1. CHAPTER 16 HOSPITAL PHARMACY

2. CHAPTER OUTLINE Hospital Pharmacy Technician Roles
Hospital Pharmacy Areas
Hospital Formulary
Communication
Computer Systems
Medical Records
Medication Orders
Order Processing
Inventory Control
Organization of Medications
Unit Dose System
Sterile Products
General Hospital Issues
Calculations
Review

3. HOSPITAL PHARMACY
Pharmacy technicians play an important role in the preparation, storage, and delivery of medications to patients in the hospital.
Training requirements vary by hospital, but most are seeking technicians with certification (CPhT).

4. ORGANIZATION OF A HOSPITAL
Patients with similar problems are grouped together and located on nursing units.
Examples: Cardiac Care Unit (CCU), Obstetrics (OB)
The nurses’ station is the work station for medical personnel on a nursing unit.
Ancillary areas
Other areas of the hospital that provide patient care
Examples: Emergency Room, Cardiac Catheterization Lab
The Pharmacy Department services nursing units and ancillary areas with medication.

5. THE HEALTHCARE TEAM
A team of healthcare workers help provide care and medications to hospital patients.
Prescribe medications for patients
physicians, physician assistants and nurse practitioner or advanced practice nurses
Administer medications to patients
registered nurses, licensed practical nurses and respiratory therapists
Assist with getting medications to patients
pharmacists, social workers, patient care techs, and pharmacy technicians

6. PHARMACY TECHNICIAN ROLES
Front counter
Satellite pharmacies
Delivery
Outpatient pharmacy
Order processing
Compounding/Unit dosing
Monitoring drug therapy
Investigational drug service
Inventory control
Narcotics/controlled substances
Cartfill
Automation
IV/clean room
Chemotherapy
Quality assurance
Pharmacy technician supervisor
Staff development

7. HOSPITAL PHARMACY AREAS
Inpatient pharmacy
Located inside the hospital; serves only patients in the hospital and its ancillary areas
Pharmacy satellite
Branch of inpatient pharmacy
Responsible for preparing, dispensing, and monitoring medication for specific patient areas
Examples: Pediatric, OR, and Oncology
Central pharmacy
Main inpatient pharmacy (when also have satellites)
Most medications prepared and stored here
The sterile product area, or clean room, usually located here

8. USP <797>
Set of regulations issued by the US Pharmacopoeia for compounding sterile products
Intended to decrease infections transmitted to patients through drug preparation, and
better protect staff in their exposure to pharmaceuticals.
All hospitals accredited by The Joint Commission (TJC) must be compliant with USP 797 standards.

9. HOSPITAL FORMULARY Hospital Formulary Closed formulary
List of drugs stocked in the hospital and selected based on therapeutic factors as well as cost.
The Pharmacy and Therapeutics Committee (P&T committee) adds, removes, and evaluates medications on the formulary.
Closed formulary
Requires physicians to order only medications in the formulary.
Non-formulary drugs
Medications not on the formulary list and not regularly stocked.
Therapeutic interchange
Allows pharmacist to change certain non-formulary medication orders to equivalent formulary medications.

10. COMMUNICATION
Ways other areas of the hospital communicate with pharmacy:
pneumatic tubes
telephones
computers
in person at the pharmacy’s front counter
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11. HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPPA)
Safeguards patients’ protected health information (PHI) when it is spoken, written, or transferred electronically.
Information in the hospital information system is highly confidential.
Illegal to give information to any unauthorized person.
Never look at a patient’s information unless necessary in fulfilling an assigned task.

12. MILITARY TIME
Most hospitals use a 24-hour clock (also known as military time) to indicate when medications are to be given and when they expire.
12–hour clock –hour clock
Midnight 00:00
1 a.m. 01:00
2 a.m. 02:00
3 a.m. 03:00
4 a.m. 04:00
5 a.m. 05:00
6 a.m. 06:00
7 a.m. 07:00
8 a.m. 08:00
9 a.m. 09:00
10 a.m. 10:00
11 a.m. 11:00
12–hour clock –hour clock
Noon 12:00
1 p.m. 13:00
2 p.m. 14:00
3 p.m. 15:00
4 p.m. 16:00
5 p.m. 17:00
6 p.m. 18:00
7 p.m. 19:00
8 p.m. 20:00
9 p.m. 21:00
10 p.m. 22:00
11 p.m. 23:00

13. MEDICAL RECORDS Health records (aka medical records)
Detailed, chronological accounts of a patient’s medical history
Electronic medical record (EMR) or electronic health record (EHR)
A computerized patient medical record
Allows authorized health care providers to access a patient’s medical information from any secure location
Integrates patient medical records with billing and appointments

14. COMPONENTS OF A MEDICAL RECORD
Demographics Personal identification information Allergies Drug and/or food allergies and the allergic response experienced Medical history Disease states (previous illnesses, surgeries, prescriptions, OTC and herbal medications) Medication orders Orders written by a physician for patient’s medication
Medication administration record Tracks medications given to a patient, time they were given, and who administered them Lab/test results Blood tests, X-rays, microbiology, etc. Documentation flow sheet Vitals on an hourly or scheduled basis, hourly rates of IV fluids and medication drips, etc. Progress notes Detail patient’s current progress

15. MEDICATION ORDERS
All written pharmacy orders for a hospital patient are done on a medication order form.
Unit clerks, nurses, pharmacists or pharmacy technicians may be responsible for entering these orders into the computer system before the pharmacist reviews them.
Computerized physician order entry (CPOE) is an electronic alternative.
Physicians can enter orders directly into the computer system, decreasing the chance of transcription errors.

16. TYPES OF MEDICATION ORDERS
Standing order
Patient receives medication at scheduled intervals (e.g., 1 tablet every 8 hours)
PRN order
Medication administered only on an as needed basis (e.g., 1 tablet every 4 to 6 hours as needed for pain)
STAT order
For medication to be administered immediately
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17. TYPES OF MEDICATION ORDERS
Restricted medications
Medication orders requiring approval by a specialty service (e.g. Infectious Disease) prior to processing
Some protocols also restrict which physicians or medical services can place orders for certain medications (e.g. chemotherapeutic agents)
Stop orders
Orders limited to a certain amount of time (e.g., 7 days) after which a new order is required to continue with the medication

18. MEDICATION ADMINISTRATION RECORD
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19. ORDER PROCESSING
The technician fills the medication order once the pharmacist has approved it.
Many medications look similar and the same medication may come in different sizes or forms.
Be sure the correct medication, dose, and dosage form is being filled.
Double check the strength, quantity, expiration date, base solution, and volume (if applicable).

20. ORDER PROCESSING Missing doses
Doses that should have been delivered to the nursing unit but cannot be located
This can be a challenge in hospitals
There are several questions a technician should ask before refilling a missing dose.

21. ORDER PROCESSING Can be manual or automated.
Often, it is a combination of both.
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22. ORDER PROCESSING Manual Automated
Medication order is written in patient chart
Copy of medication order is removed from chart
Order is picked up at nursing station or faxed or tubed to the pharmacy
Medication order is entered into the pharmacy computer system
Pharmacist reviews and verifies medication order
Medication order is filled by a pharmacy technician and checked by pharmacist
Patient-specific medication is manually delivered or tubed to nursing unit
Physician or agent of the physician enters medication order directly into hospital computer system which automatically communicates order to the pharmacy
Pharmacist reviews and verifies medication order
RN retrieves medication from point-of use automated medication station
Pharmacy technician fills inventory as medication supplies fall below par

23. INVENTORY CONTROL Inventory control responsibilities
Order medications, store and maintain par levels, check order invoices, and deal with drug recalls and shortages
Follow state and federal law when
dealing with controlled substances
Drug inventory is usually ordered through a program that communicates with the distributor/wholesaler.
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24. INVENTORY MANAGEMENT Par Drug recall Emergency drug procurement
Amount of drug product that should be kept on the shelf
Drug recall
Voluntary or involuntary removal of a drug product by the manufacturer
Usually pertains only to a particular shipment or lot number
Emergency drug procurement
Quickly obtaining a medication not currently in stock when the drug is urgently needed

25. DRUGS REQUIRING REMS (RISK EVALUATION AND MITIGATION STRATEGY)
Tracleer® (bosentan)
Aranesp® (darbopoetin alfa)
Tikosyn® (dofetilide)
Epogen®/Procrit® (epoetin alffa)
Botox/Botox Cosmetic®/(onabotulinumtoxin A)
Thalomid® (thalidomide)

26. ORGANIZATION OF MEDICATIONS
Alphabetical, using the generic drug name
By route of administration
e.g., intravenous, oral, ophthalmic, etc.
Narcotics and other controlled substances are often stored in a secure area of the pharmacy.

27. ORGANIZATION OF MEDICATIONS
Many hospitals have a designated area for compounding oral solutions and suspensions.
If an oral medication is needed in liquid form but is not available commercially, it may be extemporaneously compounded.

28. COMPOUNDING Bulk compounding log Reconstitute Extemporaneous compounds
Record of medications compounded in bulk for non-specific patients
Records all the ingredients, amounts used, manufacturer, lot numbers, and expiration dates of all ingredients used
Reconstitute
Adding water or other diluent to commercially made drug bottles or vials to make a solution or suspension from a pre-made powder form of the drug
Extemporaneous compounds
Medications prepared following a specific recipe or formula, usually because they are commercially unavailable
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29. UNIT DOSE SYSTEM Unit dose Medication cart
Contains the amount of a drug required for one dose
Eliminates need for nurses to withdraw medication from large bulk bottles
Decreases the chance of making an error
Medication cart
Has an individual drawer or tray for each patient on the nursing unit
Patient drawers are filled daily with the amount of medication(s) required for 24 hours.
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30. UNIT DOSE PACKAGING PACKAGING TYPE USED FOR
plastic blister tablets/capsules
foil blister tablets/capsules
packet powder
tube ointment/cream
foil/plastic cup oral liquid
cartridge injection
vial injection
ampule injection
foil/plastic suppository
IV syringe injections
oral syringe oral liquids
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31. CART FILLING
Technicians play a large role in manually filling medication carts.
Some hospitals have cart filling robots.
Technicians fill and run the robot.
Some nursing stations have automated dispensing systems (ADS).
Pharmacy technicians stock the ADS.
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32. UNIT DOSE SYSTEM
Some hospital pharmacies may buy ready- to-use unit-dose packages of medications.
Other hospitals buy bulk bottles of medication and use machines that automate unit dose packaging.
Oral liquids are drawn up in oral syringes either manually or using a special machine.
Hospital pharmacies must keep documentation logs of any medications they package.
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33. STERILE PRODUCTS
A large portion of hospital medications are administered intravenously.
Requires special training:
Aseptic technique
Correct drug, concentration, volume, base solution
Double checking calculations
Single vs. multi-dose vials
SVPs, LVPs, chemotherapy, TPN
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34. STERILE PRODUCTS – USEFUL TERMS
Total parenteral nutrition (TPN)
A type of large volume parenteral containing protein, carbohydrates and essential nutrients given through an IV line
Epidural
Sterile, preservative-free medication administered into a patient’s epidural space (located near the spinal cord and backbone)
Short stability
Medications that expire soon after preparation (i.e., within 1–6 hours after preparation)

35. GENERAL HOSPITAL ISSUES
Some conditions of employment that may not be required in other pharmacy settings:
Physical exam and drug testing
Hospital-wide orientation
Probationary period
Annual/semiannual performance review
Regulatory agencies that oversee hospital operations:
The Joint Commission (TJC)
Centers for Medicare and Medicaid Services (CMS)
Department of Public Health (DPH)
State Board of Pharmacy (BOP)
United States Pharmacopoeia (USP)
Drug Enforcement Administration (DEA)

36. SAFETY
Code Cart
Cart with medications and equipment commonly used in medical emergencies
Universal precautions
Practices and guidelines that reduce the probability of exposure to blood-borne pathogens
Include the use of protective barriers (gloves, gowns, masks, and protective eyewear)
Material Safety Data Sheets (MSDS)
Contain information for safe handling of harmful chemical substances or drugs
Sharps container
A RED container designated for disposal of used needles or other items that may cut or puncture the skin
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37. CALCULATIONS
Hospital pharmacy technicians must perform many calculations:
Drawing up unit dose syringes
Calculating flow rates / drip rates
Determining time of subsequent doses
Performing percent calculations
Calculating the amount of drug and diluent needed for SVPs, LVPs, and dilutions