The pharmacy manual is designed to be a reference for all Hospital staff in order to identify: & Insure Safe and accurate medication ordering, preparation,

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Presentation transcript:

The pharmacy manual is designed to be a reference for all Hospital staff in order to identify: & Insure Safe and accurate medication ordering, preparation, distribution and control Pharmacy Policies & Procedures Operational Responsibilities Departmental Relationships

Supportive Services: Blood bank, Radiology, Dietitians, Nursing… RHUH is a university hospital providing services for several nursing units ICUCCUOncology SurgeryPediatrics OBS & GYN PHARMACY

Information Technology Finance & Admin. Internal audit Nursing Material & Purchasing Pharmacy - Logistics - HR - Finance - Logistics - HR - Finance - Biomedical - Eng. & Maint. - Material Mngt - Biomedical - Eng. & Maint. - Material Mngt Management

Pharmacy Map: A-Reception B&C offices for pharmacy staff E-Purchasing office D&F- Dispensing room G- Compounding room H- Pharmacy store I- WC J- Changing room K- Library L- Kitchen Head of pharmacy office is located in the ground floor.

Central IV Admixture Unit Total Parenteral Nutrition Unit Chemotherapy Unit Dispensing by Unit Dose System

Functional Organization of the pharmacy Location & Pharmacy Extensions Operating Hours Personnel Job Description Responsibilit y & duties General rules & Regulations

 The main pharmacy is located in the basement of the hospital. It consists of the following areas: Reception and Secretary  1190 Library  1198Pharmacists Office  1192, 1193, 1194, 1195, 1197Chemotherapy Preparation Unit  1937 Drug preparation/ Dispensing Area  1196

Operating hours 8-7 during the week 8-4 on Saturdays 8-3 on Sundays Operating hours 8-7 during the week 8-4 on Saturdays 8-3 on Sundays

 Nursing Units  Emergency carriage & floor stock (replenished daily).  Pharmacist On-Call is available after closing hours.  Nursing and medical staff is are informed by a memo of the pharmacist on-call during pharmacy closing hours.  Pharmacy on call sheet should be filled including dispensed medication and duration of dispensing.

Specifying all duties assigned to the assistant of the head, supervisor pharmacists, pharmacist, assistant pharmacist, technician, secretary. - Formulating and applying pharmacy policies. - Updating hospital formulary. - Controlling stock level. - Intervening in any medical or pharmaceutical problem. e.g. Head of Pharmacy

e.g. Pharmacy Rooms should be clean at all times. Offices should be organized especially before leaving. e.g. Lab coats should be worn without exceptions. The schedule work time should be requested. e.g. Work hours in holidays are rewarded in a similar manner within a month. Pharmacist on-call should be available after closing hours to provide life-saving medications.

Performance Appraisal Student Mentorship Continuing Educations Orientation

Done during 3 month probation period. A copy is sent to he HR department. Interdepartmental competency orientation checklist is filled for each new employee. New employees should go through a general hospital orientation to introduce them to hospital organization as well as rules & regulations.

Regular evaluation of personnel Annual competency validation plan Performance appraisal is done q 6 month & retraining is done regularly. Anecdotal Report Employee of the month

Pharmaceutical & Medical lectures Competency tests & Quizzes Interventions & monthly Roundtables In-service Education program

Training Certificate Training Application Approval form university & Head Students from all universities

Cytotoxic/Anti-Neoplastic Drugs Drug Preparation: Personal preparation Protective Equipments. Preparation Area. Preparation Equipments. Work Practices in the preparation: Handling vials. Handling ampoules. Waste Disposal. Spills. Medical. surveillance

Glass ware Safety Use a dustpan and brush to pick up broken glass. Discard broken glass in a rigid container separate from regular garbage (label). Hazardous Drug Safety Hazardous materials include chemotherapeutic agents, strong acids or alkali, Corrosives, flammable items, poisonous items, human serum derived drugs, Infectious agents

General Safety No smoking, running or jumping shall be permitted. Dressing shall be in accordance with policy. Keep exits and passages clear at all times. Preventing Fire Minimize the quantity of flammable liquids kept in the pharmacy. Keep flammable liquids in approved flammable liquid storage cabinets.

Immediately activate the building fire alarm system. Learn how to use extinguisher. Do not use elevators; use building stairs. Treating Fire All electrical equipments should be wired with a grounding plug. Electrical cords or other lines shall not be suspended unsupported across rooms or passageways. Electrical Safety

Medical Emergencies Prevention of injuries should be a major emphasis of pharmacy safety program. Proper training will prevent injuries from glassware, hazardous material, burns and electrical shock. First aid should be provided immediately.