Lesson 2. Institutional Pharmacy Practice

Institutional Pharmacy Practive

provision of distributional and clinical pharmacy services at a broad range of institutional settings including hospitals, long-term care, hospice, correctional facilities, and others

Institutional Pharmacy

organized under a corporate structure, following specific rules and regulations for accreditation

organized healthcare delivery system

Institutional Pharmacy is a pharmacy associated with any _____________________________.

Hospital Pharmacy

Institutional Pharmacy

• example

Hospital Pharmacy

institutional pharmacy that dispenses and prepares drugs and provides clinical services in a hospital setting

home

more recent examples of places where institutional pharmacies can be found include:

1. _______ healthcare system

2. ________________ facilities

3. ________________ organizations

4. _________ pharmacies

1 = ?

long-term care

more recent examples of places where institutional pharmacies can be found include:

1. _______ healthcare system

2. ________________ facilities

3. ________________ organizations

4. _________ pharmacies

2 = ?

managed-care

more recent examples of places where institutional pharmacies can be found include:

1. _______ healthcare system

2. ________________ facilities

3. ________________ organizations

4. _________ pharmacies

3 = ?

nuclear

more recent examples of places where institutional pharmacies can be found include:

1. _______ healthcare system

2. ________________ facilities

3. ________________ organizations

4. _________ pharmacies

4 = ?

1752

HISTORY OF HOSPITAL PHARMACY

• Pennsylvania Hospital

• Jonathan Roberts

1841-1901

HISTORY OF HOSPITAL PHARMACY

• Bellevue Hospital, NYC

• Charles Rice

• pioneering hospital pharmacy practices

• headed three revisions of USP

1865-1916

HISTORY OF HOSPITAL PHARMACY

• Martin Wilbert

1800s

HISTORY OF HOSPITAL PHARMACY

• The few hospitals are considered places of dreaded impurity and exiled human wreckage.

• They played a small role in health care where pharmacists played small roles as well.

strong cathartics, emetics, and diaphoretics

HISTORY OF HOSPITAL PHARMACY

1800s

• Drug therapy consists of a._______________________________.

• b.________________ were treatments together with the newer alkaloidal drugs such as c._________________.

a = ?

clean air and good food

HISTORY OF HOSPITAL PHARMACY

1800s

• Drug therapy consists of a._______________________________.

• b.________________ were treatments together with the newer alkaloidal drugs such as c._________________.

b = ?

morphine, strychnine, and quinine

HISTORY OF HOSPITAL PHARMACY

1800s

• Drug therapy consists of a._______________________________.

• b.________________ were treatments together with the newer alkaloidal drugs such as c._________________.

c = ?

Civil War

HISTORY OF HOSPITAL PHARMACY

1800s

• The ________ auses the development of extemporaneous manufacturing and in purchasing medical goods.

1870 and 1880s

HISTORY OF HOSPITAL PHARMACY

• Catholic hospitals are charging patients a small fee and they are willing to train, or obtain training for, nuns in pharmacy.

1890s

HISTORY OF HOSPITAL PHARMACY

• Hospital is the center of medical care, there are advances in surgery and growth of community hospitals.

• Hospitals relied on community pharmacies to supply medicines

Early 1900s

HISTORY OF HOSPITAL PHARMACY

• More specialization in medical practice.

• Greater need for professional pharmaceutical services for handling complex therapies, though compounding is retained.

Early 1920s

HISTORY OF HOSPITAL PHARMACY

• Hospital pharmacists are being hired for Prohibition to dispense commonly prescribed alcohol, inventory control and manufacture of alcohol containing preparations

1930s

HISTORY OF HOSPITAL PHARMACY

• Because of pharmacy-related issues in hospitals, the AHA created the Committee of Pharmacy to develop minimum standards for hospital pharmacy departments and to prepare a manual of pharmacy operations.

registered pharmacist

HISTORY OF HOSPITAL PHARMACY

1930s

• Any hospital larger than one hundred beds warrants the employment of a ________________________________.

1950s to 1960s

HISTORY OF HOSPITAL PHARMACY

• Pharmacy department was perceived as a complementary service department, not an essential service.

full-time (FTE) Pharmacist

HISTORY OF HOSPITAL PHARMACY

1950s to 1960s

• The hospital size is the determinant of the availability of the pharmacist. For 300 beds or more, a a._____________________ is necessary.

• However, today, b._________________ are required for 100 occupied beds.

a = ?

13 FTE pharmacists are required

HISTORY OF HOSPITAL PHARMACY

1950s to 1960s

• The hospital size is the determinant of the availability of the pharmacist. For 300 beds or more, a a._____________________ is necessary.

• However, today, b._________________ are required for 100 occupied beds.

b = ?

drug treatment records

Universal Pharmacy Services — Services Similar to Community Pharmacy Services

• Maintaining ___________________________

medications and medical supplies

Universal Pharmacy Services — Services Similar to Community Pharmacy Services

• Ordering and stocking _____________________________

Repackaging and Dispensing

Universal Pharmacy Services — Services Similar to Community Pharmacy Services

• __________________________ medications

proper use

Universal Pharmacy Services — Services Similar to Community Pharmacy Services

• Providing information about the _______________ of medication

adverse drug reactions and interactions

Universal Pharmacy Services — Services Similar to Community Pharmacy Services

• Collecting and evaluating information about ___________________________________.

dose forms

Universal Pharmacy Services — Services Similar to Community Pharmacy Services

• Preparing medications in various _____________ for dispensing

drug therapies

Universal Pharmacy Services — Services Similar to Community Pharmacy Services

• Educating and counseling patients about their ___________

medication-related problems

Universal Pharmacy Services — Services Similar to Community Pharmacy Services

• Preventing, identifying, and resolving ____________________________

formulary

Universal Hospital Pharmacy Services — Services Provided by a Hospital Pharmacy

• Preparing and maintaining a __________________

drug use evaluations

Universal Hospital Pharmacy Services — Services Provided by a Hospital Pharmacy

• Conducting _________________________

universal precautions

Universal Hospital Pharmacy Services — Services Provided by a Hospital Pharmacy

• Following ________________________

aseptic techniques

Universal Hospital Pharmacy Services — Services Provided by a Hospital Pharmacy

• Preparing products using ______________

hazardous agents

Universal Hospital Pharmacy Services — Services Provided by a Hospital Pharmacy

• Ensuring that ____________________ are handled and disposed of properly

medication orders

Universal Hospital Pharmacy Services — Services Provided by a Hospital Pharmacy

• Filling ___________ as opposed to prescriptions

24-hour supplies of patienr medications

Universal Hospital Pharmacy Services — Services Provided by a Hospital Pharmacy

• Routinely preparing _____________________________ in a form appropriate for a single administration to a patient

nursing stations

Universal Hospital Pharmacy Services — Services Provided by a Hospital Pharmacy

• Stocking ____________________ with medications and supplies

patients’ rooms

Universal Hospital Pharmacy Services — Services Provided by a Hospital Pharmacy

• Delivering medications to _________________

drug information service

Universal Hospital Pharmacy Services — Services Provided by a Hospital Pharmacy

• Maintaining a _______________ to the other healthcare professionals in the institution.

Educating and counseling

Universal Hospital Pharmacy Services — Services Provided by a Hospital Pharmacy

• _____________________ inpatients and outpatients about their drug therapies.

patient outcomes

Universal Hospital Pharmacy Services — Services Provided by a Hospital Pharmacy

• Monitoring __________________

medication-related problems

Universal Hospital Pharmacy Services — Services Provided by a Hospital Pharmacy

• Preventing, identifying, and resolving __________________________.

clinical drug investigations and research

Universal Hospital Pharmacy Services — Services Provided by a Hospital Pharmacy

• Participating in _______________________________

in-service drug-related

Universal Hospital Pharmacy Services — Services Provided by a Hospital Pharmacy

• Providing ______________________ education

prescription services

Universal Hospital Pharmacy Services — Services Provided by a Hospital Pharmacy

• Reviewing or auditing _____________________ for evaluation of service accuracy and quality

pediatric pharmacology, nutritional support, and pharmacokinetics

Universal Hospital Pharmacy Services — Services Provided by a Hospital Pharmacy

• Providing expert consultations in such areas as ___________________________

Clinical Services

Hospital Pharmacy Services

• Many hospitals offer clinical and consultative services such as nutrition support, pharmacokinetics, critical care, and other specialties.

Drug Information Services

Hospital Pharmacy Services

• primarily responsible for making recommendations on a drug formulary

• containing reference works, including books, periodicals, microfilm, CDs, DVDs, and access to computerized or Internet databases.

Outpatient Pharmacy Services

Hospital Pharmacy Services

• to serve the medication needs of patients discharged from the hospital, as well as for those patients who are seen in the emergency room or other ambulatory clinics adjoining the hospital

acquisition, distribution, and control

Four major changes in hospital pharmacy over the 50 years

1. recognized to be in charge of drug product __________________________

2. assumed a major role in _____ safety

3. assumed a major role in promoting _______________

4. mission to foster ______________________ from medication use

1 = ?

patient

Four major changes in hospital pharmacy over the 50 years

1. recognized to be in charge of drug product __________________________

2. assumed a major role in _____ safety

3. assumed a major role in promoting _______________

4. mission to foster ______________________ from medication use

2 = ?

rational drug therapy

Four major changes in hospital pharmacy over the 50 years

1. recognized to be in charge of drug product __________________________

2. assumed a major role in _____ safety

3. assumed a major role in promoting _______________

4. mission to foster ______________________ from medication use

3 = ?

optimal patient outcomes

Four major changes in hospital pharmacy over the 50 years

1. recognized to be in charge of drug product __________________________

2. assumed a major role in _____ safety

3. assumed a major role in promoting _______________

4. mission to foster ______________________ from medication use

4 = ?

major elements

Acquisition, Distribution, and Control

• __________________ of the hospital pharmacists’ professional identity

bulk compounding and sterile solution

Acquisition, Distribution, and Control

• involved in __________________________ manufacturing

physicians and pharmacists

Acquisition, Distribution, and Control

• close relationship between a._____________________________ in hospitals

• opportunity to serve a need of b._______________

• opportunity to offer a c._____________________________

a = ?

physicians and patients

Acquisition, Distribution, and Control

• close relationship between a._____________________________ in hospitals

• opportunity to serve a need of b._______________

• opportunity to offer a c._____________________________

b = ?

professional service and build interprofessional relations

Acquisition, Distribution, and Control

• close relationship between a._____________________________ in hospitals

• opportunity to serve a need of b._______________

• opportunity to offer a c._____________________________

c = ?

Patient Safety

reduction and mitigation of unsafe acts within the healthcare system, as well as through the use of best practices shown to lead to optimal patient outcomes

Prescribing

PATIENT SAFETY

Pharmacist’s Role in the Medication Use Process

• a prescription order originates in the patient’s medical record, where physicians write all the orders (prescriptions) for the patient

• remains at the patient care area

• Influence the prescribing of other health professionals: acting as information resources, providing feedback about the quality of prescribing, and developing prescribing protocols through formulary system

Transcribing

PATIENT SAFETY

Pharmacist’s Role in the Medication Use Process

• essential that some means be used to transmit the prescription order from the patient area to the pharmacy

• medical record has a duplicate copy so the pharmacy can obtain a carbon copy of the physician’s original medication order

• original medication order is scanned and the image is electronically sent to pharmacy to be printed or reviewed on monitor

• physician writes the medication on a separate prescription blank, commonly for home use

• physician inputs the order directly into the (Computerized Provider Order Entry or CPOE)

• prescriber’s written order is copied and entered into pharmacy’s record

• Pharmacist must understand potential breakdown

Dispensing

PATIENT SAFETY

Pharmacist’s Role in the Medication Use Process

• Physically transferring the drug product following review and approval of the prescription to the are responsible for administering the medication to the patient

• Medication is made available to the patient. This can be accomplished using different distribution system such floor stock, patient prescription system or unit dose system

Administration

PATIENT SAFETY

Pharmacist’s Role in the Medication Use Process

• Clearly label medications, using bar coding systems, and unit dose packaging, reducing the time and effort involved in accessing drugs, and using technology

Monitoring

PATIENT SAFETY

Pharmacist’s Role in the Medication Use Process

• Reviewing laboratory values that are correlated with the expected medication-therapy outcomes.

• Ensuring that the drug and the dose ordered is appropriate for each patient (ex: review of culture sensitivity test to determine an appropriate antibiotic treatment and review INR for patients taking warfarin).

• Monitoring for adverse effects to ensure patient safety (ex: review of liver function for patient taking HMG-CoA reductase inhibitors and review of electrolytes for patients taking diuretics)

• Assess the need for additional or alternative drug therapy

• Monitoring patient’s response to therapy

• Prevent misinterpretation resulted from drug interference (false-positive result)

controlled drugs

ROLE OF PHARMACIST CONTRIBUTE TOWARDS PROMOTING THE RATIONAL USE OF DRUGS

• The Pharmacist shall keep all ______________________________ in a locked cabinet under his/her own direct supervision and control.

validity of prescription and identity

ROLE OF PHARMACIST CONTRIBUTE TOWARDS PROMOTING THE RATIONAL USE OF DRUGS

• The pharmacist must check ___________________________ of the patient before dispensing.

prescribing doctor

ROLE OF PHARMACIST CONTRIBUTE TOWARDS PROMOTING THE RATIONAL USE OF DRUGS

• The Pharmacist shall consult the ___________________ if there is doubt about the prescription.

complete and valid

ROLE OF PHARMACIST CONTRIBUTE TOWARDS PROMOTING THE RATIONAL USE OF DRUGS

• The Pharmacist shall only dispense controlled drugs if the prescription provided by the physician is _____________________________

cautions, warnings, and clear direction

ROLE OF PHARMACIST CONTRIBUTE TOWARDS PROMOTING THE RATIONAL USE OF DRUGS

• The Pharmacist shall provide complete information to the patient about the prescribed drug he/she is dispensing including _____________________ for use

label and mark

ROLE OF PHARMACIST CONTRIBUTE TOWARDS PROMOTING THE RATIONAL USE OF DRUGS

• The Pharmacist shall properly _______________________ containers to avoid undue intermixing that may cause harm to the patient.

Medication Use Evaluation

A performance improvement method that focuses on evaluating and improving medication-use processes with the goal of optimal patient outcomes

Medication Selection and Review

• A written medication review is prepared from available literature.

• The review should be unbiased, and committee members should discuss any conflict of interest prior to discussion of drug or drug class.

• based on efficacy, safety and cost

Medication Safety Evaluation

• evaluated through ADRs and medication errors reports

• Such reports may be local i.e SFDA or global i.e literature or press release.

Drug Therapy Guidelines

• listing of the indications, dosage regimen, duration, route of administration, monitoring parameter and special consideration.

• guidelines are often put into via pre-printed physician order sheet placed in the patient chart

Drug-distribution-centered model

Practice Models

• distribute drugs

• process new medication orders

• reactive

Clinical-pharmacist-centered model

Practice Models

• primary types of pharmacist: clinical pharmacist and distributive pharmacist

Patient-centered integrated model

Practice Models

• both clinical and distributive functions

• pharmacists exhibit a high degree of ownership of and accountability for the entire medication-use process

Critical Care Units

Different Patient Care Areas

Inpatient Care

• Patients are of higher acuity level, they have greater needs for care

• Critically ill, constantly changing

• Monitored closely

• Drug therapy is often adjusted or changed

• High potential for incompatibilities, interactions, and errors

General Care Units

Different Patient Care Areas

Inpatient Care

• Acuity of patients is less

• Drug therapy is stable

• Medication reconciliation

• Appropriate discharge orders

Outpatient Care

Different Patient Care Areas

• Similar to community pharmacy without general merchandise

• Clinic patients, patients being discharge from inpatient settings, patients with prescriptions written in emergency departments

• Emergency departments, ambulatory care clinics, home health care

Dispensing Pharmacist

Key Individuals in Pharmacy Department

Pharmacists

• Preparation of medications , either directly or through supervising the preparatory work of pharmacy technicians

Clinical Pharmacist

Key Individuals in Pharmacy Department

Pharmacists

• Serve on interdisciplinary patient-care teams, and interact directly with patients

Generalists

Key Individuals in Pharmacy Department

Clinical Pharmacists

• provide clinical pharmacy to a wide of range of patients

Specialist

Key Individuals in Pharmacy Department

Clinical Pharmacists

• defined expertise in one or more areas

Director/Supervisor

Key Individuals in Pharmacy Department

• Good knowledge of regulations and laws that govern pharmacy practice

• Basic skills in HR management, leadership, budget management

• Ensuring quality of medication use

Pharmacy Technicians

Key Individuals in Pharmacy Department

• Purchasing, stocking, preparation and compounding of medications

• Under direct supervision of the pharmacist

• Maintenance of automated dispensing technology and other information technology systems

• Collection of laboratory values and other clinical data

informatics, investigational drug services, research, compounding and emergency care

Key Individuals in Pharmacy Department

• others

Pharmacy Education

• hospital pharmacy has benefited by gaining practitioners who are better educated and better prepared to meet the demands in hospital practice

• hospital pharmacy leaders have put considerable pressure on pharmacy educators to upgrade the pharmacy curriculum, to make it more consistent with the needs in hospital practice

• in early days of clinical education, faculty members from schools of pharmacy began establishing practice sites in hospitals, which often had a large impact on the nature of the hospital's pharmacy service

1907

Evolution of Minimum Requirements for Pharmacist Education in the US

• 2 years (Graduate in Pharmacy)

1925

Evolution of Minimum Requirements for Pharmacist Education in the US

• 3 years (Graduate in Pharmacy or Pharmaceutical Chemist)

1932

Evolution of Minimum Requirements for Pharmacist Education in the US

• 4 years (B.S. or B.S. in Pharmacy)

1960

Evolution of Minimum Requirements for Pharmacist Education in the US

• 5 years (B.S. or B.S. in Pharmacy) - transition period

2004

Evolution of Minimum Requirements for Pharmacist Education in the US

• 6 years (Pharm.D.)