Hospital Pharmacy: Organisation and Management contents

Hospital Pharmacy: Organisation and Management

Contents

1.     (a) Organisational Structure — Staff, Infrastructure & Work-load Statistics

2.     (b) Management of Materials and Finance

3.     (c) Roles & Responsibilities of the Hospital Pharmacist

4.     Quick-Revision MCQs with Rationale

(a) Organisational Structure — Staff, Infrastructure & Work-load Statistics

1. Concept and Position of the Hospital Pharmacy Department

The hospital pharmacy is a clinical, scientific and administrative department responsible for the procurement, storage, compounding, manufacturing, quality assurance, dispensing, distribution, and clinical use of drugs and pharmaceutical devices within the hospital. As defined by the WHO Expert Committee, the pharmacy department must be organised as an independent, self-contained division of the hospital, headed by a qualified pharmacist and reporting directly to the hospital administrator/medical superintendent — not subordinated to nursing, medical, or general-stores administration.

Hassan's Hospital Pharmacy and the Merchant & Qadry text both emphasise that organisational placement determines the department's authority over drug policy, budget, and clinical involvement; a pharmacy buried under general administration loses its professional and clinical standing.

2. Organisation Chart — Typical Structure

A generalised hierarchy (adapted for a medium-to-large teaching hospital, ~300–500 beds) is:

Level	Position	Key Function
1	Medical Superintendent / Hospital Administrator	Overall hospital administration; pharmacy reports here
2	Chief/Director of Pharmacy (Chief Pharmacist)	Head of department — policy, budget, staffing, P&T Committee liaison
3	Deputy/Assistant Chief Pharmacist	Deputises for Chief; supervises section heads
4	Section-in-charge Pharmacists	Head of each functional section (see §3)
5	Staff Pharmacists / Clinical Pharmacists	Day-to-day dispensing, compounding, clinical rounds
6	Pharmacy Technicians / Assistants / Interns	Support dispensing, packaging, stock maintenance
7	Store-keepers, Clerks, Attendants	Inventory records, billing, housekeeping of pharmacy

3. Functional Sections/Divisions of the Pharmacy Department

●    Outpatient (OP) dispensing section

●    Inpatient (IP) / ward drug distribution section (unit-dose / floor stock)

●    Central sterile supply/manufacturing section (bulk compounding, IV fluids)

●    Sterile products / IV admixture (chemotherapy, TPN) section — laminar air-flow unit

●    Purchase and stores (bulk drug store, quarantine area, narcotic vault)

●    Drug information centre (DIC)

●    Clinical pharmacy / pharmacovigilance (ADR monitoring) unit

●    Quality control / quality assurance laboratory (in larger set-ups)

●    Administrative office and records/billing section

4. Staffing Pattern

Staffing is determined by bed strength, occupancy rate, average prescriptions/day, and scope of clinical services offered (WHO Consultative Group Report; RPS Vol. 2 Part B).

(i) Categories of Personnel

Category	Minimum Qualification	Typical Role
Chief Pharmacist	M.Pharm/Pharm.D with 8–10 yrs experience	Departmental head, policy & administration
Clinical Pharmacist	Pharm.D / Pharm.D (PB)	Ward rounds, TDM, ADR monitoring, patient counselling
Staff Pharmacist	B.Pharm / Pharm.D, registered	Dispensing, compounding, stock verification
Pharmacy Technician/Assistant	D.Pharm	Assist dispensing, labelling, packing
Store/Purchase Officer	B.Pharm with store-keeping training	Procurement, inventory records
Intern/Trainee	Final-year Pharm.D/B.Pharm	Supervised training rotations

(ii) Pharmacist : Bed Ratio (Work-load-based norms)

Exact statutory ratios vary by country/authority, but WHO and hospital-pharmacy texts recommend norms broadly of the following order for planning purposes (to be read as guidance, not fixed law):

Hospital Size	Suggested Pharmacist Strength	Basis
Up to 100 beds	1 Chief + 2–3 staff pharmacists	Minimum viable round-the-clock cover
100–300 beds	1 Chief + 1 Dy. Chief + 4–6 staff pharmacists	OP + IP + stores + DIC coverage
300–500 beds (teaching hospital)	1 Chief + 2 Dy. Chief + 8–12 pharmacists + technicians	Additional clinical pharmacy, IV admixture services
> 500 beds	Scaled proportionately with a full section-wise hierarchy	Include QA/QC, DIC, pharmacovigilance cells

★ EXAM PEARL: Staffing formula (frequently asked) Number of pharmacists required = (Average prescriptions dispensed per day) ÷ (Average prescriptions one pharmacist can safely process per day), adjusted for shifts, leave reserve (~15–20%), and non-dispensing duties (stores, DIC, clinical rounds). Always mention: workload statistics + qualitative factors (services offered, teaching/research load, extent of unit-dose or clinical pharmacy programme) — not headcount alone.

5. Infrastructure Requirements

(i) Location within the Hospital

●    Centrally located, easily accessible to OPD, wards, casualty/emergency, and OT complex.

●    Ground floor location preferred for ease of receiving bulk stores and public access.

●    Separate, secure access for narcotics/psychotropics as per statutory requirement (NDPS Act storage norms).

(ii) Space Norms (illustrative, scale with bed strength)

Area	Approx. Space Allocation	Purpose
Dispensing counter (OP/IP)	150–300 sq. ft.	Patient-facing dispensing
Bulk drug store	500+ sq. ft.	Bulk stock, FIFO/FEFO shelving
Compounding/manufacturing area	200–400 sq. ft.	Bulk compounding, repackaging
Sterile/IV admixture room	100–200 sq. ft.	Laminar air-flow bench, aseptic area
Cold storage (refrigerators/cold room)	As required	Vaccines, insulin, biologicals (2–8°C)
Narcotic vault	Small, double-locked	Schedule X/NDPS storage
Administrative office & records	100–150 sq. ft.	Documentation, billing, purchase files
Drug Information Centre	100 sq. ft.	Reference library, query desk

(iii) Environmental & Equipment Considerations

●    Adequate ventilation, temperature/humidity control (esp. for antibiotics, biologicals).

●    Fire-safety provisions; fire-resistant storage for flammable/inflammable liquids.

●    Refrigerators with continuous temperature monitoring/logging for cold-chain items.

●    Adequate shelving, bins labelled by generic name, look-alike/sound-alike (LASA) drug separation.

●    Computerised inventory and prescription-processing system (barcoding where available).

6. Work-load Statistics

Work-load data is collected to justify staffing, space, and budget, and to benchmark efficiency. Standard indices used (Hassan; Merchant & Qadry):

Statistic	Formula / Description
Prescriptions dispensed per day	Total Rx (OP + IP) processed / working day — basic workload unit
Bed-occupancy rate	(Occupied bed-days ÷ Available bed-days) × 100 — reflects IP drug demand
Doses dispensed per patient-day	Total unit doses dispensed ÷ total patient-days (used in unit-dose systems)
Turnover ratio / Inventory turnover	Cost of drugs consumed in a period ÷ Average inventory value — efficiency of stock use
Pharmacist productivity index	Prescriptions processed ÷ pharmacist-hours worked
Drug expenditure per bed per day	Total drug expenditure ÷ (Occupied bed-days) — cost-monitoring index

These statistics feed into annual reports, justify additional staff/infrastructure requests to hospital administration, and are required for accreditation (e.g., NABH) documentation.

(b) Management of Materials and Finance

1. Materials Management — Overview

Materials management covers the entire cycle of planning, procurement, storage, and control of drugs and pharmaceutical supplies to ensure uninterrupted availability at optimum cost. The core objective, per Merchant & Qadry, is: right drug, right quantity, right quality, right price, right time, right place.

2. Purchasing / Procurement

(i) Methods of Purchase

Method	When Used	Feature
Tender/Global tender	Bulk annual purchase, high-value items	Competitive bidding; most economical for large quantities
Quotation (limited)	Medium-value, moderate urgency items	Quotations invited from empanelled suppliers
Local purchase (LP)	Emergency/short-fall items	Quick procurement, usually costlier, capped by policy limits
Rate contract	Items with stable, recurring demand	Pre-negotiated rates for a fixed period (e.g., DGS&D/state rate contracts)
Direct purchase from manufacturer	Specialised/patented drugs	Bypasses distributor margin

(ii) Steps in the Purchase Cycle

5.     Indent generation (based on consumption pattern/reorder level)

6.     Approval by purchase/therapeutics committee

7.     Inviting tenders/quotations

8.     Comparative statement and selection of supplier

9.     Issue of purchase order

10.  Receipt, inspection, and quality/quantity verification (GRN – Goods Receipt Note)

11.  Payment processing

3. Inventory Control Techniques

These techniques classify stock to prioritise managerial attention and control investment in inventory.

Technique	Basis of Classification	Categories
ABC Analysis	Annual consumption value	A = ~10% items, ~70% value; B = ~20% items, ~20% value; C = ~70% items, ~10% value
VED Analysis	Criticality to patient care	V = Vital, E = Essential, D = Desirable
FSN Analysis	Movement/usage frequency	F = Fast-moving, S = Slow-moving, N = Non-moving
HML Analysis	Unit cost	H = High cost, M = Medium cost, L = Low cost
SDE Analysis	Source/availability	S = Scarce, D = Difficult, E = Easily available
Combined ABC-VED matrix	Value + criticality	Used to set differential control (e.g., category AV needs tightest control)

🧠 MNEMONIC: Remembering inventory techniques "A Very Fine Hospital Stores Everything" → ABC, VED, FSN, HML, SDE. Pair value-based (ABC) with criticality-based (VED) in answers — examiners often ask for the ABC-VED matrix specifically.

Key Inventory Control Parameters

Term	Meaning
Lead time	Time gap between placing an order and receiving the stock
Reorder level (ROL)	Stock level at which a fresh purchase order is triggered = (Lead time × average consumption) + safety stock
Safety/buffer stock	Minimum stock kept to cover unexpected delay or demand surge
Economic Order Quantity (EOQ)	Order quantity that minimises total of ordering cost + carrying cost
Maximum stock level	Upper ceiling of stock to avoid over-investment/expiry risk
Minimum stock level	Level below which stock-out risk becomes significant
Inventory turnover ratio	Annual drug consumption cost ÷ average inventory value — higher ratio = more efficient stock use

4. Storage Principles

●    FIFO (First-In-First-Out) and FEFO (First-Expiry-First-Out) shelving practice.

●    Segregation: general drugs, cold-chain items, narcotics/psychotropics, inflammables, LASA drugs, and expired/near-expiry quarantine stock kept separately.

●    Periodic physical stock verification and reconciliation with book stock.

●    Proper temperature/humidity monitoring with documented logs (esp. cold storage).

●    Bin-card/stock-card system or computerised inventory software for real-time tracking.

5. Drug Distribution Systems (Materials flow to patient)

System	Description	Advantage/Limitation
Floor/ward stock system	Bulk stock kept at nursing station; nurse administers from ward stock	Fast access; higher risk of error, pilferage, wastage
Individual prescription order (IPO)	Pharmacy dispenses against each written prescription	Better pharmacist check; delay possible
Unit-dose dispensing system (UDDS)	Pre-packaged single doses supplied per patient per administration time	Most accurate, reduces wastage/error; resource-intensive to set up
Combination system	Mix of floor stock (for emergency drugs) + unit dose for routine drugs	Balances speed and safety

6. Financial Management

(i) Sources of Pharmacy Revenue/Budget

●    Hospital general budget allocation (government/trust hospitals).

●    Revenue from drug sale to OP/IP patients (self-financing/semi-autonomous pharmacies).

●    Insurance/scheme reimbursements (e.g., government health schemes, CGHS-type panels).

●    Grants for specific programmes (national health programmes, vaccination drives).

(ii) Budgeting

Type of Budget	Feature
Line-item budget	Expenditure listed by category (salaries, drugs, equipment) — traditional, simple to audit
Performance budget	Linked to activities/output (e.g., cost per prescription dispensed)
Zero-based budget (ZBB)	Every item justified afresh each cycle, not based on previous year's figure
Programme budget	Allocated against specific programmes/services (e.g., chemotherapy unit)

(iii) Cost Control Measures

●    Formulary system / essential drugs list to rationalise purchase and reduce inventory diversity.

●    Generic substitution policy where permissible.

●    Bulk purchase and rate-contract negotiation to reduce unit cost.

●    Regular ABC/VED analysis to focus control on high-value/critical items.

●    Minimising expiry losses through FEFO practice and inter-departmental stock transfer.

●    Periodic drug utilisation review (DUR) to identify overuse/irrational use driving cost.

★ EXAM PEARL: Budget vs Inventory question overlap Students often confuse 'ABC analysis' (inventory control, based on consumption VALUE) with 'budgeting' — ABC feeds INTO budgeting by showing where money is concentrated, but is not itself a budgeting method. If asked 'techniques of cost control in hospital pharmacy', answer with: formulary system, ABC-VED analysis, bulk/rate-contract purchase, DUR, generic substitution.

(c) Roles & Responsibilities of the Hospital Pharmacist

The WHO Consultative Group Report and RPS Vol. 2 Part B classify the hospital pharmacist's functions broadly into administrative, distributive, and clinical/cognitive roles. Modern practice (Harman's Handbook of Pharmacy Health Care) places increasing emphasis on the clinical/patient-care role alongside the traditional supply function.

1. Administrative Roles

●    Departmental planning, staffing, budgeting, and policy formulation.

●    Framing and enforcing standard operating procedures (SOPs) for dispensing, storage, and record-keeping.

●    Serving as Member-Secretary/active member of the Pharmacy & Therapeutics (P&T) Committee.

●    Maintaining statutory records (narcotics register, poison register) and ensuring regulatory compliance (Drugs & Cosmetics Act, NDPS Act, Pharmacy Act).

●    Liaison with hospital administration for infrastructure, manpower, and budget approvals.

●    Training and supervision of pharmacy interns, technicians, and students.

2. Distributive (Supply-Chain) Roles

●    Procurement, storage, and inventory control of drugs and pharmaceutical supplies (see Section b).

●    Dispensing of medicines to OP and IP patients with accuracy checks.

●    Operating the chosen drug distribution system (unit dose/floor stock/IPO).

●    Compounding and repackaging of bulk drugs, extemporaneous preparation.

●    Preparation of sterile products — IV admixtures, TPN, chemotherapy reconstitution under aseptic conditions.

●    Quality assurance of all products dispensed/manufactured in-house.

3. Clinical / Cognitive Roles

Function	Description
Ward rounds / clinical pharmacy	Participating with the medical team to optimise pharmacotherapy at bedside
Patient medication counselling	Educating patients on dose, administration, storage, and adherence at discharge
Therapeutic Drug Monitoring (TDM)	Monitoring plasma levels of narrow-therapeutic-index drugs and advising dose adjustment
Adverse Drug Reaction (ADR) monitoring / Pharmacovigilance	Detecting, documenting, and reporting ADRs (e.g., to PvPI)
Drug information services	Answering queries from physicians/nurses on dosage, interactions, compatibility
Medication reconciliation	Verifying and resolving discrepancies in patient medication lists across care transitions
Participation in clinical research/ethics committee	Contributing pharmacological expertise to trials and institutional ethics review
Antimicrobial stewardship	Promoting rational, evidence-based use of antibiotics to curb resistance

4. Committee Participation

Hospital pharmacists typically serve on multiple institutional committees, contributing pharmacotherapeutic and supply-chain expertise:

●    Pharmacy & Therapeutics (P&T) Committee — formulary management, drug policy.

●    Infection Control Committee — antibiotic policy, disinfectant selection.

●    Drug and Therapeutics Review / Adverse Drug Reaction Monitoring Committee.

●    Hospital Ethics Committee (for clinical trial-related pharmacological input).

●    Purchase/Stores Committee.

●    Quality/Accreditation (e.g., NABH) Committee.

5. Summary Table — Roles at a Glance

Category	Representative Functions
Administrative	Policy, budgeting, staffing, SOPs, statutory compliance, P&T Committee
Distributive	Procurement, storage, inventory control, dispensing, sterile compounding
Clinical	Ward rounds, counselling, TDM, ADR monitoring, DIC, antimicrobial stewardship

Hospital: Organisation and Functions

HOSPITAL: ORGANIZATION AND FUNCTIONS

Definition of Hospital

According to the World Health Organization:

"A hospital is an integral part of a social and medical organization whose function is to provide complete healthcare, both curative and preventive, to the population. Its outpatient services reach out to the family and home environment, and it is also a center for training of health workers and for biomedical research."

Functions of Hospital

The major functions of a hospital are:

1. Patient Care Services

• Diagnosis of diseases.
• Treatment of diseases.
• Rehabilitation services.
• Emergency care.
• Specialized healthcare services.

2. Preventive Services

• Immunization programs.
• Health education.
• Disease prevention and screening.
• Maternal and child health services.

3. Promotion of Quality Medical Care

• Improves standards of medical practice.
• Provides evidence-based treatment.

4. Teaching and Training

• Training of doctors, nurses, pharmacists, and allied health professionals.
• Continuing medical education (CME).

5. Research Activities

• Clinical research.
• Drug utilization studies.
• Epidemiological studies.
• Biomedical research.

6. Administrative Functions

• Planning and policy formulation.
• Estimation of manpower and equipment requirements.
• Resource utilization and evaluation.

7. Community Services

• Acts as a link between the public and health policymakers.
• Community outreach programs.

8. Maintenance of Records

• Clinical records.
• Administrative records.
• Statistical reports.

9. Safety Programs

• Infection control.
• Biomedical waste management.
• Patient safety initiatives.

10. Development of Healthcare Policies

• Formulation of hospital policies and procedures.
• Maintenance of adequate and competent staff.

Classification of Hospitals

Hospitals can be classified based on:

1.     Clinical grounds

2.     Non-clinical grounds

3.     Size

4.     Cost

5.     System of medicine

1. Based on Clinical Grounds

A. Medicine-Based Hospitals

• General medicine hospitals
• Pediatric hospitals
• Psychiatric hospitals
• Neurology hospitals

B. Surgery-Based Hospitals

• Orthopedic hospitals
• ENT hospitals
• Gynecology and Obstetric hospitals
• Surgical specialty hospitals

C. Maternity Hospitals

• Short-term maternity hospitals
• Long-term maternity care centers

2. Based on Non-Clinical Grounds

A. Government Hospitals

• District hospitals
• Civil hospitals
• Army hospitals
• Navy hospitals
• Railway hospitals

B. Non-Government Hospitals

Private Hospitals (For Profit)

• Corporate hospitals.

Non-Profit Hospitals

• Charitable hospitals.
• Community hospitals.
• Mission hospitals.
• Trust hospitals.

3. Based on Size

Type of Hospital	Number of Beds
Large Hospital	More than 1000 beds
Medium Hospital	500–1000 beds
Small Hospital	100–500 beds
Very Small Hospital	Less than 100 beds

4. Based on Cost

A. Elite Hospitals

• Highly advanced technology.
• Deluxe facilities.
• Specialized services.
• Example: Apollo Hospitals.

B. Budget Hospitals

• Affordable treatment.
• Government and charitable hospitals.

5. Based on System of Medicine

• Allopathic hospitals
• Ayurvedic hospitals
• Homeopathic hospitals
• Unani hospitals
• Siddha hospitals

Organization of Hospital

Definition

Organization is a dynamic process in which various managerial activities bind people together for achieving common goals and objectives.

 

Governing Body of Hospital

The highest authority of a hospital is the:

• Governing Board
• Board of Directors
• Board of Trustees

Composition of Governing Body

Members may include experts in:

• Medical education
• Research
• Administration
• Finance
• Law
• Public health
• Government representatives

Functions of Governing Body

1.     Formulates policies and procedures.

2.     Plans hospital development.

3.     Approves budgets.

4.     Appoints hospital administrator.

5.     Monitors hospital performance.

6.     Ensures quality patient care.

Hospital Administrator

Responsible for:

• Clinical services
• Nursing services
• Pharmacy services
• Financial management
• Human resource management
• Hospital operations

Services Performed by Hospital Organization

1. Nursing Services

Characteristics

• Largest department of the hospital.
• Functions 24 hours a day.
• Provides direct patient care.

Functions

• Bedside nursing care.
• Prenatal and postnatal care.
• Patient observation.
• Drug administration.
• Health education.

Head of Department

Director of Nursing Services (DNS).

2. Outpatient Services (OPD)

Functions

• Diagnosis and treatment of minor illnesses.
• Preventive services.
• Follow-up services.
• Health education.
• Referral services.

Importance

Acts as the first point of contact between hospital and community.

3. Radiological Services

Performed under a qualified radiologist.

Facilities

• X-ray
• Ultrasonography (USG)
• Electrocardiography (ECG)
• CT Scan
• MRI
• Mammography

Functions

• Diagnosis.
• Monitoring treatment.
• Screening programs.

4. Central Supply Services (CSSD)

Central Sterile Supply Department (CSSD)

Functions

• Collection of instruments.
• Cleaning and sterilization.
• Storage.
• Distribution of sterile supplies.

Importance

Prevents hospital-acquired infections.

5. Hospital Pharmacy Services

Hospital pharmacy is responsible for safe and effective medication management.

Functions

Administrative Functions

• Drug procurement.
• Inventory control.
• Drug storage.
• Budget management.

Clinical Functions

• Dispensing.
• Patient counseling.
• Drug information services.
• Adverse drug reaction monitoring.
• Medication error prevention.
• Therapeutic drug monitoring.

Manufacturing Functions

• Preparation of sterile products.
• Compounding.
• Repackaging.

6. Medical Record Services (MRD)

Medical records contain:

• Patient history.
• Physical examination findings.
• Laboratory reports.
• Diagnostic reports.
• Physician orders.
• Medication records.
• Discharge summary.

Importance

• Continuity of care.
• Research.
• Legal purposes.
• Education.
• Quality assurance.

7. Store Services

Functions

• Receiving materials.
• Storage of supplies.
• Distribution to departments.

Types

• Medical stores.
• Surgical stores.
• General stores.

Importance

• Maintains buffer stock.
• Ensures uninterrupted patient care.

8. Miscellaneous Services

Dietary Services

Provides therapeutic diets.

Ambulatory Services

Transportation of patients.

Laundry Services

Cleaning of hospital linen.

Transport Services

Movement of patients and materials.

Mortuary Services

Storage and handling of dead bodies.

Library Services

Educational resources for healthcare professionals.

 

 

Essential Drugs Concept and Rational Drug therapy

 

Essential Drugs Concept & Rational Drug Therapy –

1. Essential Drugs (Essential Medicines) Concept

Definition (WHO)

Essential medicines are medicines that satisfy the priority healthcare needs of the population.

Selection of Essential Medicines

Essential medicines are selected based on:

• Disease prevalence in the country/region
• Scientific evidence of efficacy
• Safety
• Cost-effectiveness
• Available healthcare facilities
• Skills and training of healthcare personnel
• Ease of administration
• Storage facilities
• Patient acceptability

Mnemonic: DESC HSP

• Disease prevalence
• Efficacy
• Safety
• Cost-effectiveness
• Healthcare facilities
• Skills of staff
• Patient acceptability

Importance of Essential Medicines

Essential medicines should be:

• Available at all times
• Available in adequate quantities
• In proper dosage forms
• Of assured quality
• Accompanied by proper information
• Affordable to individuals and the community

They are expected to cover 80–90% of the healthcare needs of the population.

2. Essential Medicines List (EML)

Definition

An Essential Medicines List (EML) is a limited list of carefully selected medicines that satisfies the priority healthcare needs of a population.

Selection is based on:

• Disease prevalence
• Safety
• Efficacy
• Cost-effectiveness

The EML is regularly updated considering:

• New scientific evidence
• Drug resistance patterns
• Emerging diseases
• New medicines
• Improved formulations

3. Advantages of Essential Medicines List

Public Health

• Prevents deaths from treatable diseases
• Ensures medicine availability
• Improves quality of healthcare

Drug Management

• Easier procurement
• Easier storage
• Prevents stock-outs
• Better inventory control
• Easier transportation

Cost

• Lower procurement cost
• Lower storage cost
• Easier quality testing

For Doctors & Pharmacists

• Better knowledge of fewer medicines
• Improved prescribing
• Better patient counseling
• Fewer medication errors

Standard Treatment

• Encourages treatment according to Standard Treatment Guidelines (STGs)

4. Rational Use of Drugs (RUD)

Definition

Rational use of drugs means:

Using the right drug for the right patient, in the right dose, by the right route, for the right duration, at the right time, after proper diagnosis.

Factors Leading to Irrational Drug Use

• Self-medication
• Medicines taken for minor illnesses
• Easy access to medicines
• Advice from friends or relatives
• Avoiding doctor consultation

5. Common Types of Irrational Drug Use

1. Polypharmacy

Use of too many medicines for one patient.

2. Irrational Antibiotic Use

• Wrong antibiotic
• Wrong dose
• Wrong duration
• Antibiotics for viral infections

3. Overuse of Injections

Using injections when oral medicines are sufficient.

4. Inappropriate Self-medication

Especially with prescription medicines.

5. Not Following STGs

Failure to prescribe according to Standard Treatment Guidelines.

6. Strategies to Improve Rational Drug Use

A. Managerial

• Supervise prescribing
• Use STGs
• Prescription audits
• Feedback to doctors

B. Economic

• Incentives for rational prescribing
• Insurance reimbursement only for EML medicines
• Competitive pricing

C. Regulatory

• Drug laws
• Licensing doctors and pharmacists
• Drug scheduling
• Ban unsafe medicines
• Regulation of pharmaceutical promotion

D. Educational

• Continuing education
• Training programs
• Formularies
• Clinical supervision
• Patient counseling
• Monitoring and feedback

7. National Strategies (WHO)

WHO recommends:

1. National medicine policy body
2. Evidence-based STGs
3. Essential Medicines List
4. Drug & Therapeutics Committee (DTC)
5. Problem-based pharmacotherapy training
6. Mandatory Continuing Medical Education (CME)
7. Independent drug information
8. Prescription audit and feedback
9. Public education
10. Remove financial incentives for irrational prescribing
11. Enforce drug regulations
12. Adequate government funding

8. Role of Pharmacist in Rational Drug Use

1. Drug & Therapeutics Committee (DTC)

• Helps select essential medicines
• Assists in EML preparation
• Develops medicine policies

2. Drug Procurement

• Purchase quality medicines
• Buy at reasonable prices
• Forecast medicine requirements
• Ensure EML medicines are procured

3. Drug Storage

• Follow Good Storage Practices (GSP)
• Prevent stock-outs
• Avoid expiry
• Proper handling of narcotics and costly medicines

4. Dispensing

• Accurate dispensing
• Reduce medication errors
• Prevent pilferage
• Maintain records

5. Patient Education

• Counsel patients
• Explain dosage
• Improve adherence
• Provide verbal and written instructions

6. Pharmacovigilance

• Detect adverse drug reactions (ADRs)
• Report ADRs
• Monitor medicine safety

7. Drug Information Service

Provide unbiased information to:

• Doctors
• Nurses
• Patients
• Public
• Other healthcare workers

8. Pharmaceutical Care

A patient-centered practice where the pharmacist:

• Takes responsibility for drug-related needs
• Collaborates with doctors
• Optimizes drug therapy
• Suggests dose adjustments
• Improves patient outcomes

Important Definitions for Exams

Essential Medicines

Medicines that satisfy the priority healthcare needs of the population.

Essential Medicines List (EML)

A limited list of carefully selected medicines based on efficacy, safety, disease prevalence, and cost-effectiveness.

Rational Drug Use

Use of the right medicine, for the right patient, in the right dose, by the right route, for the right duration, at the right cost.

Polypharmacy

Use of multiple medicines in a single patient unnecessarily.

High-Yield Mnemonics

Selection of Essential Medicines

DESC HSP

• Disease prevalence
• Efficacy
• Safety
• Cost-effectiveness
• Healthcare facilities
• Skills of healthcare personnel
• Patient acceptability

Strategies to Improve Rational Drug Use

MERE

• Managerial
• Economic
• Regulatory
• Educational

Pharmacist's Roles

PDSD PDPP

• Procurement
• DTC member
• Storage
• Dispensing
• Patient education
• Drug information
• Pharmacovigilance
• Pharmaceutical care

Frequently Asked Exam Questions

1. Define Essential Medicines.
2. Write the selection criteria for essential medicines.
3. Explain the advantages of the Essential Medicines List (EML).
4. Define Rational Use of Drugs.
5. Describe the types of irrational drug use.
6. Explain the strategies to improve rational drug use.
7. List the WHO national strategies for promoting rational drug use.
8. Discuss the role of pharmacists in promoting rational use of medicines.

 

Pharmaceutical Care

Introduction

Health is defined as a state of complete physical, mental, and social well-being and not merely the absence of disease.

Medicines are used to treat, prevent, and manage various diseases. When used appropriately, medicines provide therapeutic benefits and improve patients' health. However, inappropriate use of medicines can cause harm, lead to adverse drug reactions, treatment failure, and increase healthcare costs for both patients and governments.

Pharmacists worldwide provide professional services in community, hospital, and clinical settings. Owing to their expertise in therapeutics and clinical pharmacy, pharmacists can identify drug-related problems, provide appropriate solutions, counsel patients on the safe use of medicines, and educate them about diet and lifestyle modifications to maximize therapeutic outcomes.

Pharmaceutical Public Health is the application of pharmaceutical knowledge, skills, and resources to prevent disease, prolong life, and promote, protect, and improve the health of society in an organized manner.

• Pharmaceutical Public Health focuses on health issues at the community/societal level.
• Pharmaceutical Care focuses on health issues at the individual patient level.

Pharmaceutical Care

The term "Pharmaceutical Care" was first coined by Mikeal et al. (1975) and defined as:

"The care that a given patient requires and receives which assures safe and rational drug use."

In 1990, Douglas C. Hepler and Linda M. Strand proposed a new definition that gained worldwide acceptance:

"The responsible provision of drug therapy for the purpose of achieving definite outcomes that improve a patient's quality of life."

This definition is more patient-centered and outcome-oriented, particularly for chronic diseases such as diabetes, hypertension, and asthma, where maintaining quality of life is essential.

In 1998, the International Pharmaceutical Federation (FIP) adopted this definition.

Difference Between Traditional Pharmacy Practice and Pharmaceutical Care

Traditional Pharmacy Practice

• Dispensing medicines based on prescriptions.
• Limited involvement in patient follow-up.
• Focus on medication supply.

Pharmaceutical Care Practice

• Reviews and analyzes prescriptions.
• Identifies Drug-Related Problems (DRPs).
• Resolves DRPs in consultation with physicians and patients.
• Monitors therapeutic outcomes.
• Provides patient counseling and education.
• Focuses on improving quality of life and therapeutic outcomes.

Goal of Pharmaceutical Care

To ensure that patients receive:

• Appropriate drug therapy
• Effective drug therapy
• Safe drug therapy
• Convenient drug therapy

Resulting in:

• Desired therapeutic outcomes
• Improved health-related quality of life

Principles of Pharmaceutical Care Practice

Pharmaceutical Care is a patient-centered, outcome-oriented pharmacy practice that requires collaboration between the pharmacist, patient, and other healthcare professionals.

Main Goal

To optimize the patient's health-related quality of life and achieve positive clinical outcomes with reasonable healthcare expenditure.

1. Establish and Maintain a Professional Relationship

A strong relationship between the pharmacist and patient should be based on:

• Caring
• Trust
• Open communication
• Cooperation
• Mutual decision-making

Responsibilities of the Pharmacist

• Place the patient's welfare first.
• Demonstrate a caring attitude.
• Use professional knowledge and skills for the patient's benefit.
• Ensure continuous access to pharmaceutical care.

Responsibilities of the Patient

• Provide accurate personal and medical information.
• Share preferences and concerns.
• Participate actively in the therapeutic plan.

2. Collect, Organize, Record, and Maintain Patient-Specific Information

The pharmacist should collect comprehensive patient information, including:

Subjective and Objective Information

• General health status
• Activity status
• Past medical history
• Medication history
• Social history
• Diet history
• Exercise history
• History of present illness
• Financial and insurance status

Sources of Information

• Patient
• Medical records and reports
• Physical assessment
• Family members or caregivers
• Insurance providers
• Physicians
• Nurses
• Other healthcare professionals

Requirements of Patient Information

The information should be:

• Accurate
• Complete
• Timely
• Organized
• Easily retrievable
• Regularly updated
• Maintained confidentially

3. Evaluate Patient Information and Develop a Drug Therapy Plan

Based on the collected information, the pharmacist should:

• Understand the patient's disease and treatment needs.
• Collaborate with the patient and other healthcare providers.
• Develop an outcome-oriented drug therapy plan.
• Address all disease conditions and medication-related needs.

While Designing the Plan, Consider:

• Clinical condition of the patient
• Psychological factors
• Social factors
• Cost of therapy
• Complexity of treatment
• Patient adherence/compliance

Role of the Pharmacist

• Act as a patient advocate.
• Coordinate drug therapy with healthcare providers.
• Ensure safe, effective, and economical medication use.
• Monitor therapeutic outcomes and modify therapy when necessary.

4. Pharmacist Ensures Availability of Supplies, Information, and Knowledge

The pharmacist providing pharmaceutical care assumes responsibility for ensuring that the patient:

• Obtains all prescribed medications and related products.
• Has access to necessary medical equipment and supplies.
• Understands the disease condition.
• Understands the purpose, benefits, and risks of therapy.
• Knows how to use medications correctly.
• Is capable of following the prescribed treatment plan.

5. Pharmacist Reviews, Monitors, and Modifies the Therapeutic Plan

The pharmacist is responsible for:

• Monitoring the patient's progress toward desired therapeutic outcomes.
• Assessing the effectiveness and safety of therapy.
• Coordinating changes in therapy with physicians and other healthcare providers.
• Maintaining or improving treatment effectiveness.
• Reducing healthcare costs whenever possible.
• Documenting patient progress accurately.
• Communicating relevant information to patients and healthcare providers.
• Ensuring continuity of care when patients move between community, hospital, and long-term care settings.

Practice Principles of Pharmaceutical Care

A. Data Collection

1. Initial Patient Interview

The pharmacist:

• Establishes a professional relationship with the patient.
• Initiates the patient's pharmacy record.
• Collects essential patient information.

For patients who cannot communicate directly (e.g., pediatric, geriatric, critically ill patients), information may be collected from:

• Parents
• Guardians
• Caregivers

2. Collection of Patient Information

Information collected includes:

• General health status
• Activity status
• Past medical history
• Medication history
• Family history
• Social history
• Economic status
• Present illness
• Patient perceptions and concerns

3. Physical Assessment

The pharmacist may perform:

• Blood pressure monitoring
• Blood glucose monitoring
• Weight assessment
• Other appropriate health assessments

4. Use of Secondary Sources

Additional information may be obtained from:

• Medical records
• Laboratory reports
• Family members
• Physicians
• Nurses
• Other healthcare providers

5. Pharmacy Record Maintenance

The pharmacist should:

• Create and maintain patient records.
• Keep records accurate and up to date.
• Ensure confidentiality and security.
• Release information only with patient consent or as required by law.

B. Information Evaluation

1. Evaluation of Patient Information

The pharmacist evaluates collected data to identify:

• Opportunities to improve therapy.
• Drug-related problems.
• Potential health risks.
• Need for future pharmacist intervention.

2. Documentation

All conclusions and assessments should be documented in:

• Medical records
• Pharmacy records

3. Patient Discussion

The pharmacist explains:

• Disease condition
• Treatment expectations
• Possible outcomes
• Required monitoring

to ensure patient understanding.

C. Formulating a Plan

1. Selection of Appropriate Actions

The pharmacist collaborates with healthcare providers to:

• Improve safety of therapy.
• Improve effectiveness of therapy.
• Improve cost-effectiveness.
• Prevent future health problems.

2. Development of Patient-Specific Plan

The plan may include:

• Modifying drug therapy
• Drug therapy monitoring
• Dietary recommendations
• Lifestyle modifications
• Non-prescription medications
• Non-drug treatments
• Referral to specialists
• Implementation of treatment protocols

3. Establishing Desired Outcomes

For each identified problem:

• Desired outcomes are determined.
• Goals are agreed upon with the patient.
• Monitoring parameters are established.

4. Review with Patient

The pharmacist discusses:

• Treatment plan
• Expected outcomes
• Monitoring requirements

with the patient and healthcare team.

5. Documentation

The complete plan is documented in the patient's records.

D. Implementing the Plan

1. Carrying Out the Plan

Implementation may involve:

• Contacting physicians for clarification.
• Modifying prescriptions.
• Initiating therapy.
• Educating patients and caregivers.
• Arranging medication supply.
• Addressing financial or lifestyle barriers.
• Coordinating referrals.

2. Patient Education

The pharmacist ensures that the patient:

• Understands the treatment plan.
• Knows monitoring requirements.
• Understands medication administration.
• Uses equipment properly.

Examples of monitoring:

• Blood pressure monitoring
• Blood glucose monitoring
• Laboratory investigations

3. Ensuring Availability of Resources

The pharmacist ensures timely access to:

• Medicines
• Medical devices
• Monitoring equipment
• Other supplies

4. Documentation

The pharmacist records:

• Implementation steps
• Baseline monitoring values
• Potential barriers to treatment

5. Communication

The pharmacist communicates the plan to:

• The patient
• Caregivers
• Physicians
• Other healthcare providers

to ensure continuity of care.

E. Monitoring and Modifying the Plan (Ensuring Positive Outcomes)

1. Regular Monitoring

The pharmacist regularly reviews:

• Subjective parameters (symptoms, patient feedback)
• Objective parameters (lab values, BP, glucose levels)

to assess progress.

2. Modification of Plan

If desired outcomes are not achieved:

• The treatment plan is reassessed.
• Necessary changes are made.
• Revised plans are implemented.

3. Progress Reporting

The pharmacist:

• Discusses progress with the patient.
• Provides feedback to healthcare providers.
• Encourages patient adherence.

4. Follow-Up

A follow-up mechanism should be established to:

• Monitor adherence.
• Evaluate outcomes.
• Detect problems early.

5. Updating Records

Patient records should include:

• Current progress
• Monitoring results
• Pharmacist's assessment
• Patient's assessment
• Modifications made to therapy
• Communications with healthcare providers

Quick Exam Points

Pharmaceutical Care:
"The responsible provision of drug therapy for the purpose of achieving definite outcomes that improve a patient's quality of life." — Hepler & Strand (1990)

Definite Outcomes of Pharmaceutical Care

1. Cure of disease
2. Elimination or reduction of symptoms
3. Arresting or slowing disease progression
4. Prevention of disease or Symptoms

Steps of Pharmaceutical Care

1. Establish professional relationship.
2. Collect patient-specific information.
3. Evaluate information and develop care plan.
4. Ensure patient has medicines, supplies, and knowledge.
5. Monitor outcomes and modify therapy as needed.

Ultimate Goal of Pharmaceutical Care

To achieve definite therapeutic outcomes and improve the patient's quality of life through safe, effective, and economical drug therapy.