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    Hospital Pharmacy Manual (Final)

    Uploaded by

    Jennica Jao
    The pharmacy manual outlines the policies, procedures, responsibilities and relationships within the hospital pharmacy department. It describes the pharmacy location and various units including dispensing, compounding, chemotherapy and total parental nutrition. It provides details on personnel including job descriptions, duties and evaluations. It also covers safety policies and procedures for hazardous materials, medical emergencies, fire prevention and electrical, glassware, and general safety.

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    Download as PPTX, PDF, TXT or read online from Scribd

    Hospital Pharmacy Manual (Final)

    Uploaded by

    Jennica Jao
    957 views29 pages
    The pharmacy manual outlines the policies, procedures, responsibilities and relationships within the hospital pharmacy department. It describes the pharmacy location and various units including dispensing, compounding, chemotherapy and total parental nutrition. It provides details on personnel including job descriptions, duties and evaluations. It also covers safety policies and procedures for hazardous materials, medical emergencies, fire prevention and electrical, glassware, and general safety.

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    The pharmacy manual outlines the policies, procedures, responsibilities and relationships within the hospital pharmacy department. It describes the pharmacy location and various units including dispensing, compounding, chemotherapy and total parental nutrition. It provides details on personnel including job descriptions, duties and evaluations. It also covers safety policies and procedures for hazardous materials, medical emergencies, fire prevention and electrical, glassware, and general safety.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    957 views29 pages

    Hospital Pharmacy Manual (Final)

    Uploaded by

    Jennica Jao
    The pharmacy manual outlines the policies, procedures, responsibilities and relationships within the hospital pharmacy department. It describes the pharmacy location and various units including dispensing, compounding, chemotherapy and total parental nutrition. It provides details on personnel including job descriptions, duties and evaluations. It also covers safety policies and procedures for hazardous materials, medical emergencies, fire prevention and electrical, glassware, and general safety.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    of 29

    The pharmacy manual is designed to be a reference for all Hospital staff in order to identify:

    Pharmacy Policies & Procedures

    Operational Responsibilities

    Departmental Relationships

    & Insure Safe and accurate medication ordering, preparation, distribution and control

    RHUH is a university hospital providing services for several nursing units

    ICU Surgery

    CCU PHARMACY Pediatrics

    Oncology OBS & GYN

    Supportive Services: Blood bank, Radiology, Dietitians, Nursing

    Information Technology

    - Biomedical - Eng. & Maint. - Material Mngt

    Material & Purchasing

    Finance & Admin.

    - Logistics - HR - Finance

    Management
    Pharmacy

    Nursing

    Internal audit

    Pharmacy Map:
    A-Reception B&C offices for pharmacy staff E-Purchasing office D&F- Dispensing room G- Compounding room H- Pharmacy store I- WC J- Changing room K- Library L- Kitchen

    Head of pharmacy office is located in the ground floor.

    Total Parenteral Nutrition Unit

    Dispensing by Unit Dose System

    Central IV Admixture Unit

    Chemotherapy Unit

    Functional Organization of the pharmacy

    Location & Pharmacy Extensions

    Operating Hours

    Personnel

    Job Description

    Responsibility & duties

    General rules & Regulations

    The main pharmacy is located in the basement of the hospital. It consists of the following areas:
    Reception and Secretary 1190
    Library 1198 Pharmacists Office 1192, 1193, 1194, 1195, 1197 Chemotherapy Preparation Unit 1937 Drug preparation/ Dispensing Area 1196

    Operating hours 8-7 during the week 8-4 on Saturdays 8-3 on Sundays

    Nursing Units Emergency carriage & floor stock (replenished daily). Pharmacist On-Call is available after closing hours. Nursing and medical staff is are informed by a memo of the pharmacist on-call during pharmacy closing hours. Pharmacy on call sheet should be filled including dispensed medication and duration of dispensing.

    e.g. Head of Pharmacy Specifying all duties assigned to the assistant of the head, supervisor pharmacists, pharmacist, assistant pharmacist, technician, secretary. - Formulating and applying pharmacy policies. - Updating hospital formulary.

    - Controlling stock level. - Intervening in any medical or pharmaceutical problem.

    e.g.

    Pharmacy Rooms should be clean at all times. Offices should be organized especially before leaving.

    e.g.

    Lab coats should be worn without exceptions. The schedule work time should be requested. Work hours in holidays are rewarded in a similar manner within a month. Pharmacist on-call should be available after closing hours to provide life-saving medications.

    e.g.

    Performance Appraisal

    Orientation

    Student Mentorship

    Continuing Educations

    New employees should go through a general hospital orientation to introduce them to hospital organization as well as rules & regulations.

    Interdepartmental competency orientation checklist is filled for each new employee.

    Done during 3 month probation period. A copy is sent to he HR department.

    Regular evaluation of personnel

    Annual competency validation plan

    Employee of the month

    Anecdotal Report

    Performance appraisal is done q 6 month & retraining is done regularly.

    In-service Education program

    Interventions & monthly Roundtables Pharmaceutical & Medical lectures Competency tests & Quizzes

    Approval form university & Head

    Students from all universities

    Training Application

    Training Certificate

    Cytotoxic/Anti-Neoplastic Drugs
    Drug Preparation: Personal preparation Protective Equipments. Preparation Area. Preparation Equipments. Work Practices in the preparation: Handling vials. Handling ampoules. Waste Disposal. Spills. Medical. surveillance

    Glass ware Safety


    Use a dustpan and brush to pick up broken glass. Discard broken glass in a rigid container separate from regular garbage (label).

    Hazardous Drug Safety


    Hazardous materials include chemotherapeutic agents, strong acids or alkali, Corrosives, flammable items, poisonous items, human serum derived drugs, Infectious agents

    Dressing shall be in accordance with policy.

    Preventing Fire

    General Safety

    No smoking, running or jumping shall be permitted.

    Minimize the quantity of flammable liquids kept in the pharmacy. Keep flammable liquids in approved flammable liquid storage cabinets.

    Keep exits and passages clear at all times.

    Immediately activate the building fire alarm system. Learn how to use extinguisher. Do not use elevators; use building stairs.

    All electrical equipments should be wired with a grounding plug. Electrical cords or other lines shall not be suspended unsupported across rooms or passageways.

    Treating Fire

    Electrical Safety

    Medical Emergencies

    Prevention of injuries should be a major emphasis of pharmacy safety program. Proper training will prevent injuries from glassware, hazardous material, burns and electrical shock. First aid should be provided immediately.

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