ACTIVITY 5 6.
DRUG-DISPENSING SYSTEMS IN HOSPITALS
Drugs are one of the main tools of medical therapy and are a significant part of hospital budgets. Implementing safe, organized, and efficient drug-dispensing systems is essential for controlling costs and assuring that the medical prescription is safely followed as requested within the appropriate deadline. An appropriate dispensing system is an important ally for the prevention or reduction of medication errors by helping to minimize dispensing dispensin g error opportunities in a pharmacy. At present there are various types of dispensing systems for medical prescriptions within a hospital. The first studies on the organization of such systems, specifically their relationship with medication errors, were published in the mid-sities. These studies mostly performed in the !nited "tates of America were intensified during the #$%&s and #$'&s, aiming to provide safer dispensing systems. Investigation in this area in (razil was started during the#$$&s and is still not numerically significant. Collective System
The collective system, also )nown as the traditional system, is the oldest and most obsolete. In this system, drug-related actions are centered on nursing professionals, and the pharmacy is merely a drug delivery agent. This system has many facilitating conditions for errors. It is characterized by the distribution of drugs per hospital unit*service based on a request by a nurse. It implies the establishment of inventory in these units under the nurse+s supervision.#,#% It is estimated that nurses spend about / of their time transcribing prescriptions, chec)ing inventory, filling requests, and transporting and se parating drugs in the various units. Institutional costs are high due to losses by theft, inadequate storage, and drug epiration. #%,#' The advantages of this system are that drugs are readily available at the units, there are fewer requests to the pharmacy, with a corresponding reduction in pharmacy epenses related to human resources and materials. These advantages become obstacles for improved pharmaceutical service to patients.#% A negative consequence is a high rate of medication errors, the most common being giving twice the dosage, giving the wrong drug, inappropriate dose and administration routes, and giving non-prescribed drugs. A further disadvantage is inefficient stoc) control and increased epenses related to drugs. #,#',#$
According to the first pharmacy assessment in (razil in &&, #./ of hospital pharmacies use the collective drug-dispensing system.& Individ!li"ed System
In the individualized drug-dispensing system, the pharmacy and pharmacists participate more actively on drug-use issues0 however, nursing participation and error rates are still high. In this system, drugs are dispensed per patient, usually for a 1-hour treatment period. The pharmacy dispenses drugs separately per patient, according to the medical prescription, to the hospital units. #,#% In (razil, 21.'/ of hospitals use this drug-dispensing system for in-hospital patients.& This system may be described as indirect, where drug dispensing is based on a transcription of the medical prescription made by n urses, or direct, where dispensing is based on a copy of the medical prescription 3made daily4. The indirect system has a high rate of errors and theft, as failure and omission may ta)e place during transcription and items not present in the original prescription may be added. In the direct system, the prescription may be forwarded to the pharmacy as follows#%5 a4 the prescription is written over carbon paper to produce a copy of the original. 6oor quality carbon paper or inadequate pens may result in prescription copies that are difficult to read0 b4 photocopy to reproduce the original prescription0 c4 fa from the hospital unit to the pharmacy. This method may generate illegible documents, opening the door for new sources of medication errors and allowing loss of information with time0 d4 the physician writes the prescription on computer terminals in the hospital unit and sends it electronically to the pharmacy. The main advantage is the elimination errors due to poor handwriting. 7owever, other types of errors may appear, such as printing the prescription made the previous day or not saving changes, resulting in wrong prescriptions. Also the prescriptions of or more patients may be accidentally echanged0 e4 computerized prescription5 using clinical management software interconnecting the various hospital units. The prescription and the dispensing report are made in the system that may be integrated with pharmacology and inventory control software. 6rofessionals access system data directly with no need to send files.
There are also safety systems that warn against toic doses, allergic and crossreactions, drug interactions, duplication of therapeutic classes, contraindications, and adverse effects. Automation using bar codes allows drugs to be chec)ed when dispensing and administering the drug0 f4 radio system interconnecting computers and optic readers5 the physician uses a small electronic pen-operated or touch-sensitive terminal, allowing immediate chec)ing of patient data, rapid prescription 3at the bedside4, and fewer computers in hospital units. The individualized drug-dispensing system has advantages, such as the possibility of reviewing medical prescriptions, increased control over drug use, less inventory in hospital units, reduced theft and losses, and individual patient invoicing. The disadvantages are the high rates of dispensing and delivery errors that still eist, the time spent by nurses calculating and preparing drug doses, increased epense regarding human resources and materials, and high losses due to theft and inadequate drug delivery.#,#% !sually, the pharmacy is present in hospital units. 6harmacy assistants replenish emergency stoc)s daily, collect prescriptions for the day, collect drugs returned from the previous day, and send drugs for the following 1 hours of treatment. 8n a monthly basis they also chec) drug validity in the inventory and unauthorized inventory. 6harmacists visit hospital units daily to supervise wor) done by their assistants. They also help nurses clarify doubts related to drug delivery and stability as well as storage and use of heat-sensitive and photo-sensitive drugs. 6harmacists also discuss prescription issues with physicians. In hospitals with adequate human resources allied to professional and institutional interests, pharmacists develop clinical activities with the professional health team to reduce medication errors. Mi#ed System
The mied dispensing system combines the collective and the individualized systems and is also used in (razilian hospitals. 7ospital units are supported partially or completely by the individualized systems, and specific units 3radiology, endoscopy, emergency, outpatient department, among others4 are supported by the collective system.#% The mied system is used by #2./ of (razilian hospitals for dispensing drugs.& The main disadvantage of the mied system is a trend towards the collective rather than the individualized system, favoring drug dispensing by hospital unit rather than per patient dispensing. It is easier to dispense drugs by hospital unit instead of separating and pac)aging items for each patient. 6harmacy staff should be made
aware of the importance of their wor) and that collective dispensing is easier but not as safe. Unit dose system
Drug administration in hospitals may involve & to 2& steps from prescription to delivery and monitoring. During the past & years, little has changed in this process ecept for the development and implementation of the unit dose drug-dispensing system.# The high rate of medication errors in hospitals reported in many 9orth-American studies towards the end of the #$&s, demonstrated the need to review traditional dispensing systems to improve safety in drug dispensing and delivery. In #$&, 9orth-American hospital pharmacists belonging to a multidisciplinary group developed the unit dose system, aiming to reduce medication error rates, drug costs, losses and theft, and to improve the productivity of health professionals and the quality of health care. This system consists of ordered drug dispensing with doses ready for delivery according to the patient+s medical prescription. :very drug, in all pharmaceutical forms, is dispensed ready-to-use with no need for prior transference, calculation, and handling by nurses. 8nly drugs used in emergencies are stored in hospital units, together with the necessary doses for the net 1 hours of treatment of patients.#,#% The system has the following advantages5 drug identification right up to the moment of delivery0 lower medication error rates0 less nursing time spent on drug handling, increased nurse availability for patient care0 less inventory in units, with decreased losses0 optimizing the return of unused drugs0 better hospital infection control through the practice of aseptic techniques in the preparation of drug doses0 increased adaptability for automation0 increased precision in invoicing drug use per patient0 increased assurance for physicians that the prescription will be administered0 effective pharmacist participation in defining drug therapy0 improved control over the pattern and time of drug delivery0 less space used to )eep drugs in hospital units0 and improved patient assistance. The disadvantages are resistance by nurses to the system, the need for etra staff and pharmacy infrastructure, the need to acquire specific equipment, and a high initial financial investment.#,#%;urthermore, pharmacists need to be trained to prepare parenteral drugs, )nowledge not imparted by the ma
ACTIVITY 6
or epor tADRs? 3. Howt Local Case Report Forms (CRF) should be obtained rom the !ational "ru# Re#ulator$ Authorit$. %ome countries ha&e included CRF in their !ational Formularies ('ritish !ational Formular$ Formularies o %outh Arica imbab*e etc.). There are di+erent Case Report Forms in di+erent countries. 'ut all o them ha&e at least our sections *hich should be completed, -. atient inormation, / patient identi0er / a#e at time o e&ent or date o birth / #ender / *ei#ht 1. Ad&erse e&ent or product problem, / description o e&ent or problem / date o e&ent / date o this report / rele&ant tests2laborator$ data (i a&ailable) / other rele&ant patient inormation2histor$ / outcomes attributed to ad&erse e&ent 3. %uspected medication (s), / name (I!! and brand name) / dose reuenc$ 4 route used / therap$ date / dia#nosis or use / e&ent abated ater use stopped or dose reduced / batch number / epiration date / e&ent reappeared ater reintroduction o the treatment / concomitant medical products and therap$ dates 6. Reporter, / name address and telephone number / specialit$ and occupation The completed Case Report Form should be sent to the national or re#ional A"R centre or to the manuacturer o the suspected product.
Addresses o !ational "ru# Re#ulator$ Authorities and other useul inormation can be ound on the 7ebsite o the 789 Collaboratin# Centre or International "ru# :onitorin# (***.*ho/umc.or#) or reuested rom this Centre b$ e/mail, ino;*ho/ umc.or#< b$ Fa, =6> -? >5 >@ ?@ or b$ Tel., =6> -? >5 >@ >@. 4.
How LongMus taHeal t hCar ePr ovi derKeepaPat i ent ' sMedi calRecor ds?
Ge ne r a l l y ,apr o v i de rmus tr e t ai napat i e nt ' sme di c alr e c or dsf o rs e v e ny e ar sa f t e rt he
Depar t mentofPubl i c l as tt r e at me ntdat e ,o rt hr e ey ear sf r o mt hepat i e nt ' sde at h.( Heal t h( DPH)Regs.§19a1442) . ACTIVITY -. Roles and Responsibilities Many of the responding P&TCs’ terms of reference indicated roles and responsibilities that are much broader than those related to establishing and maintaining a drug formulary listing, including but not limited to the following: •
evaluating safe, effective, ethical, and fiscally responsible drug use
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acting in an advisory capacity on all drug, as well as nutritional product use
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developing clinical guidelines and decision support tools relating to appropriate drug use providing educational activities for all health care professionals involved in the medication use process (ie, prescribing, distribution, administration!
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preparing drug budget impact analyses
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developing criteria for use, treatment guidelines, and standardi"ed orders
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reviewing adverse drug reactions and formulating recurrence prevention strategies
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establishing drug#use evaluation programs and conducting medication audits t o optimi"e drug use having direct lin$ages to the provincial Ministry of %ealth for sharing information of mutual interest, and coordinating drug#related planning andor prioriti"ing establishing subcommittees to address specialty practice areas (eg, pediatrics, oncology, anti#infectives! wor$ing with other provincial organi"ations that may fund specific drugs in order to e'pedite and coordinate formulary status
Functions and Scope of PTC
A. To serve in an evaluative, educational, and advisory capacity to the medical staff and organiztional administration in all matters pertaining to the use of drugs. B. To develop a formulary of drugs accepted for use in the organization and provide for its constant revision. C. To establish programs and procedures that help ensure safe and effective drug therapy. D. To establish programs and procedures that help ensure cost – effective drug therapy. E. To establish or plan suitable educational programs for the organizations professional staff on matters related to drug use. !. To participate in "uality assurance activities related to distribution, administration, and use of medications. #. To monitor and evaluate AD$s in the health – care setting and to ma%e appropriate recommendations to prevent their occurrence &. To initiate or direct 'or both( drug use evaluation program and studies, revie) the results of such activities, and ma%e appropriate recommendations to optimize drug use. *. To advise the pharmacy department in the implementation of effective drug distribution and control procedures. +. To disseminate information on its actions and approved recommendations to all organizational health – care staff.
2. How often does the Committee review medications?
The -T Committee meets "uarterly to revie) ne) drugs that have recently been approved by the !DA as )ell as drugs that have been !DA approved for ne) medical conditions.
The committee should meet on a regular basis to discuss the rapidly changing drug products and medical literature.
!re"uency /onthly meeting.
0ength 12342 minutes.
5ote /inimum 62 meetings7year.
3. Responsibilities, -. Formular$ s$stem maintenance,
"e&elop list o medications or use. Buidelines or optimal use o medications. Re&ie* list 4 #uidelines on re#ular basis. 1. :edication selection and re&ie*, :edication selection criteria should be set and should include medication ecac$ saet$ and cost. 3. :edication Dse E&aluation, E.#. o&eruse o antibiotics
resistant inections and increased cost.
Appro&e dru#s to be ept under restriction. 6. :edication %aet$ E&aluation, Ad&erse dru# reaction reports. :edication error reports. Re&ie* dru# inter&ention reports. 5. "ru# Therap$ Buidelines, E&aluates optimal use o dru#s e.#. dosa#e reuenc$ patient selection len#th o therap$ and combination. Buidelines should be updated routinel$. >. olic$ 4 rocedure "e&elopment, :edication procurement selection and distribution. :edication or speci0c settin#s e.#. ICD. "e&elop policies e.#. automatic stop order dru# recall.
Responsibilities,
. Education, !e*sletter is oten emplo$ed to communicate the committee decisions. !e*sletter includes the ollo*in#, Clinical inormation on dru#s added to ormular$. "ru# therap$ #uidelines de&eloped.
:edication saet$ inormation. ACTIVITY ? 1. GFormular$G "esi#nation 9nl$ those dru#s appro&ed b$ the harmac$ and Therapeutics Committee on the basis o saet$ ecac$ and cost to be most ad&anta#eous in patient care shall be desi#nated as ormular$ dru#s. These dru#s are listed in the ormular$< onl$ ormular$ dru#s are routinel$ stoced and a&ailable rom the pharmac$. 9nl$ those dru#s that ha&e been appro&ed b$ the Food and "ru# Administration (F"A) shall be considered or ormular$ addition. Thereore in&esti#ational dru#s do not meet criteria or ormular$ addition. "ru#s are included in the ormular$ b$ their #eneric names e&en thou#h trade names ma$ be in common use in the hospital. h$sicians are stron#l$ encoura#ed to prescribe dru#s b$ their #eneric names. The "epartment o harmac$ is responsible or selectin# rom a&ailable #eneric eui&alents those dru#s to be dispensed pursuant to a ph$sicianHs order or a particular dru# product. Benerall$ this choice is consistent *ith competiti&e bids a*arded b$ the Dni&ersit$ 8ospitals #roup purchasin# or#aniJation (!o&ation) 8. Selection of Guiding Principles for Admission or Deletion of Drugs Criteria: 6. Drugs must be of proven clinical value based upon e9perience. :.
The drugs must be recognized by ;<75! or their supplement.
=. The manufacturers of these drugs must be of proven integrity and dependability as )ell as having the regulation of initiating and supporting research activities of merits. >.
5o preparation of secret composition )ill be considered or admitted to the formulary.
8. 5o product of multiple composition shall be admitted if the same therapeutic value can be obtained through the use of a single drug entity.
o r mu l a r yc anc o nt a i nb ot hna me b r a ndan dg en er i cdr u gs .Pa t i e nt spa yc opa y son >. Af f or mul ar ydr ugs .I fadr ugi snotont hel i s t ,t hepat i entwi l l paymuc hmor e,upt ot hef ul l c os toft hedr ug.Ev er yheal t hc ar epl anhasadi ff er entl i s tofac c ept abl edr ugsandc opa ypr i c es . Si nc ei ti si mpos si bl et os t oc kev er yt y peofmedi c i nef orev er ydi s eas e,hos pi t al scr eat e f or mul ar i esl i s t i ngt hedr ugst heyk eepi nhous e.I ti spos si bl ef orahos pi t al t oobt ai nnonf or mul ar ydr ugsb yor der i ngt hem f r om anei ghbor i nghos pi t al orphar mac y . . !ormularies cover all the categories of medications that patients need. The list is constantly being revised and updated to ma%e sure patients receive the appropriate medication. !or e9ample, before a medication is added to or deleted from the formulary, teams of pharmacists, physicians, and other healthcare professionals in the hospital evaluate the drug products to ma%e sure that they are safe, )or% )ell, and are cost3 effective. The hilippine !ational "ru# Formular$ (!"F) is an inte#ral component o the hilippine :edicines olic$ *hich aims to mae ualit$ essential dru#s a&ailable accessible ecacious sae and a+ordable The !"F (Volume I) is the Essential :edicines List (E"L)or the hilippines prepared b$ the !ational Formular$ Committee (!FC) in consultation *ith eperts and specialists rom or#aniJed proessional medical societies medical academe and the pharmaceutical industr$. List o essential medicines that are re#istered *ith Food and "ru# Administration (F"A) ACTIVITY K I .Set upandequi pment Thec ent eri sequi ppedwi t hc omput ert er mi nal s ,pr i nt edmat er i al s( c ur r ent ,per i odi c al s ,bound j our nal v ol umes ,r ef er enc et ex t s )andhasac c es st oMedl i ne,t heI nt er netandv ar i ousot her onl i nedr ugandmedi c al r ef er enc es . Thec ent ermai nt ai nss ubs cr i pt i onst onat i onal l yr ec ogni z edj our nal sandt e xt sofPhar mac yand Me di c i n e. Di r e c ta c c es st oc omp ut e r i z e do nl i n ed at as ea r c h i n g,CDROM d at a ba s esa ndt h eWo r l dWi d e Webar eal s oav ai l abl e. ( T abl e1)
1. ro&idin# "I to patients care#i&ers and health care proessionals K 1. Creatin# a &ariet$ o educational resources or patients (e.#. tip sheets or pamphlets) -@ and health care proessionals (e.#. inser&ices) on topics such as optimal medication use -- #eneral health or select clinical uestions -1 3. "e&elopin# and educatin# health care proessionals on sae and e+ecti&e medication/
-3 use policies and2or processes -6 6. Leadin# or participatin# in continuin# education ser&ices or health care proessional -5 sta+ -> 5. receptin# and educatin# pharmac$ students and residents - >. articipatin# in ualit$ impro&ement research proects
-. ro&idin# inormation *hen there is not sucient time or the health care proessional to appropriatel$ research the "I uestion *hen there is a no*led#e #ap or *hen the uestion reuires more specialiJed "I resources 1. Establishin# and maintainin# a ormular$ based on scienti0c e&idence o ecac$ and saet$ pharmacoeconomics and institution/speci0c actors 3. Coordinatin# pro#rams to support population/based medication practices (e.#. de&elopment o pharmacotherapeutic #uidelines and medication use e&aluation criteria) 6. "e&elopin# and participatin# in e+orts to pre&ent medication misad&entures includin# > ad&erse dru# e&ent ensurin# institutional compliance to Ris E&aluation and :iti#ation %trate#ies (RE:%) and medication error reportin# and anal$sis pro#rams 5. Collectin# and appl$in# health economic and outcome anal$ses >. Coordinatin# in&esti#ational dru# ser&ices . :ana#in# dru# shorta#es includin# identi$in# alternati&e treatments de&elopin# protocols or restricti&e use and mana#in# ormular$ concernsKa ?. "e&elopin# clinical decision support tools such as order sets dosin# protocols and order/entr$ alerts
K. :aintainin# "I and medication use polic$ related intranet resources -@. receptin# or pro&idin# ad&anced "I education and trainin# to students and residents --. Coordinatin# purchase and selection o pharmac$ and institution/*ide "I resources -1. articipatin# in &arious ee/or/ser&ice proects
ACTIVITY -@ 3. To achie&e these obecti&es the Catalo# is di&ided into the si 9utcomes or impro&ement identi0ed b$ the Institute o :edicine in the report Crossin# the Mualit$ Chasm, A !e* 8ealth %$stem or the 1-st Centur$, %aet$ N a&oidin# inuries to patients rom the care that is intended to help them E+ecti&eness N pro&idin# ser&ices based on scienti0c no*led#e to all *ho could bene0t and rerainin# rom pro&idin# ser&ices to those not liel$ to bene0t atient/Centeredness N pro&idin# care that is respectul o and responsi&e to indi&idual patient preerences needs and &alues and ensurin# that patient &alues #uide all clinical decisions Timeliness N reducin# *aits and sometimes harmul dela$s or both those *ho recei&e and those *ho #i&e care Ecienc$ N a&oidin# *aste includin# *aste o euipment supplies ideas and ener#$ Euitableness N pro&idin# care that does not &ar$ in ualit$ because o personal characteristics such as #ender ethnicit$ #eo#raphic location and socioeconomic status
