Lesson 2. Prescriptions in Hospital Pharmacy

Hospital Pharmacy

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

drug therapy outcomes

Clinical Pharmacists are in charge of ___________________________.

Selecting and Procuring

HIGH-LEVEL PORTRAYAL OF A MEDICATION USE SYSTEM:

• The Pharmacy and Therapeutics Committee (PTC) is responsible for establishing the drug formulary

• Establish Formulary and Procurement which must strictly align with the formulary, limiting purchases exclusively to listed medications

• involves Clinicians and Administrators, Pharmacists

Storing

HIGH-LEVEL PORTRAYAL OF A MEDICATION USE SYSTEM:

• Storage of medications

• involves the pharmacists

Prescribing

HIGH-LEVEL PORTRAYAL OF A MEDICATION USE SYSTEM:

• assess patient, determine need for drug therapy, select and order drug

• involves Physician/Prescriber

Review, Preparing and Dispensing

HIGH-LEVEL PORTRAYAL OF A MEDICATION USE SYSTEM:

• Review and confirm order

• Prepare meds

• Distribute to patient location

• involves the Pharmacist

Administering

HIGH-LEVEL PORTRAYAL OF A MEDICATION USE SYSTEM:

• Review dispensed drug and order

• Assess patient and administer

• involves the nurse, certified immunizing pharmacists

Monitoring

HIGH-LEVEL PORTRAYAL OF A MEDICATION USE SYSTEM:

• all assigned attending healthcare professionals are requires to monitor the patient

• family members should also observe responses and report any ADRs

Hospital Pharmacy Services

depends on the individual standards set specifically by the hospitals based on patient requirements and professional resources

Dispensing, Clinical, and Compounding Services

Hospital Pharmacy Services

Dispensing Services

• Considered to be the main function of the pharmacy.

• Utilization of the technical abilities of hospital pharmacists.

• Requires expertise in pharmacology, pathophysiology, therapeutics, patient care, and basic communication skills

Procurement and storage, Inventory management, Medication preparation, packaging & labeling, Patient counseling, and Proper pharmaceutical waste disposal

Dispensing Services is comprised of:

drug products

Dispensing is an act of the pharmacist in supplying one or more ____________ to a patient, usually in response to an order from a prescriber through a prescription.

maintenance and delivery of medicines

In dispensing, pharmacists must plan, develop, control, and monitor the a.___________________________, along with the information needed for b.____________________________.

a = ?

proper storage and administration

In dispensing, pharmacists must plan, develop, control, and monitor the a.___________________________, along with the information needed for b.____________________________.

b = ?

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

Provision of drug information, Building of patient medication database, Therapeutic education/counseling, Medication therapy management (Drug Utilization Review/Drug Therapy Appropriateness Review), and DR detection, reporting & monitoring

The functions of Clinical Services are:

Compounding Service

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

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

Non-Sterile Compounding

TYPES OF COMPOUNDING

• for paper tablets

Sterile Compounding

TYPES OF COMPOUNDING

• for TPN, injection

medication request

ACTIVITIES OF A HOSPITAL PHARMACIST:

Dispensing of Pharmaceutical Items for both Inpatient and Outpatient Services:

1. Verification of ______________________ through completeness and appropriateness review

2. _______________________ of medications for patients

3. Compounding for sterile materials such as ________________________

4. Compounding for non-sterile materials such as ______________________

5. ____________ of pharmaceutical items

6. Coordinates with the _______________________________

1 = ?

Preparation and labeling

ACTIVITIES OF A HOSPITAL PHARMACIST:

Dispensing of Pharmaceutical Items for both Inpatient and Outpatient Services:

1. Verification of ______________________ through completeness and appropriateness review

2. _______________________ of medications for patients

3. Compounding for sterile materials such as ________________________

4. Compounding for non-sterile materials such as ______________________

5. ____________ of pharmaceutical items

6. Coordinates with the _______________________________

2 = ?

total parenteral nutrition and IV admixtures

ACTIVITIES OF A HOSPITAL PHARMACIST:

Dispensing of Pharmaceutical Items for both Inpatient and Outpatient Services:

1. Verification of ______________________ through completeness and appropriateness review

2. _______________________ of medications for patients

3. Compounding for sterile materials such as ________________________

4. Compounding for non-sterile materials such as ______________________

5. ____________ of pharmaceutical items

6. Coordinates with the _______________________________

3 = ?

Extemporaneous compounding (paper tabs, dermatologicals, eye wash)

ACTIVITIES OF A HOSPITAL PHARMACIST:

Dispensing of Pharmaceutical Items for both Inpatient and Outpatient Services:

1. Verification of ______________________ through completeness and appropriateness review

2. _______________________ of medications for patients

3. Compounding for sterile materials such as ________________________

4. Compounding for non-sterile materials such as ______________________

5. ____________ of pharmaceutical items

6. Coordinates with the _______________________________

4 = ?

Charging

ACTIVITIES OF A HOSPITAL PHARMACIST:

Dispensing of Pharmaceutical Items for both Inpatient and Outpatient Services:

1. Verification of ______________________ through completeness and appropriateness review

2. _______________________ of medications for patients

3. Compounding for sterile materials such as ________________________

4. Compounding for non-sterile materials such as ______________________

5. ____________ of pharmaceutical items

6. Coordinates with the _______________________________

5 = ?

healthcare team members

ACTIVITIES OF A HOSPITAL PHARMACIST:

Dispensing of Pharmaceutical Items for both Inpatient and Outpatient Services:

1. Verification of ______________________ through completeness and appropriateness review

2. _______________________ of medications for patients

3. Compounding for sterile materials such as ________________________

4. Compounding for non-sterile materials such as ______________________

5. ____________ of pharmaceutical items

6. Coordinates with the _______________________________

6 = ?

Dangerous Drugs, Antidotes, and Emergency Drugs

ACTIVITIES OF A HOSPITAL PHARMACIST:

• Handling of ________________________________________ (i.e. e-carts) including selection, procurement, dispensing, monitoring, and reducing

proper storage

ACTIVITIES OF A HOSPITAL PHARMACIST:

Inventory Management

1. Maintains _______________ of pharmaceutical items

2. Adequate control over __________________________________

3. Recording and filling of ______________________

1 = ?

Requisition and Dispensing of Medicines

ACTIVITIES OF A HOSPITAL PHARMACIST:

Inventory Management

1. Maintains _______________ of pharmaceutical items

2. Adequate control over __________________________________

3. Recording and filling of ______________________

2 = ?

documents

ACTIVITIES OF A HOSPITAL PHARMACIST:

Inventory Management

1. Maintains _______________ of pharmaceutical items

2. Adequate control over __________________________________

3. Recording and filling of ______________________

3 = ?

Financial

ACTIVITIES OF A HOSPITAL PHARMACIST:

Organization, Administrative, and Management Duties

1. includes preparation of budget, analysis of financial statement, and price management

2. includes staff scheduling, performance evaluation, preparation of training plan

3. includes PTC, AMS, ICC, CNS, Waste Management, etc.

4. other

1 = ?

Human Resource

ACTIVITIES OF A HOSPITAL PHARMACIST:

Organization, Administrative, and Management Duties

1. includes preparation of budget, analysis of financial statement, and price management

2. includes staff scheduling, performance evaluation, preparation of training plan

3. includes PTC, AMS, ICC, CNS, Waste Management, etc.

4. other

2 = ?

Representation to meetings and hospital committees

ACTIVITIES OF A HOSPITAL PHARMACIST:

Organization, Administrative, and Management Duties

1. includes preparation of budget, analysis of financial statement, and price management

2. includes staff scheduling, performance evaluation, preparation of training plan

3. includes PTC, AMS, ICC, CNS, Waste Management, etc.

4. other

3 = ?

Selection and Procurement

ACTIVITIES OF A HOSPITAL PHARMACIST:

Organization, Administrative, and Management Duties

1. includes preparation of budget, analysis of financial statement, and price management

2. includes staff scheduling, performance evaluation, preparation of training plan

3. includes PTC, AMS, ICC, CNS, Waste Management, etc.

4. other

4 = ?

presentation of a prescription

ACTIVITIES OF A HOSPITAL PHARMACIST:

• In any of these services, the patient-pharmacist transaction usually begins with the ____________________________ 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.

• As a pharmacist, always check first for COMPLETENESS.

Superscription

PARTS OF THE PRESCRIPTION:

• Rx symbol

Signa

PARTS OF THE PRESCRIPTION:

• directions for patients

Inscription

PARTS OF THE PRESCRIPTION:

• Medication prescribed

Subscription

PARTS OF THE PRESCRIPTION:

• dispensing directions to the pharmacist

Regular Prescription

TYPES OF HOSPITAL PRESCRIPTIONS USED

• contains medication orders used by doctors for admittied patients

• color: white

Physician’s Order Sheet

TYPES OF HOSPITAL PRESCRIPTIONS USED

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

basis of order transcription

TYPES OF HOSPITAL PRESCRIPTIONS USED

• The Physician’s Order Sheet serves as the ________________________

Date and Time

TYPES OF HOSPITAL PRESCRIPTIONS USED

PARTS OF THE PHYSICIAN’S ORDER SHEET

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

Doctor’s Notes

TYPES OF HOSPITAL PRESCRIPTIONS USED

PARTS OF THE PHYSICIAN’S ORDER SHEET

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

Orders

TYPES OF HOSPITAL PRESCRIPTIONS USED

PARTS OF THE PHYSICIAN’S ORDER SHEET

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

• Except for verbal or telephone orders

verbal or telephone order transcription

TYPES OF HOSPITAL PRESCRIPTIONS USED

Physician’s Order Sheet

• Except for ______________________________ (accepted only during emergencies), only physicians involved in patient care can write in the POS.

writes them down and reads them aloud

TYPES OF HOSPITAL PRESCRIPTIONS USED

Physician’s Order Sheet

1. During emergencies, the doctor communicates the orders to the nurse, who ________________________ (feedback mechanism) for confirmation.

2. The doctor must then sign the orders _______________.

1 = ?

within 24 hours

TYPES OF HOSPITAL PRESCRIPTIONS USED

Physician’s Order Sheet

1. During emergencies, the doctor communicates the orders to the nurse, who ________________________ (feedback mechanism) for confirmation.

2. The doctor must then sign the orders _______________.

2 = ?

Computerized Physician Order Entry (CPOE)

TYPES OF HOSPITAL PRESCRIPTIONS USED

• 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

• Used by physicians to directly enter orders into hospital systems through a computer software in a digital interface

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

patient safety

TYPES OF HOSPITAL PRESCRIPTIONS USED

BENEFITS OF CPOE:

1. Reduce errors and improve _______________ as it includes built-in clinical decision support tools.

2. Improve __________

3. Improve _______________ when integrated with insurance system can flag orders that require pre-approval, helping you reduce denied insurance claims

1 = ?

efficiency

TYPES OF HOSPITAL PRESCRIPTIONS USED

BENEFITS OF CPOE:

1. Reduce errors and improve _______________ as it includes built-in clinical decision support tools.

2. Improve __________

3. Improve _______________ when integrated with insurance system can flag orders that require pre-approval, helping you reduce denied insurance claims

2 = ?

reimburstment

TYPES OF HOSPITAL PRESCRIPTIONS USED

BENEFITS OF CPOE:

1. Reduce errors and improve _______________ as it includes built-in clinical decision support tools.

2. Improve __________

3. Improve _______________ when integrated with insurance system can flag orders that require pre-approval, helping you reduce denied insurance claims

3 = ?

Electronic Medication Administration Record (EMAR)

TYPES OF HOSPITAL PRESCRIPTIONS USED

• 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

Accuracy

BENEFITS OF USING EMAR:

1. ________

2. ________ if combined with CPOE, no need to transcribe a paper MAR

3. ________ can provide clinical decision support before and during administration

1 = ?

Efficiency

BENEFITS OF USING EMAR:

1. ________

2. ________ if combined with CPOE, no need to transcribe a paper MAR

3. ________ can provide clinical decision support before and during administration

2 = ?

Safety

BENEFITS OF USING EMAR:

1. ________

2. ________ if combined with CPOE, no need to transcribe a paper MAR

3. ________ can provide clinical decision support before and during administration

3 = ?

Electronic Medical Records

TYPES OF HOSPITAL PRESCRIPTIONS USED

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

• This system is usually used with CPOE in moving towards 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

• ALL medication orders must be written legibly and clearly in the prescription

patient information

Medication Orders must contain the following:

1. Correct ________________________

2. Complete _______________________

3. Prescriber ______________________

4. Other detail such as _______________

5. Approved _______________________

1 = ?

medication information

Medication Orders must contain the following:

1. Correct ________________________

2. Complete _______________________

3. Prescriber ______________________

4. Other detail such as _______________

5. Approved _______________________

2 = ?

name and signature

Medication Orders must contain the following:

1. Correct ________________________

2. Complete _______________________

3. Prescriber ______________________

4. Other detail such as _______________

5. Approved _______________________

3 = ?

date and time

Medication Orders must contain the following:

1. Correct ________________________

2. Complete _______________________

3. Prescriber ______________________

4. Other detail such as _______________

5. Approved _______________________

4 = ?

symbols and abbreviations

Medication Orders must contain the following:

1. Correct ________________________

2. Complete _______________________

3. Prescriber ______________________

4. Other detail such as _______________

5. Approved _______________________

5 = ?

Verbal/Telephone Orders

OTHER TYPES OF MEDICATION 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.

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

• The physician must acknowledge the order given by signing on the POS as soon as possible (or within 24 hours).

Non-Formulary Orders

OTHER TYPES OF MEDICATION ORDERS

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

• The pharmacist must inform the prescriber of the NF status of the order and may suggest alternative medications from the hospital formulary.

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

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

Off-Label Orders

OTHER TYPES OF MEDICATION ORDERS

• The action of prescribing current 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.

approved drug

OTHER TYPES OF MEDICATION ORDERS

Reasons for Off-Label Use:

1. No ________________ as treatment for the condition.

2. _________________________ had no therapeutic effect

3. Patient is unable to take approved treatment due to _____________________________________________

4. Conventional treatment is _______________

5. Clinical trials of already-marketed drugs for ________________ may show effectiveness

1 = ?

Conventional treatment

OTHER TYPES OF MEDICATION ORDERS

Reasons for Off-Label Use:

1. No ________________ as treatment for the condition.

2. _________________________ had no therapeutic effect

3. Patient is unable to take approved treatment due to _____________________________________________

4. Conventional treatment is _______________

5. Clinical trials of already-marketed drugs for ________________ may show effectiveness

2 = ?

allergy, contraindications, intolerance to side effects

OTHER TYPES OF MEDICATION ORDERS

Reasons for Off-Label Use:

1. No ________________ as treatment for the condition.

2. _________________________ had no therapeutic effect

3. Patient is unable to take approved treatment due to _____________________________________________

4. Conventional treatment is _______________

5. Clinical trials of already-marketed drugs for ________________ may show effectiveness

3 = ?

inaccessible

OTHER TYPES OF MEDICATION ORDERS

Reasons for Off-Label Use:

1. No ________________ as treatment for the condition.

2. _________________________ had no therapeutic effect

3. Patient is unable to take approved treatment due to _____________________________________________

4. Conventional treatment is _______________

5. Clinical trials of already-marketed drugs for ________________ may show effectiveness

4 = ?

new indications

OTHER TYPES OF MEDICATION ORDERS

Reasons for Off-Label Use:

1. No ________________ as treatment for the condition.

2. _________________________ had no therapeutic effect

3. Patient is unable to take approved treatment due to _____________________________________________

4. Conventional treatment is _______________

5. Clinical trials of already-marketed drugs for ________________ may show effectiveness

5 = ?

Compassionate Drug Use Orders

OTHER TYPES OF MEDICATION 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

Prescription Validation

PROCESSING A PRESCRIPTION

• Step 1

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

Prescription Interpretation

PROCESSING A PRESCRIPTION

• Step 2

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

• Pharmacist 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 (CDS)

PROCESSING A PRESCRIPTION

Prescription Interpretation

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

alerts and reminders

PROCESSING A PRESCRIPTION

Prescription Interpretation — Clinical Decision Support (CDS) Includes:

1. Computerized _______________________

2. Clinical ____________

3. ________________ order sets

4. _______________ support

5. Contextually relevant ______________________

1 = ?

guidelines

PROCESSING A PRESCRIPTION

Prescription Interpretation — Clinical Decision Support (CDS) Includes:

1. Computerized _______________________

2. Clinical ____________

3. ________________ order sets

4. _______________ support

5. Contextually relevant ______________________

2 = ?

Condition-specific

PROCESSING A PRESCRIPTION

Prescription Interpretation — Clinical Decision Support (CDS) Includes:

1. Computerized _______________________

2. Clinical ____________

3. ________________ order sets

4. _______________ support

5. Contextually relevant ______________________

3 = ?

Diagnostic

PROCESSING A PRESCRIPTION

Prescription Interpretation — Clinical Decision Support (CDS) Includes:

1. Computerized _______________________

2. Clinical ____________

3. ________________ order sets

4. _______________ support

5. Contextually relevant ______________________

4 = ?

reference information

PROCESSING A PRESCRIPTION

Prescription Interpretation — Clinical Decision Support (CDS) Includes:

1. Computerized _______________________

2. Clinical ____________

3. ________________ order sets

4. _______________ support

5. Contextually relevant ______________________

5 = ?

Generic

PROCESSING A PRESCRIPTION

Prescription Interpretation of Medication Orders’ Completeness

1. ________ name of the drug

2. Dosage _____________

3. Proper _______

4. __________________ (include site for topicals)

5. ___________ of administration

6. ________________________ for intravenous drips

7. ________________________, if applicable

8. _________, if necessary for dosing

1 = ?

strength and form

PROCESSING A PRESCRIPTION

Prescription Interpretation of Medication Orders’ Completeness

1. ________ name of the drug

2. Dosage _____________

3. Proper _______

4. __________________ (include site for topicals)

5. ___________ of administration

6. ________________________ for intravenous drips

7. ________________________, if applicable

8. _________, if necessary for dosing

2 = ?

Dose

PROCESSING A PRESCRIPTION

Prescription Interpretation of Medication Orders’ Completeness

1. ________ name of the drug

2. Dosage _____________

3. Proper _______

4. __________________ (include site for topicals)

5. ___________ of administration

6. ________________________ for intravenous drips

7. ________________________, if applicable

8. _________, if necessary for dosing

3 = ?

Route of Administration

PROCESSING A PRESCRIPTION

Prescription Interpretation of Medication Orders’ Completeness

1. ________ name of the drug

2. Dosage _____________

3. Proper _______

4. __________________ (include site for topicals)

5. ___________ of administration

6. ________________________ for intravenous drips

7. ________________________, if applicable

8. _________, if necessary for dosing

4 = ?

Frequency

PROCESSING A PRESCRIPTION

Prescription Interpretation of Medication Orders’ Completeness

1. ________ name of the drug

2. Dosage _____________

3. Proper _______

4. __________________ (include site for topicals)

5. ___________ of administration

6. ________________________ for intravenous drips

7. ________________________, if applicable

8. _________, if necessary for dosing

5 = ?

Infusion rate and dilution

PROCESSING A PRESCRIPTION

Prescription Interpretation of Medication Orders’ Completeness

1. ________ name of the drug

2. Dosage _____________

3. Proper _______

4. __________________ (include site for topicals)

5. ___________ of administration

6. ________________________ for intravenous drips

7. ________________________, if applicable

8. _________, if necessary for dosing

6 = ?

Duration and/or Indication

PROCESSING A PRESCRIPTION

Prescription Interpretation of Medication Orders’ Completeness

1. ________ name of the drug

2. Dosage _____________

3. Proper _______

4. __________________ (include site for topicals)

5. ___________ of administration

6. ________________________ for intravenous drips

7. ________________________, if applicable

8. _________, if necessary for dosing

7 = ?

Weight

PROCESSING A PRESCRIPTION

Prescription Interpretation of Medication Orders’ Completeness

1. ________ name of the drug

2. Dosage _____________

3. Proper _______

4. __________________ (include site for topicals)

5. ___________ of administration

6. ________________________ for intravenous drips

7. ________________________, if applicable

8. _________, if necessary for dosing

8 = ?

Preparation

PROCESSING A PRESCRIPTION

• Step 3

• Filling of the prescription ordered appropriately by comparing the medication with the medication order 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.

Automated Dispensing Cabinet

PROCESSING A PRESCRIPTION

• includes Pyxis MedStation ES, Omnicell XT, and ARxIUM MedSelect Cabinets

Dispensing and Education

PROCESSING A PRESCRIPTION

• Step 4

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