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Pharmacy Practice48
much, additional personnel may be employed. This system will
be saved. Moreover this system has additional advantage that
the director or chief pharmacist can exert a great degree of
control and supervision on the activities of the department.
Inpatient department can be located on the ground floor or
first floor of the building but it should be near the outpatient
department and centrally located so that the staff can easily
reach there. The inpatient dispensing should be carried out by
a pharmacist helped by skilled and qualified staff.
Inpatient pharmacy is a multifunction department for
storage, dispensing manufacturing of IV fluids, parenteral,
etc. In recent years, there is a tendency to operate satellite
pharmacies either at the level of wards or on the basis of floors.
This is a case of decentralized service.
Since in the inpatient department a great deal of nursing
time is consumed by the frequent trips to the pharmacy to
obtain drugs and supplies, it is appropriate and ad visible that
hospital pharmacist must assume the responsibility for
medications from the time of their selection to the time of their
administration. Drugs on nursing stations can be classified into
two categories.
There are four systems for inpatient drug distribution
department:
1. Individual prescription order system
2. Complete floor stock system
3. Combinations of individual prescription order and floor
stock system
4. Unit dose dispensing method.
1.1.
1.1.
1.
Individual PIndividual P
Individual PIndividual P
Individual P
rescription Order Systemrescription Order System
rescription Order Systemrescription Order System
rescription Order System
This system is generally used in small and /or private hospitals
because of its economics consideration and reduced manpower
requirements. This system has the following advantages:
1. All the medicament orders are directly reviewed by the
pharmacist so that there are fewer chances of medication
errors.
2. It provides closer liaison among pharmacist, physician,
nurse and the patient in the medication matters.
3. It provides closer control of inventory.
Drug Distribution System in Hospital 49
4. This system has certain disadvantages.
5. There may be possible delay in obtaining the required
medications for administration to the patient.
6. Increase in the cost to the patient.
2.2.
2.2.
2.
The Complete Floor Stock SystemThe Complete Floor Stock System
The Complete Floor Stock SystemThe Complete Floor Stock System
The Complete Floor Stock System
Under this system the nursing station carries both “charge”
and “non-charge” patient medication. According to this system
the drugs are stored at the nursing station and are administered
by a nurse according to the chart order of the physician. Only
the commonly used drugs in considerable quantities are
stocked on the floor stock or in the ward (warm stock). Rarely
used for costly drugs are not included in the floor stock but
dispensed when the order is received for the individual
patients. Mainly this system is used in hospitals where the
charges are not made to patients.
Since these drugs are used in large quantities, they are pre-
packed in standard containers. Nursing staff from each floor
or ward sends their written demands of drugs according to
the list provided to each floor and ward, daily to the hospital
pharmacy herself or through a messenger and collects the
medicines from the pharmacist. This system has the following
advantages:
1. The drugs are readily available for administration.
2. Minimum return of drugs.
3. Reduced inpatient prescription orders.
4. Reduction in the number of pharmacy personal required.
The disadvantages of this system include:
1. Increase in chance of medication errors due to lack of
review by pharmacist.
2. Greater opportunity for misuse of drugs resulting in
financial loss.
3. Increase in drug inventory.
4. Increased chances of drug deterioration due to lack of
proper storage facilities.
5. Increased chances of drug deterioration due to unnoticed
drug degradation.
6. Increased workload on nurses due to medication
activities.
Pharmacy Practice50
The drugs on the nursing station are known as floor stock
drugs. They are classified into two parts:
1. Charge floor stock drugs, and
2. Non-charge floor stock drugs.
i. Dispensing of charge floor stock drugs
1. Charge floor stock drugs are those for which the patient
is charged for every single dose administered to him.
Selections of these drugs in various wards are decided by
“Pharmacy and therapeutics committee.
2. Once the floor stock list is prepared, it becomes the
responsibility of the hospital pharmacist to make the
drugs available.
3. Charge floor stock drugs stored at various nursing
stations.
4. The patients are charged mostly because of the high cost
of such drugs. Such drugs include injections or other
unit’s dosage forms.
5. An envelope is used to dispense such drugs at nursing
stations.
6. Under this system, pre-labeled envelopes are filled with
predetermine quality of specific drugs and are placed at
the disposal of the nursing unit.
7. When the drug is administrated, the patient name and
room number is entered on the envelope and sent to
pharmacy for record.
ii. Dispensing of non-charge floor stock drugs
Non-charge floor stock drugs are the medicaments that are
placed at the nursing station for the use of all patients on the
floor. For these drugs, there shall be no direct charge from the
patients account.
1. Non-charge floor stock drugs consist of a predetermined
list of medication available on every nursing unit of the
hospital. The non-charge floor stock drugs are selected
on the basis of cost of drug, quantity required, frequency
of use, etc.
2. Drug basket method is adopted where nurses check the
medicines in all rooms and in the refrigerator and
prepare a master list for the pharmacy.
Drug Distribution System in Hospital 51
3. Nurses fill a requisition form for delivery of drugs at their
floor.
4. When there is an empty container, the nurse places it in
the drug basket.
5. Once the procedure is completed the drug basket
containing the empty containers and requisition for floor
stock supplies is then sent to the pharmacy.
6. Immediately in the morning, the pharmacy staff
commences to fill each container and dispense the
requested drugs.
7. Once the basket is completed, it is delivered to the floor
via message service.
8. Alternatively a mobile dispensary unit can be utilized.
It is a specially constructed stainless steel truck measuring
60 inches high, 48 inches wide and 25 inches deep. It is mounted
on bottom tyres. Four of which are swivel type.
3.3.
3.3.
3.
Combinations of Individual Drug Order and FloorCombinations of Individual Drug Order and Floor
Combinations of Individual Drug Order and FloorCombinations of Individual Drug Order and Floor
Combinations of Individual Drug Order and Floor
Stock SystemStock System
Stock SystemStock System
Stock System
This system is used those hospitals where patients pay for their
hospitalization and the hospitals use the individual prescription
order system as their primary means of dispensing but have
several drugs in the floor stock.
4.4.
4.4.
4.
Unit Dose Dispensing MethodUnit Dose Dispensing Method
Unit Dose Dispensing MethodUnit Dose Dispensing Method
Unit Dose Dispensing Method
In unit dose dispensing the multiples of single dose
administration of medication are prepared by the pharmacists
who are ready for administration to a particular patient by the
prescribed route and the prescribed time rather than supplying
containers of drugs to nursing units where the nurse is required
to prepare the drug for administration. A single unit package
is one which contains one complete pharmaceutical dosage
forms, e.g. one tablet, one capsule or 10 ml oral liquid, etc.
Liquids are pre-measured, powders are accurately weighed
and diluted, parenteral preparations are suitably diluted
and accurately measured into sterile syringes ready for
administration.
Pharmacy Practice52
The following are some advantages of a unit dose system:
1. Patients receive improved services round the clock and
are charged for only those doses which are administered
to them.
2. All doses of medications required at the nursing station
are prepared by the pharmacy thus allowing nurses more
time for direct patient care.
3. Medication errors are decreased because of direct check
by the pharmacist.
4. Excessive duplication of orders and paper work at the
nursing station and pharmacy are eliminated.
5. Contamination due to handling eliminated.
6. It eliminates wastage of drugs and pilferage.
7. More efficient utilization of professional and no-
professional personal is promoted.
8. More space is available in nursing units by eliminating
bulky floor stock.
9. Extends pharmacy coverage and control throughout the
hospital from the time the physician writes the order to
the time patient receives the unit dose.
10. Communication of medication orders and delivery
systems are improved.
The unit dose dispensing has following disadvantages:
1. It requires more space since packaging material increase
the bulk of the dosage forms.
2. It requires increased number of skilled and lay personnel
in the pharmacy.
3. The cost of medication is increased to the patient due to
increased handling charges.
Two methods of dispensing unit doses are:
1. Centralized unit dose drug distribution (CUDD) system.
2. Decentralized unit dose drug distribution (DUDD)
system.
i. Centralized unit dose dispensing
1. All inpatient drugs are dispensed unit doses and all the
drugs are stored in central area of the pharmacy and
dispensed at the time the dose is due to be given to the
patient.
Drug Distribution System in Hospital 53
2. To operate the system as effective delivery systems
various medication carts are used to carry unit doses to
the patients and also to send a copy of the physician's
original medication order to the pharmacy for direct
interpretation and filling.
ii. Decentralized unit dose dispensing
1. This operates through small satellite pharmacies located
on each floor of the hospital.
2. The main pharmacy is for procurement, storage,
manufacturing and packaging. It serves to all the satellite
pharmacies.
3. This type of system is used in a hospital with several
buildings.
The following producer is adopted in a hospital when
decentralized unit dose system is adopted:
1. Patients profile card containing full date, disease,
diagnose is prepared.
2. Prescriptions are sent directly to the pharmacist which
are then entered in the patient profile card.
3. Pharmacist checks medication order for allergies, drug
interactions, drug laboratory test, etc.
4. Dosage schedule is made and coordinated with nursing
personnel.
5. Patient profile card and prescription order is filled by
pharmacy technicians.
6. Pharmacist then checks carts prior to its release.
7. The nurses administer the drugs and make the entry in
their records.
8. Upon return to the pharmacy the cart is rechecked.
This process requires the availability of pharmacist for
consultation by doctors and nursing staff.
CHARGING POLICYCHARGING POLICY
CHARGING POLICYCHARGING POLICY
CHARGING POLICY
The hospital should have uniform scheduled for charging of
drugs. An equitable price for drugs should be charged to all
categories of patients and it should be kept in mind to protect
the hospital financial interests. These polices can be categorized
under several systems like:
Pharmacy Practice54
1. A per diem drug charge or all inclusive or no special rate:
In this system charges for about 250 patients are studied and
their average daily charges for drugs and pharmaceutical
services are calculated. A comparison of the actual charge,
and the projected per diem rate would produce the same
revenue as the itemized charging methods. This system
provides quality pharmaceutical services and enables
hospital to reduce administrative and accounting cost.
2. A part-inclusive rate: Charges are made for drugs not on
the “free” or supplied list.
3. The professional fee concept: This fee concept is the
exclusive professional fee to meet all operating expenses,
including overhead and compensation but not the actual
cost of drug and container.
The concept is well growing and is prepared as it recovers
expenses of pharmacy, total hospital expense. This
professional fee concept should not be merged with “make
up” or “margin” as these terms imply that a percentage to
wholesale or selling price is used as a basis for recovering
all direct and indirect expenses.
4. Break-even point pricing: It is a useful tool in overall
analysis of cost volume relationship and is defined on the
level at which there is neither profit nor loss.
For this pharmacist should ascertain the fixed and
indirect expenses including expenses of hospital
administration, maintenance housekeeping, depreciation of
plant and equipment. Various costs like housekeeping cost,
overhead costs (administration, light, water) are calculated
by dividing the actual cost of these services by the number
of prescriptions filled.
5. A cost-plus rate system: In this system, pharmacist
maintains a better control using formula:
Desired income from drugs
100
Cost of prescription durgs
It helps in adjustment of cost fluctuation, difference in
currency value, financial requirement. It offers fairness to the
fairness to the hospital.
Drug Distribution System in Hospital 55
LL
LL
L
ABELINGABELING
ABELINGABELING
ABELING
Drug labels include instructions, ingredients, and a lot other
pieces of information. A drug label refers to all the printed
information included with any dietary supplement, over-the-
counter medicine, or prescription drug.
or
Label means a display of written, printed or graphic matter
upon immediate container or the wrapper of a drug package.
The label contains
1. The name of preparation: Generic name—according to
Drug Labeling and Packaging Rules, 1986. International
non-proprietary name means the name of a drug as recom-
mended by WHO or may be notified by the federal
government in the official gazette and brand name which
is used to market the drug.
2. Strength and dosage form: It is amount of active drug per
unit dose, e.g. amoxicillin 250 mg capsules and amoxicillin
500 mg capsules.
3. Dosage form: Dosage form of the medicine should be
mentioned on the label, e.g. different dosage forms of
amoxicillin like capsule, syrup, etc.
4. Quantity: Quantity/volume present per a packaging unit
quantity/volume present per a packaging unit, e.g. the
container hold 20 tablets and each tablet has a dosage
strength of 500 mg per tablet.
5. Instructions for the use: Shake well before use in case of
emulsion and suspension and storage conditions like
store in a cool place: Not more than 0°–8°C is necessary for
many products.
6. Precautions and warnings: In case of suspension like “Not
for injection”. For photosensitive drugs like “Light resistive
containers should be used”.
7. Registration number: A number given to a specific drug
when it is registered according to specific rules by
registration board set up by federal government.
8. Batch number: A designation printed on label of a drug that
identifies the batch and permits the production history of
Pharmacy Practice56
the batch including all stages of manufacturer and controls
to be traced and is viewed.
9. Manufacturing and expiry date: Manufacturing date, e.g.
3-6-11 indicates that product is formulated on 3rd June 2011
and expiry date: Date stated on the label of a drug after
which a drug is not expected to retain its claimed efficacy,
safety, quantity, or potency or after which it is no
permissible to sell the drug.
10. Price: Price embossed on the label the cost at which it is to
be sold in market.
11. Name and address of manufacturer: The name and address
of pharmaceutical industry.
DISPENSING TO AMBULDISPENSING TO AMBUL
DISPENSING TO AMBULDISPENSING TO AMBUL
DISPENSING TO AMBUL
AA
AA
A
TORTOR
TORTOR
TOR
Y PY P
Y PY P
Y P
AA
AA
A
TIENTSTIENTS
TIENTSTIENTS
TIENTS
Ambulatory refers to patients not occupying beds in hospitals
or other in patient settings, and to care given in physicians'
offices, clinics, health centers. The hospitals divide their
ambulatory patient load into three categories—emergency,
referral or tertiary care and primary care. The term emergency
care is self-explanatory and tertiary care means care beyond
that of primary care. Primary care means range of services
adequate for meeting the great majority of daily personal health
needs.
Primary health serve the patient as an entry point into a
comprehensive healthcare system. Once entry is made— initial
care needed at the time of entry given—the primary care locus
or program should be responsible for assuring continuity of
all the care the patient may subsequently need. The need for
ambulatory care clinics is due to the following reasons:
i. The need of the hospital to supplement its inpatient
teaching program.
ii. The demand by the community lay as well as pro-
fessional, for comprehensive diagnostic and treatment
centers.
iii. The need of the hospital and physician to exercise greater
control over patients receiving investigational use drugs.
iv. The lack of a sufficient number of physicians in some
areas.
Drug Distribution System in Hospital 57
v. The fact that the emergency service of a hospital is always
available, whereas a physician, in some rural areas, may
not always be available.
The essential elements of any ambulatory-care pharma-
ceutical service program are as follows:
i. The ambulatory-care pharmacy program must be
directed by a qualified pharmacist.
ii. The appropriateness of the choice of drug and its
dosage, route of administration, and amount must be
verified by the pharmacist.
iii. All medications dispensed to patients will be completely
and correctly labeled and packaged in accordance with
all applicable regulations and accepted standards.
iv. Upon dispensing a new (to the patient) medication, the
pharmacist will ensure that the patient or his representa-
tive receives and understands all pieces of information
required for proper use of the drug.
v. All drugs in ambulatory-care service areas will be
properly controlled.
CONTROLLED DRUGSCONTROLLED DRUGS
CONTROLLED DRUGSCONTROLLED DRUGS
CONTROLLED DRUGS
A drug or other substance that is tightly controlled by the
government because it may be abused or cause addiction. The
control applies to the way the substance is made, used, handled,
stored, and distributed. Controlled substances include opioids,
stimulants, depressants, hallucinogens, and anabolic steroids.
Controlled substances with known medical use, such as
morphine, Valium, and Ritalin, are available only by
prescription from a licensed medical professional.
Controlled substances: A drug or other substance, or
immediate precursor, included in schedules I, II, III, IV or V of
part B of this title. The term dose not includes distilled spirits,
wine, malt beverages or tobacco.
In dispensing of controlled substances, the following
requirements should be considered with prescriptions:
1. Drugs may be dispensed on the oral prescription in an
emergency situation.
2. Prescription shall be retained in conformity with the
requirements of this law.