintenance of medication profiles

for patients
routinely treated at the institution to prevent duplicate
drug therapies
and the use of contraindicated drugs.
3. All medications dispensed to patients will be
completely and
correctly labeled and packaged in accordance with all
applicable
regulations and accepted standards of practice.
4. Upon dispensing a new (to the patient) medication, the
pharmacist
will ensure that the patient or his representative
receives and
understands all information required for proper use of the
drug.
5. All drugs in ambulatory-care service areas will be
properly
controlled.
Hospital Pharmacy
70
LOCATION OF OUT-PATIENT DISPENSING AREA

There is no set rule as to the best area to locate an

out-patient
dispensing pharmacy. This is evidenced by the fact
that in today's
practice three equally suitable provisions are made for
this area:
a. A separate out-patient pharmacy is available.
b. A combined in-patient and out-patient unit with service
provided
from the same "window."
c. A combined in-patient and out-patient unit with service
provided
from separate "windows."
A separate out-patient pharmacy is usually established
whenever
the out-patient department and the pharmacy are
geographically widely
separated. Although this arrangement has the
advantage of being a
separate and distinct unit with a specialized function, it
possesses the
disadvantages of requiring a separate staff as well as
consuming a great

deal of time, on the part of other pharmacy

department personnel, in
transporting supplies and drugs to the area.
The above disadvantages are obviously eliminated
whenever
both in- patient and out-patient facilities are combined.
An additional
advantage to this arrangement is that the director of
the pharmacy
service is able to exert a greater degree of control and
supervision.
Hospital Pharmacy
71
TYPES OF PRESCRIPTIONS RECEIVED
Depending upon the location and kind of hospital,
the
prescriptions received in the out-patient department
pharmacy will
generally include those of private patients (where
permitted by the state
board of registration in pharmacy), indigent patients,
non-indigent
patients, employees, and patients being discharged from
the hospital. It

is a known fact that in any large metropolitan

teaching hospital, the
largest volume of prescriptions comes from the
indigent or partially
indigent group of patients. It is also established that
every patient who
visits the clinics does not have his prescription filled
in the hospital.
Indeed, hospitals with 500 or more beds fill
approximately I
prescription per 3 out-patient visits, whereas the 100
to 199-bed
hospitals average about 1.25 prescriptions for each visit.
Because many of these indigent patients are supported
by some
type of welfare program, their prescriptions require
special
identification, and the billing for such must be in
accord with the
requirements of the particular agency.
Hospital Pharmacy
72
DISPENSING ROUTINE

The dispensing pattern involved in providing clinic

patients as well
as those patients being discharged with "take home
drugs" is identical
with that carried on by a community pharmacy.
In both instances, a prescription is written by the
physician and
the patient takes it to the pharmacy where it is
compounded by a
pharmacist. If there is to be a waiting period, the
pharmacist will make
use of a prescription call check which numerically
identifies the
patient, and the finished prescriptions (Fig.3-1). Once in
the hands of
the pharmacist, the prescription and label are
numbered by a
numbering machine; the directions and other pertinent
information are
placed on the label; ancillary labels are affixed; the
proper medication
is then placed in the container; a check for accuracy is
then conducted;

and finally the prepared prescription is wrapped and

dispensed.
For internal audit purposes, hospital prescriptions are
separated
into out-patient and in-patient discharges and therefore
may utilize two
different colored blanks.
Figure (3-2) represents one type of hospital
prescription. It is
rather ingenious combination of prescription call
check, prescription
and label in a single form was that of the Philadelphia
General Hospital
now closed. This form Fig (3-3) has many advantages
in that it
combines three forms into one; it saves the
pharmacist's time in
handing out a call check and typing a label; and finally, it
is probably
more economical. It would seem that it's only
disadvantages are that
the prescription on file does not carry the directions for
use and that the

directions for use written by the physician on the label

portion of the
form, more often than not, will be illegible to the patient.
Many other types of prescription forms are in current use
in the
Hospital Pharmacy
73
hospitals of the nation. Some consist of multiple pages
attached to a
pre-punched card ready for use in a computer system;
others consist of
a prescription blank the back of which is affixed with
coded magnetic
tape thereby rendering the prescription suitable for
use in automatic
billing and electronic data-retrieval systems.
Hospital Pharmacy
74
Name
--Pharmacy Portion
Address
PETER BENT BRIGHAM HOSPITAL

721Hwntington Avenue
Boston 15, Moss.
Fig (3-1) Prescription call check used in the out patient
dispensing pharmacy as a
means of matching the correct patient and prescription
PRESCRIPTION CHECK
No. 5007
PRICE
PETER BENT BRIGHAM HOSPITAL
721Hwntington Avenue
Boston 15, Moss.
To avoid errors please present this
Check when calling for your
Prescription
--Pharmacy Portion
No. 5007
Hospital Pharmacy
75
THE CHILDREN'S HOSPITAL.
MEDICAL CENTER
300LONGWOODAVE.. BOSTON 02115

TEL. NO.: 734-6000

AREA CODE: 617
DATE
CLINIC OR
DIVISION
RECORD NO.
PT'S
NAME
PARENT
ADDRESS
AGE OF PATIENT
R
PLEASE LABEL
CONTENTS
ORGENERIC DRUGS ESTABLISHED UNDER THE
CHILDREN-S HOSP. MED. CTR. FORMULARY SYSTEM
Fig (3-2). A prescription blank developed by The
Children's Hospital Medical Center
in Boston. Note the emphasis on the patient's age.
Hospital Pharmacy
76

No 2720
RETAIN THIS CHECK
NOTB TO
PHYSICIAN
1. Pill in both section of
prescription, including
signature.
2. Write directions in
English in lower
section as this serves
as label.
DATE
Philadelphia General Hospital
Date Prescription No
Clinic
Patient
Address
CODE
R
M.D
AMOUNT

 M.S.S.W.
Amount
No

2720

PhiladelphiaGeneralHospital
Prescription No Date
Patient
DIRECTIONS

M.D
Form 76
Fig (3-3). A prescription blank developed by the children's
hospital medical center in
Boston. Note the emphasis on the patient's age
Hospital Pharmacy
77
INVENTORY CONTROL
CENTRAL STORAGEVS. PHARMACY STORAGE
The dichotomous storage arrangement of supplies is
prevalent in
many hospitals, although it is common knowledge that
central storage

is ideal.
The proponents of centralized storage facilities are
quick to demonstrate the reduction in labor and record
keeping, as well as the tight
control afforded by centralization.
In contrast, it should be pointed out that the
responsibility for the
storage of drugs should be placed with competent
individuals who have
been educated, trained and licensed to handle
pharmaceuticals. These
individuals are the pharmacists.
In order that the pharmacist may properly supervise
the storage of
drugs, they should be stored in an area directly under his
control. This
allows him the freedom of stock arrangement, instituting
of inventory
controls, the adjustment of inventory based upon his
knowledge of the
prescribing trends of the staff and the preparation of
inventory cost
reports to management.

Therefore, all merchandise ordered by or for the

pharmacy should be
shipped directly to the pharmacy receiving area.
Should the merchandise be received by the hospital post
office or central storeroom, it
should immediately be forwarded to the pharmacy in
the unopened
state.
Hospital Pharmacy
78
Upon the receipt of the merchandise in the pharmacy
receiving
area, the department personnel then process it in the
routine manner,
namely, checking the receiving slip with the copy of the
purchase order
and preparing a receiving memorandum.
Hospital Pharmacy
79
STOREROOM ARRANGEMENT
There is no definite rule specifying how a pharmacy
storeroom should

be arranged. Each individual may so arrange the area to

meet both his
and the institution's needs.
In general hospitals handling a variety of supplies,
the storeroom is
divided into the following areas.
1. Alcohol and Liquors 7.Biologicals and other cold room
inventory
2. Capsules and Tablets 8.Laboratory Instruments
3. Chemicals 9.Surgical Instruments
4. Gallon Goods 10.Rubber Goods
5. Narcotic Vault 11.Sutures
6. Ointments 12.Medical and Surgical Supplies
Alphabetical arrangement is followed, where possible,
within the section. Each shelf, drawer, or bin within the
section is
numbered to facilitate location of the item during the
taking of a
physical inventory as well as to locate the item for
new
personnel.
Hospital Pharmacy

80
Unit Review
1- Define the following:
Ambulatory care
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------Primary care
-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Tertiary care
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------Emergency care
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------2- Mention the minimum standard for
ambulatory- care pharmaceutical
services
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------3- What are the methods of
arrangement of drugs and inventory control in

out- patient department?

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------4- Out patient pharmacy is used in:
a- Daily clinics
b- Specialist clinic
c- Emergency services
d- All of this
Hospital Pharmacy
81
References:
1- William E. Hassan, JR. (1986) "Hospital Pharmacy" Fifth
Edition
Lea and Febiger, Philadelphia
2-Don A. Ballington, /Mary M. Laughlin
(2003)"Pharmacology for Technicians"
Second Edition EMC Paradigm
3-A.J. Winfield / R.M.E. Richards, (1998) "Pharmaceutical
Practice"

Second edition, Churchill Livingstone London