PRESCRIPTIONS IN HOSPITAL PRACTICE

HOSPITAL PHARMACY

• Oversee the different steps in the medication management and use system from the drug procurement (selection, purchasing, responsibilities and control), drug storage and inventory control, medication preparation and distribution (unit dose system) until monitoring of the drug therapy outcome to optimize patient safety and improve patients’ health-related quality of life.

Selecting and Procuring

• Establish Formulary;

• Procurement

Storing

• Storage of medications properly to ensure they remain effective and safe to use

Prescribing

• Assess patient;

• Determine need for drug therapy;

• Select and order drug

Preparing and Dispensing

• Review and confirm order;

• Prepare meds;

• Distribute to patient location

Administering

• Review dispensed drug and order; 

• Assess patient and administer

Monitoring

• Assess patient response to drug;

• report reactions and errors

HOSPITAL PHARMACY SERVICES

• Depends on the individual standards set specifically by the hospitals based on patient requirements and professional resources.

DISPENSING SERVICE

• Considered to be the main function of the pharmacy

• Utilization of the technical abilities of hospital pharmacists 

Dispensing require expertise in

• pharmacology

• pathophysiology

• therapeutics

• patient care

• basic communication skills

dispensing is comprised of

• Procurement and storage

• Inventory management

• Medication preparation, packaging and labeling

• Patient counseling

• Proper pharmaceutical waste disposal

DISPENSING SERVICE

• Act of the pharmacist in supplying one or more drug products to a patient, usually in response to an order from a prescriber through a prescription

• Pharmacists must plan, develop, control and monitor the maintenance and delivery of medicines, along with the information needed for proper storage and administration.

CLINICAL SERVICE

• Specialized pharmacist function that promotes individualized patient care through therapeutic monitoring

• Promotes integration of the pharmacist in the healthcare team as someone who interacts with other medical professionals for holistic patient management

CLINICAL SERVICE

• Includes functions such as:

• Provision of drug information

• Building of patient medication database

• Therapeutic education/counseling

• Medication therapy management (Drug Utilization

• Review/Drug Therapy Appropriateness Review)

• ADR detection, reporting and monitoring

COMPOUNDING SERVICE

• Preparation of medications, special dosage forms, and formulations not readily available in the market.

Compounging services requires __

• understanding of pharmacologic principles involved in medication preparation in special dosage forms, such as bioavailability/bioequivalence, stability, microbiology, and manufacturing techniques.

ACTIVITIES OF A HOSPITAL PHARMACIST

• Dispensing of pharmaceutical items (i.e. drugs, chemicals, drug devices, medical supplies) for both inpatient and outpatient services

• Handling of Dangerous Drugs, antidotes, and emergency drugs (i.e. e-carts)

• Inventory Management

• Organization, administrative and management duties

Dispensing of pharmaceutical items (i.e. drugs, chemicals, drug devices, medical supplies) for both inpatient and outpatient services

• Verification of medication request (i.e. completeness and appropriateness review)

• Preparation and labeling of medications for patients

• Compounding

  • Sterile (Total Parenteral Nutrition, IV Admixtures)

  • Non-sterile (Extemporaneous compounding – paper tabs, dermatologicals, eye wash, etc.)

• Charging of pharmaceutical items

• Coordinates with the healthcare team members

Handling of Dangerous Drugs, antidotes, and emergency drugs (i.e. e-carts)

• Selection, procurement, dispensing, monitoring, recording

Inventory Management

• Maintains proper storage of pharmaceutical items

• Adequate control over requisition and dispensing of medicines

• Recording and filing of documents

Organization, administrative and management duties

• Financial (preparation of budget, analysis of financial statement, price management)

• Human Resource (staff scheduling, performance evaluation, preparation of training plan)

• Selection and procurement

• Representation to meetings and hospital committees (PTC, AMS, ICC, CNS, Waste Management, etc.)

In any of these services, from compounding to dispensing, the patient-pharmacist transaction usually begins with

the presentation of a prescription containing the medications for hospital patient use, whether while admitted or even after discharge. 

PRESCRIPTION

• A written order and instruction from a licensed prescriber to the pharmacist for the use of drug product/s for a specific patient.

• All medication orders must be documented and signed by a physician affiliated with and authorized by the hospital.

Regular Prescription

containing medication orders used by doctors for admitted patients

Physician’s Order Sheet (POS)

• Document with prescriber’s notes regarding patient’s progress, therapeutic orders (diagnostics, medication, diet, etc.), and management plan.

Physician’s Order Sheet (POS)

serves as _

• basis of order transcription

Physician’s Order Sheet (POS)

• Except for verbal or telephone order transcription,

only physicians involved in patient care can write in the POS. A separate documentation sheet is used by other members of the healthcare team of their notes.

Parts of a Physician’s Order Sheet

• date & time

• doctor’s notes

• orders

DATE AND TIME

• Documents the time frame in which the doctor wrote in the POS to ensure good turn-around time for transcribing orders

DOCTOR’S NOTES

• Where physicians document pertinent therapeutic details (vital signs, diagnoses, management plans, etc.) which are not necessarily orders to be carried out.

ORDERS

• Where physicians write orders to be carried out (medications, laboratory/ancillary tests, diet changes, etc.)

Computerized Physician Order Entry (CPOE

• A variety of computer-based systems that share the common features of automating the medication ordering process and that ensure standardized, legible, and complete orders (Kaushal et al., 2003)

Computerized Physician Order Entry (CPOE

used by physicians to __

directly enter orders into hospital systems through a computer software in a digital interface.

Computerized Physician Order Entry (CPOE

a system that allows_

• direct, electronic entry of orders into an electronic health record by licensed independent practitioners or other staff with prescribing privileges.

Computerized Physician Order Entry (CPOE

benefits

• Reduce errors and improve patient safety (includes built-in clinical decision support tools)

• Improve efficiency

• Improve reimbursements (when integrated with insurance system that can flag orders that require pre-approval, helping you reduce denied insurance claim)

The use of CPOE is associated with

• reduction in eror

• involvement in patient saftey

• enhanced efficiency

REDUCTION IN ERROR

• Due to assurance of standardized and complete orders before being processed/dispensed

IMPROVEMENT IN PATIENT SAFETY

• As clinical decision tools (drug allergy checker, drug interactions analysis, etc.) can be programmed into the software

ENHANCED EFFICIENCY

• As the manual process of transcription by a separate medical professional is eliminated

ELECTRONIC MEDICATIONADMINISTRATION RECORD (EMAR)

• Application within an integrated electronic health record, or nursing documentation system that allows nurses and other providers administering medications to document medications administered to patients. 

• May be utilized with or without bedside barcoded medication administration (BCMA) functionality.

Benefits of using EMAR 

• Accuracy 

• Efficiency (If combined with CPOE, no need to transcribe a paper MAR)

• Safety (Can provide clinical decision support before and during administration

ELECTRONIC MEDICAL RECORD

• Digital method of ordering and documenting in-patient stay and care that removes the manual use of paper.

• This system is usually used with CPOE in moving toward digitizing patient records.

MEDICATION ORDERS

• These initiate the beginning of patient therapeutic management.

• Part of a patient’s medical records that documents sequence of events during in-patient stay.

• Serve as main communication tool among healthcare providers.

MEDICATION ORDERS

Must contain the ff

1. Correct patient information

2. Complete medication information

3. Prescriber name and signature

4. Other details, such as date and time

5. Approved symbols and abbreviations only 

Verbal/Telephone Orders

• In emergency cases, in which a delay in carrying out an order can compromise patient care, orders may be given by the physician to authorized personnel (e.g., nurses, pharmacists) via telephone or verbally in person. 

Verbal/Telephone Orders

the physician must __

• verify the transcribed order through readback method, in which the personnel who received the order relay their transcription. Once approved, the order may be carried out immediately.

• Within 24 hours, the physician must acknowledge the order given by signing on the POS as soon as possible.

Non-Formulary (NF) Orders

• Medications ordered by physicians which are not part of the official list of medications/formulary approved for use in the hospital.

• These orders must be reviewed on a case-to-case basis before the order is approved and the medication is dispensed. 

The pharmacist must inform the prescriber of the NF status of the order and

may suggest alternative medications from the hospital formulary.

Non-formulary medications

are not usually stocked in the pharmacy, and delays in medication administration may be expected.

Off-Label Orders

• The action of prescribing currently available medications for an indication that is not yet approved, or the use of a medication in a patient population, dosage, or dosage form with no official approval. 

• These orders need sufficient reason/indication for prescribing prior to approval, usually from the Pharmacy and Therapeutics Committee.

Reasons for Off-Label Use

• No approved drug as treatment for the condition

• Conventional treatment had no therapeutic effect 

• Patient is unable to take approved treatment (allergy, contraindicated with other comorbidities, intolerance to side effects, etc.) 

• Conventional treatment is inaccessible 

• Clinical trials of already-marketed drugs for new indications may show effectiveness

Compassionate Drug Use Orders

• The use of new and unapproved medications to treat or manage a patient’s life- threatening condition with no other alternative treatment available. 

• These fall under Off-Label Use, as well.

PROCESSING A PRESCRIPTION

• prescription validation

• prescription interpretation

• preparation

• dispensing and education

STEP 1: PRESCRIPTION VALIDATION

• Checking for completeness and correctness of information, including the date, patient identifiers, prescriber information (name, signature, license number, S2 license for Dangerous Drugs), etc.

STEP 2: PRESCRIPTION INTERPRETATION

• Pharmacists assess the medication order for completeness of information, patient and disease appropriateness, and medication availability based on the formulary and hospital inventory.

  • Pharmacists may use several sources as references, such as hospital formulary and other in-hospital documents, primary and tertiary references, online sources, etc.

Clinical Decision Support

•  system that provides health providers with knowledge and person-specific information to enhance health and health care. 

Clinical Decision Support

these tools include

• Computerized alerts and reminders

• Clinical guidelines

• Condition-specific order sets

• Diagnostic support

• Contextually relevant reference information

A COMPLETE MEDICATION ORDER CONTAINS

• Generic name of the drug (brand is optional)

• Dosage strength and form

• Dose

• Route of administration (include site for topicals) 

• Frequency of administration

• Infusion rate and dilution for intravenous drips

• Duration of therapy, if applicable 

• Indication, if applicable 

• Weight, if necessary (for weight-based dosing) 

STEP 3: PREPARATION

• Filling of the prescription ordered appropriately by comparing the medication with the medication order  in the Rx and preparing the necessary labels

• Prior to dispensing, the correctness of the picked medications and label must be validated by a separate individual.

• Charging/billing is usually done at this step before proceeding to the next.

STEP 4: DISPENSING AND EDUCATION

• Dispensing the medication must always include education about the drug or therapy, including indication, possible side effects, optimal dosing time/schedule, etc.