of health resources When hay eauitable, balancing the nee be provided in these activites develop a personal philosophy 2. Observation of other department tal through @ planned program of in the teaching of pharmaceutical and therapeutic subjects to Y 9'OUpS Such as; pharmacy technicians, nursing students, dieticians in sts (Anesthetis) and the members of the house staf some particular pharmacy problem should be completed as one of ments for the residency. ion can be defined as the principle by which individuals and groups of '0 behave in a manner conducive to the promotion, maintenance or restoration wever, as there are multiple definitions of health, there are also multiple of health education. The Joint Committee on Health Education and Promotion nology of 2001, defined Health Education as: “any combination of planned learning rovide individuals, groups, and communities the Role of a Pharmacist: The future Pharmacists will have seven principal roles to play- + Leader + Manager * Lifelong leamer Role model- Somerton Health care system: Pharmacists play a vital role in health care system through the Medicing information they provide. ‘ While responsibilities vary among the different areas of pharmacy Practcg a bottom line is that Pharmacists help patients get well. Pharmacist responsibilities include; a range of care for patients, from Medications to monitoring patient health and progress to maximize their espn the medication. Pharmacists educate consumers and patients on the use of prescriptions an ov, the-counter medications, and advice physicians, nurses, and other heaty Professionals on drug selection and utility. Pharmacists also provide expertise about the composition of drugs, including the, chemical, biological, and physical properties and their manufacture and use, They ensure drug purity and strength and make sure that drugs do not interact in harmful way. Pharmacists are drug experts ultimately concerned about their patients’ health ang wellness. The World health organization (WHO) report on “The role of the Pharmacist in the heaty Care system” states that the competence of the Pharmacist is already proven and control, In health promotion and social responsibilities. In the direction and administrative of pharmaceutical services. In drug regulation and control. In the formulation and quality control of pharmaceutical products. In the inspection and assessment of drug manufacturing facilities. In the assurance of product quality through the distribution chain. In drug procurement agencies. In National and institutional formulary & therapeutics committees. In health promotion and social responsibilities: A Pharmacist has an important role to play in health promotion and primary, secondaly and tertiary prevention, especially in relation to the management of chronic diseases. REVIEW QUESTIONS =a Multiple Choice Questions: 1. The training and education activities in the ___ hospitals include undergraduate at! graduate programmes. (a) American (b) Indian (Q) Brazilian (d) None of these 14.10hapter ose 1 § PRESCRIBED MEDICATION ORDER AND COMMUNICATION SKILL 4 INTRODUCTION ‘Almost everyone in the modern world, takes medication at one time or another. Most of time these medications are beneficial or at least they cause no harm, but on occasion ey do injure the person taking them. The Adverse Drug Event (ADEs) and medication errors ye most common types of injuries experienced by hospitalized patients. A medication error is any preventable event that may cause or lead to inappropriate edication use Or patient harm, while the medication is in the control of the health care fessional, patient or consumer. Such events may be related to professional practice, th care products, procedures and systems including; prescribing, order communication, ‘oduct labeling, packaging and nomenclature; compounding; dispensing; distribution; ministration; education; monitoring and use. Medication errors are a serious public health blem and have received a great deal of attention in recent years, harming at least 1) jin people every year. Their effects can range from small injuries to the patient's death \d these errors can occur at any stage of the medication system. Medication errors are one the most common patient safety issues and prescribing errors are one of the most ymmon types of medication errors. The medication system starts with the prescription. A rescription is ‘a written order, which includes detailed instructions of what medicine should civen, to whom, in what formulation and dose, by what route, when, how frequently, and 1 how long The art of prescription writing is an ancient inheritance and is one of the most important rapeutic transactions between health care professional and patient. Its importance ough the centuries has made it one of the most significant written communications of the man race. The ancient symbol, “Rx” established centuries ago and has been carried down the present time. A prescription is an instruction from a prescriber to a dispenser. The rescriber is not always a doctor but can also be a paramedical worker, such as a medical ‘sistant, a midwife, The dispenser is not always a pharmacist, but can be a pharmacy hnician, an assistant or a nurse. Accurate diagnosis; proper selection of medication, losage form and route of administration; proper size and timing of dose; precise dispensing: curate labeling and correct packaging all must be provided for complete understanding ind accuracy to avoid undesirable and/or serious effects on the patient 15.1"cation (ward, room no, and bed no). name. and route of administration. hysician, ‘order was written. medication orders should be agreed to and jointly sing, pharmacy and medical records staff Do not Of the order except in emergency situations. This permits the ‘or problems with drug orders before the drug is dispensed and which may arise when drug orders are transcribed into another bby the pharmacy. orders are written,‘Shereny Proce romechanleally: Copying copy of the, iypkionsense” 4, computerized: COmPUIe System, In which the phypician enters orders into 8 h . To develop maintain an effective system of clinical Renabitation Fig. 1.1: Functions of a Hospital 1a 7s Use Books contdiagnosis and treatment. It is further sub-divided on the basis of pitals that provide treatment other than surgical hospital.“ailopathle Hospitals: eg. Ram Manohar Lohla Hospital, New Deh Public Ownership hospitals may be gover Central Government, €9. Medical Sciences, New Delhi, P.G. Loe Government, these hospitals are run by mul oF corporation 9. BMC Hospital, shagwati Hospital in Mumbai N.O.M.C. Hospital New Delhi [Link] Private Ownership imu and Trivandrum (a city in Ker Beach Candy Hospital, Mumbai has a bed capacity of 130 beds, 320 beds, P, D. Hinduja National Hospital, Mahim, Mumbai hasof Services: Services provided by the hospital should be rated in terms of efully maintained, Responsibility should be assigned appropriately, Once reported 10 the superion for its ing. by competent medical experts and non- 4 programme to attract good physicians Promacy Ceneras s ‘Transporation Fig. 1.2: Block Diagram Depicts the Organizational Structure of Hospitalnostic Services mon Services sometimes eared toa Environmental Series) Administration Services hospital. ve and oversee the operation of departments, procedures. President. Vice Presidents, Executive Assistants yy Occupational Therapy (OT): Goal of treatment is to help patient regain fine motor skils so that they can function independently at home and work. OT treatments might include; arts and crafts that help with hand-eye coordination, games and recreation to help patientsChapter ..2 HOSPITAL PHARMACY AND ITS ORGANISATION INTRODUCTION The word “hospital” comes from the Latin hospes, signifying a stranger or foreigner, hence a guest. Another noun derived from this, hospitium came to signify hospitality that is the relation between guest and shelterer, hospitality, friendliness, and hospitable reception. Hospital term is derived from Greek word “Hospices” it means where a person (who is sick or ill) can rest, eat and get medical attention timely due to his or her health issues. Hospital's primary goal is patient and pharmacy care typically a hospital works around the dlock (24 hours a day). Thus hospital pharmacy either centralized or floor stack services play a ital role in patient care. When seen from the broadest possible angle, hospital pharmacy is the practice of pharmacy within the hospital. In a hospital, as we have already learned, it is one of the most widely used service department. The service of pharmacy is under the supervision of professional pharmacist. Hospital pharmacy is an important department, which provides to the needs of physicians, nurses and other staff members of the hospital. [22 DEFINITION OF HOSPITAL PHARMACY The practice of pharmacy within the hospital under the supervision of a professional pharmacist is known as hospital pharmacy. Hospital pharmacy is the department, service or an area in the hospital organization managed under the direction of a professionally knowledgeable, legally qualified pharmacist and deals with © Supply of drugs, medicine and allied products to the nursing units and other such services. “+ Filing of special prescriptions for ambulatory and out-patients and dispensing as per the intension of a physician. * Manufacturing of the drugs and formulations in bulk and in particular the large volume parenterals which are required for the use of indoor patients. ® Storage and dispensing of narcotic and biological products ® Supply and storage of ancillary products and articles required in the hospitals. 24es and other lied 0705 a5 pay» ‘There Committee, ts for drugs and pharmaceutics supplies, and adequate control over dispensing of all drugs and pharmaceuticalresponsibility towards its staff on the one hand and The following are the area wise functions and personnel working in the department. The Director or Dean or Medical superintendent Purchasing and [esesre] [ Renn Sora I I ‘Outcoo" patient Inpatients Medical, suice! supplies Laboratory supplies Ward susples. cone! Narcotics Fig. 2.2: Functions of Hospital Pharmacy Depart: (Eat. No. [ST ATRDS | licen] ZOAOS | storage of esseniy Organizational Structure of Hospital Pharmacy wolved in patient care op Indoor Pharmacists Responsibilities effects, drug interactions, ec of the “patient care” and ensure followed propery.‘that pharmacy sa regarding em s peemeee manel in his section are property Pationt Care Ares To periodically inspect the medication areas on the runing unit and to male sure that they always keep adequate supclies with drugs and other articles requiveds——eeEEeEeEE Functions Dispensary Preparation room Store room. Office Manufacture of pills & compressed tablets (Capsulation Fig. 2.4: Typical Layout of Hospital Pharmacy Manufacture under aseptic. 8 There are great variations in the size of floor space devoted to the pharmacy inh Repacking operation Parenterals 3/8/8/8 Narcotics Office desk Shelf space acy library, Dispensing window for nurses and ou washable and acid resistant. In Is should be smooth, painted inundertaken in a hospital, tubes, fibers, powder mi “L_ To provide and evaluate pharmaceutical serces and thereby supporting the medical Fees consideration of the objectives and policies of the hospital. 2.6.3 Personnel or Staff Require! 2 lan for hospital pharmacy administration and to evolve responsibilities of ry of personnel involved in pharmaceutical services such as; assistant irement of personnel for j the nature and quantum of Service to be the requirements for the department and enforce the policies and procedure for the requirement of recruitment of adequate and competent staff. . To provide the means and methods by which personnel can work with other groups in interpreting the objectives and policies of the hospital. “6. To develop and maintain an effective system of clinical and administrative records 1. To partici 3. To estimate the need: proper control of inventory, stock, dispensing and manufacturing of the Bed Strength 5 medicaments. pte 50 bed 1. To initiate, utilize and participate in research projects designed for the improvement other ad ive and hospital services. Upto 300 beds Up to 500 bedshospital pharmacist must be at “Pharmaceutical Services" in a hospital (hospital pharmacy) comprise of the handling of drugs for example r we eis "___ through a number of activities. large quantities in a big sized hos uate the iat ‘rugs in bulk quantities Provided eon 7 4 smaller hospitals of bed strength 50, how many Pharmacists are required One (©) Two (@ Al there should be a separate room for___ products preparation. (0) Non-sterile (8) None of these cor more beds provides the opportunity for departmentalization of (©) 75 (@ 200 __5q. feet area for any sized hospital. (b) 350 training programme: The pharmacist must be capable g wifi e in hospital. He may prepare lectures ang drug usage, dosage drug usage ang 1um area required for dispensary in 100 bedded hospital is_Sq. Ft 250 (©) 350 The chief hospia 150 @ 250 ample; budgeting, soc inimum area required for preparation room in 300 bedded hospital s_$q. Ft 00 (©) 400 600 500 600 inimum area required for office in 100 20 330 ie Vani oa y (0) Staff bers. Cha ra) ADVERSE DRUG REACTION INTRODUCTION Drugs are prescribed with specific intension and a physician would expect a drug to act effectively and selectively without any undesirable phenomenon in the organism. Thus, when a physician prescribed a drug for cardiac dysfunction, he would very much like to select a drug which acts only on heart, and on no other physiological system. A drug with such an ideal selectivity, however exists only in our imagination as there in no drug which does not exert some action on the system other than one on which its clinical use in based. To certain extend such side effects are tolerated but they become problematic when the side effects are also as potent as therapeutic effect and particularly when they cause distress to the patient and treating physician. All such side effects of drugs are generally classified as Adverse Drug Reactions (ADR). DEFINITION AND SIGNIFICANCE OF ADVERSE DRUG _ REACTIONS : The World Health Organization defined as adverse drug reaction as: “Any noxious and unintended effect of drug which occurs at doses normally used in man for the prophylaxis, diagnosis or therapy of disease or for the modification of physiological functions”. It includes the documented and accepted adverse drug effects e.g. toxic side effects of the cytotoxic drugs; but excludes important drug related problems resulting from accidental overdose ie. accidental self-poisoning, prescribing and dispensing errors and intentional overdose ie. attempted and successful suicide or homicide. Adverse drug reactions are more frequent in patients taking large number of drugs. In general, 3 percent of the admissions to medical wards occur because of the adverse drug feactions. It has been estimated that an average medical hospital patient receives between five to ten different drugs during a ten day stay in a hospital. In this period, around 25 Per cent of the patient's experiences one or more adverse drug effects and 1 percent experience a life-threatening event due to drugs. Most of the adverse drug reactions occurring in the hospital are minor. Around 70 per cent of the reported adverse drug reactions include; rash, headache, GIT disturbance. itching, insomnia, drowsiness, weakness, etc 341 in excess dose cause profound hypotension, Adverse reaction due effects may also appear at usual therapeutic dose in certain ‘Most of the incidences of adverse drU9 1. Dispensing and Medication admit The pres ndition. These include: Patients with kidney disease particulary those who have lost more than 70 % kidney leads to overuse oF misuse Of the function. Hypoalbuminemia which may be due to failure of albumin production as in liver ines when abused oF mi disease or albumin loss as in nephrotic syndror Patient at the extremes of the age range: i ions can be minimized by dose adjustment after knowing Jeading to adverse drug reaction. 12. Failure to set therapeutic end point: Potent me effects or even death, Failure of the physician to set y) the reason for adverse reactions fOr drugs lke; digi. may cause advers therapeutic end point corticosteroids diuretics, . Bioavailability differences: Difference sect, Any effects which are associated with 2 as secondary effects. Drugs have several therapeutic dose but itis prescribed solely for one of these of patient affects adverse dog susceptible tos aia kin reactions or for their anti- due to marked difference in ty sa el . ue nervous system effets) This action may be of lite b tying on bed but it may have disastrous consequences if a ug reactions may be due to inh drug reactions may be due 10 oheii aaa patient is motor dive. Ths efect may be greatly exacerbated if the patients are also faking typnotics, trancuilizer, cough suppressant as medicines or is consuming alcohol. Loss of potassium or extracellular fuid concentration folowing thiaxide diuretics therapy in treating hypertension. ion of drugs. Adve ertain specific enzymes. * Rebound Response on Dis 2. Unpredictable: reactions and anaphylaxis, reaction. Other example of idiosyncrasy includes: patients with renal disease. Long term azathioprine, cyclophosphamide may pharmacological effect of the dru to over dosage of a drug. hypoglycemia and central nervous system dep ‘cancer may develop in Patients who have received "I therapy in the pastPharmwcyPectee a Characteristics of Wiosycrasy, allergy and torcty are compared In the below: 120 ‘Table 3.1: Comparisons between Idiosyncrasy, Allergy and Toxic [Link]. Idiosyncrasy r ww percent of |In all subjects ay doses. on averse Org Rastion Table 3.2: Common Allergic Orug Reactions in Human Symptoms dvs Drugs ‘Urticaria, ching, rashes. | Pericllin, — aaphin, _barbnuates, sulfonamides. streptomycin. 1. [Occurs in genetically rmatiis fi abnormal subjects. Dermatitis. Tetracycline ‘Alldruae Difficulty in breathing. Pencil, local anaesthetic. heroin. | Prior drug ex unnecessary, 2._ | Marises for few drugs. Decrease in B.P. Penicillin, aspirin. 3. | Prior drug exposure unnecessary. Haemolytic anaemia. Penicilin, methy\-dopa, quinidine. 4 | Response is dose- Dose dependent. Phenylbutazone, thiouracits. J ependent ; ic reaction. It occurs only after secones Mechanism explained by drug-receptor interaction, pharmacological action of the drug. to the drug and the development of afect. drugs (eg. B-receptor blocking drugs and ampicilin and cloxacifin) I in practice for jon of tetracycline in patients receiving irorvcalcium preparation occurs, which in poor absorption. arcoal absorbs many drugs in the stomach and so prevents their ne[Prarmacy Practice cy Practice Aavorse Oru Rasetion Altered Drug Excretion: tion for Active Tubular Secretion: Active tubular secretion of mary drugs delays gastric emptying and reduces j 8 9 intstng the loop of Henle. If two drugs, which are normally n of many drugs, e9. digoxin, Cigorln, quid Metaclopramide increases gastric emf rapid absorption of drug from the upper whereby greater than expected amount of one or other are retained in the body. For example, interaction occurs between probenecid and penicillin in which long the action of penicillin. Reabsorption of drug is decreased in renal tubule by changing raged 2s, for example, in salicylate or of the urine will increase elimination of tion of these drugs. Similarly, pressure metal excrete via bile by drugs by modityng or eliminating ites : © elimination rate of amphetamine, fenfuramine and quinidine. 3.4,7.3.2 Pharmacodynamic Drug Interaction | tteccurs as follows: the greater the conc 1 absorption rate, Altered Drug Distribution: Some dru ly bound to plasma proteins, fx example coumarins, sulphonyl ureas and phenytoin. inergi may be prescribed with an anticholinergic drug, then interooular ‘and non-polarizing muscle relaxant and procainamide Many factors are responsible for the adverse effects of drugs in patients receiving it. The ‘drug depend on its dose, duration, toxicity and other individual factors atients and total number of drugs administered.the adverse effects. T rer enzyme system. Also, rug which is readily predictable wher ficult to detect and quantity (Non- Case Reports een ecting doubts about drug related diseases, A ted, He therefore reponse drug. By in a letter to the m prescribers are alerted to the posi Reporting Agencies" resulting information which a given ever the event is pois, ished in several countries With y ing @ Serious adveng_ pon the voluntary spontaneous repontng oj ‘Adverse Drug React port. t important or has been previously reported in te) 3.5.2 Vital Statistics and Record Linkage Studies The details of cause of di recorded on the discharge letter who do not have the disease (the ‘controf") re obtained and compared. If @ drug is causing far in excess of that found in the controls. Case control studies can be conducted rapidly and efficiently at relatively low cost. However, it must be conducted correctly and resulting data must be interpreted correctly. Following precautions should be taken case control studies: The disease must be defined clearly, precisely idy must have reasonable risk of being drug- ulation of cases with the exception interest. The method used to describe drug use must be identical in cases and controls. Interpretation must be accurate, ‘guidelines would be helpful. the drug, higher isthe risk of toxicity to use combination of drugs that are highly protein bound, required for proper and safe control. -soluble at physiological pH should be considered a candidate its enzyme inducing capability, and the dosage should be appropriately adjusted. Use Books CartfullyPharmacy Proctieg __— os ig history and medical © Maintain 2 detail dru record of the patient Cholce Quertions: 1. When a physician prescribes» drug for cardiac dysintion, to select a drug which acts ony on sates ea re 7 ina re ‘ame aah i. pion ewes 5 Sa. Sa (@) NSAIDS (©) Antibiotics 8. Potent medicines when abused or misused may cause.