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Every hospital small or big wants to have its own pharmacy to cater to the needs of the out patients. It is also one of the revenues generating centres of the hospital and at the same time one of the critical areas for hospital administrator as well, from the point of view of pilferages, theft, procurement methods of medicines. The name and fame of the hospital and hospital administrator is also tagged with the quality of medicines, being procured in the hospital pharmacy. A good pharmacy is a blend of several things: technical manpower, equipment’s, efficient organization, sound budgeting, transparency in procurement of drugs and cooperation of medical, nursing and administrative staff of the hospital.
Pharmacy (from the Greek = drug) is the health profession that links the health sciences with the chemical sciences, and it is charged with ensuring the safe use of medication. The scope of pharmacy practice includes more traditional roles such as compounding and dispensing medications, and it also includes more modern services related to patient care, including clinical services, reviewing medications for safety and efficacy, and providing drug information. The Philadelphia College of Pharmacy and Science was founded in 1821, the first school of its kind in the United States. The American Pharmaceutical Association was formed in 1851.
In the field of pharmacy, the first drug stores were opened by Muslim pharmacists in Baghdad in 754, while the first apothecary shops were also founded by Muslim practitioners. The advances made in the Middle East by Muslim chemists in botany and chemistry led Muslim physicians to substantially develop pharmacology.
In ancient Japan, the men who fulfilled roles similar to those of modern pharmacists were highly respected. The place of pharmacists in society was expressly defined in the Taiho Code (701) and restated in the Yoro Code (718). Ranked positions in the pre-Heian Imperial court were established; and this organizational structure remained largely intact until the Meiji Restoration (1868).
Drugs are the most important component of therapy, common to both the outpatients as well as inpatients for the treatment of diseases in a hospital. Functions of the pharmacy department in a hospital are as follows.
The dispensing pharmacy stocks and dispenses drugs manufactured by various pharmaceutical manufacturers under generic and trade names as per the prescriptions issued by qualified registered medical practitioners.
They are manufacturers of drugs according to “National Pharmacopeia”, a work containing monographs of therapeutic agents and standards set for their strength, purity, and formulations. Generally, large hospital pharmacies deliver combined services of both manufacturing and dispensing of drugs.
The outpatient pharmacy is the dispensing unit of medicines to outpatients during normal outpatient clinic working hours. It is located in the outpatient service area with the following facilities:
The inpatient pharmacy is the dispensing unit of medicines, infusion and minor surgical accessories to inpatients round the clock. Facilities provided are as same as outpatient pharmacy. The manufacturing unit and the office of the head of pharmacy are normally located adjacent to inpatient.
Procedures include checking of drugs and other materials on delivery; storing of disinfectants and poisons; checking prescriptions for patients’ possible allergies; and weighing and measuring prescribed drug quantities. They include replenishing ward drug inventories, filling prescriptions, preparing sterile solutions, and disposing of outdated drugs.
Rules include drugs are to be dispensed only on physicians’ or other authorized person’s original written prescription; dangerous drugs should be stored separately in containers labelled distinctly; liquids are to be poured from container with label facing upwards; pre-packaged drugs are only to be removed by authorized persons when pharmacist is unavailable; Containers which are damaged, have no label or worn, illegible or make-shift label should be destroyed.
Hospital formulary is an official list of drugs approved for prescribing or administration to patients of a hospital or to beneficiaries of a health insurance program. The drug list should be expanded to include recommended daily dosage and cautions, warnings, restrictions, pharmacology and similar other information to facilitate correct use of the drugs. This formulary should be updated frequently.
Various types of the pharmacy services prevalent can be classified as follows:
a. The OPD patients
b. The inpatients
c. Combination of the above two
d. Dispensing of the medicines to the outside patients in addition to the above categories.
Because of the complexity of medications including specific indications, effectiveness of treatment regimens, safety of medications (i.e., drug interactions) and patient compliance issues (in the hospital and at home) many pharmacists practicing in hospitals gain more education and training after pharmacy school through a pharmacy practice residency and sometimes followed by another residency in a specific area. Hospital pharmacies can usually be found within the premises of the hospital.
12. Veterinary pharmacy: These are specifically for the animal use and all veterinary hospitals and clinics of veterinary doctors own such pharmacies.
13. Clinical pharmacy: Clinical pharmacists provide direct patient care services that optimizes the use of medication and promotes health, wellness, and disease prevention. Clinical pharmacists care for patients in all health care settings but the clinical pharmacy movement initially began inside hospitals and clinics.
14. Compounding pharmacy: Compounding is the practice of preparing drugs in new forms. If the drug is not palatable, to make it palatable, is an example of compounding.
15. Consultant pharmacy: Consultant pharmacy practice focuses more on medication regimen review (i.e., “cognitive services”) than on actual dispensing of drugs. Consultant pharmacists most typically work in nursing homes, but are increasingly branching into other institutions and non-institutional settings.
16. Military pharmacy: Military pharmacy is an entirely different working environment due to the fact that technicians perform most duties that in a civilian sector would be illegal. State laws of technician patient counselling and medication checking by a pharmacist do not apply.
17. Nuclear pharmacy: nuclear pharmacy focuses on preparing radioactive materials for diagnostic tests and for treating certain diseases. Nuclear pharmacists undergo additional training specific to handling radioactive materials, and unlike in community and hospital pharmacies, nuclear pharmacists typically do not interact directly with patients.
18. Internet pharmacy: Since about the year 2000, a growing number of Internet pharmacies have been established worldwide. Many of these pharmacies are similar to community pharmacies, and in fact, many of them are actually operated by brick-and-mortar community pharmacies that serve consumers online and those that walk in their door. The primary difference is the method by which the medications are requested and received.
a. Flow of OPD traffic.
b. Flow of drugs to and fro pharmacy.
c. Need of future expansion.
d. Accessibility to patients and hospital staff to reduce travel time.
The floor area of pharmacy depends upon the size and the type of the hospital and also upon the hospital’s policy regarding drug dispensing and drug distribution.
| No of beds | Floor area |
| 100 | 10 sq. feet/bed |
| 200 | 6 sq. feet/bed |
| >200beds | 4 to 5 sq. feet/bed |
2. Design: There is no set pattern of design, every hospital will have their own pattern but the design will centre on the following areas:
a. Dispensing area
b. Preparation area
c. Administrative area
d. Storage area
a. Dispensing area: It will include:
i. Patient’s waiting area
ii. Dispensing counters, sufficient in number, separate for males, females, senior citizen and handicapped patients.
iii. Adequate storage area for keeping drugs.
iv. Platform for writing and recording orders.
v. Compounding area of drugs.
vi. Separate provision for storage of narcotic drugs under lock and key.
vi. Storage area for cold temperature devices like refrigerator, ice line refrigerator (ILR) for vaccines walks in refrigerator or cold room storage.
vii. Storage for volatile materials like rectified spirit.
viii. Room for pharmacist and record room of pharmacy for keeping various ledgers and indent files.
b. Preparation area: This area will include:
i. Bulk compounding area.
ii. Packaging and labelling of drug area.
iii. Clinical sinks and hand washing facilities like wash basins.
c. Administrative area: The area will include:
i. Reception of pharmacy.
ii. Secretary’s office.
iii. Chief pharmacist’s room.
iv. Waiting area for visitors, representatives, etc.
v.Conference room.
vi. Facilities like change room, lockers, toilet, duty room, lounge, etc.
d. Storage area: This area will consist of:
i. Storage
ii. Sub stores
iii. Refrigerated storage areas
iv. Storage used for narcotic drugs
vi. Storage used for forms, ledger and stationery.
4. Floors: The floors should be resilient, smooth, easily cleaned and acid resistant.
5. Wall: The surface should be smooth, painted with washable paints and of light colours.
The Staffing will depend upon the size and type of the hospital. It will also depend upon the number of items, to be served per patient; Hospitals having up to 200 beds need to have a head pharmacist. Hospital having more than 200 beds should employ a chief pharmacist and an assistant pharmacist. The study group 1968 has recommended the following criteria:
| Bed compliment | No of Pharmacists |
| Up to 50 | 3 |
| Up to 100 | 5 |
| Up to 200 | 8 |
| Up to 300 | 10 |
| Up to 400 | 15 |
Recommended staff for a teaching hospital of 750 bed capacity as follows:
| SI No. | Staff | No. |
| 1 | Chief pharmacist | 1 |
| 2 | Manufacturing pharmacist | 1 |
| 3 | Assistant chief pharmacist | 1 |
| 4 | Technical assistant, Pharmacy | 3 |
| 5 | Head Pharmacist | 2 |
| 6 | Pharmacists | 10 |
| Total 18 | ||
This will include:
There is a need to have a hospital formally for each hospital and if possible, for each organization. There is tremendous pressure from the pharmaceutical industries to prescribe new and costly drugs to patients; sometimes even the drugs are in the trial phase or the physician themselves participating in the clinical trials, sponsored by the pharmaceutical companies. To reduce the variety particularly the proprietary drugs; what happens the same medicine is prescribed by different names by different doctors and the list of medicine is enlarged; the problems are faced in procurement as well as the inventory control of such drugs. So, there is dire need of the hospital formulary also to check the indiscriminate use of the antibiotics.
A formulary is nothing but the formal compilation of the list of the drug to be used in a hospital. To develop a formulary, a formulary committee is appointed; this committee will have:
Scheduling doses, setting infusion rates, and using TV infusion equipment are important aspects of the drug use process. There is constantly changing array of drugs with increasing potency and specificity. Drug administration is usually the responsibility of nursing services. Pharmacy, however, should be involved in all aspects of policy and procedure development related to drug administration.
Apart from the traditional pharmacy system, the developed one is called unit dose dispensing system. In the traditional pharmacy system, the pharmacy sends to each patient in the ward, a supply of medication, which may be for several days. The nursing staff then prepares the individual dose from the supply. In the unit dose system, the doses are premeasured by the pharmacy so that the nurse has only to administer the medication. The system uses a cassette mechanism, which designates one drawer for each patient in the medication cart or cabinet. The nurse rolls the unit dose cart to each individual patient room, removes the dose of medication to be given from the respective patient drawer in the cart, and administers it to the patient. It reduces nursing time for pouring, counting and dispensing. Reduces medication errors, and increases control and recording of medications by the pharmacy.
The concept of unit dose system can be extended to intravenous solutions, for which there are two methods:
The activity relates to mixing of medications with IV solutions. In the traditional system, IV solutions are stocked in the nursing unit. Medications are sent to the unit by the pharmacy, and the nurse mixes or adds medications to the IV solution. In the additive system. The medications and the IV solutions are mixed in the pharmacy itself. The premixed bottles are then sent to the nursing unit and the nurse merely administers the solution. As in the case of unit dose system, the advantages are reduction in nurses’ time as well as in wastage and medication errors.
The quality and efficiency of pharmacy services has a great bearing on the patient care process and its results and, therefore, on the level of satisfaction of patients. Any improvement would require a continuous control and evaluation on the basis of certain predetermined criteria which should be relevant, measurable and understandable such as given below. The therapeutic committee can be given the task of periodic evaluation against the criteria, detecting the deficiencies and recommending the corrective measures which can be implemented and reviewed periodically for effectiveness.
The factors contributing to the quality of medicine Identity of the product by the right name and are:
The information on any drug should give its nature, indications, contraindications, side-effects, precautions, formulation and dosage, duration of treatment and other information, in addition to its pharmacology, pharmacokinetics and bio availability by routes of administration. Information regarding incompatibility, drug interactions, and advisability of administration during pregnancy, childhood and old age, and in renal, hepatic and other diseases should be available. Books and journals on legislation and regulations of drugs should be available.
Prescription means a written formula for the preparation and administration of any remedy consisting of the following four parts:
The prescription should bear the name, sex, age and hospital number of the patient to identify him properly. The prescription should be written legibly and duly signed by the prescribing physician with his register number, date and name.
Modern hospitals are equipped with computerized Local Area Network and terminals are provided in medical records, cash counters, admitting office, laboratory, radiology, billing section, pharmacy, physician’s cubicles, and nursing units, etc. when a prescription is entered in the relevant module, it is received at the pharmacy terminal. The patient collects his medicines by producing his identity and proof for payment. In case of chronic patients the drugs are repeated by refill mechanism where the pharmacist dispenses medicines on the basis of previous instructions by the physicians.
Shortages
Shortages are always possible due to human counting errors especially in loose tablets and capsules. This can be avoided by counterchecking before each delivery and keeping recounted, checked, and packed fast moving drugs in specified packs.
Managing Short Supplies
Short supply means incoming stocks are not sufficient to meet the demands. This may be due to:
| Department | Relationship |
| Physicians | Dealing prescriptions, pharmacy & therapeutics committee. |
| Nurses | Administration of drugs |
| Engineering | Maintenance of refrigerators |
| Central stores | Indenting, purchase & supplies |
| Security services | Safety & loss prevention |
| Medical records | Verification & counterchecks with prescriptions & audits |
Computers can be used to support all aspects of the drug use process. Some examples of common computer applications in pharmacy are:
Hospital pharmacy services play a crucial role in the process of patient care because drugs form the most vital component of therapy of every patient. Satisfaction of patients, therefore, depends a lot on the performance of pharmacy services. It is also important from the financial point of view as nearly a third of the total operating budget is spent on pharmacy and huge funds are locked up in maintaining the inventory. Inefficiency in the form of date expiry, redundancy, pilferage, stock outs, and unwise purchases can cause serious (avoidable) losses. In addition, it can also cause dissatisfaction of patients due to delayed recovery (because of dubious quality drugs) and long waiting lines at the pharmacy counters. An efficiently managed service on the other hand not only promotes patient satisfaction but can also be a source of generating revenues by stopping the losses. It is, therefore, of utmost importance that a program of quality management and continuous monitoring be implemented in every hospital for continuous improvement of quality of pharmacy services.
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