Chapter 9: Institutional Pharmacy Practice

ASAP Order

As soon as possible! but it’s not an emergency

Aseptic Technique

Procedures used in the sterile compounding of hazardous and nonhazardous materials to minimize the introduction of microbes or unwanted debris that could contaminate the preparation

Automated Dispensing System (ADS)

Computerized cabinets and integrated systems that control inventory on nursing floors, in emergency departments, and in surgical suites and other patient care areas.

Computerized Physician Order Entry (CPOE)

Computerized order entry

Electronic systems that can quickly and clearly transfer patient orders and information to and from the pharmacy

Crash Carts

Moveable carts containing trays of medications, administration sets, oxygen, and other materials used in life-threatening situations, such as cardiac arrest; also known as code carts

Electronic Medication Administration Record (E-MAR)

A computer program that automatically documents the administration of medication into certified electronic health record (EHR) systems; the report serves as a legal record of medications administered to a patient at a facility by a health care professional.

Floor Stock

Drugs not labeled for a specific patient and maintained at a nursing station or other department of the institution (excluding the pharmacy) for the purpose of administration to a patient of the facility

Formulary

A list of drugs approved for use in hospitals by the pharmacy and therapeutics committee of the institution that have become the standard stock carried by the pharmacy and other departments

Institutional Pharmacy

A pharmacy in facilities where patients receive care on site (e.g., hospitals, extended-living homes, long-term care, and hospice facilities); institutional pharmacies are also found in government-supported hospitals run by the Department of Veteran Affairs, Indian Health Service, and the Bureau of Prisons.

Investigational Drug

A drug that has not been approved by the U.S. Food and Drug Administration (FDA) for marketing but is in clinical trials; also, an FDA-approved drug seeking a new indication for use

Medication Order

A prescription written for administration in a hospital or institution

(similar to a regular prescription written for a patient to bring to a retail pharmacy)

NKA (acronym)

No Known Allergies

NKDA (acronym)

No Known Drug Allergies

Nonformulary Medications

Drugs that are *NOT* approved for use within an institution unless specific exceptions are filed and accepted by institutional protocols

Parenteral Medication

Medication that bypasses the digestive system but is intended for systemic action; the term parenteral most commonly describes medications given by injection such as intravenously or intramuscular

Periodic Automatic Replenishment (PAR)

A set level of certain medications kept on hospital floors

PRN

Take as needed

Protocol

A set of standards and guidelines by which a facility operates

Pyxis

An automated dispensing system often used in hospitals

Satellite Pharmacy

A specialty pharmacy located away from the central pharmacy, such as an operating room (OR), emergency department (ED), or a neonatal pharmacy; satellite pharmacies typically are staffed by a pharmacist and a pharmacy technician

Standing Order

Written procedure for drug or treatment that is to be filled immediately, as quickly as is safely possible to prepare the dose, usually within 10 to 15 minutes.

SureMed

An automated dispensing system often used in hospitals

The Joint Commission (TJC) *OR* (JACO)

An independent, nonprofit organization that accredits hospitals and other health facilities in the United States; the facility must be accredited to receive Medicare and Medicaid payment

Unit Dose (UD)

Individualized packaged doses used in institutional practice settings

United States Pharmacopeia (USP)

A compendium of drug information, published annually, compromising enforceable guidelines for the safe preparation of sterile products

P&P's

Policies and Procedures

SOPs

Standard Operating Procedures

Hospital Pharmacy

Most common institutional setting and most challenging area to work

- Fewer job openings for technicians

- More highly skilled technicians required

- Multitasking and more complicated tasks

Tasks for Pharmacy Technician in a Hospital Setting

- Preparing IV medications and loading patient medication in drawers

- Entering data into pharmacy computer system

The size of a hospital depends on _________

The number of patient beds available.

*Small: 50 beds or fewer

Large: 50 to 250 beds or more*

Other differences: Diagnosis, surgery, outpatient services

2 Type of Hospitals

Nonprofit and For-Profit

Nonprofit Hospital

A facility that does not pay either the state or local taxes or federal income taxes because it is considered charity

For-Profit Hospital

Also known as an investor-owned hospital, owned by private investors or owned publicly by shareholders.

LAFW

Laminar AirFlow Workbench; IV Hood

Used for the preparation of parenteral products or replace any missing medications in the automated systems or in the patients' cassette drawer

HEPA

High-Efficiency Particulate Air

CACI

Compounding Aseptic Containment Isolator

Hospital Pharmacy Setting Differences

The Layout of the pharmacies

Older Hospital Pharmacy Settings

Central Inpatient Pharmacy

Larger, newer hospitals:

Central and satellite pharmacies

Teaching Hospitals:

Pediatrics, Burn Units, Intensive Care Units (ICU's), cancer units

Satellite Pharmacies

Specialty pharmacies that supply a clinic

Discharge Pharmacies:

Fulfill the same duties as a community pharmacy

PNT

Pharmacy and Therapeutics Committee

Policies and Standard Operating Procedures

- P&Ps manual is found in all pharmacies

> Outlines facility's rules

- Rules apply to all employees

> Information concerns daily work activities, benefits, emergency situations, mandatory training

Hospital Protocol

- Determines which medications are formulary drugs and which are nonformulary drugs

> Purpose: To choose best medicines for patients

Formulary vs Nonformulary Medications

- Formulary Medications: Approved for use by a particular health care entity

- Nonformulary Medications: Not approved for use by a particular health care entity

- Formularies are developed by a group of specialty physicians and pharmacists

> Drugs are evaluated based on cost, effectiveness/safety, and patient demographics

The Pharmacy and Therapeutics Committee

Composed of pharmacists, physicians, nurses, and other healthcare workers---and administrators

They meet on a routine basis to discuss appropriate changes to protocols.

Purpose: to choose the best medicine for patients at the best cost.

Pharmacy and Nursing Staff Relationship

- Nurses are the pharmacy's primary customers; they should receive the highest level of support

- They are generally responsible for 80% of the total calls or electronic contacts with the inpatient pharmacy.

- Nurses depend on the pharmacy for all medications

- Nurses often make inquiries to pharmacies, including:

> Patient medication status and drug interaction

> Dosing ranges and pharmacy calculations

> "Where are the medications I ordered?" (most common)

Regulatory Agencies

- Hospitals all must meet federal and state guidelines

- Department of Public Health sets standards of safe operation

- State Board of Pharmacy inspects facilities and ensures that personnel are working within guidelines

Regulatory Agencies that Govern Operations:

The Joint Commission (TJC or JACO), United States Pharmacopeia (USP), Centers for Medicare and Medicaid Services (CMS), Department of Public Health (DPH), State Board of Pharmacy (BOP)

Centers for Medicare and Medicaid Services (CMS)

Formally known as the Health Care Finance Administration (HCFA), it regulates and administers Medicare, Medicaid, the Children's health Insurance Program (CHIP), the Health Insurance Portability and Accountability Act (HIPPA) standards, and several other health-related programs.

They inspect facilities and must give approval for hospitals to provide care and receive reimbursement for patients covered by Medicaid and Medicare.

Department of Health and Human Services (HHS)

The primary agency that protects the health of the American people and provides essential human services.

- Includes more than 300 agencies, covering areas in diseases, infections, preventive care, and disaster preparedness

Department of Public Health (DPH)

Inspects hospitals and hospital pharmacies to ensure that they are in compliance with DPH regulations

*EACH STATE HAS ONE*

State Board of Pharmacy (BOP)

Develops, implements, and enforces pharmacy practice standards in that state for the purpose of protecting the public. They regulate the pharmacists and pharmacy technicians that work in each facility

*EACH STATE HAS ONE*

Flow of Orders

- Prescriber visits patient in hospital and writes a medication order (equivalent to a prescription)

- Medication order is written on the prescriber's order sheet and placed in the patient's record (chart)

- Unit Clerk checks chart and sends new orders to appropriate department

- Orders arrive in the pharmacy around the clock, 365 days a year

- Various methods used to send orders include pneumatic tube system, computerized physician order entry, fax machine, staff member

- As orders are entered, labels are produced

> Name Alert stickers are used when two patients with same last name are on same the floor

- Technician pulls labels off printer and fills order

Methods to Send Orders to and from the Pharmacy

CPOE

Pneumatic Tube System

Manually (staff member delivers)

Pneumatic Tube System

Allows a person to send orders and other small items by way or an air-propelled tube.

Disadvantage: Carrier can get jammed, or item can accidentally be sent to the wrong department. Controlled substances may also be destroyed due to this mode of transporting items

Patient Information on Form of Orders

- Full Name

- Date of Birth

- Medical Record Number

- Room Number

- Diagnosis, Weight

- Drug Allergies

Different Types of Orders

- STAT

- ASAP

- Standing Order

- Emergency Situation

STAT

"at once"; order must be delivered within minutes; takes precedence over all orders

Filled in less than 10 minutes (usually no more than 15)

ASAP

"as soon as possible"; not as urgent as STAT, but filled before new orders

Emergency Situation

Order is filled immediately

Point-of-Entry Systems (POE)

Provides electronic access to medical information and drug information data

Also allows physicians, nurses, and pharmacists to communicate to each other

CADM

Computerized Adverse Drug Event Monitoring

BPOE

Bar Code Point of Entry

POE Systems include:

(also known as COW)

CPOE

IV Smart Pumps

CADM

BPOE

COW

Computers on Wheels

located at the patient's bedside

Mainly used in ICU's

What do Computerized Physician Order Entries (CPOE) do?

- Electronic systems that can quickly and clearly transfer patient orders and information to and from the pharmacy

- Provides electronic access to medical information and drug information data, limiting errors on transcription

- Medication orders can be clearly identified, and the computer systems check new medications against current medications for interactions or contradictions

- Health care providers can enter all lab results, dietary requirements, medications and special notes into the computer

- Reduced errors as medication orders were now clearly identified

- Can check for contraindications and interactions with other drugs with alerts

HITECH

Health Information Technology for Economic and Clinical Health Act

They enacted as part of the American Recovery and Reinvestment Act of 2009, was signed into law in February 2009.

It promoted the adoption and meaningful use of health information technology

Barcode Point of Entry

- Each unit of medication is bar coded and can be scanned with a handheld device

- Nurse is notified of any warnings or special notes

- Orders are sent in "real time"

> Nurse must verify order before administering the drug

Computerized Monitoring for Adverse Drug Events

- Computerized systems can detect and monitor adverse drug events

- Pharmacies must make sure all medications are barcoded for identification

- The information in the computer must accurately reflect the way the dosage form is to be given

Institutional Pharmacy Technicians Responsibilities

- Flexibility needed to work all shifts; must be multi-functional for all shifts

- IV Room

- Chemotherapy, controlled substances, and patient medication

- Medication preparation and inventory

- Miscellaneous duties

- Specialty Tasks: Clinical duties and anticoagulant therapy tasks, preparing nuclear medications

Pharmacy Technician's Role in the Investigational New Drug Process

- Investigational drug technicians

> Prehuman and human testing phases

- Clinical Trials

- Investigational drugs go to the central pharmacy; these are separated from other drugs

> Often used in hospitals, but under strict regulations

> Every drug has a logbook

Technician Responsibilities in Institutions: Chemotherapy

Prepares cytotoxic agents and other medications that may accompany these agents

Technician Responsibilities in Institutions: Controlled Substances

Gathers all controlled substance inventory sheets from all areas of the hospital; technician may also fill and deliver all controlled substances; pharmacist is required to verify pharmacy inventory daily

Technician Responsibilities in Institutions: Discharge Pharmacy

Fills prescription orders as patients are discharged from the hospital; medications are sent to the floor for patients, or patients may come to the pharmacy window to pick up medications

Technician Responsibilities in Institutions: Filling Requisitions

Fills all requisitions sent to the pharmacy; stocks inventory; orders pharmacy stock; controls narcotics inventory and audits narcotics if required; transports medications throughout hospital facility

Technician Responsibilities in Institutions: Inventory

Orders all medications and supplies for the pharmacy; also may order specialty items for other area of the hospital; handles all returns and recalled items that must be sent back to the manufacturer; responsible for handling all invoices and for putting all stock in appropriate bins; rotates stock; performs nursing floor inspections, and inspects other pharmacy supply areas for outdated drugs and inventory levels; restocks these areas if necessary; this may include the operating room , postoperative area, preoperative area, and other sterile areas

Technician Responsibilities in Institutions: IV Room

Prepares all parenteral IV preparations, including large-volume drips and parenteral nutrition; prepares drugs that are under investigational trial and logs these special medications in appropriate manner as required by law

Technician Responsibilities in Institutions: Medication Conciliation

Reviews and documents patient's arrival medication (for pharmacist review), assuring appropriate dose, route, frequency, and duration of therapy; may review records fro drug-drug interactions, duplication, and drug-allergy interactions; assists with arrival medication order entry; participates in hospital committees relevant to the area.

Technician Responsibilities in Institutions: Miscellaneous Duties

Able to work in all areas of the pharmacy as needed; answers phones, trains new technicians and pharmacist interns; works on a team with other technicians, clerks, and pharmacists

Technician Responsibilities in Institutions: Patient Medication

Fills medication drawers on a pharmacy cart that will deliver filled medications to all hospital patients; also may deliver carts to all patient areas and restock any floor stock medications; if hospital uses an automated medication dispensing system instead, technician must fill this unit on all floors; fills prescriptions for patients who will be discharged on as-needed basis

Technician Responsibilities in Institutions: Preparation of Medication

Fills unit doing bulk medications; compounds drugs for ointments, creams, and solutions

Technician Responsibilities in Institutions: Satellite Pharmacy

May be responsible for all tasks related to a small, isolated pharmacy, such as answering phones, ordering and putting away stock, preparing parenteral medications, transcribing and pulling all medication orders, and making deliveries to nursing stations

Patient Cassette Drawers and/or Pyxis Machines

- Loading patient cassette drawers from a pick station is a long-standing daily task of the hospital pharmacy technician

- Medications needed for the next day must be loaded in a cassette drawer

> Automated floor dispensing system:

- Pyxis

- SureMed

UD

Unit Dose

Patient Cassette Drawers

- Held in large push carts so that they may be delivered to the floor each day

- Robot dispensing machine: Fills each patient's medication cassette with 99% accuracy as the cassette moves along a conveyor belt

> Speeds up delivery of medication and helps ensure accuracy

The *3* main advantages of this type of cabinet are as follows

Inventory Control

Reduced Wait Time

Accuracy

Inventory Control

Inventory sheets can be generated in the pharmacy. Also the patient can be charged exactly as each item is dispensed from the ADS machine

Reduced Wait Time

Nurses can directly access the patient's drugs from the ADS. No starter dose needs to be sent to the floor from the pharmacy.

Accuracy

Nurses who access the ADS machines are allowed to take only the specific medication or medications ordered for their patients. In this way, an incorrect medication is less likely to be dispensed.

Automated Dispensing Systems (ADS)

- Pyxis MedStation 4000

> Uses fingerprints

> Touchscreen for medication removal

> Drawer opens for removal, then closes and records the removal

Unit Dose Medications

- Important daily task of pharmacy technicians: Preparation of unit dose medications not available from the manufacturer or stocked by the pharmacy

> Pharmacist performs the final check

- Unit Dose Liquids

> (TJC) now requires hospitals to make all medications patient-dose specific

> Every liquid dose is prepared in a unit dose package and labeled

Controlled Substances

- Counting, dispensing, and tracking narcotics is a critical job for technicians and nurses

- Each hospital conducts an actual count of controlled substances by two nurses every shift

- All controlled substances are counted *3* times daily

- Controlled Substances are kept in a locked room in the pharmacy at all times

- After each narcotic count, the technician signs out each drug onto a dispensing sheet, which is used to deliver medications

- Controlled substances must be kept unidentifiable during the delivery

> They are placed in stapled brown bags

> Technicians should never let these out of sight

- Return of controlled substances to the pharmacy

- Registered nurses (RNs), not licensed practical nurses (LPNs), can sign for controlled substances

Intravenous Preparations

- Printing of IV labels

- Keeping up with changes in patient status

- Reconstructing and preparing all IV medications in a horizontal flow hood

- Delivery of medications to nursing floors

Aseptic Technique

- Method used to prevent contamination of an object by microorganisms

- Extremely important in the preparation of all IV medications, chemotherapy, and opthalmics

- Samples are periodically tested for microbial contamination

Nonhazardous Intravenous Preparation

- Parenteral Medications: Meant for quick action

- Some must be prepared with additives

> Prepared in a laminar flow hood, in a clean room outside the compounding area

United States Pharmacopeia

- Enforceable United States Pharmacoepeia (USP) regulations for facilities that prepare sterile products, both nonhazardous and hazardous (such as chemotherapeutic drugs)

- Compounding must be done only in a clean room rated International Standards Organization (ISO) Class 8 or better

- Glove Box isolators can be added

An ISO class 8 environment means that the filter captures ____________ parts per cubic meter that measure greater that 0.5 mcg

3,520,000

Intravenous Therapy and Chemotherapy Preparation

- Technician is responsible for preparation of IV therapies and chemo therapies

- Horizontal flow hood; Used to prepare IV medications

> Orientations of hands must not block flow of air

- Vertical flow hood: Used to prepare chemotherapeutic drugs

> Technician must wear gown and double gloves

> Hands must not move over the top of any vial, needle, or IV bag