Chapter 9 - Technician · Intravenous Admixture Service • Most hospitals provide an IV admixture...

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Chapter 9

Hospital Pharmacy Practice


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.


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


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


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


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


Inpatient Drug Distribution Systems

• Medication orders • Unit dose • Floor stock • Narcotics in a hospital pharmacy • Intravenous admixture service • Medication administration record


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


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


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


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


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


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


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.


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


Unit Dose

Only unopened unit doses can be returned to stock.


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


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.


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.


Terms to Remember

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

Safety Note


Unit Dose

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


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.


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


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.


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


Terms to Remember

cart fill list a printout of all unit dose profiles for all patients


Terms to Remember

floor stock medications stocked in a secured area on each patient care unit


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


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


Floor Stock

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


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.


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


Intravenous Admixture Service

• Most hospitals provide an IV admixture service, including injectable – Antibiotics – Thrombolytics – Nutrition – Cancer chemotherapy

• Staffed by specially trained pharmacists and technicians


Terms to Remember

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



• 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.


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



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



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


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


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


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.


Terms to Remember

electronic medication administration record (eMAR)

documents the administration time of each drug to each patient often using bar-code technology


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.


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


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.


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


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


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


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.


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


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)


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


Terms to Remember

accreditation the stamp of approval of the quality of services of a hospital by the Joint Commission


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


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.


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


Inventory Management

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

• Budgetary planning and accurate inventory management are crucial.


Inventory Management

• Purchasing • Ordering • Receiving and storage


Purchasing

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


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.


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.


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


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.


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

Chapter 9 - Technician · Intravenous Admixture Service • Most hospitals provide an IV admixture...

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