Chapter 9 - Denali Rx

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Nov 13, 2013 (3 years and 11 months ago)

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1

Chapter 9

Hospital Pharmacy
Practice

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2

Hospital Organization


Hospitals vary by type, size, and
function.


Nearly all have a hospital pharmacy.


Pharmacy technicians have been
employed in hospitals since the
1960s.

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The Director of Pharmacy

The director of pharmacy has overall
responsibility for the hospital’s
pharmacy services:


Managing the budget


Hiring and firing personnel


Developing a strategic vision


Ensuring compliance with state and
federal laws and regulations


Developing policies and procedures

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The Director of Pharmacy

The director of pharmacy determines
the level and scope of services offered:


Type of medication distribution systems


Hours of

operation


Provision of

specialty services,

such as outpatient

services

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Hospital Pharmacy

vs. Community Pharmacy


The hospital pharmacy carries out
many of the same services as the
community pharmacy.


Unlike most community pharmacies,
hospital pharmacies also dispense


Parenteral drugs


Biological agents


Potentially hazardous chemotherapy
medications

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Inpatient Drug Distribution
Systems


In many hospital pharmacies, this system
consists of


Unit dose


Floor stock


IV admixture


TPN service


System is often highly automated, thereby


Improving quality and efficiency of services


Minimizing medication errors

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Inpatient Drug Distribution
Systems


Medication orders


Unit dose


Floor stock


Narcotics in a hospital pharmacy


Intravenous admixture service


Medication administration record

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Medication Orders


Prescriptions in the hospital pharmacy take
the form of a medication order.


There are several types:


Admitting order


written by physician when the
patient is admitted


New medication order


like a new prescription
in the community pharmacy


Stat order


emergency medication, receives
priority attention


Continuation order


like a refill in the
community pharmacy

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Terms to Remember

medication order

a prescription written in the hospital
setting


admitting order

a medication order written by a
physician on admission of a patient to
the hospital; may or may not include a
medication order


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Terms to Remember

stat order

a medication order that is to be filled and
sent to the patient care unit immediately


continuation order

a medication order written by a
physician to continue treatment; like a
refill of medication

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Unit Dose


An amount of medication
prepackaged for a single
administration


Systems in use since the
early 1960s


Increases efficiency by
making the drug
formulation as ready to
administer as possible

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Terms to Remember

unit dose

an amount of a drug that has been
prepackaged or repackaged for a single
administration to a particular patient at a
particular time

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Terms to Remember

inpatient drug distribution system

a pharmacy system to deliver all types of
drugs to a patient in the hospital setting;
commonly includes unit dose,
repackaged medication, floor stock, and
IV admixture and TPN services

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Unit Dose


Technician uses a fill list to add unit doses
for each patient.


Each patient on each

care unit has a

designated removable

medication drawer.


Drawers are delivered

to each patient care unit

in a unit dose cart.

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Terms to Remember

unit dose cart

a movable storage unit that contains
individual patient drawers of medication
for all patients on a given nursing unit

Safety Note

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Unit Dose

Only unopened unit doses can be
returned to stock.

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Unit Dose

Although packaging costs are higher,
unit dose system saves time and
money:


Provides increased security for
medications


Reduces medication errors


Reduces nursing staff time


Makes administration, charging, and
crediting easier

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Unit Dose


Larger hospitals use
automated robotic
systems to fill unit dose
orders.


A robotic arm pulls
medication and transfers
it to a collection area.


Pharmacy technician’s
primary role is stocking
the robotic system.

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Unit Dose


Pharmacy staff sometimes must repackage
medications to achieve a unit dose:


Manufacturers do not prepare all drugs in unit
dose form.


Sometimes a nonstandard dose is ordered for a
patient.


Single dose prepared for a specific patient
is called a medication special:


Single doses are labor intensive to prepare.


They are usually the responsibility of the
pharmacy technician.

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Terms to Remember

medication special

a single dose preparation not
commercially available that is
repackaged and made for a particular
patient

Safety Note

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Unit Dose

Expiration dates and lot numbers
must be included on all repackaged
medications.

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Unit Dose


Repackaged medications must be carefully
labeled.







Pharmacy is legally required to record and
document information about repackaged
medications in a repackaging control log.

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Terms to Remember

repackaging control log

a form used in the pharmacy when
drugs are repackaged from
manufacturer stock bottles to unit doses;
the log contains the name of the drug,
dose, quantity, manufacturer lot number,
expiration date, and the initials of the
pharmacy technician and pharmacist

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Unit Dose


Medication orders are filled on a
regular basis (every 24 hours or less).


Orders are entered into a database.


Patient
-
specific unit dose profile is
created.


Printout of all unit dose profiles serves
as a cart fill list.

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Terms to Remember

unit dose profile

the documentation that provides the
information necessary to prepare the
unit doses, including patient name and
location, medication and strength,
frequency or schedule of administration,
and quantity for each order

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Terms to Remember

cart fill list

a printout of all unit dose profiles for all
patients

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Terms to Remember

floor stock

medications stocked in a secured area
on each patient care unit

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Floor Stock


Floor stock is an inventory of frequently
prescribed drugs stored on the patient care
unit.


Automated delivery systems can be used
for floor stock:


Allow secure, locked storage


Free up nursing staff time


Capture charges for dispensed medications


Track medications by type of drug, patient, and
caregiver

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Floor Stock


Pharmacy maintains floor stock inventory.


Patient care units send reports requesting
replacement inventory.


Pharmacy technician

inspects floor stock for


Expired drugs


Excess inventory


Proper storage

Safety Note

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Floor Stock

No food items can be placed in a
refrigerator that is dedicated to
storing medications.

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31

Narcotics in a Hospital
Pharmacy


Schedule II controlled substances
must be secured in a locked cabinet.


A careful audit trail must be kept for
each medication.


Complete information is kept in the
Schedule II drug administration
record.

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Terms to Remember

Schedule II drug administration record

a manual or electronic form on the
patient care unit to account for each
dose of each narcotic administered to a
patient

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Intravenous Admixture
Service


Most hospitals provide an IV
admixture service, including injectable


Antibiotics


Thrombolytics


Nutrition


Cancer chemotherapy


Staffed by specially trained
pharmacists and technicians

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Terms to Remember

IV admixture service

a centralized pharmacy service that
prepares IV and TPN solutions in a
sterile, germ
-
free work environment

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Intravenous Admixture
Service


Many hospitals also have a total parenteral
nutrition (TPN) service.


TPN service often consists of a specially
trained or certified


Physician


Nurse


Nutritionist


Pharmacist


Service provides all nutritional needs for
the patient who cannot or will not eat.

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Terms to Remember

total parenteral nutrition (TPN)

a specially formulated parenteral
solution that provides nutritional needs
intravenously (IV) to a patient who
cannot or will not eat

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Intravenous Admixture
Service

Larger hospital pharmacies use
automation in their IV admixture and
TPN services:


Allows pharmacy to operate more
efficiently


Minimizes medication errors


Significantly reduces inventory

Safety Note

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38

Intravenous Admixture
Service

Although automation reduces
errors, technical errors must still be
monitored.

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39

Medication Administration
Record


When any type of medication is
administered, it is recorded on the
medication administration record (MAR).


MAR is patient specific and includes


Medication orders


Names of all drugs


Doses


Routes and times of administration


Start and stop dates


Any special instructions

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Terms to Remember

medication administration record
(MAR)

a form in the patient medical chart used
by nurses to document the
administration time of all drugs

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Medication Administration
Record


Record can also be electronic (eMAR).


eMAR documents the administration time
of each drug to each patient.


Medication orders are input into handheld
computers and sent directly to pharmacy.


Patient information is scanned from a
barcode on the patient’s wristband.


Pharmacy checks, fills, and sends
medication to unit.

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42

Terms to Remember

electronic medication administration
record (eMAR)

documents the administration time of
each drug to

each patient

often using

bar
-
code

technology

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43

Hospital Committee Structure


Many committees support the
functions of a hospital.


Those relating to pharmacy include


Pharmacy and therapeutics (P&T)


Infection control


Institutional review board (IRB)


A pharmacy technician often
represents the department on these
committees.

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Pharmacy and Therapeutics
Committee


Reviews, approves, and revises the
hospital’s formulary


Maintains hospital’s drug use policies


Consists of


Medical staff


Hospital and nursing

administrators


Director of pharmacy


Drug information

pharmacist

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Pharmacy and Therapeutics
Committee


Medical staff can apply to P&T
committee to have a new drug added
to the formulary.


Cost, advantages, and disadvantages
of the new drug are compared with
the existing formulary drug.


Full committee then considers the
application.

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46

Terms to Remember

institutional review board (IRB)

a committee of the hospital that ensures
that appropriate protection is provided to
patients using investigational drugs;
sometimes referred to as the human use
committee

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Institutional Review Board


Charged with ensuring the safety of
patients in terms of investigational drugs or
procedures or other clinical research
studies


Committee consists of a consumer
representative as well as members from


Medicine


Pharmacy


Nursing


Hospital administration

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Terms to Remember

investigational drugs

drugs used in clinical trials that have not
yet been approved by the FDA for use in
the general population or drugs used for
nonapproved indications

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Institutional Review Board


Investigator or researcher submits an
application to the IRB outlining the
study:


Number, age, and type of subjects


Informed consent forms to be used


The job of the IRB is to protect the
patient by assuring adequate
knowledge of risks and confidentiality
of the medical information collected.

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Terms to Remember

informed consent

written permission by the patient to
participate in an IRB
-
approved research
study in terms understandable to the lay
public

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Terms to Remember

Joint Commission

an independent, not
-
for
-
profit group that
sets the standards by which safety and
quality of health care are measured and
accredits hospitals according to those
standards; previously called the Joint
Commission on Accreditation of
Healthcare Organizations (JCAHO)

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The Joint Commission


An independent, non
-
profit group


Sets and measures standards for
quality and safety of health care


Evaluates hospitals’ performance and
accredits those that meet standards

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The Joint Commission


Requires all hospital departments to
have an up
-
to
-
date policies and
procedures manual


Performs random and unannounced
inspections


Provides education and guidance to
improve hospitals’ performance

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Quality of Care Standards


Joint Commission has National Quality
Improvement Goals for select patient
populations, such as those suffering from


Heart attack


Heart failure


Pneumonia


Surgical infections


A hospital’s performance with these
populations is compared with already
accredited hospitals of similar size.

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Safety
-
Related Standards


Almost half of the Joint Commission’s
standards are directly related to
patient safety.


For the pharmacy, these standards
include


Reconciling a patient’s medical profile
with subsequent medical orders


Improving the safety of medication use
and drug infusion pumps

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Inventory Management


As much as 70% of a hospital
pharmacy’s budget is spent on
pharmaceuticals.


Budgetary

planning and

accurate

inventory

management

are crucial.

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Inventory Management


Purchasing


Ordering


Receiving and storage

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Purchasing

Most hospitals purchase their
pharmaceuticals from a wholesaler and
their IV materials directly from the
manufacturer.

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Purchasing


In a larger hospital, an inventory
control pharmacist or technician may
develop specific purchasing criteria
based on budget planning.


Suppliers and manufacturers then
compete for the hospital’s business
through a confidential, sealed bid
process.

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Ordering


An important part of the pharmacy
technician’s job is the receipt,
storage, and ordering of
pharmaceuticals.


Automation on the wholesaler’s side
is making inventory management less
costly and more accurate.

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Receiving and Storage

Once drugs are received from the
wholesaler, the technician should


Verify the invoice


Inspect the shipment


Properly store the drugs


Rotate the stock on the shelves

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Receiving and Storage

Two types of pharmaceuticals require
special procedures:


Controlled substances


CSA defines inventory, filing, and
recordkeeping requirements.


DEA form 222 must be used.


Investigational drugs


These must be maintained in a secure area.


Special ordering, handling, and
recordkeeping procedures are necessary.

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Receiving and Storage


Pharmacy technician must identify and
deal with expired drugs:


Remove from storage


Return to wholesaler for credit


Pharmacy technician must also properly
handle manufacturer or FDA recalls:


Identify the affected lot number


Remove recalled drugs from storage


Fill out necessary paperwork


Return recalled drugs to wholesaler for credit