MOHAMMED YOUNUS, R.Ph.
Key Words: Pharmacy, Good Pharmacy Practice (GPP), Hospital, Clinical, Community Pharmacist, Branches of Pharmacy, Prescription Error, Transcription Error, Adverse Drug Reactions (ADR’s), Emergency Medicines, Pharmacy Registration, Pharm D.
“What is your advice as a health professional for a type 2 diabetic patient who wishes fasting during Holy Ramadan and at the same time he/she is on insulin??”
“What should be the approximate duration of an intramuscular injecting time??”
“What are the life saving drugs should always available in Hospital Emergency Tray/Bag/Crash Cart??”
These are some of the questions that were asked to a newly graduated Pharmacist during an interview session for a Hospital Pharmacist Position in a tertiary care hospital in Bangladesh. I am sure most of these questions are very unfamiliar or not clear for a Pharmacist who has graduated from Bangladesh and of course this is not due to the lack of knowledge of a Pharmacist but the lack of information into the education system of Pharmacy disciplines in Bangladesh. Yes as a Bangladeshi Pharmacist these are some experiences from my current career as a Hospital Pharmacist for few years at home and abroad.
Prospects of Hospital, Clinical and Community Pharmacy Practice in Bangladesh:
Our Pharmacy education structure in Bangladesh has greater concentration on Industrial Pharmacy Practice which is obviously a good sign when we have observed tremendous development in Pharmaceutical manufacturing sector. But at the same time we have to be very careful and serious to ensure that those pharmaceutical products are storing, prescribing, administering in proper way at the end user point. In Bangladesh we mostly see industrial pharmacy practice but if you just look into the many other branches of pharmacy profession will understand where we are comparing with other countries in this world.
Different Branches of Pharmacy Practice areas 1;
|ü Industrial pharmacy||ü Consultant pharmacy|
Where each an every branches have their own sub-branches or specialties like Production, QC, QA, RND, Marketing in industrial pharmacy practice. But only industrial pharmacy is broadly practicing in our country where rests of the branches are completely unfamiliar in Bangladesh.
Now questions arises why our Pharmacy Schools are not designing their syllabus in such a way that it will facilitate a Pharmacy student to become competent in hospital and clinical sector as well? There might be so many reasons but for me it looks like the lack of opportunities and facilities in our health sector and future career in Bangladesh. People outside Bangladesh get surprised when they heard we don’t have graduate pharmacists in hospitals and community pharmacy level. Only two or three tertiary and sophisticated private hospitals in Bangladesh have placed graduate pharmacists to run Pharmacy Department as Global Standard requirement. I have started my career in such type of hospital in Bangladesh which is JCI (Joint Commission International) accredited and it requires graduate pharmacists to operate pharmaceutical services in the hospital. JCI is a U.S origin gold seal approval that maintains global standard in health sector like ISO 9001 in other sectors. That’s how we have got an opportunity to establish hospital pharmacy practice in that hospital for the first time in Bangladesh. Now while working abroad and hear that same hospital appointed more than twenty graduate pharmacists I really feel happy and appreciate it.
But these one or two hospitals cannot create opportunities for our pharmacists in Bangladesh. Actually the first foot steps should come from the government by make it mandatory to have graduate pharmacists in every hospitals at least. Depending on our population size it will be difficult to place graduate pharmacists in every community pharmacy due to the number of pharmacist we have but still we can manage to put into community pharmacies in main cities, district cities and diploma pharmacist can be placed into our community pharmacies of township, rural areas rather than anybody who does not have anything to do and finally just to open a medicine shop and start business. Yes sometimes these medicine shop’s owners get a drug license from Drug Administration but it is less then basic requirements which I will describe later part why. Let us see why hospital, clinical and community pharmacy practice is important and vital for a health sector in a country.
Importance of Good Pharmacy Practice (GPP)
Hospital Pharmacists plays a vital supportive role in healthcare team in other countries. Pharmacists are the right person to give an in depth information about a drug or medicine to other healthcare professionals as well as patients. Of course a doctor plays the main stream role in any health care services but the success comes through the team efforts where we have nurses, pharmacists, dieticians, laboratory experts etc. We cannot bring success and provide quality services unless all these team member’s efforts. Everyone should do whatever they suppose to do during patient care. Unfortunately in our country pharmacists does not get scope to do their job in the hospital.
Hospital pharmacists can play role starting from participation in disease management team, prescription screening, dispensing, patient counseling, medicines information providing, parenteral preparations, procurement of medicines, proper storage condition of medicines etc. In the disease management team a pharmacist can provide vital drug information for indication, dose calculation, administration to facilitate doctors to take their decisions where during prescription screening they can ensure the right medicine, right strength, right dosage form, right duration has been prescribed rationally and dispensed to the right patient and trace prescriptions error, transcriptions errors and adverse drug reactions (ADR’s). Someone may get confused and say are these really a pharmacists job to verify these indicators? Yes this is the real job for a hospital pharmacist. Our respected doctors are very busy with diagnosis of a disease but unfortunately they had to spend more time for prescription writing rather diagnosing the disease.
Imagine if your hospital has an updated hospital formulary with right choice of medicine for a particular disease it becomes easier for a doctor to prescribe his/her patient. Hospital formulary is like a bible for health care providers, it also ensures that quality medicines are being kept in that hospital. Imagine after treating rightly if a patient die or not responding to the treatment just due to the lack of quality of the medicines how pathetic it is for everybody. We may have different manufacturing brands around but hospital formulary will ensure only the quality brands will be available in that hospital through quality assessment.
Patient counseling on when, how a patient should take his/her medicines rationally and get maximum output of treatment can be done by hospital pharmacists. Whenever any kind of information needed about medicines who can be the best person rather than a pharmacist to provide. It helps other health professional to facilitate their decisions and services in the hospital. Total parenteral nutrition, cytotoxic admixture preparation also done by pharmacist following right procedure and aseptic technique. One of my finding while I worked in Bangladesh is that still most of the nurses in our country don’t aware of the right way of reconstitutions and dilutions technique of powder for injections and I don’t blame them for this because it is not there job at all neither they had that skill from their nursing school. All the powder for injections preparation should reach to patient bed side as ready to administer form. Imagine if you inject a less diluted injections through reconstitutions to an infant’s or child where there is chance of remaining undissolved medicines it may cause serious adverse drug reactions (ADR’s) along with burning, phlebitis sensation to the patients. Pharmacist can provide proper guideline on how to dilute a powder for injection before administration to the patient.
Hospital pharmacist also ensures the emergency medicines trays/bags are always updated so that any emergency situations e.g. accidents, strokes, allergic reactions, epileptic sessions etc can be managed faster. Hospital pharmacist’s also plays key role to make total procurement plan of medicines for a particular time for that hospital, which ensures vital medicines are always available whenever needed and at the same time less expiries occurred. Maintaining right storage conditions of medicines is also very important role of a hospital pharmacist. Apart from these so many other activities like continuous education development by providing lectures on particular medicines to other health professionals so that everyone updated about new information on medicines arrived.
Ultimately all these practices ensure patient safety during treatment. May be we don’t have an idea how many patient everyday are dying due to wrong treatment and adverse drug reactions in different health facilities in Bangladesh unintentionally. But Good Pharmacy Practice (GPP) in hospital can ensure right treatment to right patient and reduce prescription error, transcription error and ADR’s by rechecking, giving assistance to other healthcare providers.
It is true we have struggled a lot when pharmacists started to do these activities in a hospital for the first time in Bangladesh since it was totally a new culture for our healthcare system but have succeed. Our dear doctors, nurses and other healthcare providers get satisfied when they have observed we have ultimately made their task easier and ensured patient safety. They have started response to our activities and appreciated. Hospital also itself got benefits through the proper management of medicines and Pharmacy Department became second contributory after Consultation Department in the annual profit margin. That’s how a hospital pharmacist can play a vital supportive role in health care system in Bangladesh.
As I expressed earlier that why so called c-grade registration for those medicines shops to practice pharmacy in Bangladesh is less than basic requirements is because if you just think wisely most of our medicine shops are the prominent point of abusing Good Pharmacy Practice (GPP), they don’t have minimum education on medicine storage condition and if you want them to screen prescription, dispensing, counsel patients, control medicine records it will be like cut your cloth beyond your needs. Rather what are they doing now a days if just mention few you will understand the problem, selling substandard medicines for high profit, selling prescription medicines without prescriptions to the patients, selling narcotic and sleeping pills to drug abusers, prescribing medicines to the patients, even they are prescribing antibiotics themselves to patients how funny is this? Some of them are doing some minor surgeries and stitching as well without any education background. For me these medicines shops are the only points in Bangladesh who is responsible for all kinds of drug abuse, irrational use of medicines which results high number of patient death, drug resistance, sub- standard medicines, increase social disturbance as a source of drugs for abusers. I really don’t have any idea approximately how many medicine shops right now we have in Bangladesh, but I won’t be surprised if it is more than a million.
Requirements for Hospital, Clinical and Community Pharmacy Practice in Bangladesh
For now we have quite a good number of Graduate Pharmacists in Bangladesh who can be placed in hospitals to make sure pharmaceutical services are available. Now the question arises whether our pharmacists are competent enough for hospital and clinical sector or not? In this regard government can play a strong role by make it mandatory and create opportunity for each and every pharmacy graduate to go for minimum six months to one year hospital internship immediate after graduation. In fact in most of the countries graduation will not be completed until this hospital internship is done. Pharmacy syllabus has to be redesigned as per global standard to create competent pharmacists who will have knowledge in every sector of pharmacy practice. Bangladesh Government can involve Pharmacy Council of Bangladesh and other relevant stake holders to perform these activities. It is mandatory that every pharmacist must have registration before they get into their professional career. Unfortunately since more than five years Bangladeshi Pharmacists are not getting registration due to administration problems. Even some pharmacists tried to go abroad but they were not allowed to sit for registration exam in other countries as they didn’t have registration from country of origin where they completed their graduation. As an overseas Pharmacist whenever someone will try to sit for registration exam in any other country in the world, that particular registration council will ask for Registration Certificate from the country of origin where graduated and Good Standing Certificate from that council who issued registration certificate. It is so pathetic that though our pharmacists are not getting any job opportunity in the country now days and due to the lack of this registration issue they are also not managing to move abroad even after having job opportunities there. I will heart and sole request to Pharmacy Council of Bangladesh to solve this issue as soon as possible and assist our newly graduated pharmacists to pursue career worldwide. We all know the problems why registrations are not given, I am not opposing registration examination system but I think it will be wise to follow how medical professionals in Bangladesh are getting their registrations through central examination every year standardized by BMDC (Bangladesh Medical and Dental Council). So that when students completed his/her graduations will be automatically registered by the council rather than conduct a registration exam at the end of 4-5 years after graduation. This is simply my point of view but Pharmacy Council of Bangladesh is the right authority to come up with solution. In fact in the Republic of Botswana where I am working now they don’t apply registration exam for their local candidates but they do apply for foreigners. But it is mandatory to have minimum 1 year hospital internship for both local and foreign candidates. The similar procedures are following in the Republic of South Africa as well and these countries recommended placing graduate pharmacists in the industry, hospital and community sector. If Botswana like countries can apply this practice where there is no pharmacy school still now why not Bangladesh where we have more than 15-20 Pharmacy school in both public and private institutions? I think its really late but not too late to begin the journey.
Recently I have read an article on the future of Pharm D (Doctor of Pharmacy) in Bangladesh and I completely agree with them. Pharm D is the best qualification right now to become competent in all sector of pharmacy practice worldwide. But we have to come up with all kind of pre requisition set up and facilities to start this degree otherwise the situation of pharmacy practice will remain same as it is now. There is no doubt we have most experienced and highly qualified faculties but we need some more faculties having higher education and experience in hospital, clinical pharmacy. Completely revised syllabus along with laboratory and hospital internships facilities has to be created for these areas as well. We don’t want Pharm D which will only concentrate on industrial pharmacy like as B. Pharm in Bangladesh but at the same time we all know how important it is now days to have Pharm D as many developed countries applied Pharm D as the first professional degree to become eligible to practice as a Pharmacist. If you don’t have Pharm D you cannot practice with your existing B. Pharm/M. Pharm degree and this network of countries that requires Pharm D as first professional degree are increasing. I think our elders in Pharmacy arena and of course the government of Bangladesh should take steps about it.
At least our government can make it mandatory to place graduate Pharmacists for the community Pharmacy in main cities, district cities and Diploma Pharmacists in township and rural areas. If someone says Pharmacy owners will be in difficulties to pay graduate and diploma pharmacists I won’t believe that. Instead of having ten medicine shops in the same road if we have one community pharmacy with right professionals why it won’t be possible to pay them with a handsome remuneration? Depending on the patient volume size in different areas or locations I think it is possible to design exactly how many community pharmacies are required in that particular place and authority can strictly permit those to practice who full fills the requirements.
I have elaborated this writing from some in-depth experience of my career that’s why I tried to share in details which may bother some of us who are well informed about these issues but I really want our other Pharmacists and Pharmacy Students who may not have that much practical ideas about hospital, clinical and community pharmacy practice with current education system. I also tried to give some ideas to other health professionals like doctors, nurses etc in Bangladesh so that they can play as a supportive role to develop this sector in our healthcare system. Finally I hope our non health professional colleagues, friends; politicians, government officials, ordinary peoples also can get some ideas from this writing about the hospital, clinical and community pharmacy practice and its importance, necessity for our national health care system and the society so that these will be the basic requirements along with other health care services to ensure a healthy nation. Pharmacists along with other health professionals like Doctors, Nurses can play these vital supportive roles to bring this success and at the same time new employment opportunities will be created for our newly growing Pharmacists in Bangladesh.
“At the very beginning of my writing I expressed three questions from an interview board of Hospital Pharmacist recruitment, actually these questions was asked to me when I went for the interview at Apollo Hospitals Dhaka, Bangladesh in 2007 as a very fresh Pharmacy Graduate for a Hospital Pharmacist position. I was really surprised to hear those questions but tried best to answer them from the knowledge that I have gathered from my pharmacy school though I felt I could have answer them best at that time if my pharmacy school could have put some more concentration in the hospital, clinical & community pharmacy sector”
Let me put answers for those questions below before I finish;
- Every type 2 diabetic patients whose are on insulin and at the same time wish fasting during Holy Ramadan should adjust their insulin dose, types of insulin through consulting relevant physicians depending on the sugar level status and may not need to perform extra physical exercise that much like since sugar level will remain comparatively lower than other time due to fasting. As hypoglycemia is a common problem depending on the severity of sugar level for the patients taking insulin that’s why this dose adjustment is very important during Holy Ramadan.2,3
- Approximate duration for an intramuscular injecting time should be 3-5 minutes. This is important for a Hospital Pharmacist to know the drug administering procedures and injecting time to analyze Adverse Drug Reactions (ADR’s), Drug hypersensitivity etc.
- Along with emergency equipments life saving medicines into a emergency tray/bag/crash cart also may vary from hospital to hospital but most common medicines that always should be there to attend cardiac arrest or severe allergic reactions that requires immediate interventions are as follows;
- epinephrine, atropine, amiodarone, lidocaine, sodium bicarbonate, dopamine, and vasopressin
- First line drugs for treatment of common problems such as: adenosine, dextrose, diazepam or midazolam, epinephrine for IM use, naloxone, nitroglycerin
- Other Drugs for rapid sequence intubation: Succinylcholine or another paralytic, and a sedative such as etomidate or midazolam; endotracheal tubes and other intubating equipment, devices etc
Emergency Tray regularly must be checked by hospital pharmacist to replace missing drug or equipment, near expiry replacement and replenishment after every incident or Code Blue in medical terminology. During a Code Blue/Cardiac Arrest session an emergency team must reach to patient side, Pharmacist will open the crash cart and assist them to use drugs whatever needed. 4, 5