Learning Outcomes
After completing this chapter, you will be able to
Describe the differences between centralized and decentralized pharmacies.
List at least two types of services that are provided by hospital pharmacy departments.
Explain how pharmacy policy and procedure manuals help technicians function efficiently in a large number of duties, responsibilities, and situations.
List at least three different methods of drug distribution in which technicians play an active role.
List the components of—and the role the technician has in—the medication management process.
Describe the role accrediting and regulatory agencies play in a hospital pharmacy.
List two types of technology that a pharmacy technician will work with in a hospital pharmacy.
Describe quality control and quality improvement programs, including how they are used in hospital pharmacy practice.
List at least three organizations that are involved with patient safety.
Describe the financial impact that third-party payers have on hospitals.
Key Terms
| automated medication dispensing device | A drug storage device or cabinet that contains an inventory of medications that are electronically dispensed so they may be administered to patients in a controlled manner. |
Decentralized Pharmacy Services
Accrediting and Regulatory Agencies |
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Hospital pharmacy practice offers many interesting and challenging opportunities for pharmacy technicians. Many valuable services are provided by pharmacies in the hospital setting, including the traditional duties of drug procurement, storage, preparation, and administration, as well as the distribution of drugs and supplies to patients. Hospital pharmacy professionals also ensure that medications are used in a safe and effective manner, which involves clinical services, drug therapy monitoring, medication safety, patient education, and other related activities.
As in other settings, the scope of hospital pharmacy practice is ever changing and expanding to meet advances in technology, rising health care costs, and the increased requirements of regulatory and accrediting agencies. Technicians are an integral part of the pharmacy team that provides these services in the hospital setting. As the pharmacy profession continues to expand its realm of activities to include direct patient care, the responsibilities and opportunities for technicians are also expanding. This chapter provides a general overview of hospital pharmacy practice and describes the current roles and responsibilities of pharmacy technicians.
Historical Perspective
Pharmacy services have existed in hospital settings in one form or another for many years. In the past, the typical hospital pharmacy was primarily involved with traditional functions related to distributing drugs to patients. These services were primarily performed from a central pharmacy that was usually located away from patient care areas, such as in the basement of the hospital. Pharmacy services were often limited in scope, responsibility, and number of personnel. The focus was on medication products, including procurement, repackaging and labeling bulk supplies, and delivery to patient care areas.
At this time, it was common for bulk supplies of medications to be stored on nursing stations as floor stock. When a patient needed a medication, the nurse would take the medication from the floor stock and perform all necessary calculations and preparations before administering it to the patient. Nurses would also prepare all intravenous (IV) medications in the patient care area without the use of a laminar flow hood and often without proper quality control procedures. As a result, the potential for medication errors was very high.
The practice of hospital pharmacy has made tremendous advances over the past 40 years. In the mid-1960s, pharmacies began to assume more accountability for the entire medication use process in order to reduce the potential for medication errors. In fact, efforts to improve medication safety continue to be a major focus for hospital pharmacies today. As hospitals become more knowledgeable about the common causes of medication errors, there is a corresponding change in requirements by regulatory and accrediting agencies, which helps all hospitals continue to improve the safety and quality of care provided to patients.
Automation and technology have also played a major role in changing the practice of hospital pharmacy. These technological changes have improved not only the efficiency of the drug distribution processes, but also medication safety.
In addition, the pharmacy profession has been moving from a primary focus on medication preparation and distribution to one that focuses on patient care by providing services that help patients realize safe and effective drug therapy outcomes.
The impact of changing reimbursement and the financial burdens placed on health care systems with rising costs and diminishing resources have required hospital pharmacies to adapt as well. These changes have resulted in greater efforts to provide the best quality care possible in an efficient and timely manner. The ultimate goal when treating patients is to achieve positive outcomes without causing harm—harm that could lead to additional days in the hospital and an increased use of limited health care resources.
Organizational Structure
Health care institutions are usually organized into several levels of management. Managers at the top of an organization are primarily involved in setting a direction and vision for the hospital. As you move down the organizational structure, the responsibilities become more defined and are targeted to meet specific goals of the hospital. Each level of management is designed to allow a distinct range of activities to be performed in an organized manner. Defining clear levels of responsibility and hierarchy ensures that the activities of employees are organized, efficient, and productive. Organizational structures also allow for appropriate lines of communication throughout the institution.
Typically, at the top of the hospital organization is the board of directors. Just below the board of directors is the chief executive officer (CEO), president, or hospital director. The CEO helps set a direction for the hospital by creating a vision and mission for the institution. The CEO reports to the hospital’s board of directors and is responsible for ensuring that necessary budget, personnel, and operations are in place to help achieve the mission of the hospital. The medical staff and the second level of management report directly to the CEO.
Hospitals usually have a chief operating officer (COO) or vice president who represents a second level of management. The COO is responsible for the daily operations of the hospital. A chief financial officer (CFO) is also a second-level manager who is responsible for the financial management of the hospital. Another second level of management commonly seen today is the vice president of patient care services. This manager is usually responsible for departments that provide direct patient care, such as the pharmacy, nursing, and respiratory therapy departments. The number of additional levels of management is dependent on several factors, including the size and scope of services provided, the financial status of the facility, and the management philosophy of the CEO or equivalent manager. Individual departments are routinely grouped either by patient care (e.g., nursing, pharmacy, or radiology), ancillary services (e.g., materials management or environmental services), or support services (e.g., medical records or information systems).
Variations of organizational structures can be found depending upon a facility’s size, needs, and goals. One such variation is the patient-focused care model. In this model, managers are given responsibility for all employees and activities provided to specific patient types (e.g., surgical, pediatric, or medical patients). The philosophy underlying this structure is that all health care workers function as a team, with everyone having a role in providing patient care, regardless of discipline or the tasks performed.
Pharmacy Department Structure
The director, or chief of pharmacy services, is at the top of the pharmacy department hierarchy. The director of pharmacy is responsible for all activities within the pharmacy, including, but not limited to, the budget and drug expenditures, medication management, regulatory compliance, and medication safety. The number and levels of management reporting to the director of pharmacy depend on the department’s size and scope of services. For example, a hospital affiliated with a university may need one manager to coordinate pharmacy students and the residency program and another to coordinate staff development and all clinical pharmacy services. Pharmacy technicians may be assigned to management or lead responsibilities. In this capacity, the technician supervises the activities of other technicians. The lead technician will be responsible for management functions such as scheduling and performance evaluations. The structure of the pharmacy department is based on the types of pharmacy operations provided, such as centralized or decentralized pharmacy services.
Centralized Pharmacy Services
Centralized pharmacy services, as the name implies, handle pharmacy personnel, resources, and functions from a central location. A typical centralized pharmacy contains a sterile preparation area, known as a clean room, which is designed for the aseptic preparation of IV medications (e.g., antibiotic piggybacks, large-volume parenteral solutions with additives, total parenteral nutrition, and chemotherapeutic agents), a medication cart filling area, an outpatient prescription counter, and a storage area for medications and supplies. Central pharmacy services are beneficial when resources (i.e., personnel, equipment, and space) are limited. The advantage of centralized services is that fewer staff members are needed to control, store, inspect, prepare, and dispense medications for the entire institution. The disadvantages of offering only centralized pharmacy services are the lack of face-to-face interactions with patients and other health care providers and the increased time to deliver medications to patient care areas.
Many centralized pharmacies now have better access to patient care information through the use of computerized documentation. Although patient information is readily available in the pharmacy, the pharmacist may still need to go to the patient care floor when making therapeutic assessments regarding medication orders. Unless a hospital is completely electronic, there will be information written on the patient’s chart that may be needed when drug therapy is reviewed. The pharmacist may also need to consult with the health care professionals treating the patient to obtain additional information, as well as interview or assess the patient for information regarding drug therapy decisions.
As mentioned above, it may take longer to deliver medications to all areas of the institution from a central location.
Technology and automation, such as automated medication dispensing devices (e.g., Pyxis® MedStation™ and MedDispense™) can help hospitals improve the availability of medications for administration to patients. These are secured storage cabinets that allow medications to be kept in a patient care area (figure 4–1). Technicians have now expanded their scope of responsibility to include operating and maintaining these forms of automation, including checks to ensure adequate supplies of medications are in the devices.
Figure 4–1. Pharmacy technician restocking an automated dispensing device in a patient care area.
Other technician responsibilities in a central pharmacy involve preparing IV medications (e.g., total parenteral nutrition and chemotherapeutic agents), filling patient medication carts, delivering narcotics, extemporaneous compounding (i.e., preparing products not available from a manufacturer), performing functions related to quality control and quality improvement, billing, and completing miscellaneous paperwork.
Decentralized Pharmacy Services
Decentralized pharmacy services do not replace centralized pharmacy services; rather, they are used in conjunction with a central pharmacy. Decentralized pharmacy services are provided from patient care areas. There are many types of decentralized pharmacy services, but one common form of a decentralized pharmacy (with opportunities for pharmacy technicians) is a pharmacy satellite. Pharmacy satellites have designated areas on a hospital floor or a patient care unit where drugs are stored, prepared, and dispensed for patients (figure 4–2). Pharmacy satellites may be staffed by one or more pharmacists and technicians. The proximity of a pharmacy satellite to the patients and other health care providers has several advantages. It allows the pharmacist more opportunities to interact with patients in order to obtain pertinent information, monitor and assess their response to drug therapy, provide patient education, and disseminate educational materials. The pharmacist also has more opportunities to discuss the plan of care, answer drug information questions, and make appropriate drug therapy recommendations while being face-to-face with other health care providers. Technicians have the advantage of being close to medication storage areas used by nurses. They can respond quickly to any problems with medication storage cabinets and prepare any needed medications in a timely manner. Technicians are an accessible, helpful source of non-clinical information to health care providers in decentralized pharmacy satellites.
Figure 4–2. Pharmacy technician in a pharmacy satellite.
The disadvantage of decentralized pharmacies is that they require additional resources, such as personnel to staff a decentralized satellite, equipment (e.g., laminar flow hoods, computers, and printers), references, and a second inventory of medications and supplies.
The technician’s role in decentralized pharmacies varies from institution to institution. Technicians are given considerable responsibility in pharmacy satellites to free up the pharmacist to provide pharmaceutical care. Some responsibilities of satellite technicians are to maintain appropriate inventory (e.g., medications and supplies), including the disposal of expired medications; clean and maintain laminar flow hoods; and prepare all unit-dose and IV medication orders in a timely fashion. The experienced technician may answer specific non-clinical questions from nurses and make judgments regarding when to refer a question to the pharmacist. Technicians can be responsible for all aspects of running the pharmacy satellite under the supervision of a pharmacist.
Use of Clinical Practitioners
A pharmacy department may also have patient-focused care or clinical pharmacy services as part of its structure.1 These services require clinical skills from a trained clinical pharmacist or practitioner. Clinical practitioners are involved in all aspects of drug therapy to ensure appropriate, safe, and cost-effective care. Patient-focused care is accomplished by ensuring all patient-specific problems requiring drug therapy are being treated, the medication selected is appropriate for the indication, the dose ordered is correct, and the dosage form and administration technique meet the patient’s needs.
After the medication has been administered, clinical practitioners monitor the effects of the medication through laboratory results (e.g., serum drug levels, culture and sensitivity results, or serum creatinine levels) as well as patient-specific parameters (e.g., heart rate, temperature, or respiration rate). Clinical practitioners also play a significant role in the education of patients and other health care providers regarding the use of medications. They are able to spend more time with patients directly and in the patient care areas than centralized pharmacists.
Pharmacy technicians are being used to help pharmacists in these patient-focused models by collecting routine clinical data, tracking medication errors, and assisting in other clinical projects.2–6
Committee Participation
Committees are essential to effectively plan and implement the day-to-day working decisions in hospitals. There are two common types of committees: standing committees and ad hoc committees. Standing committees are permanent or on-going. They are often incorporated into official documents, such as policies and procedures. An example of a common standing committee is the Pharmacy and Therapeutics (P&T) Committee. This committee is multidisciplinary, with typical membership including, but not limited to, representatives of the medical staff, pharmacy, nursing, hospital administration, and dietary. The committee is required to meet on a routine basis to make decisions about the care of patients, with a focus on the safe and effective use of medications. The P&T committee will oversee and make decisions for the institution’s formulary as an example of this responsibility. A hospital formulary is an approved list of medications to treat the types of patients the hospital typically serves.
Ad hoc committees are temporary and formed to address a specific purpose. An example of an ad hoc committee is a committee formed to address the implementation of a new computer system for the hospital. This type of initiative takes a great deal of work and coordination between departments. Once the new computer system is implemented, the ad hoc committee may no longer be needed.
RX for Success
Pharmacy technicians are often asked to participate in a variety of hospital committees, based on their training and understanding of many hospital processes, especially as they relate to drug distribution systems.
Pharmacy Department Services
The services that a particular pharmacy department provides varies from hospital to hospital. This section describes a few examples of these services, including drug distribution services, clinical services, and investigational drug services. The policy and procedure manual is a great resource to identify the services provided by a hospital pharmacy department.
Policy and Procedure Manuals
Every hospital pharmacy is required by The Joint Commission to maintain a policy and procedure manual. Such a manual is critical for the successful operations of the department. Policy and procedure manuals contain descriptions of all of the functions and services that a pharmacy department provides, as well as written documents that describe the policies for operations and the procedures explaining how to execute them. They include detailed directions on how to perform a wide variety of functions to meet the needs of the hospital and its patients. These written procedures allow the functions in the pharmacy to be carried out in a consistent and standardized manner. They also serve as a way to communicate and educate new employees on how to do their jobs. Many policies and procedures in hospitals are multidisciplinary, so one policy can be used by all health care providers who are involved with carrying out a particular service or patient care activity.
Drug Distribution Services
Drug distribution services in hospitals involve all of the steps required to get a drug from the pharmacy to the patient. Exactly how this is done in each hospital varies significantly, depending on the physical layout of the hospital, available space, types of patient care services provided (e.g., oncology, pediatrics), and the types of automation and technology available. Regardless of the specific drug delivery systems used, the pharmacy is ultimately responsible for providing medications to patients. Fulfilling that responsibility requires that several sequential processes, such as procuring, storing, preparing, and delivering medications to patient care areas, are executed accurately and efficiently. Drug distribution services are essential to allow for the medication use process, which starts when a physician orders a medication and runs through the time the medication is administered to the patient. Medical staff, nursing, and pharmacy personnel must work together to ensure that the medication processes occur in a safe and timely manner. As an example, for a patient to receive one aspirin tablet, the following steps must occur:
1. The drug must be in the inventory, which means it was ordered from the wholesaler, received, inspected, stored, inventoried, and periodically reviewed to ensure that it did not expire.
2. The medication order must be written (or submitted electronically) by the physician and received by the pharmacy.
3. The medication order must be reviewed and verified by the pharmacist.
4. The medication order must be processed and added to the patient’s medication profile so the drug can be dispensed and delivered to the nursing station or made available in a medication dispensing cabinet.
5. Once at the nursing station, the drug is administered to the patient and the dose is documented as given in the patient’s medication administration record (MAR).
6. Once the medication is administered, physicians, nurses, and pharmacists monitor the patient to ensure that the patient is responding to therapy, and they also watch for the development of any adverse events that may occur.
In the past, compounding and repackaging medications was a major part of drug distribution services. The advent of unit dose drug distribution systems, however, has eliminated or minimized this time-consuming process for most of the solid dosage forms dispensed. A unit dose is an individually packaged medication that is ready to be dispensed and administered to the patient, including all necessary labeling requirements (i.e., drug name, strength, lot number, expiration date, etc.).
The distribution services mentioned up to this point focused primarily on new medication orders. Once the initial order has been processed and is on the patient’s medication profile and MAR, the pharmacy needs to ensure that an adequate supply of maintenance medications is available to be administered by the nurse. Two primary methods are used in hospitals to dispense maintenance medications to patient care areas. The first involves the use of automation and the second is a manual process.
There are many forms of automation used to distribute medications to patient care areas. This section will focus on automated medication dispensing cabinets. Regardless of which form of automation is used, pharmacy technicians play a key role in maintaining an appropriate inventory of medications to be stocked in these devices. Inventory in these devices requires frequent adjustments to meet the current needs of the patients served. Having the proper inventory in these devices is important; it allows the nurse to obtain the right medication and the right dose (in the right form) so it can be administered to the right patient at the right time.
The second distribution system is a manual process that usually requires the use of medication carts or cassettes. In this system, each patient is assigned to a medication drawer, usually arranged by bed number. To fill each medication drawer, a report known as a fill-list is generated. This list is typically sorted by bed number to correspond with the labeling of the drawers. The fill-list will contain patient information (i.e., weight, height, allergies, etc.) to help the pharmacist when checking the carts. All medications scheduled to be given during the selected fill-list time will print, usually within a 24-hour period. The technician will fill each patient’s drawer based on the fill-list. Once these cassettes are filled, the pharmacist will check the carts for accuracy. In some states, technicians are able to check other technicians for filling accuracy. Studies have shown that technicians are as accurate at checking medication carts as pharmacists.7 Once the cassettes are filled and checked, the technician can deliver the cassettes to the patient care area to exchange them with cassettes from the previous time frame.
It is common for automated and manual systems to be used simultaneously. When both systems are used, it is a matter of logistics, resources, and philosophy as to when one system is used over the other.
Some drug distribution needs require unique procedures. An example is filling emergency crash carts. These carts or trays supply medications that are commonly used in emergency situations. Each cart or tray will have a defined list of medications and quantities to be filled and stored. Once these carts/trays are filled and checked by a pharmacist, they are locked and sealed. They can then be delivered to the designated patient care area. These emergency carts/trays are subject to unit inspections, as described later in this chapter.
Pharmacy technicians are often involved in the discharge medication process. Once the decision is made to discharge a patient from the hospital, a series of activities needs to occur, which includes writing prescriptions for medications. This is an important opportunity for the pharmacist to review the discharge medication orders for appropriateness and also to counsel patients on their medications. Some hospitals supply discharge medications directly to patients; pharmacy technicians play a key role in helping with this process.
Clinical Services
Pharmacists began providing patient-focused services, often referred to as clinical pharmacy services, in addition to product services sometime in the 1960s. Examples of such services include pharmacokinetic dosing, infectious disease consultations, drug information, and nutritional support services. The pharmacy profession realized that, in order to achieve optimal outcomes and improve patient satisfaction, it had to be accountable for all patient medication-related needs.
Clinical services were incorporated into a model known as pharmaceutical care. Pharmaceutical care is defined as “the responsible provision of drug therapy to achieve definite outcomes intended to improve a patient’s quality of life.”8 In this model, the pharmacist is an advocate for the patient. Not only are all medication therapy decisions made for the patient’s benefit, but the patient is involved in the decision-making process.
The pharmaceutical care model also allowed for new roles for the technician. Some institutions are now relying on the use of technicians to record laboratory results in the pharmacist’s patient database.2–6 As an example, pharmacy technicians might record the serum creatinine levels for patients who receive certain medications. The pharmacist uses these values to assess kidney function in order to make appropriate recommendations for dosing medications.
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Pharmacy technicians may obtain lab test results for the pharmacist, such as serum creatinine, bacterial cultures and sensitivities, serum drug levels, electrolytes (e.g., potassium and sodium), and other biological markers (e.g., blood cell counts).
Technicians can screen medication orders for nonformulary status or to identify if the medication is on the hospital’s restricted list based on its high cost, high toxicity, or potential for over-prescribing. In such cases, the technicians then notify the pharmacist that there is a need to take action on these types of orders. Technicians can also review and collect missing information for a patient’s database, such as allergies, height, and weight.
Investigational Drug Services
Investigational drug programs are another form of service seen in hospital pharmacies. Investigational drug services are provided by hospitals that participate in clinical trials involving medications. Clinical trials evaluate the efficacy and safety of medications. There are many types of drug studies. For example, a new drug that is not FDA-approved is required to go through a series of clinical trials classified into four phases. Each phase is treated as a separate clinical trial. These phases are designed to determine the efficacy, safety, or dosing requirements before they are approved to be marketed. Other studies involve medications already approved by the FDA that are being studied for efficacy and safety for a new indication or a new dose. Another way of classifying trials is by their purpose—for instance, prevention trials, diagnostic trials, or treatment trials.
Before a study is approved to be conducted in the hospital, a study protocol is developed, reviewed, and approved by the Institutional Review Board (IRB), which often includes pharmacy representation. The protocol is the operating manual for the clinical trial. In order to carry out a successful drug study, there are specific requirements and procedures that must be followed. These include proper storage, record keeping, inventory control, preparation, dispensing, and labeling of all investigational drugs. Technicians may be involved with these procedures under the supervision of the pharmacist. Clinical trials are often conducted at multiple sites and it is important that each site perform the trial in the same way. Following a protocol accurately is an important responsibility because the validity of the research results and the conclusions of the study depend on the accuracy of the dispensing records. As an example, when a patient is enrolled in a study, depending on the study protocol, the patient will be randomized to determine which study treatment the patient will receive (i.e., study drug or placebo). The randomization is commonly done in a double-blind fashion, which means that both the patient and the researchers are unaware of which treatment is being given to prevent bias. Once the patient is randomized to a treatment arm, it is important to follow all protocol procedures for labeling the medication to prevent the researcher or patient from being aware of which treatment is given. All these processes need to be documented accurately as part of the analysis upon completion of the study. The results and recordkeeping of an investigational study can be audited by the FDA to see if they correctly followed the study protocol. In addition, all investigational medications must be stored in a separate section of the pharmacy with limited access and comply with all federal and state requirements.
Medication Management
Medication management involves the entire medication use process, including
selection and procurement of drugs
storage
prescribing
preparation and dispensing
administration
monitoring the effects of the medication
evaluation of the effectiveness of the entire system
All of these processes are so important to the safety and quality of care provided to patients that each of the steps is part of a Joint Commission standard. Following is a brief discussion of each of these components using different scenarios, including you as a patient, to demonstrate what can happen if these steps are not performed accurately and appropriately.
Selection and Procurement
Imagine that you are a patient just admitted to the hospital for a lung infection. Your diagnosis is communityacquired pneumonia, and your doctor orders intravenous levofloxacin, a common antibiotic used to treat this type of infection. However, the hospital does not have this medication in stock. It will take 1–2 days to order it from the wholesaler, place the medication into stock, prepare the medication, and deliver it to the patient care area so you can receive the medication. This is not an ideal situation because treatment is delayed, which could impact your recovery.
To prevent this scenario, hospitals implement policies and procedures that describe the appropriate selection and procurement of drugs so that, when the pharmacy receives a medication order from the prescriber, the pharmacy has the medication available to dispense and administer to the patient.
To guide the pharmacy regarding which drugs to order and keep in stock, the hospital’s Pharmacy and Therapeutics (P&T) Committee establishes a hospital formulary. Formulary medications are approved based on several criteria, such as
indications for use
effectiveness
drug interactions
potential for errors and abuse
adverse effects
cost
Hospitals typically operate with a closed formulary, which means that the list of available drugs is limited. For example, a hospital may have only a few drugs in a specific class of medications. This is in contrast to an open formulary, seen in a community pharmacy, in which most of the common drugs in a therapeutic class are available.
When the pharmacy receives a request by a physician to add a drug to the formulary, a drug monograph is used, containing the information listed above. The P&T Committee will use the information in the monograph to decide whether to add the drug to the formulary. If the formulary already includes other drugs with the same indications for use, the P&T Committee will compare the drugs and decide which drug is the best choice based on efficacy, safety, and cost. In some cases, drugs are removed from the formulary when better drugs become available or when purchasing trends show that a drug is no longer being used. The technician may support the P&T Committee in formulary decisions by providing comparative drug costs or drug usage trends.
Pharmacy technicians play a key role in the procurement of medications. In fact, many pharmacy departments have created a specific position for pharmacy technicians to ensure that the appropriate amounts of medications are ordered to maintain an appropriate inventory. The specific procurement process is based on the hospital’s approved formulary and the department’s policy and procedures (see Chapter 19: Purchasing and Inventory for more detailed information).
In the levofloxacin example above, the hospital may have a different medication on its formulary that would be appropriate for your treatment, and the pharmacist may suggest that the physician prescribe the formulary drug instead of levofloxacin. If the physician thinks that levofloxacin is the best choice for you, however, the hospital will implement procedures to allow for its temporary use as a non-formulary drug. The technician would refer to the specific policy and procedure for how to handle this non-formulary request.
Storage
Let’s return to the example above in which levofloxacin is prescribed to treat your pneumonia. This time the medication is in stock and available to be dispensed and administered. However, the technician identifies that the medication is past its expiration or “beyond use” date. In fact, the medication expired more than one year ago. Again, this is not an ideal situation.
The hospital pharmacy is responsible for the appropriate inspection of all medication storage areas to ensure that the “beyond use” dates of medications have not expired.
The proper storage of medications is critical to the safe use of medications. Though everyone who handles medications should check expiration dates, inspections are primarily performed by pharmacy technicians. All medication storage areas in the hospital are assigned to be inspected at least monthly. These inspections are often referred to as unit inspections. When expired medications are found, they need to be returned or disposed of according to regulatory and legal requirements. Each medication has specific storage requirements from the manufacturer, such as temperature (e.g., room temperature, refrigerated, or frozen) and protection from light. Such special storage requirements for temperature and light ensure stability and potency of the drug product throughout its shelf life.
There are also specific storage and documentation requirements for controlled substances. As this is the most highly regulated class of drugs, the requirements are stringent and based on the abuse and diversion potential. The hospital needs to comply with all legal and regulatory requirements and safeguards. Technicians need to be trained and knowledgeable about these requirements.
Prescribing
Your physician just explained to you that you have pneumonia, and he will be starting you on levofloxacin to treat your infection. He walks out of your room and verbally tells the nurse to start the antibiotic right now. However, since he did not electronically enter or write the order immediately and there was a lot of noise outside of your room at that time, the nurse mishears the name of the medication and administers the wrong drug to you.
This scenario is an example of what can happen without proper policies and procedures for ordering and prescribing medications. Policies and procedures for prescribing medications are created to prevent medication errors and patient harm. Verbal orders are not recommended, but there are times when a verbal order is necessary, such as in the event of an emergency or if the prescriber is off-site and is without access to the patient’s chart. If a verbal order has to be given, there are procedures for carrying out these orders to minimize errors. For example, an authorized professional within his or her scope of practice may accept a verbal order, but the order needs to be reduced to writing immediately and read back to the prescriber to clarify its accuracy. In such cases, the prescriber signs the transcription of the verbal order later to validate it. Every medication order should be clear and concise and contain the drug name, the dose, frequency, and route. It is especially helpful if the indication is on the order as well, to prevent misinterpretation that could lead to a medication error and patient harm.
Prescribers can either initiate an order verbally (as mentioned above), enter the order electronically (i.e., computerized physician order entry [CPOE]), or write the order. All three methods of medication orders require a pharmacist to review the order for appropriateness.
The pharmacist will review each medication order to determine if it is the most appropriate medication for the indication being treated, check for any potential allergies, screen for drug-drug interactions or therapeutic duplications, check correct dose and correct route, and identify any other contraindications. If the order is written, the order has to be manually entered into the pharmacy patient profile system. With electronic order entry, the pharmacist simply verifies the physician’s order, although a product may still need to be selected. The pharmacy system usually has patient safety features like drug-drug or drugallergy interaction alerts, and it is used to print medication labels. Usually, the pharmacy system interfaces with the electronic chart, so that, when medication orders are entered into the pharmacy profile system, the medication order information appears on the Medication Administration Record (MAR), which lets the nurse know when a medication needs to be administered. In some hospitals, the MAR and Patient Medication Profile systems are separate, stand-alone systems. When this is the case, there needs to be an additional verification and reconciliation to assure that the pharmacy patient profile (i.e., what the pharmacy dispenses) matches the nurses MAR (i.e., what the nurse will administer) to avoid any medication errors. Technicians are often involved in transcribing these orders into the patient medication profile. The pharmacist must still review the accuracy of the transcription and review the order for appropriateness before the medication is dispensed and administered to the patient.
If a medication order has missing information or is unclear, the technician must alert the pharmacist, who will get clarification of the order before the patient receives the medication.
