AN OVERVIEW ON THE HOSPITAL PHARMACY SET-UP WITH THE ROLES & RESPONSIBILITIES OF HOSPITAL PHARMACIST

MOHAMMED YOUNUS, R.Ph.

KEY WORDS: Hospital Pharmacy Practice, Good Pharmacy Practice (GPP), Hospital Formulary, Drugs & Therapeutic Committee (DTC), Prescription Screening, Prescription Error, Transcription Error, Adverse Drug Reactions (ADR’s), Dispensing Error, Emergency Crash Cart, I.V admixing, Ready to administer, Unit dose system, Patient Consultation, Drug Information, Drug utilization review (DUR), Rational use of medicines (RUD), Drug-drug interactions, Pharmacovigilance, Pharmacoeconomics, Managed Care Pharmacy (MCP), Pharmaceutical waste management, Standard Operative Procedure (SOP)

 ABSTRACT: “Quality does not come in a cheap way” – is a famous quote by a famous scholar and this is very much true in real life. In fact we should not compromise with quality when deals with human life. Hospital Pharmacy is core component of a health facility which will ensure availability of quality health commodities in the hospital and their proper management. From this above explanation on hospital pharmacy practice we can understand its scope and needs in a hospital. Unfortunately in Bangladesh still we don’t have such practice in both public and private hospitals except 2-3 private hospitals which are a serious risk for the entire nation on health matters. Imagine a patient well diagnosed and prescribed medicines but a patient was not cured due the sub-standard of quality of medicine, wrong method of dilution, wrong site of administration due to lack of information and knowledge. Medicine can also lose its potency and efficacy if is not stored in recommended temperature as mentioned. Sometimes expired medicines can also give to the patient unknowingly which can have a serious threat. To err is human but we must have proper system and right people in place to minimize it up to tolerant level. Pharmacists are the skilled personnel to discover, manufacture, storing, dispensing of medicines through proper counseling and sharing of information’s with the patients and other healthcare provider and there is no other choice to establish hospital pharmacy in a hospital to ensure quality of standard in those areas. We should engage right people for right work in right place on right time to do the right job for the right customer. Without proper policy, regulations, plan, budget from policy makers and employers it may not be possible to roll out such practice in the whole country and of course policy makers must have a good intention to serve quality health service to the entire nation.

 My intention to write this article was to inform about a basic set-up of a hospital pharmacy in a hospital in Bangladesh and at the same time to communicate with all healthcare providers so that we all understand the need of it. More especially pharmacy students or fresh graduates can gather some practical knowledge from this article for their future development since our pharmacy academic syllabus is not yet much helpful for hospital, clinical, community pharmacy practice as importance more given on industrial practice. This time it was an overall briefing of all components in a short manner but may be in future I will try to write more on individual components with in-depth details.  I did not follow any particular references while writing despite few references below especially for some structure, charts and tables but I have tried to share from my professional experiences from past 8-9 years in hospital pharmacy practice at home and abroad. I hope this article will help you for a better understanding of hospital pharmacy set-up and practice. Following references may help you further to get more information and clarification on hospital pharmacy set-up & practice to benchmark with your knowledge for establishment and continuous improvement of hospital pharmacy practice in Bangladesh.

INTRODUCTION

Pharmacy as a multi-disciplinary course enables pharmacists to work in multi-dimensional areas in health and pharmaceutical sector. A pharmacist has skill on the technical, chemical knowledge’s of pharmaceutical products as well as clinical, pharmacological knowledge’s of their usage at point of users. A pharmacist is a best person to detailing on medicines to both patient and health professionals as he has in depth knowledge on pharmacological & therapeutic use. Out of many areas of pharmacy profession hospital pharmacy profession are most popular and vital around the world. Most of the fast world countries has managed to place qualified pharmacists in different health facilities by health ethics and made it mandatory by applying relevant act. Even so many middle income countries have managed to do the same. Unfortunately an immersing country like Bangladesh where I am from are still struggling to make sure that we have qualified graduate pharmacist in health facilities like hospitals, clinics and other health set up while our neighboring countries like India, Pakistan, Srilanka has been practicing hospital pharmacy profession since long ago. In fact so many countries in African continent also doing the same. In the preliminary stage that could be a reason due to the unavailability of graduate pharmacist against huge number of population in Bangladesh but as moving forward I think at present we have good number of pharmacists who can be placed in health facilities now a days.  As pharmaceutical industries remaining the only profession for pharmacists till now in Bangladesh by creating job at health facilities will also create new employment opportunity for our country. Now the question is how we can do it and what relevant act needs to be taking on board to implement it. But we have to also convince policy makers by showing that why they should make it mandatory to have qualified graduate pharmacists in all health facilities both public and private sector. From this necessity I will try here to share my experience and knowledge regarding hospital pharmacy profession as I practicing this profession from the very beginning of my career. I would like detail on the roles and responsibilities of a hospital pharmacist as well as the benefit towards the health facility, health sector as well as patient themselves.

Before I precede further let me give you a quick introduction of my career so that it make sense of sharing my experience and knowledge with intended readers. I started my career as a hospital pharmacist at Apollo Hospital Dhaka, Bangladesh in 2007 after my graduation from university of development alternative (UODA) in the same year. I was very happy to be the part of foundation team to set up a full fledged hospital pharmacy service there. In 2009 I joined Department of clinical services, Ministry of Health, Republic of Botswana where I am currently practicing as a registered pharmacist. While working under Botswana government I had a chance to work in different sector like hospitals, Pharmaceutical policy & treatment guideline at national level, and national procurement & supply chain management of pharmaceuticals in the whole country. Botswana is a middle income country with a very small population only 2 million but they had managed to place qualified graduate pharmacist from top to bottom level of their health sector both in public and private sector despite unavailability of pharmacy school here. That means most of the practicing pharmacists here either expatriates or locals gathered degrees abroad by government scholarships. You can easily understand that how importantly Botswana government took this initiative for the sake of Botswana people and their health safety. Botswana is a country with high prevalence rate of HIV/AIDS and Botswana government provides 100% free of all kind of medications and related commodities for the nation. It’s a great opportunity for me to be able to work here and mean time I have gathered post graduate training on HV/AIDS treatment management from Botswana-Harvard HIV/AIDS Institute under school of public health, Harvard University, USA and a post graduate training on Paediatric HIV/AIDS treatment management from Botswana-Baylor Children’s Clinical Care of Excellence under Baylor College of Medicines, Texas, USA. As a demand in my profession I was lucky to get a masters degree in business administration which enables me to manage my responsibilities in a strategic way to achieve my desire goal.

WHAT IS HOSPITAL PHARMACY?

By the terminology itself “Hospital Pharmacy” anyone especially in the context of our country’s current scenario may think of a medicine shop inside a hospital which sells medicines to patients raised from that hospital. But in reality this is just not means a medicine shop with non-qualified personnel’s we usually see in our country. Hospital Pharmacy is a vast area which may contains different kinds of services based on the size and level of the hospital. I will try to present a standard set up which can be followed in a tertiary care hospital. The very first requirement to set up a hospital pharmacy is to have qualified graduate pharmacist along with some qualified diploma pharmacists or pharmacy technicians under direct supervision of graduate pharmacists. Prime objective of a hospital pharmacy is to review prescriptions and serve quality and safe medicines to patients with detail information and counseling to ensure the best use of medicines as per prescription raised by the doctor. Hospital pharmacist must protect seven rights i.e. right patient, right dose, right route, right time, right drug with the right information and documentation while providing pharmaceutical care. Hospital pharmacist may communicate with prescribers if there is any need to re-look or change in the prescription by the prescriber. Hospital pharmacist assist prescribers to take proper decision regard to medicines choice for the intended diagnosis or indication. Unfortunately you may see most of the doctors in our country spend almost 80% of their consultation time for a patient to write prescription rather concentrating on diagnosis which is the core part of their profession. Hospital pharmacist can assist them by availing medicines information in finger tip which will enable doctors to spend more time on diagnosis rather thinking of medicines. I will detail on these roles by hospital pharmacist below under different services. A hospital pharmacy should have following components to be able to serve the patients as well as other health professionals to assist them in treatment management;

  1. Current Good Pharmacy Practice (cGPP) Guideline
  2. Hospital Formulary
  3. Drugs & Therapeutic Committee (DTC)
  4. Treatment Management Team
  5. Drug Utilization Review (DUR) & Rational Uses of Medicines (RUD)
  6. Prescription Screening Unit
  7. Pharmacovigilance Unit (Adverse Drug Reaction)
  8. Quality Assurance Unit
  9. Central Pharmacy
  10. In-patient Pharmacy
  11. Out-patient pharmacy
  12. Ward / ICU’s stock
  13. Manufacturing Unit (Cytotoxic & other IV admixing)
  14. Drug Information Unit
  15. Emergency Crash Cart & Emergency team member
  16. Reduction of Expires
  17. Destruction of Expired & Damaged medicines
  18. Pharmacoeconomics (Treatment Cost Management)
  19. Managed Care Pharmacy (MCP)
  20. Continuous Medical Education (CME)
  21. Standard Operative Procedure (SOP)

WHO IS HOSPITAL PHARMACIST?

Minimum qualification for a hospital pharmacist is to have a bachelor degree in pharmacy, B. Pharm (Hon’s) along with the registration with relevant professional governing council in that country. Depending on the policy of a country it may vary like as the minimum qualification to be able to practice as a pharmacist in USA is Pharm. D (Doctor of pharmacy). In Bangladesh bachelor pharmacy program mostly designed to concentrate on industrial pharmacy practice and a very little attention in hospital pharmacy practice which creates serious lack of clinical knowledge among the newly graduate pharmacists. Pharmacy Council of Bangladesh must look into this and review the curriculum according to the global demand rather local only. Otherwise it will be very difficult and risky to implement hospital pharmacy practice widely in the country. Beside that a hospital pharmacist can also have specialties in hospital & clinical pharmacy and other different areas i.e. oncology, infectious disease, cardiovascular, diabetes, neurology, radiology, public health etc through a masters and/or PhD. Hospital pharmacist can also enhance their skills by having post graduate degrees in non-medical areas like logistics & supply chain management, business administration etc. Though in our country specialty degrees for pharmacists still not recognized by the Pharmacy Council of Bangladesh but I think time came for them to think about it. A hospital pharmacist must have continuous medical education (CME) to keep himself updated with latest information’s regarding disease, drugs, adverse reactions, drug interactions, changes in the national & global formularies, treatment guideline etc.

HOSPITAL PHARMACY SET-UP WITH THE ROLES & RESPONSIBILITIES OF HOSPITAL PHARMACIST

Now we will look into all the components that are necessary to set up a hospital pharmacy system in a tertiary care-based hospital. Hospital pharmacist is the core personnel of a hospital pharmacy system with relevant skills and knowledge’s and lots of roles & responsibilities towards health facility, other health professionals and most importantly the patients. Let’s see their roles & responsibilities in context with different components in a hospital pharmacy system in the health facility;

Current Good Pharmacy Practice (cGPP) Guideline1: Good Pharmacy Guideline by World Health Organization (WHO) is a global standard of pharmacy practice in health settings. The very first requirement to set up a hospital pharmacy is to develop own pharmacy policy and/or Standard Operative Procedure (SOP) as per cGPP and implement or to follow as it is so that WHO global standard is maintained. All the processes and procedures should be controlled and well documented so that the system can maintain similar quality of service at all point as the same time it is audit-able. Hospital pharmacist is the custodian and responsible for all policies and SOP’s generated for the hospital pharmacy and shall ensure that they are properly followed, reviewed periodically and well up dated as per current demands.

Hospital Formulary:  Hospital Formulary is like a bible of any hospital pharmacy system; it controls the quality of medicines as well as guides health professionals on their appropriate usage. Usually a hospital formulary contains list of generic medicines with specific brands along with detail information’s of their indications, dosage information’s, side effects, cautions, contra-indications etc that are permitted by drugs and therapeutic committee to use in that hospital2. Hospital pharmacist usually the secretary of DTC and responsible for maintaining hospital formulary updated. If a pharmaceutical company wants to include their product in the hospital formulary then they has to submit all the required information and documents like Certificate of Analysis (COA), Batch Manufacturing Record (BMR), Registration certificate, Dossiers etc to the secretary of DTC. Product will be presented to DTC members with all these provided information to justify the quality of the product. Upon DTC’s approval a product can be included in the formulary so that it can be used in that hospital. Hospital pharmacist must ensure that the formulary is being followed by health professionals as well as during procurement of medicines for the hospital.

Drugs & Therapeutic Committee (DTC): This is a committee within the hospital that interferes with all kind of problems, decisions, interpretations in regard to medicines and pharmaceutical care in the hospital. Chairperson of the committee is usually the head of medicine department (physician) and secretary is the head of pharmacy department (pharmacist) 2. Beside that the committee also consists of other physicians from different departments, pharmacists, nurses and other health professionals within the hospital. DTC is a very vital part of hospital pharmacy and hospital pharmacist in charge should make sure that DTC meets on regular basis at least once in a month to resolve the issues on the ground.

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Figure 1: A Typical Structure of DTC

Treatment Management Team: Hospital pharmacist may need to play a role in the treatment management team by providing necessary information and evidence regarding indication, dosage information’s, starting and maintenance dose calculations, half-life and elimination rate, precautions, side effects, drug interactions to make a firm decision by the prescriber for the patient. Usually this is applicable when there is critical situations arise due to the age of the patient i.e. paediatric and geriatric patient, cancer patient, chronic patient, multi-drug resistant patient, adverse drug reactions and whenever there is a need hospital pharmacist has to be always available. Usually this role has been playing by a clinical pharmacist if available otherwise hospital pharmacist should meet this need.

Drug Utilization Review (DUR) & Rational Uses of Medicines (RUD): Hospital pharmacist plays a vital role to promote rational use of medicines in the hospitals. In most developing countries basically medicines are being prescribed by doctors but not pharmacists, nurses despite some developed countries where there are prescribing pharmacists and nurses are available as per their national medicines policies. But nevertheless whoever prescribing medicines must have current update and information’s regarding medicinal uses and their related side-effects, adverse effects, warnings, pre-cautions and there is need to assess prescription patterns on periodically basis to review drug utilization4. Especially in our country we have noticed that most the prescriptions contain 2-3 or more antibiotics and medicines like anti-ulcerants, NSAIDs, vitamins etc without appropriate need3. Inappropriate dose administration is also a serious concern among the most of the prescribers. Ultimate impact of such prescribing pattern may have several effects on patient like antibiotic resistance, pills burdens, drug-drug interactions which will render intended outcomes and patient will keep coming to the hospitals. DTC can conduct drug utilization review using WHO indicators3 which can helps to see the current prescription pattern and address problems if there is any which will help to promote rational use of medicines and ensure patient safety. WHO recommended Defined Daily Dose (DDD) can also be followed for commonly used medicines to avoid over dosing or inappropriate dose administration2. Hospital pharmacy department can liaise with International Network for Rational Use of Drug (INRUD) of World Health Organization (WHO) to have continuous support to promote rational use of medicines. In future I will write in detail on how to conduct drug utilization review in a hospital.

Strategies or interventions that can be used to promote more rational drug use may be categorized into three main types2:

  • Educational strategies which aim to inform and persuade users
  • Managerial strategies which aim to structure and guide decisions made by users
  • Regulatory strategies which aim to restrict or limit the decisions of users.

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Figure 2: Changing a drug use problem: an overview of the process2

Prescription Screening Unit: This is a unit either can centrally screen all prescriptions or within in-patient & out-patient pharmacy to screen particular prescriptions. Prescription screening is one of the major roles of a hospital pharmacist in a health facility. Every day a tertiary care hospital may experience more or less 500 prescriptions arises both from in-patient and out-patient service. All this prescription has to be screened by hospital pharmacist to detect if there is any kind of mistakes, risks lying or unnoticed by the prescribers. Pharmacist can ensure seven rights like right patient, right age, right medicine, right dose, right strength, right dosage form, right route for the medicine prescribed. Pharmacist should also looks for all the possible drug-drug and drug-food interactions in the prescriptions and shall inform the prescriber about the possible end result so that prescriber can re-look and decide on changes if needed based on risk & benefit ratio. This screening is not an oversight on what doctor has prescribed rather a safe-guard to make sure a safe prescription reached to patient’s side. If prescriptions are system generated then there is a chance of error while capturing in the system.

“A medication error is an unintended failure in the drug treatment process that leads to, or has the potential to lead to, harm to the patient. Mistakes in the prescribing, dispensing, storing, preparation and administration of a medicine are the most common preventable cause of undesired adverse events in medication practice and present a major public health burden5.”

Following are the two types of error usually happen during prescription generation;

  • Prescribing Error: If prescribe a medicine that is contra-indicated, not indicated for the patient. Wrong dosage form and wrong dose prescribed based on patient age. Hospital pharmacist should immediately communicate with the prescriber and take necessary action to make corrections wherever applicable. Sometimes a prescription may have incomplete information’s which may lead to dispense of wrong medicines also should be treated as prescribing error.
  • Transcribing Error: Once prescribed by the physician someone may need to capture it in the system software so that it is available for dispensing by the pharmacy. During this process there is a chance of making mistake by capturing wrong medicines, dose other than the prescriber actually prescribed? Hospital pharmacist should immediately communicate with the relevant prescriber and compare with the original prescription to make corrections.

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Figure 3: Sources of Medication Errors

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Figure 4: Reasons of Medication Errors

Hospital pharmacist has to prepare a monthly report on the all prescription errors raised in a particular month and present to the management. Rate of prescription errors in a health facility is directly linked with the quality of services and also find out the gap for further improvement.

Pharmacovigilance Unit (Adverse Drug Reaction): This unit of hospital pharmacy keeps a close eye on all the Adverse Drug Reactions (ADR’s) occurs in the hospital. Usually when there is an ADR occur it has to be reported to the Pharmacovigilance unit so that they can further investigate the reason of ADR5. Hospital pharmacist should report to hospital management and relevant authority in the country i.e. Directorate of Drug Administration on all ADR’s occurs on a monthly basis. ADR’s history helps to review a particular drug profile further by the inventing company and to take necessary action either by withdrawal of that drug or further research for modification if needed. Sometimes ADR’s may remain unreported by the physicians intentionally or unintentionally, prescription screening can detect those by looking at the contents of the prescription and by further confirmation with the physicians. Hospital pharmacist also plays a key role to ensure rational use of medicines in the hospital by providing necessary information regarding appropriate use. In Bangladesh poly pharmacy and irrational use of medicines especially antibiotics are very common problem which were never detected as a cause of patient death, hospital pharmacist can actually keep a close eye on the poly pharmacy and suggesting prescriber to avoid unnecessary medicines as well as using antibiotics rationally. Most of the available antibiotics seem resistant in our population and future is really not good. We may soon start experiencing patient death due to lack of antibiotic that is susceptible for the patient.

Central Pharmacy: This is the hub of all kinds of medicines and related substances that are being used for the patients in the whole hospitals at different user points. Main responsibility of central pharmacy lies into the availability of necessary medicines in the hospital as per hospital formulary. Hospital pharmacist must ensure that all the medicines that have been procured based on hospital formulary to maintain availability of quality medicines in the hospital. All the medicines have to be properly stored as per temperature recommended and Current Good Pharmacy Practice (cGPP) has to be followed to maintain the quality of all medicines. If I summarize core responsibilities of hospital pharmacist in the central pharmacy will be reflected like as follows;

  • Annual Forecast & Quantification of required medicines and related substances
  • Annual budget based on forecast.
  • Custodian of Hospital Formulary & maintenance as recommended by DTC.
  • Procurement of medicines & related substances from recommended manufacturers and/or suppliers as necessary.
  • Quality assurance inspection of all medicines and related substance shall be conducted by pharmacist up on arrival from the supplier. During inspection pharmacist have to check right medicine, right quantity, right strength, right dosage form, right expiry date, intactness of primary and secondary packaging materials, coloration & sedimentation for syrup, suspension and injectables, temperature log for cold chain items during transportation, proper storage of cold chain items during transportation etc.
  • Storage and Distribution of medicines to different point of users i.e. in-patient, out-patient pharmacy, theatre, ICUs etc in the hospital following Current Good Pharmacy Practice (cGPP) guideline and Standard Operative Procedures (SOP’s).
  • Manufacturing of Total Parenteral Nutrients (TPN) and other IV Fluids if needed.
  • Handling customer returns from user points and conduct quality checks before take back to the main inventory
  • Reduction of expiry rate below 3% by applying new strategies and methods. Sensitize in-patient and out-patient pharmacy to follow up with prescribers so that they can use them on their patient if necessary. Pharmacist also can come up with memorandum of agreement with suppliers for certain expensive products so that if they get expired supplier will replace stock with better expiry dates.
  • Monthly and Annual stock count shall be conducted to check accuracy of the inventory and should present to the management to appreciate. All the variances should a acceptable clarification for write off/on by the management.
  • Management of expired and damaged goods as per cGPP.
  • Daily, Monthly and Annual sales report shall be generated and presented to management to appreciate. Central pharmacy can combined all the sales report from in-patient and out-patient pharmacy and come up with a consolidated sales report. Also to come up with new strategies to get best benefit out of sales.

In-Patient Pharmacy: This is the point where all patients that are admitted into the hospital get their medicines dispensed from here. As I said earlier prescription screening unit can be a centrally operated unit or it can be separately within in-patient or out-patient pharmacy. I will prefer if it is separate as the nature of prescription are quite different in this two point and also the types of error also different. So it’s easy for a hospital pharmacist to monitor and screen the prescriptions while they are separated. Usually quality hospitals follow unit dose system for their in-patients i.e. dispensing not more than 24 hours medications at a time in a ready to administer form.

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Figure 5: IN-PATIENT PHARMACY

If I summarize hospital pharmacist role in in-patient pharmacy will be like as follows;

  • Prescription screening to ensure seven rights i.e. right patient, right age, right medicine, right dose, right dosage form, right route in right time. If there is any confusion arise pharmacist should immediately communicate with the relevant prescriber to correct or get clarification. Pharmacist should also check transcribing error if it’s a system generated prescription and correct accordingly. All the possible drug interactions have to be informed to the prescriber so that he is aware of it and change prescriptions if needed. Hospital pharmacist can ask for patient history file and test results from the ward to confirm certain issues if necessary. Computerized hospitals should have this information available in the system to be able to use by certain users. Remember patient information is a very confidential matter and be very careful when you are handling it. Do not disclose patient information to anyone other than relevant healthcare personnel for treatment purpose.
  • Dispensing medicines as prescribed for admitted patients and ensure right patient, right medicine, right dose, right strength, right dosage form, right expiry and right quantity dispensed with properly labeled and in ready to administer form i.e. unit dose pack, suspension ready to use, powder for injectables reconstituted and ready to administer as per recommended dose prescribed, admixed IV fluids and ready to administer, Prepare and mixing of ointments, cream as prescribed when such ratio not available in the market etc. All the reconstitution and admixing must be done under laminar air flow hood system to avoid contamination and exposure to sensitive medicines. All the commodities must be dispensed as per FIFO (First Come First Out) or FEFO (First Expire First Out). Pharmacist must maintain separate register with detail information to dispense habit forming or narcotic drugs to control its use.

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Figure 6: LAMINAR AIR FLOW HOOD

  • Minimize dispensing error i.e. wrong medicines, wrong strength, wrong dosage form and generate a monthly dispensing error report to assess the quality of service as well as to put measures to avoid such incidents in future. To avoid dispensing error inventory should be stored in such a way that all the “SOUND ALIKE”, “LOOK ALIKE” are kept separately.
  • Provide all necessary information’s and precautions needed to use a particular medicines to other health care providers like physicians, nurses as well as patients.
  • Morning rounds with the therapeutic team in the in-patient area to assess and ensure quality of service in previous 24 hours. Also to provide information and assistance to other health care providers wherever necessaries during the round.

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Table 1: Common Dispensing Errors

  • Admitted Patient counseling to explain the use of the medicine prescribed along with all the side effect they may experience during the treatment. Also to explain why they should take their medicine on right time following prescribed instruction to get the best output of treatment. Especially cancer patients shall be thoroughly counseled to make them understand about the serious side effects they may experience which will be disappear up on withdrawal or completion of treatment.

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Figure 7: Classification of dispensing errors

  • Storing medicines at recommended temperature and monitor temperature log on daily basis. Storing sensitive medicines separately like Cytotoxic, radioactive, habit forming drugs or narcotics (under lock and key), life saving drugs etc and properly labeled with precautions.
  • Placing order to replenish stock from central pharmacy as required following a minimum stock level strategy on daily basis.
  • Receiving of stock from central pharmacy following a quality check and make sure stock properly captured into the main inventory.
  • Handling customer returns from the ward and ensure quality check been done before stock goes back to the inventory. Temperature sensitive items like insulin and other cold chain items have to be carefully handled to accept.
  • To attend query, complaints from other health care providers like doctor, nurse regarding medicines, other pharmaceutical services and provide feedback accordingly.
  • All the emergency crash carts in the wards and ICUs that contains life saving drugs and necessary equipments shall be monitored and check on monthly basis to ensure recommended quantity and their expiry dates. On the occasion of any emergency i.e. cardiac arrest there will be a “CODE BLUE “ announced by hospital means all the member of emergency team have to go to the patient site, hospital pharmacist is also a member of the team to open crash cart for users and dispense accordingly. Once purpose served pharmacist shall replace stock back and keep it under lock & key always.
  • Pharmacist is also responsible for admixing cytotoxic medicines to prepare chemo for the patient. This process shall be performed under laminar air flow hood with necessary precaution as these drugs are highly toxic and may cause serious damage to the person admixing.
  • In-patient pharmacist should also monitor and check ward stock on a periodical basis to ensure medicines are stored properly and are not expired.
  • Daily, monthly and annual sales report shall be prepared and present to management to appreciate. Also to come up with new strategies and policies to get better benefit from the overall sales.
  • Monthly & Annual stock take should be conducted to ensure the accuracy and expiry date of medicines. Report shall be submitted to management to appreciate results with explanation on all variances.
  • Pharmacist should play role to reduce expiry rate by applying strategies so that expiry rate remains below 3% which is WHO standard. All the near expiry items have to be communicated with prescribers so that they can use them on their patient if necessary.
  • All the expired and damaged stock shall be returned back to central pharmacy for write off and destruction following approved method of disposal.

Out-Patient Pharmacy: This is the place where all the patients raised from out-patient consultation area get dispensed of their medications. Out-patient pharmacy also serves patients to refill their prescriptions on wards. Most of the activities and functions are quite similar with the in-patient pharmacy though contains of the prescriptions quite different than in-patient pharmacy. As most of the patients are stable nature of prescriptions are usually more of solid dosage forms rather than injectables and fluids. Remember for out-patients this is the only place to get detail counseling and information regarding the usage of medicines that’s why patient counseling is a very important role of pharmacist here. For refill patient this the point to hear complaints from patient or new symptoms so that pharmacist can provide necessary feedback or forward to physician for follows up.

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Figure 8: OUT-PATIENT PHARMACY

Let me put major roles and responsibilities of the hospital pharmacist in out-patient as below;

  • Prescription screening rose from out-patient consultation area to ensure seven rights i.e. right patient, right age, right medicine, right dose, right dosage form, right route in right time. Also to check for transcribing error if it’s a system generated prescription. Always communicate with relevant prescriber to get clarification if needed.
  • Dispensing medicines as prescribed and ensure right patient, right medicine, right dose, right strength, right dosage form, right expiry and right quantity dispensed with properly labeled and necessary usage instructions written on the label for the patient. Sometimes ointment or creams may prescribe in a certain ratio which should be mixed by the pharmacist accordingly before dispensed. All the powder for suspensions should be dispensed in a ready to use form.
  • Patient counseling is a very important part at Out-patient pharmacy and pharmacist should take more time to counsel patient properly. Counseling should be done on the use of medicines, side effects, effects of drug-drug and drug-food interactions for them to be careful while on treatment, precautions, warnings, contra-indications and administrations. Patient need to understand the benefit of using medicines on time and to complete the course of antibiotics as well as the losses if they don’t do so.
  • Pharmacist should check blood pressure and blood sugar for chronic patients when they come for refill to ensure treatment is effective or else forward to the physician if things are not going right. Out-patient pharmacy is always a point to trace new complications, side effects related complication and treatment outcome.
  • Storing medicines at recommended temperature and monitor temperature log on daily basis. Storing sensitive medicines separately like Cytotoxic, radioactive, habit forming drugs or narcotics (under lock and key), life saving drugs etc and properly labeled with precautions.
  • Placing order to replenish stock from central pharmacy as required following a minimum stock level strategy on daily basis.
  • Receiving of stock from central pharmacy following a quality check and make sure stock properly captured into the main inventory.
  • Handling customer query and complaints regarding medicines and other pharmaceutical services.
  • To attend query, complaints from other health care providers like doctor, nurse regarding medicines, other pharmaceutical services and provide feedback accordingly.
  • Daily, monthly and annual sales report shall be prepared and present to management to appreciate. Also to come up with new strategies and policies to get better benefit from the overall sales.
  • Monthly & Annual stock take should be conducted to ensure the accuracy and expiry date of medicines. Report shall be submitted to management to appreciate results with explanation on all variances.
  • Pharmacist should play role to reduce expiry rate by applying strategies so that expiry rate remains below 3% which is WHO standard. All the near expiry items have to be communicated with prescribers so that they can use them on their patient if necessary.
  • All the expired and damaged stock shall be returned back to central pharmacy for write off and destruction following approved method of disposal.

Ward/ICU’s Stock: Some commonly used medicines and surgical items are always being kept with a particular quantity in the ward and intensive care units (ICU’s) for easy access when ever needed especially for new patients. Basically ward stock is being handled by the nurses in the ward and it must be under maintenance of in-patient pharmacy department. Pharmacist shall ensure that stock has been replenished at least weekly basis and expiry dates are fine. Habit forming drugs like morphine, pethedine shall not be kept in the ward stock due to the sensitivity of abuse. Ward stock list shall be updated at least yearly basis depending on the current demand of different items in the ward. Ward stock list may vary in different ward based on the category such Maternal, Cardiac, Neurology and different ICU’s.

Manufacturing Unit (Cytotoxic & other IV admixing): This is a very important part of hospital pharmacy and usually tertiary care based hospitals must have this function to ensure smooth supply of certain IV fluids and chemotherapy preparation at all time. Usually this unit runs under in-patient pharmacy as demand raise from the admitted patients. Items like total parenteral nutrition’s (TPN), sterile IV fluids, reconstitution of injectables and admixing in IV fluids for ready to administer, cytotoxic chemotherapy preparation etc can be done in the manufacturing unit by the pharmacists. This area must be set up following aseptic technique as per cGMP (current good manufacturing practice) guideline and access has to be controlled to avoid hospital borne microorganism’s contamination. All the admixing shall be carried out under laminar air flow hood using protective cloths, gloves and masks. Hospitals that are having unit dose dispensing system can package unit dose medicines in the manufacturing unit. All the medicines have to be properly labeled with required information and manufacturing date, expiry date must be written on the label.

baxter-compounding-safety

Figure 9: IV PREPARATION AREA (Manufacturing Unit)

Drug Information Unit: This is the information hub of all medicines and related materials along with their usage, safety, side-effects, warnings, dosage and administrations etc. Usually bigger hospitals like to keep this unit as a separate entity but it can be a part of in-patient and out-patient pharmacy as well. Pharmacist shall avail all kinds of information’s regarding medicines and related materials required by other health care provider and even patients if required. This unit keep all the health care providers up to date with latest drug information’s, warnings, side –effects, information’s on new molecules, ongoing researches etc. Drug information unit should have access to authentic reference around the globe like, USP, BP pharmacopoeia, WHO guidelines, BNF etc. Pharmacist shall always communicate new information’s to the health care providers on a regular basis. If there is a warning or batch withdrawal request raised from the manufacturers, it shall be communicated and acted accordingly. Drug information unit can also avail a scientific journal of its own for health care providers on a monthly or quarterly basis, where different health care providers can share their articles on health and medicines related issues. Pharmacist can organize a committee for editorial board so that all the publication can be peer reviewed before get published in the journal or newsletter. Drug information unit should have a library consists of medicinal references and health related books. Drug information unit can also conduct a monthly continuous medical education (CME) for the health care providers in that hospital.

DRUG INFORMER2

Figure 10: DRUG INFORMATION NEWSLETTER

Emergency Crash Cart & Emergency team member: Every hospital should have emergency crash cart and bag under lock and key at different user point in the hospital e.g. ICU’s, Wards, emergency area, out patients area etc. The idea is for easy access and usage of vital and essential life saving medicines and other resuscitate equipments whenever there is a cardiac arrest happens with patients in the hospitals. This emergency crash carts and bags shall be under the responsibility of hospital pharmacist. Whenever there is a cardiac arrest happens, a signal like “CODE BLUE” will be announced through hospital sound system so that all the members of emergency team will be at the side of cardiac arrest including the pharmacist. Pharmacist shall open the crash cart and dispense as required. After use crash cart shall be replenished and locked for next cardiac arrest management. Contents of emergency crash cart may vary at different user point based on the extent of use, but commonly used medicines and resuscitate materials that need to be there are as follows;

Top, Side, and Rear of the Cart: First Drawer (Medications)
◻ Defibrillator/Cardiac Monitor ◻ Adenosine 6mg/2ml vial
◻ Defibrillator pads ◻ Amiodarone 150 mg/3ml vial
◻ Latex gloves ◻ Atropine 1mg/10 ml syringe
◻ Eye protection ◻ Calcium chloride 1g/10 ml syringe
◻ Adult and pediatric multi-function electrodes ◻ Dopamine 400 mg/250 ml IV bag
◻ 5 in 1 connector and 02 tubing ◻ Epinephrine 1 mg/10 ml (1:10,000) syringe
◻ Adult and pediatric BVM with masks ◻ Flumazenil
◻ Surgical cone masks ◻ Lidocaine 100 mg 5ml syringes
◻ Oxygen tank and gauge ◻ Lidocaine 2 g/250 ml IV bag
◻ Cart inventory list ◻ Dextrose 50% 0.5 mg/ml 50 ml syringe
◻ Defibrillator gel ◻ Diphenhydramine 50mg/ml vial
◻ Sharps container ◻ Sodium bicarbonate 50mEq/50 ml syringe
◻ Code blue forms ◻ Sodium chloride 0.9% 10 ml vial
◻ Procedures sheet ◻ Sterile water Injection 20 ml vial
◻ Vasopressin 20 units/ml 1 ml vial
Second Drawer (Pediatric Medications and IV Solutions) Third Drawer (Adult Intubation Supplies)
◻ Atropine 0.5 mg/ 5 ml syringe ◻ Endotracheal tubes of different sizes
◻ Sodium bicarbonate 10 mEq/10 ml (8.4%) syringe ◻ Nasopharyngeal airway
◻ Saline flush syringes ◻ Intubation tray
◻ Sodium chloride 0.9% 10 ml flush syringe ◻ Suction catheters
◻ Sodium chloride 0.9% 100 ml IV bag ◻ Batteries: size C and D
◻ Dextrose 5% 250 ml IV bag ◻ Tongue depressor
◻ Sodium chloride 0.9% 1000 ml IV bag ◻ Kelly clamp with rubber tip
◻ Carbon dioxide indicator
Flashlight
◻ Forceps and syringes
◻ Laryngoscope blades
◻ Laryngoscope handle

Figure 11: List of Medicines & Equipment’s in Emergency Crash Cart

CrashCart-Front

Figure 12: EMERGENCY CRASH CART

Instructions Related to Crash Cart Use:  Carts are of three types. These include adult crash carts, pediatric crash carts, and newborn intensive care crash carts. The guidelines for crash cart use that need to be followed by the hospitals and clinics include: The crash carts have to be conveniently placed near the emergency rooms, treatment rooms for anaphylaxis, etc.

  • There has to be an inventory of medications, equipment, and IV fluids listed by the contents of each drawer in the carts.
  • The inventory of the crash cart items, such as the drugs and the IV fluids, should contain the name, strength, and amount of the drug along with its expiration date.
  • The inventory of the crash cart contents has to be checked on a monthly basis to check for the IV fluids and drugs and their expiration date.
  • The drugs need to be replaced before the expiration date.
  • In case of battery-assisted equipment, batteries need to be checked.
  • Defibrillator load checks must be performed once daily, with the defibrillator plugged in, as well as unplugged.
  • The defibrillator should be checked on a daily basis, and it has to be documented.
  • If changes are made to the cart’s contents, the drug and equipment inventory list needs to be updated.
  • The crash cart must be locked or should have an integrity seal. If the seal of the cart is broken, the reason for the same needs to be documented, with the necessary details such as the date, time, individual’s initials, and the new lock or seal number.
  • The oxygen tanks must be secured to the side of the cart. If the oxygen tank is empty, oxygen cylinders need to be replaced.
  • Drawers of the crash cart need to be clearly labeled.

On a concluding note, it is extremely essential that carts are well-stocked with all the necessary drugs and equipment to ensure that the doctors are able to confidently handle emergencies. A licensed official is designated for the purpose of checking the defibrillator, oxygen cylinder levels, and the other contents of the crash cart. He/ She is also responsible for rechecking and restocking the cart following its use. He is also responsible for documenting compliance on crash cart checklist. In fact, code drills are often conducted to check the response of the staff during such situations.

Reduction of Expires: This is a very sensitive and core responsibility of a hospital pharmacist, as we know most of the pharmaceutical and related commodities has a shelf life by which it should get used otherwise may end up into expired product which is a loss to the organization. Now the question comes is it possible to achieve zero percent expires in any pharmaceutical inventory, answer will be may be not possible but will be really difficult because the demand of medicines varies time to time and also you cannot go without stocking some medicines which may not need always but whenever needed it has to be availed instantly to serve the purpose as an emergency. So the ideal should be as much as you can keep your expires low will be better to avoid loss and WHO recommendation is to keep expires ≤ 3% at any given time is a standard for a pharmaceutical inventory management. A hospital pharmacist can use his/her skills and knowledge to implement several strategies to achieve this goal of keeping lower expire rate round the year, some of the strategies can be;

  • Establish policy to control inbound movement of short dated medicines from suppliers. Example like Remaining Shelf Life (RSL) approval should be taken by suppliers ahead of deliveries if it is below 80%. Acceptance range may vary depend on the consumption rate of medicines. But this control will ensure short dated products are not in high numbers from suppliers which may end up increase your expiry rate.
  • Establish FIFO (First in First Out) and/or FEFO (First Expiry First Out) system in the inventory management to ensure near expiry items move first and fast.
  • Management of near expiry items that are left with 3-6 months shelf life by holding meetings with prescribers to find a way forward to use them within shelf life.
  • Establish memorandum of agreement with suppliers for replacing stock with better shelf life under circumstances where it is expiring and also no demand currently.
  • Establish policy to approach other hospitals in the region if they have a demand and eagerly want to buy it. List of such items can be circulated among those hospitals.
  • Quantification of such items that are frequently expires need to be re-adjusted and shipment may splits into several segments to avoid such situations in future.

Destruction of Expired & Damaged medicines: This is a very important and sensitive part of any pharmaceutical warehouse or business and hospital pharmacists must play a vital role to ensure all the expired & damaged medicines has been destructed properly as per recommended disposal method to avoid environmental pollution and risk. Hospital may develop its own disposal guideline as per WHO recommendation or adopt “Guidelines for Safe Disposal of Unwanted Pharmaceuticals in and after Emergencies”. Pharmacist shall seek write-off permission from the hospital management with proper explanations on expires and damages. Once write-off is approved then plan for disposal shall be encountered. Sometimes hospitals may have their own capacity for destruction of expired & damaged medicines and in case unavailability of such capacity hospital can engage a professional clinical waste management company to destroy. But even if it will be done by a third party still hospital pharmacist shall present at the time of destruction to ensure that recommended disposal method has been followed by the company. In case destruction of habit forming or narcotic drugs presence of local security authority likes police, narcotic department may need as per country’s medicine related legal requirement. Once destruction is done, a destruction certificate signed by required personnel’s shall be produced by the destruction company which hospital need to be preserved for a particular period for future reference and record.

Table 2: WHO Recommended Disposal Methods for Pharmaceutical Wastages

CATEGORY DISPOSAL METHODS COMMENTS
Solids
Semi-solids
Powders
Landfill
Waste encapsulation
Waste inertization
Medium and high temperature incineration (cement kiln incinerator)
No more than 1% of the daily municipal waste should be disposed of daily in an untreated form (non- immobilized) to a landfill.
Liquids Sewer
High temperature incineration (cement kiln incinerator)
Antineoplastics not to sewer.
Ampoules Crush ampoules and flush diluted fluid to sewer Antineoplastics not to sewer.
Anti-infective drugs Waste encapsulation
Waste inertization
Medium and high temperature incineration (cement kiln incinerator)
Liquid antibiotics may be diluted with water, left to stand for several weeks and discharged to a sewer.
Antineoplastics Return to donor or manufacturer
Waste encapsulation
Waste inertization
Medium and high temperature incineration
(cement kiln incinerator)
(chemical decomposition)
Not to landfill unless encapsulated.
Not to sewer.
No medium temperature incineration.
Controlled drugs Waste encapsulation
Waste inertization
Medium and high temperature incineration
(cement kiln incinerator)
Not to landfill unless encapsulated
Aerosol canisters Landfill
Waste encapsulation
Not to be burnt: may explode.
Disinfectants Use
To sewer or fast-flowing watercourse: small quantities of diluted disinfectants (max. 50 liters per day under supervision)
No undiluted disinfectants to sewers or water courses.
Maximum 50 liters per day diluted to sewer or fast-flowing watercourse.
No disinfectants at all to slow moving or stagnant watercourses.
PVC plastic, glass Landfill Not for burning in open containers
Paper, cardboard Recycle, burn, landfill

Pharmacoeconomics (Medicine Cost Management): A very new feature in modern hospital pharmacy practice is “Pharmacoeconomics” or medicine cost management for the patients. Pharmacoeconomics can be defined as the branch of economics that uses cost-benefit, cost-effectiveness, cost-minimization, cost-of-illness and cost-utility analyses to compare pharmaceutical products and treatment strategies. Especially patient with chronic disease like hypertension, diabetes etc may fall under such category and can benefit by reducing cost of medicines. By the Pharmacoeconomics assessment it helps prescriber to decide on proper treatment strategy patient should follow to maximize effectiveness in minimum cost.

Key Concepts of Pharmacoeconomics;

  • Pharmacoeconomics identifies, measures, and compares the costs and consequences of drug therapy to healthcare systems and society.
  • The perspective of a pharmacoeconomic evaluation is paramount because the study results will be highly dependent on the perspective selected.
  • Healthcare costs can be categorized as direct medical, direct nonmedical, indirect nonmedical, intangible, opportunity, and incremental costs.
  • Economic, humanistic, and clinical outcomes should be considered and valued using pharmacoeconomic methods, to inform local decision making whenever possible.
  • To compare various healthcare choices, economic valuation methods are used, including cost-minimization, cost-benefit, cost-effectiveness, and cost-utility analyses. These methods all provide the means to compare competing treatment options and are similar in the way they measure costs (dollar units). They differ, however, in their measurement of outcomes and expression of results.
  • In today’s healthcare settings, pharmacoeconomic methods can be applied for effective formulary management, individual patient treatment, medication policy determination, and resource allocation.
  • When evaluating published pharmacoeconomic studies, the following factors should be considered: study objective, study perspective, pharmacoeconomic method, study design, choice of interventions, costs and consequences, discounting, study results, sensitivity analysis, study conclusions, and sponsorship.
  • Both the use of economic models and conducting pharmacoeconomic analyses on a local level can be useful and relevant sources of pharmacoeconomic data when rigorous methods are employed. 

Managed Care Pharmacy (MCP): An organized health care delivery system designed to improve both the quality and the accessibility of health care, while containing costs7. This type of system can be established within a hospital pharmacy set up in a healthcare facility to provide service for chronic patients having hypertension, diabetes, cancer etc. Below is a short description of a basic model of managed care pharmacy which may contain following scopes to improve health care delivery, may be in future will try to detail on this topic.

Disease Management
Disease management is the concept of reducing health care costs and improving quality of life for individuals with chronic conditions by preventing or minimizing the effects of the disease through integrated care.

Drug Utilization Review
Drug utilization review (DUR) is defined as an authorized, structured, ongoing review of prescribing, dispensing and use of medication.

Electronic Prescribing
E-prescribing is the use of health care technology to improve prescription accuracy, increase patient safety, and reduce costs as well as enable secure, real-time, bi-directional, electronic connectivity between clinicians and pharmacies.

Formulary Management
Formulary management is an integrated patient care process which enables physicians, pharmacists and other health care professionals to work together to promote clinically sound, cost-effective medication therapy and positive therapeutic outcomes.

Maintaining the Affordability of the Prescription Drug Benefit
The purpose of this paper is to explain how managed care organizations (MCOs) are able to secure lower drug prices from pharmaceutical manufacturers.

Medication Errors
Medication errors are among the most common medical errors, harming at least 1.5 million people every year.

Medication Stockpiling
AMCP is concerned about the harmful effects that medication stockpiling could have on individual patients as well as the population as a whole.

Outcomes Research
Outcomes research is a facet of research that measures results of various medical treatments and/or interventions in patient populations.

Patient Confidentiality
Patient Confidentiality Congress passed the Health Insurance Portability and Accountability Act (HIPAA) in 1996.

Prior Authorization
Implementation of a well-designed prior authorization program optimizes patient outcomes by ensuring that patients receive the most appropriate medications while reducing waste, error and unnecessary prescription drug use.

Specialty Pharmaceuticals
Over the past several years, utilization and cost of specialty pharmacy products have been increasing at a rate substantially greater than that of other pharmaceuticals.

Continuous Medical Education (CME): Continuous Medical Education (CME) or more specifically Continuous Pharmaceutical Education (CPE) is a key component for any healthcare provider so that everyone is well updated about current information and/or changes on pharmaceutical products. Since pharmacists are the technical personnel of pharmaceutical products is their core responsibility to gather current information’s on medicines and related commodities from relevant source and then communicate it among all relevant healthcare providers. As in Bangladesh, hospital pharmacy practice is not well established yet basically it has been directly done by pharmaceutical companies to the prescribers. In a hospital where there is a hospital pharmacy, hospital pharmacist shall do this for his hospital. Pharmaceutical companies shall not visit a prescriber directly without consulting pharmacist rather hospital pharmacist should arrange an in-service lectures for all relevant healthcare provider and brief them on new information and/or changes of pharmaceutical products. Remember when a hospital pharmacist will do that he/she is not going to promote a specific brand of a company but the generic product itself. Since there is a hospital formulary approved by Drugs and Therapeutic Committee (DTC) of that hospital, all the brands that are there will be normally prescribed. Hospital pharmacists can communicate through in-service lectures, seminars, symposiums in the hospital. Not only new information but also existing drug interactions, side-effects, pre-cautions, warnings shall be re-communicated as well. All in all a hospital pharmacist him/her self has to gather knowledge continuously and study more so that they are competent enough when communicate a information to the prescribers. Pharmaceutical companies can also sponsor these types of CME’s in the hospital in collaboration with hospital pharmacy department where they can promote their brand which is already in the hospital formulary. CME’s or CPE’s improves overall knowledge of healthcare providers about pharmaceutical products and their usage properly and increase confidence level while prescribing. Drug administration is another critical component especially for nurses who administer medicines to in-patients. Procedure of dilution, re-constitutions, right dose picking, site of administer for injectables, procedure to use inhalers etc can be also shared during a CME program. Most of the time in Bangladesh patients does not response properly due to wrong administration of medicines and there is no way to train them if a hospital does not have an established hospital pharmacy with relevant skilled pharmacists in place.

Standard Operative Procedure (SOP): Actually I should have talk about this at the very beginning but I have decided to talk about it at the end because of better understanding of its importance. Standard Operative Procedure (SOP) is a written document of a particular procedure which is granted and approved by a designated authority of the hospital and must be followed when performing that particular procedure. Basically SOP is a part of Quality Management System (QMS) and the system need to be developed, implemented, monitor and review by a specific group of people or a specific department in the hospital. We may have different competent level of personnel in a health facility and if something like SOP is not available you may experience different way of performing of a particular procedure which may result different outcomes. So it is very important to ensure that whoever performs procedure it has to be equal and similar at any point. Starting from the beginning up to now whatever components of a hospital pharmacy department I have discussed, has so many processes and procedures which must be available in an approved documented form in the hospital and has to be strictly followed when performing a procedure. Usually SOP is developed based on current demand in the ground and it may changes with time that’s why review of SOP after a specific period like 1-2 years need to be conducted.  Usually an organization with QMS system is well recognized by other accreditation body like Joint Commission International (JCI), Council for Health Services Accreditation for Southern Africa (COHSASA) etc for a health care facility. A hospital either can adopt a QMS system from such types of accreditation body or can come up with its own QMS system to ensure quality standard of working procedure in their organization. Beauty of such standard is that similar kinds of QMS can ensure similar standard of working procedures in different facility around the world which helps to reduce errors at work and improves overall performance of the organization. Nevertheless QMS is a vital component of an organization which details organization’s policy, mission, vision, and objectives which can be implemented in a SOP format to be able to use it. Hospital pharmacist must have skill to be able to develop SOP as per requirement and train their staffs on each and every procedure periodically. During review of SOP everyone involves with that SOP shall contribute to review and update if needed. Few examples of different procedures in a hospital pharmacy set-up mentioned below that need to be in a SOP format to ensure quality of standard;

  • Procedure of addition and/or deletion of items in the hospital formulary
  • Procedure conducting drug utilization review
  • Procedure of reporting adverse drug reactions (ADRs)
  • Procedure of reporting medication errors
  • Procedure of receiving goods from suppliers
  • Procedure of quality inspection of goods
  • Procedure of prescription screening
  • Procedure of dispensing and/or patients consultation
  • Procedure of dispensing narcotic or habit forming drugs (HFD)
  • Procedure of delivery to the ward, ICUs, theatres etc
  • Procedure of preparing cytotoxic admixing or other IV Fluids
  • Procedure of handling customer returns and/or complaints
  • Procedure of stock take and reconciliation
  • Procedure of return to supplier
  • Procedure of write-off / write-on of inventory
  • Procedure of disposal of expired & damaged products
  • Procedure of preparing annual sales report
  • Procedure of preparing annual forecast & budgeting etc

REFERENCES:

  1. http://apps.who.int/medicinedocs/documents/s21088en/s21088en.pdf
  2. http://apps.who.int/medicinedocs/en/d/Js4882e/
  3. http://banglajol.ubiquity.press/index.php/BMJ/article/viewFile/18496/12951
  4. https://www.prxn.com/docs/PRxN%20DUR.pdf
  5. http://www.ema.europa.eu/ema/index.jsp?curl=pages/special_topics/general/general_content_000570.jsp
  6. http://www.ema.europa.eu/docs/en_GB/document_library/Regulatory_and_procedural_guideline/2015/11/WC500196979.pdf
  7. http://www.amcp.org/ConceptsInManagedCarePharmacy/
  8. https://www.fip.org/www/uploads/database_file.php?id=331&table_id=
  9. http://apps.who.int/medicinedocs/documents/s19622en/s19622en.pdf
  10. https://www.fip.org/files/fip/Statements/latest/Dossier%20003%20total.PDF
  11. http://www.rpharms.com/support-pdfs/rps—professional-standards-for-hospital-pharmacy.pdf
  12. https://www.ashp.org/DocLibrary/BestPractices/SettingsGdlMinHosp.aspx
  13. http://www.mm3admin.co.za/documents/docmanager/0C43CA52-121E-4F58-B8F6-81F656F2FD17/00052829.pdf
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