1. Nouf Aloudah

2. Reference  Chapter 18

3.  Pharmacy is responsible for the safe and effective use of medication throughout the entire hospital ◦ Product selection ◦ Procurement ◦ Storage ◦ Preparation for administration ◦ Distribution to the patient care units ◦ Appropriate prescribing ◦ Guidelines are in place “All medication cycle are managed properly”

4.  Product dispenser to one of expanding clinical responsibilities  We were completely isolated from patient care areas, never had the opportunity to react to the actual medication order written by the physician  Repackaging bulk supplies of medications orders by requisition from nurses (who were the ultimate interpreters of all medication orders and prepared the medication for administration to the patients)  The pharmacist had no opportunity to use his or her extensive education to enhance the quality and safety of drug therapy

5.  1960s the beginning of significant changes in the medication distribution systems as few hospitals experimented with a concept under which the pharmacist assumed the responsibility for preparing all doses of medication for patients and routinely monitored the appropriateness of all prescribed drug therapy  Genesis of drug distribution system  Changes continue! increased automation……

6.  This lecture focuses on those distributive activities that transpire between the time a medication order is written until the prepared package is delivered by pharmacy to the nurse, physician or other health care professional for administration to the patient

7. BACKGROUND  Historical overview The pharmacy signal function were the compounding, repackaging, and relabeling of multiple dose supplies of medications into containers for subsequent dispensing and storage on a patient care unit (PCU)

8. BACKGROUND  Historical overview There were two systems 1. Floorstock system 2. Patient prescription system

9. BACKGROUND  Historical overview 1. Floorstock system  More commonly used  The pharmacist dispensed multiple dose, bulk supplies of drugs to the PCU, where nurses prepared all doses of medication intended for administration to the patient (including compounding of IV admixture)

10. BACKGROUND  Historical overview 1. Floorstock system  Not labeled for a specific patient and could therefore be used for several doses for numerous patients  It was common for 150- 200 medication to be stored in a minipharmacy on each PCU  The pharmacist sow only transcribed drug requisitions sent by nursing personnel

11. BACKGROUND  Historical overview 2. Patient prescription system  The physician wrote a prescription order, the nurse transcribed this order onto a medication administration profile and generated a drug order for pharmacy, the pharmacist dispensed a 2 to 5 days supply of medication, and the nurse maintained the bottles in stock and used a reminder system to determine when the medication was to be administered

12. BACKGROUND  Historical overview 2. Patient prescription system  The pharmacist review order (but not relevant information about patient )

13. Unit dose system  The university of Iowa hospitals and clinics and the university of Arkansas medical center in the middle 1960\s designed, implemented, and measured several indicants associated with a concept known as the “unit dose drug distribution system”  More active role of the pharmacist in the medication cycle with the patient reaping the benefits of a trained medication practitioners responsible for the medication cycle and the return of the nurse to patient care responsibilities

14. Unit dose system  The pharmacist review an actual copy of the physician order  Oversee all medication preparation steps  Maintain patient specific drug profiles that detail allergy, organ function indices, and patient response data  Pharmacist-physician interactive role began to emerge  US general accounting office concluded that “The unit dose system is the most cost effective of all pharmacy distribution systems when the entire spectrum of drug delivery activities within a hospital is considered”

15. Unit dose system components  The pharmacist review a copy of all medication orders written by the physician prior to dispensing medications ◦ Triggered the success of the unit dose system ◦ Given birth to clinical pharmacy practice (the pharmacist intervene with inappropriate drug prescription)

16. Unit dose system components  Pharmacist review the order by transcribing the prescription content to pharmacy recorders, or FAX it  Others used structural, multiplay medication order form which requires that medication orders be written within columns labeled for drug name, dose, route of administration and interval ◦ (no transcribing improved efficiency) ◦ Eases the transition to automation entry bec. Simplifies order entry process ◦ Pharmacist and the nurse interpret order more efficiency and accurately

17. Unit dose system components  So a copy reach the pharmacy  The Pharmacist review it and compare it with previous drug order and information kept in patient specific medication profile, intervene with inappropriate prescription  A pharmacy technician prepares the medication needed during coming 24 hr period

20. Unit dose system components  The pharmacist check it after preparation for accuracy and authorization to go to PCU  The majority of medications are dispensed via a specially designed medication administration cart, which positioned in PCU until administration time  Nurse document in medication administration record after administration

21. Unit dose system components  It is a unit dose packaging  Each dose into separate package that bear a label listing drug name, strength, or concentration, batch no, expiration date (many drugs available commercially)

25. Unit dose system components  In PCU drugs are stored in med cart that can be accessed only be authorized personnel

26. Unit dose system component Medication that are needed prior to the med cart is scheduled delivered to PCU via different method ◦ Pneumatic tube carrier ◦ Pharmacy courier system (every 30-60 min)

28. Unit dose system component PRN delivered by  Fulfilling of specific need requests sent to pharmacy by the nurse  Automatic placement of predetermined supply of PRN medication into the patient\s drug bin located on the med cart  Placement of select floorstock supplies of medication on the PCU  Limited floorstock supplies of medications with low toxicity potentials are placed onto the med cart so that the nurse can quickly and easily administer a dose when needed by the patient

29. Unit dose system component Controlled substances (drug enforcement agency (DEA) schedule II,III,IV,V drugs has a substantial potential for abuse and must be securely stored in the pharmacy and PCU Handled separately Medication order cycle is the same Limited floorstock storage in a secure area of the PCU

30. Unit dose system component Drugs of “blue code” Preassembled emergency drug kit to all PCU’s of the hospital

32.  Unit dose system design  What is the scope of the pharmacy services that will be provided is it ◦ Unit dose system? ◦ Unit dose packaging and distribution program?

33.  Unit dose system design ◦ Unit dose system:  One that includes clinical pharmacy services along with drug distribution activities; that is, the two components go hand on hand

34.  Unit dose system design ◦ Unit dose packaging and distribution program:  If the scope is essentially confined to drug distribution activates  Which requires only that pharmacy prepare doses of medication, use unit dose packaging, and deliver patient specific supplies of medication to PCU on a routine basis (negligible clinical pharmacy)

35.  Unit dose system design ◦ Unit dose system:  Requires greater personnel recourses, includes high level of job content for pharmacy staff, and has a greater impact upon the quality of medication therapy

36.  Emerge from a central location :Centralization  Or one or more decentralized pharmacy will be established :decentralization

37. Centralization  Services are provided from a single, self continued location within the hospital  In hospital with limited space, small size, or vertical design,

38. Decentralization  Two or more dispensing locations commonly called “satellite”  At minimum provide pharmacist order review and first dose dispensing  Act as the base from which clinical pharmacy services are provided  Usually he central pharmacy provide services such as unit dose medication cart fill, medication repackaging, IV admixture compounding, and controlled substance distribution, then transferred to the satellite for final delivery it to the PCU  200 m2, near one or more PCU’s, serves from 60-120 pt. for 16 hour a day

39. Decentralization  Staffing includes one or two pharmacists and two pharmacy technician per each day and evening shifts  Staffing is normally reduced during night hours  Actual no depend on ◦ Patient population ◦ Spectrum of clinical services provided ◦ Presence or absence of centralized pharmacy support services

40. Decentralization Space requirements are affected by  Scope of distribution services to be provided from the satellite ◦ Complete distribution services or provision of only first dose)  Type of patient population being served

41. Decentralization Specialized pharmacy satellite Particular service objectives are identified relative to specific clinical services such as pediatrics, oncology, critical care, emergency room

42. Personal responsibilities  Professional staff ◦ changed dramatically with unit dose system ◦ Many of the activity once performed by the nurses have been assumed by pharmacy personnel ◦ A study showed that it allowed the saving in nursing labor attributable to one pharmacy satellite serving 130 general medicine beds to be equivalent to 5.5 full time registered nurse positions

43. Personal responsibilities  Professional staff ◦ From simple, recurring mechanical duties to professional services responsibilities for the hospital’s complete medication order cycle ◦ Become highly visible member

45. Personal responsibilities  Pharmacy technician

46. Evaluation of unit dose services  Cost analysis  Improved patient care Improved patient care can lead to decreased of hospitalization and during these days of prospective payment system decreased cost

47. Evaluation of unit dose services  Actual cost savings are based upon decreased expenditures for drugs and nursing personnel time associated with medication related activities. Although cost of purchasing and /or preparing unit dose med. Is higher, this cost is offset by reduction of drug inventories necessary to stock each PCU under a unit dose system  Smaller inventories on each PCU lead to reduced drug wastage, as dose the packaging per se, bec the ability to return unused doses to stock

48. Evaluation of unit dose services  Nursing personnel requirements in medication related activities can be reduced and reassigned existing staff to other patient care duties  A teaching hospital witness a 12% improvement in medication charting accuracy, which at that time translated into an annual increase in revenue of over $1 million

49. Evaluation of unit dose services  Reduction in the medication errors is sometime the basis for implementing the unit dose system ◦ Double checking of each dose ◦ Safety element of labeling

50. Evaluation of unit dose services  Greatest positive impact is the subsequent enhancement of overall clinical pharmacy services

51. Enhancement of clinical role  The unit dose system has led to greater use of the pharmacist’s drug therapy expertise and in turn improved patient care  With this system the pharmacist assumes responsibilities not only for delivery a carefully prepared drug product to the patient in a safe, accurate, and timely manner but also the monitoring all prescribed drug therapy to assess appropriateness of dose, suitability of therapy in light of the patient’s condition, cost effectiveness of therapy, and the potential for drug interactions  These combined activities form the foundation of clinical pharmacy practice

52. Evolution of other pharmacy activities  Patient care services  Quality assurance  Productivity monitoring  New technologies

53.  Robot in pharmacy  KFSH & RC robot pharmacy report

54.  The future