THESIS

Title: Quality of Pharmacy Services in POF Hospital, Wah Cantt

Dr. Mahfishan Kiran Syed

MS.c Healthcare Administration

(Registration No. NUMS/AFPG/20/MSC/030)

Academic Supervisor

MAJ. GEN WASIM ALAMGIR, HI (M)

Department of -Health care Administration

Institute -AFPGMI

National University of Medical Sciences,

Rawalpindi
Title of Research Project: Quality of Pharmacy Services in POF Hospital, Wah
Cantt

Synopsis submitted for: Discipline:

þMaster □M.Phil. □ Ph.D. Healthcare Administration
Name of the Applicant: Qualifications (list all; with date)
Dr.Mahfishan Kiran Syed MBBS in 1994

Date of Enrollment: Registration No.

NUMS/AFPG/20/MSC/030
Supervisor
Signature:
Name: Maj. Gen Wasim Alamgir, HI
(M) Qualification: FCPS, FRCPL, MRCP(UK
& IRE), DIP CARD (LONDON)
Designation: Advisor Neurology Pak Army, Professor of Medicine AM
College, Consultant Neurologist, PEMH Rawalpindi
Address:
AFPGMI Rawalpindi.
Phone No: 0321-9836934 Email: [email protected]
Head of Department
Signature:
Name:
 TABLE OF CONTENTS

List of abbreviations……………………………………………………………….…1

Project summary…………………………………………………………………….2

Key words ……………………………………………………………………………3

Chapter 1: Introduction..................................................................................................4

Chapter 2: Review of Literature.....................................................................................8

Chapter 3: Materials and Methods...............................................................................11

References....................................................................................................................14

Institutional review board …………………………………………………………16

Annexures.......................................................................................................……17-23
 LIST OF ABBREVIATIONS

AFPGMI Armed Forces Post Graduate Medical Institute

Asst Assistant
GPP Good pharmacy practice
ASHP American Society of Health System Pharmacists
POF Pakistan Ordnance Factories
WHO World Health Organization
LMIC Low- and Middle-Income Country
CPPQ Community Pharmacy Patient Questionnaire
OTC Over the counter
FIP International Pharmacy Forum
 ABSTRACT

Pharmacy deals with purchasing, preparation and delivery of medicines not only to the
admitted patients but also to the outdoor patients according to the prescription of physicians,
ensuring the safety and health of patients in effective manners. Now hospital pharmacy
includes modern services related to health care, like clinical advices, reviewing medication for
safety and efficacy and providing drug information. Hospitals that fail to understand the
importance of delivering quality services and customer satisfaction may be inviting a possible
loss of patients. Patient satisfaction is widely used to measure quality of healthcare by
identifying potential areas for improvement, to increase the effectiveness of healthcare system.
An evaluation of hospital pharmacy practices is essential to assure that they meet the global
standards and to prioritize practice advancements. POF hospital is responsible to provide
health care facilities to serving/ retired POF’s employees and families / parents of the
employees, army personnel posted to POF (including their families/ parents). The health of the
POF employees and their families is fundamental to the welfare of the organization. The
medical store functioning in POF hospital is the backbone of the setup. It plays an important
role in improving access to health care and in closing the gap between the potential benefits of
medicines and the actual value realized. Patient satisfaction depends on the patients’
experience within different departments in the hospital as well as patients’ expectations during
their visit to the pharmacy. The objectives of the study are to identify the existing practices of
the pharmacy along with satisfaction level of patients and suggest recommendations for
improvement. It will be an observational cross-sectional quantitative study. Study setting will
be POF hospital Wah Cantt with a time duration of one year. The data collection tool will be
structured questionnaire and it will be analyzed by SPSS version 25. The anticipated findings
about pharmacy services and patient satisfaction level will be presented. The study will give
an insight of the existing gaps in the performance of pharmacy services and patient
satisfaction level and will show a way forward to bring improvement in the system.
 Key words

Customer satisfaction; Hospital pharmacy; Patient satisfaction; Quality services;

 INTRODUCTION

1. The health care system is an engine for innovation that develops and broadly
distributes progressive, life-enhancing treatments and offers a wide set of choices for
consumers of health care. The existing health care system should provide massive assistance,
as there are considerable opportunities for improvements that would cut down costs, increase
opportunities, enhance value, and improve the health of the citizens. An individual’s health
can be maintained or improved in many ways by introducing changes in individual behavior
and through proper consumption of health care services.
Pakistan has achieved improvement in social, agricultural abundance economic sectors.
However, the progress of the health sector in Pakistan could not be overlooked as we still lack
in many ways and need to expand in many directions. The health care system is in progress
and is moving towards improvement. Pakistan has tried to make much betterment in its
healthcare delivery system and has brought out many reforms.

2. Pharmacy is an establishment that deals with the provision, preparation and delivery
of medicines not only to the admitted patients but also to the outdoor patients according to the
prescription of physicians, ensuring the safety and health of patients in effective manners.
Pharmacy is the backbone of any good hospital and health care delivery system. Different
hospitals adopt different health services. The hospital pharmacy practice includes not only
conventional roles like compounding and dispensing medication but also helps patients
regarding actions and reactions of the drugs prescribed to them.

3. Community pharmacies are an integrated part of the healthcare system globally.

These pharmacies play a very vital role in providing medication and patient care services.
During the last three decades, philosophies of pharmacy practice have changed worldwide
from apothecary to effective therapy, with ensured patient safety and a reduction in treatment
cost, supported by collaboration with other healthcare providers. In earlier decades, various
innovative communal pharmacy services have been successfully established to provide
sufficient health outcomes for many clinical areas. Modern community pharmacy practices
exhibit a standard shift from providing medicines to clinical activities. (Aziz et al., 2019)

4. Nowadays hospital pharmacy includes modern services related to health care, like
clinical advice, reviewing medication for safety and efficacy, and providing drug information.
In recent years, as standards of living have improved, there is an increasing demand for better
health care as well. With improved lifestyles, improvement in the quality of medical care
services has become a primary concern for patients and health providers. For provision of
better services to patients, quality has become increasingly important for hospitals in respect
of sustaining and retaining patients. Hospitals that fail to understand the importance of
delivering quality services and customer satisfaction may be inviting a possible loss of
patients whereas hospitals that value patients and their demands and needs experience loyalty
from patients to their hospital.

5. Patients’ satisfaction is related to the extent to which general healthcare needs and
condition-specific needs are met. Assessment of patient satisfaction with health services is
clinically relevant, as content patients are more likely to comply with treatment. They take an
active role in their care to continue using pharmacy services and stay within a health care
facility and maintain loyalty with a definite system. So pharmacy service is an essential
element of the healthcare system that has a direct contribution to improving public health and
positive health results.(Kebede et al., 2021)

6. Patient satisfaction is widely used to measure the quality of healthcare by identifying

potential areas for improvement and to increase the effectiveness of the healthcare system. A
local study conducted among patients visiting public health clinics showed that the more
satisfied groups were less educated and elderly. (Ismail et al., 2020)

7. There is growing pressure to demonstrate and improve the quality of health care
delivered in community pharmacies. This demand is partly driven by the need to determine
and evaluate the extended role of community pharmacy teams that contributes towards health
service delivery and the reduction of pressure on other health sectors. (Alhusein & Watson,
2019)

8. Patient satisfaction data can be used for different purposes. It includes improvement in
potential areas for health care services. This data can provide a comparison of quality of
different health care programs. It also assists in the identification of patient dissatisfaction
level and disenrollment of certain health care plans. Patient satisfaction is not only a quality
indicator but can predict health-related behavior of patients as well. Research on patient
satisfaction with assessment of quality of services provided by pharmacies began almost 3
decades back. A significant body of literature is available internationally. However, very less
amount of research work has been done on this aspect in Pakistan.

9. An evaluation of hospital pharmacy practices is essential to assure that they meet the
global standards and to prioritize practice advancements. An assessment of hospital pharmacy
functioning was first conducted in 1998 by the American Society of Health-System
Pharmacists (ASHP) using a nationwide survey. The survey examined the role of the
pharmacist in distinct stages: prescribing, transcribing, dispensing, administrating, monitoring,
and educating patient.(Almaghaslah et al., 2021)

10. POF Hospital was established in 1962 with an initial capacity of 103 beds. Current
bed strength is 676 due to introduction of new departments over following years. It is now a
modern tertiary care hospital providing teaching facilities to Wah Medical College. The
hospital is responsible to provide health care facilities to serving/ retired POF’s employees and
family/parents of the employees, army personnel posted to POF (including their families/
parents) and employees of associated departments (CMA, IDA etc.) The hospital also extends
diagnostic, investigative and treatment facilities to general community living in the area on
payment.

11. POF Hospital has been endeavoring since its foundation to provide comprehensive
health care services to its clientele. The entire effort of the hospital consists of acquiring best
qualified human resources in the form of specialists and staff, modern diagnostic facilities and
therapeutic procedures but also provision of quality medicines in a congenial manner to cure
the patients.

12. The medical store functioning in POF hospital is the backbone of the setup. It
provides all types of indoor as well as outdoor treatment facilities. The health of the POF
employees and their families is fundamental to the welfare of the organization. Barriers to
better health include deprivation and inadequate access to quality medical opportunities, lack
of access to specialized health professionals and care, an insufficient health workforce,
unreasonable cost of care and poor standards of education of health-care professionals. So, to
overcome all these parameters a good internal and external audit of the entire pharmacy setup
is required. This study will give us an opportunity to develop the strategies to meet the
patient’s expectations and improve the quality of care and services being offered by the
medical store.

13. The aim of POF Hospital pharmacy is to provide medicines to patients in a

convenient and efficient manner within minimum possible waiting time and also making
patients comfortable in congenial environment. This study will not only endeavor to evaluate
the working of pharmacy and level of patient satisfaction but will also identify the problem
areas on part of service providers so as to solicit recommendations for further improvement.
 LITERATURE REVIEW
SECTION –I

Origin and Development of Pharmacy

The word Pharmacy  comes from Greek word “Pharmakon” which implies a

drug or medicine. The word pharmacy has been in use since 15-17TH centuries. It not only
implies the profession but also the shop where the drugs are sold and dispensed.

a. Before the Dawn of history. Ancient man learned from instinct, from observation of birds
and beasts. Cool water, a leaf, dirt, or mud was his first soothing application. By trial, he
learned which served him best. Eventually, he applied his knowledge for the advantages of
others.

b. Pharmacy in Ancient Babylonia. Babylon, jewel of ancient Mesopotamia, often called

cradle of civilization; it provides the earliest known practice of the art of the apothecary.
Practitioners of healing of that era (about 2600 B.C.) were Priest, Pharmacist and
Physician beat one.

c. Pharmacy in Ancient China. Chinese pharmacy stems from Shen Nung (about 2000 B.C.),
an emperor who sought out and investigated the medical value of several hundred herbs.
Medicinal plants included podophyllum, rhubarb, ginseng, stramonium, cinnamon bark,
ephedra etc

d. Theophrastus - Father of Botany. Theophrastus (about 300 B.C.), was the best early Greek
philosopher and biologist. He was also called the ‘father of botany”. His observations and
writing regarding with the medical qualities and peculiarities of herbs are unusually accurate,
even within the light of present knowledge.
e. earthenware an Early “Trademarked” Drug. Man learned early of the
celebrated advantage of trademarks as a way of identification of source and of gaining
customers confidence. one in every of the primary therapeutic agents in contact like mark
was Samian ware (Sealed Earth), a clay tablet originating on the Mediterranean island of
Lemnos before 500 B.C.

f. Dioscorides A Scientist Looks at Drugs. Pedanios Dioscorides (first century A.D.)

contributed mightily to such a transition in Pharmacy. He observed, recorded and spread the
exceptional rules for collection of medication, their storage and use. His texts were considered
basic science as late because the sixteenth century.

g. Monastic Pharmacy. During the center age era, the western knowledge of pharmacy and
medicine were reserved within the monasteries (fifth to twelfth centuries). Manuscripts from
many islands were translated or copied from monastery libraries. The monks gathered herbs
and raised them in their own herb gardens. They want to prepare medicines consistent with the
art of apothecary for the advantage of sick and injured.

h. the primary Apothecary Shops. The Arabs separated the art of apothecary and Physician
from each other They established the primary privately owned drug store in Baghdad in late
eighth century. They preserved most of the Greco-Roman wisdom to boost the art of drugs.
They also developed syrups, confections, H2O and alcoholic liquids with the help of their
natural resources.

i. Avicenna -The “Persian Galen”. Among the brilliant contributors to the sciences of
pharmacy and medicine during the Arabian era was one genius who seems to face for his time
– the Persian Ibn Sina (about 980 to 1037 A.D.), also called Avicenna by the western world.
He was a pharmacist, poet, physician, philosopher and diplomat. He made contribution to the
sciences of pharmacy and medicine by his pharmaceutical teachings.
j. Separation of pharmacy and medicine. In European countries, public pharmacies began to
look within the 17th century. In Sicily and southern Italy, pharmacy was separated from
medicine for the primary time.

k. the primary Official Pharmacopoeia. the concept of a pharmacopoeia with official status,

to be followed by all apothecaries, originated in Florence. The Nuovo Receptario, originally
written in Italian, was published and have become the legal standard for city – state in 1948.

l. The Marshall Apothecary. Christopher Marshall, an Irish immigrant, established an

apothecary shop in Philadelphia in 1729. For next 96 Years this pioneers pharmaceutical
enterprise became a number one mercantile establishment, nucleus of large-scale chemical
manufacturing; a “practical’’ training school for pharmacists; and a crucial supply depot
during the Revolution. Christopher earned the title of “The fighting quaker” during the
Revolution.

m. First Hospital in Colonial America. Colonial America s’ first hospital (Pennsylvania)

was established in Philadelphia in 1751.The first hospital pharmacy began in 1752. First
hospital pharmacist was Jonathan Roberts; but it absolutely was his successor, John Morgan,
whose practice as a hospital pharmacist (1755-56), and whose impact upon pharmacy and
medicine influenced changes that led to the event of professional pharmacy in north America.

n. Scheele – Greatest of the Pharmacists Chemists. During his few short years Carl
Wilhelm Scheele gave to the planet discoveries that have bought its people incalculable
advantages. He made thousands of experiments, discovered Oxygen, Chlorine, Molybdenum,
tungsten, hydroxy acid, glycerin, nitroglycerine, and countless other organic compounds that
entered in today’s existence, industry, health, and luxury.

o. Craigie – America’ s First Apothecary General. the primary man to carry the rank of a

commissioned pharmaceutical officer in an American Army was the Bostonian apothecary,
Andrew Craigie. His duties included procurement, storage, manufacture and distribution of the
Army’ drug requirements. He also developed an early wholesaling and maker.
 SECTION –II

ROLE OF MUSLIMS IN PHARMACY PRACTICES

15. Prophet of Islam Hadhrat Muhammad Salalah o alaihi Wasalam

Holy prophet told astonishing facts about Anatomy, physiology of the body,
health principles, characteristics of medicines, benefits of various vegetables and fruits etc.
Islam has also established some rules that make a healthy society like instructing the Muslims
to scrub their bodies, foodstuff, houses and streets. Islam has also mentioned the items and
practices which are harmful for the body and prohibited them. It instructed the Muslims to
concentrate to the cleanliness of their bodies, mind and health, and has even considered this
among the characteristics of religion. Islam was the primary religion that suggested a system
of treatment and protection against illness which is kind of just like medical quarantine that
was adopted by modern countries to stop diseases and epidemics.

16. There are many traditions of Bukhari and Muslim which shows that individuals use
to return to the prophet [PBUH] regularly and tell him about their ailments. He accustomed
advise them to urge the medicines first and so pray to God to induce eliminate diseases. On
several occasion he himself suggested medicines. for example, for loss of appetite he
frequently advised to require Talbina, a preparation of Barley and dates. Senna could be a
medicine accustomed recommended for constipation, also used now a days for same purpose.
He also recommended regular use of honey for keeping fit, similarly for various ailments he
wants to advise for taking herbal drugs like Olive, Black Cumin, Chicory, Endive Fenugreek,
Ginger, Marjoram, Saffron, Vinegar etc. He also emphasized on the importance of cleanliness
by practicing waddu five times every day before every prayer.

17. Some relevant hadith (saying and quotations of Holy prophet [PBUH] are as under.

a. O slaves of Allah! Seek medical treatment, for Allah has not sent a disease without sending
a remedy for it.”
b. If you hear a few plagues breaking get in a land, don't enter it and if it appears during a land
during which you happened to be, don't leave it.” (Al-Bukhari)”. This hadith shows the
knowledge of Prophet of Islam about the results and prevention of communicable diseases.

c. Cleanliness is half of faith (Iman). This hadith shows the importance of, and emphasis on
hygiene and sanitation.

18. Muslim’s contributions to the medical medicines.

within the medical Islamic culture medicine was a central a part of focus. Islamic Physicians
and students, responding to circumstances of your time and place, developed an outsized and
complicated medical literature exploring and synthesizing the speculation and practice of
medicines. Islamic medicine was initially built on tradition, chiefly the theoretical and
practical knowledge developed in Arabia and was referred to as at prophet’s time. Ancient
Hellenistic medicine like Unani, Ancient Indian medicine the Ayurveda, the old Iranian
medicine of the Academy of Gundishapur, the work of Greek, and Roman’s physicians
Hippocrates, Galen and Dioscorides also has impact on Islamic medicines. Ophthalmology
(the field of Eye diseases] has been described because the most successful branch of drugs that
was researched at that point. The works of Ibn Alhathim still remained an authority within the
field of ophthalmology until early present.

19. Muhammad Bin Zakaria “Al –Razi” More commonly called al Razi was the chief
surgeon in many hospitals within the cities of Rey and Baghdad, and have become an advisor
to Muslim’s rulers of the time. He earned the title “Galen of Arabs” because of his authority
and achievements in medicine, and was considered the daddy of Islamic medicine, he greatest
physician of Muslim world yet as an Honorable Philosopher. he's known for separating the
“the science of physic, into two different aspects; physical and spiritual. The physical house
the “physiological diseases. “While the later controlled the spiritual self. He felt that so as to
know the science of the body completely, a doctor should be a master of both physical and
spiritual knowledge regarding the body. Al-Razi was also curious about medical Ethics, about
which he wrote Ahlaq al –Tabeeb. In Ahlaq Al-Tabeeb (Medical Ethics) Al-Razi wrote about
the morality in medicine. He introduced the primary model for ethics. He felt that it absolutely
was important not just for physician to be an expert in his field, but also to be a task model.
His ideas of medical Ethics were divided into three aspects: The physician’s responsibility to
patients and to self, and also the patients’ responsibilities of patients.

20. Additionally to being a famous physician, Al-Razi is understood for being an

encyclopedic scholar, compiling quite 200 works during his life time, half of them on
medicine.

a. The Kitab-al Hawi fi al-Tibb (The comprehensive book of medicine) was one in all his
largest works a group of medical notes that Al-Razi made throughout his life within the kind
of extracts from his reading and observations from his own medical experience. In its
published form, it consists of 23 volumes, each cater to specific parts of diseases of the body,
although the grouping of illnesses is often idiosyncratic. Al Hawi remained a text book on
medicine in most European universities, regarding until the seventeenth century because the
comprehensive work ever written by a caregiver.

b. Al Mansuri (Liben Almansoren) was written by Mansur ibn Ishaq ibn Ahmed. The book
consists of books based mainly on Greek science. It remained as a textbook for medical
students for hundreds of years.

c. kitab Tibb al-Muluki (Regius). This book covers the treatments and cure of diseases and
illnesses through dieting. it's thought to own been written for the noble class who were known
for his or her gluttonous behavior and who frequently became ill with stomach diseases.

d. other works include a Dissertation on the reason behind Coryza which occurred within
the spring when rose emit their scent, a tract within which Al-Razi discussed why it's that one
contracts coryza or respiratory disease by smelling roses during the spring season.

e. Bur’al Sa’a (Instant Cure) during which he named medicines which instantly cured
certain diseases.

21. Abu-Ali al-Husayn ibn Abdalah ibn Sina : Abu Ali al-Husayn ibn Abdalah ibn-Sina,
who more commonly known as Ibn-Sina (or Avicenna) was an Iranian Philosopher and
physician of tenth and eleventh centuries. He was famous for his scientific works, but
specially his writing on medicines. Ibn-Sina is credited with many varied medical
observations and discoveries, such as recognizing the potential of air borne transmission of
diseases., providing insight into many psychiatric conditions, recommending use of
forceps in complicated deliveries due to fetal distress, differentiating central from
peripheral facial paralysis and describing trigeminal neuralgia particularly. His most
famous work included Al-canon fi Al-Tibb (The cannon of medicine), and also the Book
of Healing. His other efforts include subjects of angiology, heart medicines and treatment
of kidney diseases.

22. Avicenna’s medicine became the representative of medicine mainly through

influence of his famous work al-Canon fi Al-Tibb (The cannon of medicine). The book
was originally used as a textbook for instructors and students of medical science in the
medical school of Avicenna. The book is divided into 5 volumes; The first volume is a
compendium of medical principles, the second is reference for individual drugs, the third
contains organ specific diseases, the fourth describes systemic illnesses as well as section
of preventive health measures, and the fifth contains description of compound medicines.
The canon was widely use in medical schools and by later medical writers for further
research.

23. Other scientists: List of Muslim scientists is too long, however names of few
famous scientists related to the fields of medicines and allied fields are given below.

24. Physicians and Surgeons

i. Khalid ibn Yazid (Calid)

ii. Jafar al Sadiq

iii. Shapur ibn Sahl (d.889), Pioneer of pharmacy and pharmacopia

iv. Abbas ibn Firnas

v. Al-Kindi (Alkindus) (801-873) Pioneer of pharmacology

vi. Al- jahiz, pioneer of natural selection

vii. Ali ibn Sahal Rabban ai-Tabbari, pioneer of medical encyclopedia

viii. Ahmad ibn Sahal al-Balki

 ix. Ishaq bin Ali al-Rahwi (854-931) Pioneer of peer Review and medical peer

review

x. Al Farabi (al-Pharabius)

xi. Ibn Al-Jazzar (circa 898-980)

xii. Abu Hasan Al-Tabari-Physician

xiii. Ali ibn Sahal Rabban Al-TAbari-physician

xiv. Ali ibn Abbas Al-Majusi (d.994), pioneer of obstetrics and perinatology

xv. Ibn Bajjah (Avempace)

xvi. Averroes

xvii. Ibn al-Baitar

xviii. Ibn Jazla

xix. Ibn al Quff (1233-1305) pioneer of embryology

xx. Kamal al-Din al-Farasi

xxi. Ibn al-Khatib

xxii. Mansur ibn Ilyas

xxiii. Saghir Akhtar-Pharmacist

xxiv. Syed Zia ur Rehman, Pharmacologist

xxv. Toffy musivand

xxvi. Muhammad B. Yunus, the “father of our modern Fibromyalgia

xxvii. Hulusi Behcet, known for discovery of Behcet’ s disease.

xxviii. Mehmet QZ, cardiothoracic surgeon

 SECTION –III

Elements of pharmaceutical care:

24. Pharmacy practice has changed significantly since the past years from product
oriented to patient-oriented practice to ensure the best drug therapy and patient safety and
continues to advance towards the provision of pharmaceutical care.

Pharmaceutical care as a concept was first discussed in 1990 and was officially endorsed and
defined in 1993 as “The direct responsible provision of medication-related care for the
purpose of achieving definite outcomes that improve patient’s quality of life”

25. Pharmaceutical care is a professional training, the patient being the main beneficiary.
This practice involves the responsible provision of pharmacotherapy to achieve definite results
related to the improvement of the patient’s health and quality of life. Several studies carried
out in other countries addressing patient satisfaction with pharmaceutical care in community
pharmacies showed that the provision of pharmaceutical care contributes to patient
contentment.

26. Elements:

a. Medication Related. Pharmaceutical care involves not only medication therapy but also
choices about medication use for individual patients. As suitable, this includes decisions not to
use medication therapy as well as judgments about medication selection, dosages, routes and
methods of administration, medication therapy monitoring, and the provision of medication-
related material and counseling to individual patients.

b. Care. Overall patient care consists of integrated domains of care including medical care,
nursing care, and pharmaceutical care. Health professionals in each of these disciplines
possess exceptional expertise and must cooperate in the patient’s overall care. At times, they
share in the execution of the various types of care. To pharmaceutical care, however, the
pharmacist contributes unique knowledge and abilities to ensure optimal outcomes from the
usage of medications. At the center of any type of patient care, there exists a one-to-one
communication between a health-care provider and a patient.
The health and well-being of the patient are supreme. The health care provider makes a direct,
personal, caring commitment to the individual patient and acts in the patient’s finest interest.
They cooperate directly with other professionals and the patient in designing, implementing,
and monitoring a therapeutic plan intended to produce definite therapeutic outcomes that
improve the patient’s quality of life.

c. Results. It is the goal of health care provider to improve an individual patient’s quality of
life through achievement of definite (predefined), medication-related therapeutic outcomes.
The outcomes sought are

1. Cure of a patient’s disease.

2. Elimination or reduction of a patient’s symptomatology.

3. Arresting or slowing of a disease process.

4. Prevention of a disease or symptomatology.

A medication-related problem is an event or circumstance involving medication therapy that

actually or potentially interferes with an optimum outcome for a specific patient. Following
are some categories of medication-related problems:

• Untreated indications. The patient has a medical problem that requires medication therapy
(an indication for medication use) but is not receiving a medication for that indication.

• Improper drug selection. The patient has a medication indication but is taking the wrong
medication.

• Subtherapeutic dosage. The patient has a medical problem that is being treated with too little
of the correct medication.

• Failure to receive medication. The patient has a medical problem that is the result of not
receiving a medication (e.g., for pharmaceutical, psychological, sociological, or economic
reasons).

• Overdosage. The patient has a medical problem that is being treated with too much of the
correct medication (toxicity). Medication Therapy and Patient Care: Organization and
Delivery of Services–Statements 331 332 Medication Therapy and Patient Care: Organization
and Delivery of Services–Statements
• Adverse drug reactions. The patient has a medical problem that is the result of an adverse
drug reaction or adverse effect.

• Drug interactions. The patient has a medical problem that is the result of a drug–drug, drug–
food, or drug– laboratory test interaction.

• Medication uses without indication. The patient is taking a medication for no medically valid
indication.

Thus, in an imperfect world, intended outcomes from medication-related therapy are not
always achievable. Patients bear a responsibility to help achieve the desired outcomes by
engaging in behaviors that will contribute to—and not interfere with—the achievement of
desired outcomes. Pharmacy workers and other health professionals have an obligation to
educate patients about behaviors that will contribute to achieving desired outcomes.

d. Quality of Life. Some tools exist now for assessing a patient’s standard of living. These
tools are still evolving, and health care professionals should maintain familiarity with this
subject. A complete assessment of a patient’s quality of life should include both objective and
subjective assessments. Patients should be involved, in an informed way, in establishing
quality-of-life goals for their therapies.

e. Responsibility. The fundamental association in any type of patient care is a mutually

beneficial exchange in which the patient grants authority to the provider and the provider
gives competence and commitment to the patient. Responsibility involves both moral
reliability and accountability. In pharmaceutical care, the direct relationship between an
individual health care provider and an individual patient is that of a professional covenant in
which the patient’s safety and wellbeing are entrusted to the health care provider, who
commits to honoring that trust through competent professional actions that are in the patient’s
best interest.

As an answerable member of the health-care team, the pharmacy workers must document the
care provided. The pharmacist is personally accountable for patient outcomes that ensue from
the pharmacist’s actions and decisions.
 SECTION –IV

Quality of Services:

27 Hospitals vary from each other in terms of their specialty, services offered, and
resource availability. Their services are widely measured with scales that gauge patients’
perspective. Across the world, economic conditions shape people’s expectations of service
quality and their lifestyle. Patients’ perceptions play an important role within the failure of any
product or service. Consequently, organizations develop tactics to supply greater service
quality to customers to thrive within the current economic climate.

a. Concept of Quality: the concept of quality originated in manufacturing organizations, but

it's equally significant for service organizations. it's now well recognized that the supply of
quality services is closely related to organizations’ incremental customer satisfaction,
consumer maintenance, consumer commitment, budgets and productivity, facility assurance,
and economic presentation. (Shafiq et al., 2017). In health care system, customers and
consumers are mainly the patients who are using the service

b. Patient Adherence: It's a crucial humanistic testimony to see the end result, services and
sustainability of any health care system. The evidences promulgate that satisfied patients
uphold good relationship with their health care providers and cling to treatment that ultimately
led to higher health outcomes. More satisfied patients are persistent in using the identical
health care services and values their health care providers. (Aziz et al., 2018)

c. Pharmacy services Pharmacy services are increasingly expanded beyond simple

medication supply to become a more patient-centered and caring service. (Ayalew et al.,
2017).

A patient’s perception of the service provided by a health care provider is crucial for the
successful delivery of health care. The patient’s perspective as a humanistic outcome can
improve the service provision and increase the help-seeking behavior of the patient, leading in
to higher adherence, or increase the patient’s commitment toward the service provider.
Moreover, as some health care systems aim to supply special reimbursements sure enough
service elements provided within the pharmacy, like consultation, analyzing variations in
commission quality are important from a health system and a policy perspective. (Guhl et al.,
2019)

d. Enhanced pharmacy services: These are identified as a mechanism to deal with medicines
and drug-related problems. Over recent decades, there has been considerable worldwide
increase within the morbidity and mortality related to chronic diseases. This has been linked
with lack of individualized patient care and consequent medication-related issues.

e. Roles of International organizations: World Health Organization (WHO) and also the
International Pharmaceutical Federation (FIP) have recognized the requirement to develop
pharmacy services as the simplest way to fulfill the fast-growing demand for safe and quality
uses of medicines, alongside affordable healthcare service provision.

f. Current situation in Pakistan: Pakistan may be a low- and middle-income country

(LMIC) that has been recently ranked not up to all other South Asian countries at 152th out of
189 countries. Pakistan is fighting variety of threats to the optimal use of medicines, including
high prevalence of medication errors and adverse drug reactions, misuse of controlled, and
excessive self-medication. there's also a growing list of medicine-related issues that demand
immediate participation of pharmacies within the patient’s welfare, including over-the-counter
(OTC) availability of prescription medicines, inappropriate use of medicines, formulation
issues, unsafe storage and disposal of medicines, and poor availability of medicines.

g. Health conditions for female population: Additionally, poor health within the female
population, elderly, and medically underserved rural populations in Pakistan need scalable and
affordable community pharmacy services, like health screening (e.g., diabetes., cholesterol,
osteoporosis), timely immunizations, pain control, and home-based supplying and planning
services. (Atif et al., 2020)
h. Communication skills: Communication skills on pharmaceutical services are necessary for
effective interactions. Pharmacies are required to positively interact with patients and
contribute to the suitable use of the drugs while simultaneously building mutual trust. They
also give advices and offer guidance on the side effects of the medication and warn them
about the items that may be harmful when using that drug. Hence, communication and
understanding between the patient and healthcare workers significantly contribute to the
patient’s views and feelings toward the services of the professional. (Ragma, 2018)

i. Medication counselling: Modern pharmacy practices display an evolving example from

traditional drug dispensing to more active and expanded clinical roles, including patient-
oriented medication counseling activities. Medication counseling refers to “providing
medication information orally or in written form to the patients or their representatives on
directions of use, advice on side effects, precautions, storage, diet, and lifestyle modifications”
 SECTION –V

Good Pharmacy Practices:

28. Good pharmacy practice is an integral a part of a health-care system. It

consists of a well-functioning system that works harmonical with the requirements of patients.

It is considered that top level of customer’s approval is going to be achieved if Good

Pharmacy Practice (GPP) is realized within the pharmacy, and therefore the roles played by
pharmacists and their assistants as anticipated by patients and people. per the FIP/WHO, GPP
is

“The practice of pharmacy that responds to the requirements of the those who use the
pharmacists’ services to produce ideal, evidence-based care.”

29. An honest quality pharmacy service will assure pharmacists to arrange, obtain,
store, secure, distribute, administer, dispense, and lose medical products, provide effective
medication therapy management, maintain and improve professional performance, and
contribute to boost effectiveness of the health-care system and public health. (Ayalew et al.,
2017)

30. The concept of excellent Pharmacy Practices (GPP) and Pharmaceutical Care (PC)
orbits around ideal patient care with improved quality of life. Since the standard assessment
proportionate with patients ‘satisfaction, the standard standards of GPP and PC carry
substantial importance in healthcare system. the standard of pharmaceutical services is
evaluated on three aspects including structure, process, and outcome. The structure includes
assets and settings, while the method comprises actions, and outcomes include the results of
the care on the individual’s health. (Alotaibi et al., 2021)

31. Patient views towards pharmacy practices: These are valuable predictors for
estimating health service management and provision systems. Patient perception is
additionally a very important indicator by which to gauge community pharmacy services. This
feedback from patients helps to advance pharmacy services. Community pharmacies can
develop policies and techniques to enhance their services on the premise of patients’
preferences and choices. (Aziz et al., 2019)
32. Drawbacks in today’s time: It's against the law for pharmacists to diagnose a patient’s
disease or to dispense medications without prescription in pharmacies. Unfortunately, many
pharmacists still dispense medications for chronic diseases, oral contraceptives, and antibiotics
without prescriptions in their pharmacies. (Al-Jedai et al., 2016)

33. Client satisfaction of pharmacy services: it's a vital tool to live the amount of pharmacy
services offered to consumers and therefore the application of pharmaceutical care in
hospitals. Clients or patients who are satisfied with the service provided are more likely to
require medications properly and fewer likely to vary from one health care professional to a
different. during this way the patient will develop trust towards the care providers and can
become confident with their treatment. the most idea of maintaining client satisfaction is by
providing higher quality and reliability in pharmaceutical services with none shortcomings.
(Semegn & Alemkere, 2019)

34. Underlying philosophy: The mission of pharmacy practice is to contribute to health

improvement and to assist patients with health problems to form the simplest use of their
medicines. There are six components to the present mission:

— being readily available to patients

— identifying and managing or triaging health-related problems

— health promotion

— assuring effectiveness of medicines

— preventing harm from medicines

— making responsible use of limited health-care resources

35. Requirements of excellent pharmacy practice:

• GPP requires that a pharmacist's first concern altogether settings is that the welfare of
patients.

• GPP requires that the core of the pharmacy activity is to assist patients make the most
effective use of medicines. Fundamental functions include the availability of medication and
other health-care products of assured quality, the availability of appropriate information and
advice to the patient, administration of medication, when required, and also the monitoring of
the results of medication use.

• GPP requires that an integral a part of the pharmacist's contribution is that the promotion of
rational and economic prescribing, also as dispensing.

• GPP requires that the target of every element of pharmacy service has relevancy to the
patient, is clearly defined and is effectively communicated to all or any those involved.
Multidisciplinary collaboration among health-care professionals is that the key factor for
successfully improving patient safety

36. Many studies conducted previously state that the behavior and attitude of the health-
care providers and pharmacy workers play a key role in developing an honest relationship
with the patients. For general services, pharmacist attitude, medication accessibility,
convenience, pharmacy facilities, and site were found to strongly influence patient satisfaction
positively. All of those if provided are considered under good pharmacy practice. (Ayalew et
al., 2017)
 SECTION –VI

Role of Pharmacy Technicians:

37. In the community setting, pharmacists tackle the normal roles of dispensing and
counselling. the three classes of medication are:

a) over-the-counter (those that may be accessed without a prescription, which are within
patients’ reach),

b) behind-the-counter (those dispensed by a pharmacist without a prescription, which don't

seem to be within patients’ reach),

c) prescription (those that need a prescription). (Al-Jedai et al., 2016)

38. The obstacles for a health care service includes poor access to quality medicine,
unaffordable cost of medicine, poor education and lack of access for skilled health
professionals.

In low-income countries like Pakistan, about 75% of hospitals didn't have waiting rooms in
hospital pharmacies which caused dissatisfaction with pharmaceutical services. Unavailability
of convenient facilities like chairs, water facility and reading materials within the room may
compromise client satisfaction. Long waiting time before they received service is additionally
one factor that affects client satisfaction. (Semegn & Alemkere, 2019)

39. Pharmacists, unitedly with other health professionals, have a responsibility to

boost the standard of care among patients. Since the healthcare system has moved from
episodic care to population health management and from volume to value-based care, the role
of pharmacists and health-care workers and their contribution has been emphasized in
treatment and prevention of chronic diseases and their related complications. The outpatient
hospital pharmacy (OPh) may be a priority area of the pharmacy department in hospitals as a
result of an outsized number of visiting patients and also the subsequent economic impact on
the healthcare system. Adequate use of human and financial resources during this area directly
improves patient ‘s health outcomes. (Alotaibi et al., 2021)
40. Pharmacists, Pharmacy Technician and Nurse:

The Pharmacist, Pharmacy Technician or dispenser in pharmacy and nurse, male or female are
the key persons chargeable for smooth functioning of pharmacy and ward.

a. The Pharmacist: A pharmacist is a crucial person working in pharmacy for careful

interpretation of physician’s prescription and dispensing of medication to the patient, agent of
patient or to ward for indoor patients, consistent with the recommendation of physician. The
role of pharmacist has shifted from the classical ‘lick ‘’ ‘stick” and pour’ dispensary rules
(that is “lick and stick” the labels count and poor the pills”), to being an integrated member of
the pharmacist undergo university-level education to know mechanism of action of
medication, drugs use and therapeutic rules side effects potential interactions and monitoring
parameters. this can be mated to education n Anatomy, physiology and pathophysiology.
Professional interpretation and communization of this specialized knowledge to patients.
physician and other health care providers are function which pharmacists provides, and are
central to the supply of safe and effective drug therapy. Rule of pharmacist includes:

(1). Clinical medication management, including reviewing and monitoring of physician

prescriptions before issue of medicines.

(2). Assessment of patients with undiagnosed or diagnosed conditions and asserting clinical
medication management needs.

(3). Specialized monitoring of disease states, like dosing drugs in renal and hepatic failure.

(4). Compounding medicines.

(5). Providing pharmaceutical information.

(6). Providing patients with health monitoring and advice, including advice and treatment of
common ailments and disease states.

(7). Supervising pharmacy technicians and other staff.

(8). Oversight of dispensing medicines on prescription

(9). Pro-vision of non-prescription or over the counter drugs

(10). Education and counselling of patients and other health care providers on optimal use of
medicines (e.g., proper use, avoidance of over medication

(11). Referral to other health care provider if necessary

(12). Pharmacokinetic evaluation.

(13). Promoting public health by administering immunizations.

b. Pharmacy Technician: A pharmacy technician could be a health care work who performs
dispensing of medicines and related jobs at hospital pharmacy. he's employed usually under
the supervision of a certified and licensed pharmacist. He also sometimes works in an
exceedingly long-term care facility, pharmaceutical manufacturers, third party insurance
companies, computer software companies or in government or teaching. Job duties including
dispensing pharmaceuticals and other devices to patients and instructing on their use. they will
also perform administrative duties in pharmaceutical practice like reviewing prescription
request with doctors’ offices insurance companies to make sure correct medications and
provided and payment is received.

Pharmacy technician do a range of tasks related to preparing and dispensing prescribed

medication to patients but can also perform compounding of medicines, provide advice for
nonprescription medications, Inventory and track medication and provide orders and follow
abreast of payment and other administrative tasks. counting on the character and organization
of health care system, particularly the provision of licensed pharmacist s and other support
staff (such as generally pharmacy aides), Pharmacy technician may counsel patients on the
correct use of medicines oversea the operational management of the dispensary and /or
perform routine.
 SECTION –VII

Patient Satisfaction:

41. Patient Satisfaction: It is defined as a subjective emotional opinion based mainly on

patient expectation and their previous experiences compared to the currently received service.
Within the services sector, special attention is paid to the actual fact that patient satisfaction is
connected not only with what the patient receives but also largely with how the whole process
proceeds. For this reason, reaching to know patient needs and expectations, like their
satisfaction with the services provided, seems essential for the event of patient-centered care.
(Bratkowska et al., 2020)

42. Patient satisfaction also can determine the degree of competitiveness among
healthcare organizations. Patients perceive their satisfaction to be supported the hospital’s
responsiveness to their views and wishes, the standard of the healthcare services delivered by
the hospital, and therefore the overall doctor-patient relationship. Therefore, it's vital for
hospitals to grasp the determining factors of patient satisfaction. Hospitals have to assess what
patients’ value and the way they perceive the standard of care. Hospitals can use patient
satisfaction information to work out a way to improve service quality, the acceptable methods
to use, and also the timing for using these methods. (Lim et al., 2018)

43. Patient satisfaction could be a multidimensional concept, still lacking complete

construct consistency, inspired by a broad set of promoting and healthcare theories. We take
as a reference the definition of Linder-Pelz that views patient satisfaction because the

” Positive evaluations of distinct dimensions of the health care”.

In this manner, patient satisfaction with pharmacy services informs quality management
events in the least levels of the health care system, increases patient adherence to medication
(e.g., diabetes, and improves patient education regarding their own condition (e.g., the
importance of home vital sign monitoring, or public health issues generally. (Druică et al.,
2021)

44. Patient satisfaction is an indicator which will be accustomed evaluate the excellence
of healthcare services. The measure of patient satisfaction as a patient’s subjective assessment
of healthcare service could be a significant parameter to boost the power in both community
and hospital settings. It also indicates the break between the quality-of-service expectation and
patient perception. Assessing patient satisfaction is an approach to spot and consider changes
in patient needs, that the results may be wont to conduct program assessments for improved
services and maximize the professional capacity in pharmacies. (Larasanty et al., 2019)

45. Satisfaction of patients for pharmaceutical services: Satisfaction of patients reflects

their likings and expectations, and also the realities of care. it's important to grasp the extent of
dissatisfaction for pharmaceutical services. The evaluation of satisfaction will help to spot the
precise areas of the service in dire necessity of improvement and also enhance the positive
changes within the current pharmaceutical services. This successively will provide
information to optimize services to confirm clients’ health outcomes by addressing their
concerns and needs (Alotaibi et al., 2021)

46. Patients who are contented with pharmaceutical services are more likely to require
their medications properly and fewer likely to vary from one healthcare to a different Hence,
consistent provision of high-quality pharmaceutical services to patients that meets their
expectation could be a crucial step within the process of maintaining such satisfaction.
Therefore, understanding the extent of dissatisfaction with pharmaceutical services and its
associated factors are going to be a key commencement toward optimizing such aspects of
healthcare. (Nigussie & Edessa, 2018)

47. Provision of pharmaceutical facilities may be a business making way; therefore,

customer satisfaction should be one amongst the essential aims. While assessing clients’
satisfaction with pharmaceutical services it had been underlined that the attitude and behavior
of the pharmacist and provision of data about drugs to clients were important. (Semegn &
Alemkere, 2019)

48. Factors affecting patient satisfaction:

Patient satisfaction will be plagued by a range of things, including a patient’s individual

characteristics. Association between these characteristics like age, gender, educational status,
religion, race, legal status (etc.), and patient satisfaction are widely inconsistent and
contradictory across studies. Additionally, to individual characteristics, clinical settings either
outpatient or inpatient are found to moderate patient satisfaction. Evidence suggests, as an
example, greater satisfaction within the outpatient reconstruction of anterior cruciate ligament
compared to the identical surgery in an inpatient setting. (Adhikari et al., 2021). Many
factors play a significant role in modifying the functioning of a system. As mentioned in an
exceedingly study before that pharmaceutical service is multifaceted and may be full of
technical, interpersonal and environmental components, like waiting room, waiting time,
medicine availability, etc. (Kassa et al., 2021)

49. Provision of pharmaceutical services could be a business venture and thus customer
satisfaction should be one in all the supreme goals. While assessing patients' satisfaction with
pharmaceutical services, it absolutely was underlined that the attitude of the pharmacist and
provision of knowledge about drugs to patients, were important. Other factors in promoting
patient satisfaction include opening times which might increase accessibility to medicines.

50. Positive outcomes: Patient fulfilment and gratification affects clinical processes and
patient outcomes. Various studies have shown that positive patient outcomes are related to
improved patient satisfaction. A prospective study showed that the satisfied patient had two
occasions higher odds of improved quality of living. it's showed that patient satisfaction was
positively related to patient safety, clinical effectiveness, compliance to recommended care,
and also the use of screening services. Similarly, it's noticed that patients within the highest
satisfaction percentage were less likely to go to hospital emergency departments compared to
those within the lowest satisfaction quartile. Further, higher patient satisfaction was found to
be related to decreased use of specialty care, hospitalization, and laboratory services.
Realizing various positive outcomes, patient satisfaction has been adopted widely in
developed countries as an index of health care quality. (Adhikari et al., 2021)

51. Through medication counseling, healthcare and pharmacy workers may identify
and proper drug-related problems, improve the patient’s knowledge about the right use of
medicines, increase patient satisfaction with the pharmacy service, and consequently optimize
the patient quality of care. Satisfaction analysis is taken into account a very important
indicator of the standard of the pharmacy service because it reflects whether the service is
meeting one’s expectations or values. there's an increasing trend to assess satisfaction level
when the pharmacy service has begun to expand its scope of practice.
 SECTION –VIII

Pharmacovigilance:

52. Pharmacovigilance is that the practice of monitoring the consequences of medical

drugs after they have been licensed to be used, especially so as to spot and evaluate previously
unreported adverse reactions. Medicines and vaccines have transformed the prevention and
treatment of diseases. Additionally, to their benefits, medicinal products may have side
effects, a number of which can be undesirable or unexpected. in line with WHO,
Pharmacovigilance is that the science and activities referring to the detection, assessment,
understanding and prevention of adverse effects or the other medicine/vaccine related
problem.

53 Whenever one discusses pharmacovigilance and principles of reporting it's impossible

to ignore the thalidomide catastrophe. In fact, the thalidomide disaster after the Second war
was the foremost reason for the globe Health Organization (WHO) to introduce the Program
for International Drug Monitoring (PIDM), preferentially for early detection of ADRs. This
activity is termed as pharmacovigilance and is understood as, “science and activities
associated with the detection, assessment, understanding and prevention of adverse
effects or the other possible drug-related problems”

54. ADRs occur during drug therapy and most of them are preventable with proper
management and organization. ADR monitoring may be a vital task of the standard assurance
department in developed nations but unfortunately Pakistan encompasses a limited
accountability system for medicines. the particular number of deaths associated with ADRs
isn't known because of an underdeveloped process of pharmacovigilance. a pair of hospitals
practicing ‘state of the art’ pharmacy services—namely Aga Khan University Hospital and
Dow University Hospital—are providing localized pharmacovigilance services. (Syed et al.,
2018)

55. Pharmacovigilance is gaining motion as a brand-new aspect of pharmaceutical

sciences and is critically important publicly health and clinical practice. it's developed as a
vital aspect toward better pharmacy services. Underreporting of ADRs by health care
professionals affects the general public health domain. So new methods are being devised to
avoid such mistakes within the future. For that reason, the most reasons must be ruled out
first, many factors are liable for underreporting of ADRs. Inman has designated them as
“seven deadly sins” comprised of:

• Financial incentives: Rewards for reporting;

• Legal aspects: Fear of enquiry and prescribing data compilation;

• Complacency: ADRs are well documented by the time a drug is promoted;

• Diffidence: Only reporting ADRs that are surely caused by particular drug;

• Indifference: Only one case observed by me cannot improve medical knowledge;

• Ignorance: Confidence that it's necessary to report serious and unexpected ADRs; and

• Lethargy: Delay in reporting or lack of your time to seek out a report and other excuses.

56 The participation of health care professionals in spontaneous reporting is

predicted to be improved by strengthening equally the intrinsic factors (knowledge, attitude
and practices) and extrinsic factors (relationship between health professionals and their
patients, the health system and also the watchdogs). The knowledge and attitude of health care
professionals are core factors that require extensive exploration during this regard. (Syed et
al., 2018)
 SECTION – IX

Dispensing Errors

57. A dispensing error is a discrepancy committed by the staff working at the pharmacy
in delivering the medicines to the point or distributing to the ward on the basis of prescription
by the physician, including the dispensing of a medicine with inferior pharmaceutical or
informational quality.

Common dispensing errors:

(a). Dispensing medicine for the wrong patient

(b). Dispensing the wrong medicine

(c). Dispensing the wrong drug strength

(d). Dispensing at the right time

(e). Dispensing the wrong quantity

(f). Dispensing the wrong dosage form

(g). Dispensing an expired or almost expired medicine

(h). Omission (i.e., failure of dispense)

(i). Dispensing a medicine of inferior quality

(j). Dispensing an incorrectly compounded medicine

(k). Dispensing with the wrong information on the label

(Incorrect patient name)

(l). Incorrect drug name

(m). Incorrect drug strength

(n). Incorrect instruction 9including incorrect dosage)

(o). Incorrect drug quantity

(p). Incorrect dosage form

(q). Incorrect expiry date

 (r). Omission of additional warnings

(s). Incorrect pharmacy address

(t). Other labeling errors

Common causes of dispensing errors:

(a). Over work of fatigue

(b). Erroneous wrong interpretation of prescription due to illegible

hand writing

(c). Lack of technical knowledge

(d). Similar appearance of some drugs

(e). Ignorance

(f). Negligence

(g). Preoccupied mind due to service or family problems

(h). Jumbled up medicines in a narrow space

(i). Lack of interest due to low incentives

(j). Dim Light

(k). Loud noise

(m). Pre occupied mind due to family or service pressure

 SECTION –X

Medication Errors:

58. Many healthcare systems suffer from poor quality resulting in preventable deaths,
reduced quality of life or serious adverse events, like medication errors.

Quality and quality improvement are multi-dimensional concepts. Quality improvement was
defined as ‘the combined and unceasing efforts of everyone – health-care professionals,
patients and their families, researchers, payers, planners and educators – to create the
changes that may result in better patient outcomes (health), better system performance
(care) and better professional development (learning)’. (Alhusein & Watson, 2019)

The most typical reasons for errors include failure to speak drug orders, illegible handwriting,
wrong drug selection chosen from a computer menu, confusion over similarly named drugs,
confusion over similar packaging between products, or errors involving dosing units or
weight. Medication errors is also because of human errors, but it often results from a flawed
system with inadequate backup to detect mistakes.

59. Administration errors:

Administration errors occur when a discrepancy occurs between the drug received the patient
and also the drug therapy intended by the prescriber. Drug administration has long been
associated with one in every of the best risk areas in nursing practice, with the ‘five rights’
benefit the cornerstone of nursing education. During administration errors largely involves
errors of omission which drug isn't administered for a range of reasons. Other kind of drug
administration errors include an incorrect administration technique and therefore the
administration of incorrect or expired preparations. The intravenous route of administration
could be a particularly complex process during which errors frequently occur and is related to
significant risk to patients as some have died as a result of the administration of cytotoxic
drugs intrathecally rather than intravenously. The result has been that the department of health
has made this patient safety. A result study of intravenous drugs administration suggested a
slip-up rate of fifty in either the preparation of the drug or its administration. the foremost
common form of error identified was the deliberate violation of guidelines when injecting
bolus doses faster than the recommended time of 3-5 minutes.
60. Medication Error:

While there's no uniform definition of a drugs error, The National Coordinating Council for
Medication Error Reporting and Prevention defines a medicine error as: “any preventable
event that will cause or result in inappropriate medication use or patient harm while the
medication is within the control of the healthcare professional, patient, or consumer. Such
events could also be associated with professional practice, health care products, procedures,
and systems, including prescribing; order communication; product labeling, packaging, and
nomenclature; compounding; dispensing; distribution; administration; education; monitoring;
and use.”

Medication errors can occur at many steps inpatient care, from ordering the medication to the
time when the patient is run the drug. In general, medication errors usually occur at one in
every of these points:

• Ordering/prescribing

• Documenting

• Transcribing

• Dispensing

• Administering

• Monitoring

Medication errors are commonest at the ordering or prescribing stage. Typical errors include
the healthcare provider writing the incorrect medication, wrong route or dose, or the incorrect
frequency.

61. Issues of concern:

Medication errors are grouped by different taxonomies by the Joint Commission, World
Health Organization, and therefore the National Coordinating Council for Medication Error
Reporting and Prevention.
Some taxonomies consider the source of the error:

• Deteriorated drug error from compromised storage

• Drug utilization process error from the administration, dispensing, or monitoring

• Prescribing errors

62. Types of Medication Errors

• Prescribing

• Omission

• Wrong time

• Unauthorized drug

• Improper dose

• Wrong dose prescription/wrong dose preparation

• Administration errors including the wrong route of administration, giving the drug to the
incorrect patient, extra dose or wrong rate

• Monitoring errors like failing to require into consideration patient liver and renal function,
failing to document allergy or potential for drug interaction

• Compliance error like not following protocol or rules established for dispensing and
prescribing medications

63. Causes of Medication Errors:

a. Expired Product

Usually occurs because of improper storage of preparations leading to deterioration or use of

expired products.

b. Incorrect Duration
Duration errors occur when medication is received for a extended or shorter period than
prescribed.

c. Incorrect Preparation

This error usually occurs with compounding or another variety of preparation before the
ultimate administration. An example is selecting the wrong diluent to reconstitute.

d. Incorrect Strength

Incorrect strength may potentially occur at many points within the medication process. it
always occurs thanks to human error when similar bottles or syringes with the wrong strength
are selected.

e. Incorrect Rate

Most often occurs with medications that are given as IV push or infusions. this is often
particularly dangerous with many drugs and should end in significant adverse drug reactions.
Examples include tachycardia because of rapid IV epinephrine or Redskin syndrome thanks to
the rapid administration of vancomycin.

f. Incorrect Timing

In both home and institutional settings, it's challenging to be completely accurate with
scheduled doses. the priority is that some medication's absorption is significantly altered if
smitten or without food. As such, it's important to stick to scheduled times as commonly; this
could cause under or overdosing.

g. Incorrect Dose

This error includes overdose, underdose, and an additional dose. An incorrect dose occurs
when an inappropriate or different medication dose is given apart from what was ordered,
errors of omission when a scheduled dose of medication isn't given, and when a drug is given
via an incorrect route. Errors because of incorrect routes usually occur because of unclear
labeling or tubing that's adaptive to multiple connectors/lines of access. Incorrect routes often
lead to end in significant morbidity and mortality.
h. Incorrect Dosage Form

This occurs when a patient receives a dosage form different than prescribed, like immediate-
release rather than extended-release.

I. Incorrect Patient Action

This occurs when a patient takes a drug inappropriately. Patient education is that the only
thanks to prevent this sort of error.

j. Known Allergen

Dispensing a drug that the patient has an allergy often thanks to failure to speak with the
patient, inappropriate chart review, inaccurate charting, or lack of technologic interface.

k. Known Contraindication

This occurs when medications aren't vigilantly reviewed for drug-drug, drug-disease, or drug-
nutrient interactions.

l. Pharmacist

Errors by pharmacists are usually judgmental or mechanical. Judgmental errors include failure
to detect drug interactions, inadequate drug utilization review, inappropriate screening, failure
to counsel the patient appropriately, and inappropriate monitor. A mechanical error could be a
mistake in dispensing or preparing a prescription, like administering an incorrect drug or dose,
giving improper directions, or dispensing the wrong dose, quantity, or strength.

The most common causes involve workload, similar drug names, interruptions, lack of support
staff, insufficient time to counsel patients, and illegible handwriting.

m. Distractions

One of the key causes of medication errors is distraction. Nearly 75% of medication errors are
attributed to the current cause. Physicians have many duties during a hospital (e.g., examining
patients, ordering laboratory and imaging studies, talking to consultants, rounding on their
patients, chatting with patient relations, conversing with insurance carriers before ordering
studies), and within the midst of all this, they're often asked to put in writing drug orders and
prescriptions. within the rush to be through with writing drug orders, sometimes a lapse of
judgment develops, and a medicine error occurs. It can happen to the most effective physician.
Sometimes the physician is also on the phone, and a clinician is also standing with the order
chart next to him or her requesting a drug order. The physician may quickly scribble in an
exceedingly drug order, not taking note to the dose or frequency. it's the unscheduled events
within the lifetime of a healthcare provider like the constant pages, attendance at meetings,
and answering telephone calls that disrupt patient care. Many physicians don't acknowledge
that these distractions are a controversy, but really, these distractions are often the reason
behind medication errors.

To minimize distractions, hospitals have introduced measures to scale back medication errors.
Most hospitals are performing on ways to decrease distractions to confirm that medication
orders don't occur. for instance, physicians are urged to order drugs at a group time after
rounding on their patients; this is often after they also write their daily progress notes. Other
clinicians are requested to not disturb the physician at now of the day. Also, clinicians are
asked only to disrupt the physician for an emergency. Physicians are being urged to develop a
structure for his or her patient care that's organized in order that distractions are limited. While
answering a page is commonly necessary, many hospitals recommend that physicians not
answer patient calls until patient duties are completed. Additionally, healthcare institutions are
now penalizing physicians who still have too many medication errors thanks to distractions;
the result's a restriction in prescribing privileges.

Of course, not all distractions is eliminated because the practice of drugs is itself unpredictable
and chaotic at the simplest of times.

n. Distortions

A prevalent reason behind medication errors is distortions. the bulk of distortions may
originate from poor writing, misunderstood symbols, use of abbreviations, or improper
translation. a big number of healthcare providers within the u. s. are from foreign countries
and infrequently write orders for medications that aren't even available domestically. When a
practitioner questions the drug, the physician often asks the nurse or pharmacist to substitute
the medication prescribed for an analogous drug. this sort of distortion can result in major
errors because neither the non-prescribing practitioner nor the pharmacist can substitute a
drug. All hospital pharmacies have an inventory of medicines available within the formulary,
and doctors should know what's available and limit the ordering from this list.
o. Illegible Writing

Illegible writing has plagued both nurses and pharmacists for many years. Physicians are often
during a hurry and regularly scribble down orders that don't seem to be legible; this often
leads to major medication mistakes. Taking shortcuts in writing drug orders could be a
prescription for a lawsuit. Often the practitioner or the pharmacist isn't able to read the order
and makes their best guess. If the drug required may be a dire emergency, this also adds more
risk to the patient. To eliminate such errors, most hospitals have rules that practitioners and
pharmacists should follow; if the drug order is illegible, the physician must be called and
asked to rewrite the order clearly. The practitioner or the pharmacist should never guess what
the drug/dose is. The bad writing by physicians has become such a significant problem that the
Institute of Safe Medication Practices has recommended the whole elimination of handwritten
orders and prescriptions. This problem has been resolved using electronic records where
everything is typed, and poor writing isn't any longer an issue; however, errors still can occur
from writing the incorrect drug, dose, or frequency.

p. Approach every prescription with caution: There are many new drug releases within the
last decade, and generics with similar names have flooded the market. Additionally, to having
similar names, many of those medications have multiple uses and alternative names. If the
diagnosis isn't stated on the prescription, there's a risk that the drug is also prescribed for too
long or an inadequate amount of your time. With dozens of recent generics with similar
names, the danger of error is incredibly high. To counter the results of unintended
substitutions for medications, the US Pharmacopeia has listed the names of look-alike
medications, and therefore the ISMP has developed an inventory of abbreviations that are
routinely misinterpreted.
 SECTION –XI

Initiations for a Better system:

64. In developing countries, the health-care system is largely controlled by government

and often struggles with the absence of quality. In these surroundings, there has been the
beginning that encourages health administrators to identify health-care quality as one of the
key drivers for strengthening health systems. Although there has been significant attention
paid to improve the quality of health system, the extent of quality of health care system or its
sections is in infancy. Hospital pharmacy service is one characteristic of health care that needs
to be delivered to the standard in order to improve overall quality of health care. The service
provided by the hospital pharmacy unit is a vital component of an institutional healthcare
system. Medication supply and drug circulation, compounding, medication consumption
review, adverse drug reaction observation, and drug information provision are the key services
delivered through this unit.(Ayele et al., 2020)

65. In the last few decades, patients have emerged as the essential concern in health
care provision and quality assurance. In progressing countries, patient satisfaction is a key
factor in quality assessment of the health care system, whereas in evolving countries, the main
quality apprehension has been the availability to health care services.

66. Developing nations and their efforts: Developing nations like ours are making every
effort to entitle their citizens to receive fundamental healthcare because of limited customer
resources. Community hospitals play an important role in providing health facilities or
amenities for citizens who seek fundamental medical provision, while the outpatient
department (OPD) part of the hospital is very essential. A world without basic health facilities
would be a world of despair and grief. Supposedly speaking, if the world had a fundamental
healthcare system that was universally recognized as providing below average services, that
would only invite greater despair and grief. In this supposed system, the cost of healthcare
would further burden and deepen, adding up to patient concern. A healthcare facility is useless
if it is unable to decrease patients’ distress. The healthcare division of any country is a vital
pillar for its overall progress, because it also impacts all the other sectors, such as medical,
political, societal, and business. Furthermore, it has a number of commercial implications.
(Hussain et al., 2019)

67. Resource limitations in low-income setups have led to a more urgent focus on the
availability of basic supplies and services rather than a focus on quality in these situations. As
already discussed in a study that Nepal is a low-income country in South Asia that has not
highly prioritized improving patient satisfaction. The health facilities in Nepal showed that
only 3% of facilities have a functional client response system. It further discussed that about
23% of the caretakers of sick children were dissatisfied with the services provided by higher-
level hospitals due to long wait and delay. (Adhikari et al., 2021)

68. POF hospital pharmacy: The hospital pharmacy is working since the establishment of
POF hospital since 1962. The starting capacity of the hospital was hundred beds which has
now touched 658 beds. The medical services have been improved along with increasing
number of poulation. Efforts are being done to readjust in line with the evolution of new needs
and requirements of increasinf clientele depending upon POF hospital. It is the duty of the
hospital to provide complete healthcare facilities to POF employees and their families living
in the estate area and comprising of 14000 household approximately.

69. Over the time, system of provision of medicine to the patients has witnessed many
flaws in terms of efficiency and patient approval. This has called reevaluating the pharmacy
system of the hospital with the view to improve the working of hospital pharmacy and to meet
the expectations of the patient. As an everyday exercise patients in POF hospital after getting
the prescription from the specialists/medical officer report to hospital pharmaceutical service.
Here they have to go to multiple windows to get the required medicines from the respective
counters established in one place. They usually have to wait in ques in front of these counters
to get the medicines. The waiting depends on the number of patients at that particular time and
point of delivery. To further add to the suffering more often than not some local purchase
medicines are not available and patients often have to revisit the pharmacy again on the next
day to collect the remaining medicines.

70. To advance the quality of services and improve patient satisfaction following
facilities maybe recommended:
a.location of the pharmacy should be close to the outpatient department

b. electronic queing system should be installed

c. computerized inventory control system

d. spacious and comfortable waiting area

e. separate windows for senior citizens and ladies

these reforms may increase approachability and convenience for the patients and make the
system easier to operate and increase the efficiency through time and economy.

Thus, to address the quality of services in hospital pharmacy this study aims to assess patient
satisfaction and determine various factors associated with satisfaction to improve not only
services but also confidence and commitment of the patients toward hospital pharmacy.
 CHAPTER # 3

MATERIALS &
METHODS

Aim
1. The aim is to improve the pharmacy services in POF Hospital, Wah.

Objectives
2. The objectives of the study are: -

a. To determine the satisfaction level in patients reporting to the hospital

pharmacy.
b. To suggest recommendations to improve the pharmacy services for improved
health care.

Methodology

The methodology is described below:

a. Study Design.

It is a descriptive observational cross sectional study involving response of

patients visiting the pharmacy.

b. Study Type

It is a quantitative study.

c. Study Setting.

The study is carried out with patients visiting POF Hospital Wah Cantt.

d. Time Duration.
 The study has been carried out in 9 months period after approval of synopsis
from September 2021 to June 2022.

e. Study Population.

The study population of this study is as follows:

Patients reporting to P.O.F Hospital pharmacy

f. Sampling Technique.

Following procedure was adopted for sampling.

Non probability Convenience Sampling

Structured Questionnaires

g. Sample Size.

The Sample size for the study is 340. It was calculated as suggested by (Shafiq
et al., 2017) .

h. Sample Selection.

Sample selection criteria are laid out as under.

(1) Inclusion Criteria.

POF employees reporting in pharmacy

Dependent males and females that are entitled to the facility including
army personnel posted in Wah Cantt

Retired POF employees

 (2) Exclusion Criteria.

Children and non-willing patients and staff

i. Data Collection Tools.

The data collection tool is a pretested, structured, self-administered

questionnaire adapted from a study, carried out by “Pharmaceutical
Services Negotiating Committee” in UK with the title of community pharmacy
patient questionnaire (CPPQ). Attached as annexure B.

j. Data Collection Procedure.

Purpose and details of study was communicated to the respondent in detail by

the researcher. Questionnaires for the patients reporting to the pharmacy was
self-administered. Any further inquiry about questionnaire was resolved
through telephonic conversation with the respondents. All statements were
measured on a 5-point Likert scale showing very poor and fairly poor were
taken as low satisfaction and quality level whereas fairly good and very good
were taken as high satisfaction and quality levels. Don’t know was taken as
neutral.

k. Plan of Data Analysis.

Data was analyzed by using Statistical Package for Social Sciences

(SPSS) version 25. Description of all variables included in questionnaire
is provided by reporting frequency and percentage for categorical
variables whereas mean and standard deviation for numerical variable.
Graphical representation was made by using line and bar charts.
l. Ethical Considerations.
Following are the ethical considerations:
a) Ethical approval was obtained from Institutional Review Board (IRB) of
Armed Forces Post Graduate Medical Institute (AFPGMI) Rawalpindi.
b) Informed consent was taken from all the participants of the survey with
assured confidentiality regarding identity of participants and their responses to
the questions.
 Chapter # 4:

ANALYTICAL STUDY AND RESULTS:

A total o 340 individuals reporting in POFH pharmacy from Wah Cantt were included in this
study. A pre tested, structured questionnaire was adopted from a study out by ‘Pharmaceutical
Services Negotiating Committee’ in UK with the title of community pharmacy patient
questionnaire (CPPQ). The questionnaire has been self-administered. A proper consent was
taken from every participant before starting the questions.

Table No. 01:

Descriptive Statistics of Age of Participants
N = 340
Minimum Maximum Mean Std. Deviation

Age of Participants 18.00 68.00 44.5529 11.92628

Descriptive Statistics of Age of Participants; The criteria for age started from below 26
years to above 65 years. The minimum age of participants in the study was 18 years and the
maximum age group was 68 years. The mean age turned out to be 4.55 years with standard
deviation of 11.92 years. (Table no 01)

Chart No 01:
Frequency Statistics of Age Group of Patients
N = 340

Chart Title

120 110

100 90

80
64

60
40

40
21
15
20

0
No. of Participants

< 26 years Age 26-35 years Age 36-45 years age

46-55 years age 56-65 years age > 65 years age

Frequency Statistics of Age Group of participants: Out of 340 participants: 15 were below
26 years of age,90 was between 26-35 years of age, 64 was between 36-45 years,110 were
between 46-55 years, 40 were between 56-65 years and 21 were above 65 years (Chart no 01)

Chart No 02:
Frequency Statistics of Age Group of Participants
N = 340

No. of Participants

88

252

Male Female

Frequency Statistics Of Gender Of Participants; Out of 340 participants of the study 252
were males and 88 were females (Chart no:2)

Chart No 03:
Frequency Statistics of Education Level of Participants
N = 340

Chart Title

133
140
121

120

100

80
58
60

40
20
20 8

0
No. of Participants

No Formal Education Secondary school Bachelor's Degree

Master's Degree Higher Degree Series6

Frequency Statistics Of Educational Level Of Participants: As for education of 340

participants of the study; 20 had no formal education 133 studied up to secondary school
(matric). 121 participants had bachelors degree,58 had masters degree and 08 participants had
higher degree (Chart no:3).

Chart No 04:
Frequency Statistics of Employment of Participants
N = 340
 No. of Participants

80; 24%

135; 40%

103; 30%

22; 6%

POF Employee Dependant POF Employee Retired POF Employee

Army Personnel Others

Frequency Statistics of Employment Status Of Participants: Out of 340 participants of

the study 135 were POF employees, 22 were dependents 103 were retired POF employees and
80 were army personnel. As for percentage, it turns out to be: POF employees 40%, Retired
POF employees 24%, Dependents 30%and Army personnel 6%

QUANTITATIVE ANALYSIS:
The questionnaires were analyzed and indicators were marked in the activity area representing
the objective of the study that is satisfaction level of patients reporting in POF pharmacy. The
indicators of performance include:
 Purpose of visit
 Waiting time in pharmacy
 Cleanliness, convenience and availability of medicines
 Behavior of pharmacist and staff
 Health information in pharmacy
 Over all performance of pharmacy
 Preference of the patient
 Rating of the pharmacy

 Reason To Visit the Pharmacy:

Out of 340 participants 229 visited the pharmacy to collect the medicines for them selves
which makes 67.4%of the total 100%.89 people came to take medicines for someone else
 (spouse, parent, children) and it makes 26.2%. Only 22 participants (6.5%) visited to
collect the medicines for both (Table no )

Reason for Pharmacy Visit

Cumulative
Frequency Percent Valid Percent Percent
Valid Yourself 229 67.4 67.4 67.4
Someone Else 89 26.2 26.2 93.5
Both 22 6.5 6.5 100.0
Total 340 100.0 100.0

 Waiting Time in Pharmacy:

To collect the prescription how much waiting time was experienced by the participants in
the pharmacy. Out of 340 participants 280 (82.4%) received their medicines straight away
in 10-15 minutes. 56 participants (16.5%) waited for 30 minutes to one hour to receive
their prescription. Only 04 people (1.2%) were asked to com back later for collection of
medicines. (Table no:03)

Prescription Collection
Cumulative
Frequency Percent Valid Percent Percent
Valid Straight Away 280 82.4 82.4 82.4
Waited in Pharmacy
56 16.5 16.5 98.8

Come Back Later 4 1.2 1.2 100.0

Total 340 100.0 100.0

Satisfaction Level: It has been observed that the participants reporting in the pharmacy for
collection of medicines have different levels of satisfaction for the waiting time they
experience. Out of 340 participants 200 (58.8%) were fairly satisfied with their waiting time.
108 (31.8%) were not satisfied with the waiting time in the pharmacy. Unfortunately, 32
(9.4%) were not at all satisfied with their waiting time.
(Table no:3a)
Satisfaction Level
Cumulative
Frequency Percent Valid Percent Percent
Valid Not at all Satisfied
32 9.4 9.4 9.4

Not very Satisfied

108 31.8 31.8 41.2

Fairly Satisfied 200 58.8 58.8 100.0

Total 340 100.0 100.0
Table No. 04:
Frequency statistics of “Thinking about any previous visits as well as today's, how would
you rate the pharmacy on the following factors?”

Very Poor Fairly Poor Fairly Good Very Good Don’t Know
Cleanliness of Pharmacy 21 (6.2%) 93 (25.4%) 170 (50%) 51 (12.3%) 05 (1.5%)
Comfort and 20 (5.9%) 82 (24.1%) 168 (49.4%) 62 (18.2%) 08 (2.4%)
Convenience of waiting
area
Availability of Medicine 20 (5.9%) 95 (27.9%) 163 (47.9%) 55 (16.2%) 07 (2.1%)
Clear and Well- 20 (5.9%) 88 (25.9%) 170 (50%) 56 (16.5%) 06 (1.8%)
Organized Layout
Privacy available or not 21 (6.2%) 101 (29.7%) 158 (46.5%) 55 (16.2%) 05 (1.5%)

 Environment and working of pharmacy: the participants were questioned about the
surroundings, cleanliness, convenience and availability of the medicines in the
pharmacy. A scale of very poor, fairly poor, fairly good, very good and don’t know
were taken as parameters to note the working in the pharmacy.

Cleanliness in pharmacy:
 21 (6.2%) participants said that the cleanliness in the pharmacy is very poor. However,
93 (25.4%) think that it is fairly poor, where as 170(50%) were satisfied to the level of
fairly good.51 (12.3%) said that it is very good and 05 (1.5%) participants were neutral
about the cleanliness by saying don’t know. In overall view 50% thinks that the
cleanliness is fairly good and 25.4%says that it is fairly poor.

Comfort and convenience of waiting area:

Out of 340 participants 168 (49.4%) said the waiting area is comfortable, on scale it is
fairly good.82 (24%) think it is fairly poor and 62 (18.2%) agreed that the comfort
level is very good. 20 (5.9%) were of the opinion that it is very poor and 08 (2.4%)
didn’t know about it.

Availability of medicines:
163 (47.9%) participants said that the availability of the prescribed medicines is fairly
good. Whereas 95 (27.9%) said it is fairly poor.55 (16.2%) were very satisfied by
saying very good. Out of 340 participants 20 (5.9%) were of the opinion of very poor
and 07 (2.1%) said they don’t know.

Clear and well organized lay out:

170 (50%) participants said that the over all arrangements in the pharmacy are very
clear and well organized. All the offices and counters are properly numbered and
instructions are also displayed for the convenience of the patients.88 (25.9%)
participants found the lay out fairly poor and 56 (16.5%) said it is very good and easily
understandable. 20 (5.9%) thought it is very poor and 06 (1.8%) don’t know about it.

Privacy setting;
158 (46.5%) found fairly good privacy in the pharmacy to talk to the pharmacist or MO
I/C Medical stores about their treatment and insturctions.101 (29.7%) said its fairly
poor and 55 (16.2%) said that the privacy arrangements are very good. How ever 21
(6.2%) were oof the opinion that availability of privacy is very poor in the pharmacy
and 05(1.5%) didn’t know about this facility.

Table No. 05:

Frequency statistics of “How would you rate the pharmacist and the other staff who
work there?”

Very Poor Fairly Poor Fairly Good Very Good Don’t

Know
Pharmacist Polite and 21 (6.2%) 53 (15.6%) 207 (60.9%) 54 (15.9%) 05 (1.5%)
Taking Time
Pharmacist Answering 17 (5%) 56 (16.5%) 208 (61.2%) 54 (15.9%) 05 (1.5%)
Question
Other Pharmacy Staff 21 (6.2%) 43 (12.6%) 217 (63.8%) 54 (15.9%) 05 (1.5%)
Service
Providing Efficient Service 21 (6.2%) 49 (14.4%) 210 (61.8%) 55 (16.2%) 05(1.5%)
Staff Overall Attitude 21 (6.2%) 59 (17.4%) 201 (59.1%) 54 (15.9%) 05 (1.5%)

 Behavior working of pharmacist and staff:

340 participants were inquired about the behavior in terms of politeness and answering
the queries of the patients. The participants also gave their opinion about the
performance of the staff in the pharmacy, irrespective of the efficiency and attitude
towards patients.

a. Politeness of pharmacist: 207 participants (60.9%) found the pharmacists fairly

good in terms of politeness and answering the questions raised by patients. 53
patients (15.6%) said that the pharmacist’s behavior was fairly poor and 54 patients
(15.9%) were very satisfied by saying that the attitude of the pharmacist was very
good towards them. 21 participants (6.2%) said that the pharmacists have very poor
attitude and 5 persons (1.5%) were neutral about it as they said they don’t know
about it.
b. Response time: 208 participants (61.2%) said that the pharmacist answered their
questions fairly good. However, 56 participants (16.5%) were of the opinion that
the response of pharmacist was fairly poor and 54 people (15.9%) said that that the
pharmacist was very good. Meanwhile, 17 individuals (5%) thought that it was
very poor and 5 individuals (1.5%) didn’t know about it.
c. Other pharmacy staff: out of 340 participants 217 (63.8%) said that the staff
working pharmacy is fairly good. Whereas 43 people (12.6%) think it is fairly poor
 and 54 individuals (15.9%) said that the staff is very good and co-operative. 21
(6.2%) participants were of the opinion that the staff is very poor and 5 persons
(1.5%) don’t have an opinion about it.

d. Provision of efficient services: 210 participants (61.8%) think that the services
provided by the pharmacy are fairly good. 49 participants (14.4%) said that it is
fairly poor and 55 (16.2%) said that it is very good. 21 individuals (6.2%) were not
very happy and said that the services are very poor and 5 (1.5%) of them didn’t
know about it.

e. Overall staff attitude: the overall attitude of the staff was found fairly good and
helpful by 201 participants (59.1%). 59 people (17.4%) found it fairly poor and 54
(15.9%) of them said it is very good. 21 (6.2%) were of the opinion that it was very
poor and 5 (1.5%) didn’t know about it.

Table No. 06:

Frequency statistics of “How well do you think the pharmacy provides each of the
following services?”

Not at all Not very Fairly Well Very Well Never

Well well Used
Advice for Current Health 321 (94.4%) 19 (5.6%) - - -
Problems
Providing General Healthy 316 (92.9%) 24 (7.1%) - - -
Life Style Advice
Disposing of Medicine 328 (96.5%) 12 (3.5 %) - - -
Providing available health 330 (97.1%) 10 (2.9%) - - -
service guidance

 Health information and advice in the pharmacy : Many pharmacies provide health
information and instructions to the patients about healthy lifestyle. In this regard
unfortunately POF hospital pharmacy has no arrangements available yet. The patients
are not guided about the dosages or disposing of medications which are not further
required to the patients.

a) Advice for current health problems: out of 340 participants 321(94.4%) said
that they were not at all advised about their health problems in the pharmacy
where as 19 (5.6%) said they were not informed very well.

b) Healthy life style advices: 316(92.9%) participants said that they were not at all
provided with any information about healthy life style. Where as 24(7.1%) were
not very clear and said they were not informed very well.

c) Discarding the medicines:328 (96.8%) participants said that they were not
advised by any one in the pharmacy about stopping or discarding any medicine
which is no more required in their prescription. Nor they told how to dispose off
expired medicines.12 (3.5%) said that they were not very well informed at all.
d) Providing health guidelines: 330 (97.1%) participants out of 340 said that no
health guide lines were shared with them while they visit the pharmacy. However,
10 (2.9%) said they were not sure about it.
Chart No. 05:
Frequency statistics of “How well do you think the pharmacy provides each of the
following services?”

Chart Title
350
322 321 314
300

250

200

150

100

50
18 19 26

0
Advice for Stopping Smoking Advice for Healthy Eating Advice for Physical Exercise

Yes No

 HEALTH SERVICES BY PHARMACY:

Many pharmacies provide information about
hazards of smoking, eating healthy food, avoid junk food and doing physical exercise
to promote healthy life style improve health of the patients.

a) Advice to quit smoking: 322 participants out of 340 said they were not advised to
quit smoking while they visit the pharmacy.18 agreed that they were asked to quit
smoking according to their health conditions and prescription.
b) Advice for healthy Eating: 321 people were of the opinion that they were not at all
guided about dietary habits and healthy eating in the pharmacy. 19 participants said
that they were told by the pharmacy staff about healthy dietary habits.

c) Advice for Physical Exercise: 314 participants said that they were never advised
about physical exercise or activity by the pharmacy staff but 26 said they were given
information about the importance of an active lifestyle and exercising.
Chart No. 06:
Frequency statistics of “Which of the following best describes your preference about this
pharmacy?”

No. of Partcipants

21

105

214

Visit Every Time Only Pharmacy Available Convineint to visit today

 PREFERENCE OF THE PATIENT:

The participants were asked about their preference to visit the POF hospital pharmacy
above other pharmacies. 214 participants agreed that this is the only pharmacy
available for them to visit. 105 out of 340 said that they visit POF pharmacy every
time whenever they require medication and 21 people visited the pharmacy for the first
time as it was convenient for them on their visit to the hospital.

Chart No 07:
Frequency Statistics how would you rate the pharmacy where you received this
questionnaire?
N = 340

Chart Title

160
142

140
117
120

100

80
55
60

40
21

20 5

0
No. of Participants

Poor Fair Good Very Good Excellent Series6

 RATING OF THE PHARMACY:

340 participants were included in this study and were asked questions about the overall
working of the pharmacy. In the last question they were asked to rate the pharmacy
according to their experience while they visit there. 142 people rated it fair, while 117
said it is good, 55 said it is very good and 5 were of the opinion that the working of the
pharmacy is excellent. However, 21 said that their visit to the pharmacy was a poor
experience and were not satisfied.

CHAPTER # 5
FINDINGS AND DISCUSSION
In Pakistan, hospital pharmacies have added value to the healthcare system as dispensers of
medicinal products, or as clinical service providers. Notwithstanding this, the dominance
within healthcare personnel lies with the physicians and nurses. However, due to the
increasing complexity of chronic disease and associated medicine use, there is a growing need
for enhanced pharmacy services in hospital and community settings. The aim of the study was
to improve the quality of pharmacy services in POF hospital, Wah Cantt. Patient satisfaction
with service rendered should be considered as an outcome measure of the care provided which
helps improve the quality of the pharmacy service. This study examined patients’ satisfaction
towards out-patient pharmacy service at POF hospital.

During the study it was found that most of the people using the pharmacy services were males
with age group between 46-55 years. Most of them had their education till secondary school
and bachelor degree. As for employment status, the major group of participants were either
POF employees or retired personnel. Evidences indicate better satisfaction from patients with
little or no formal education. In agreement with this, in this study, patients who attended
secondary education scored higher satisfaction compared with patients who had a certificate
and above. This might be due to lower awareness about the service delivered in pharmacy
from patients with less education compared with their counterpart.

Most of the participants visited the pharmacy to collect medicines for themselves and they
received their prescription without any delay. Those who had to wait were fairly satisfied with
the waiting time they experienced in the pharmacy.
An institutions-based cross-sectional study was conducted from April 20 to May 5, 2014, by
sampling five pharmacies and eight drug stores through simple random sampling. Clients,
424, who came to the MROs during the study period were included in the study. Data were
collected using structured questionnaires measuring expectations and satisfaction of clients
using a Likert scale of 1-5 through face-to-face interviews. Out of the total 424 interview
encounters, 422 (99.5% response rate) questionnaires were included in the analysis, of which
61.1% were of males. The overall mean expectation of respondents toward MRO setting and
services was 3.82 and that of satisfaction of the respondents was 3.02. Much more than half
(58.5%) of the respondents were dissatisfied with the comfort and convenience of private
counseling area. Also, nearly half (47.6%) of the respondents claimed that pharmacy
professionals did not provide information regarding the storage condition of medications.
There was statistically significant difference in overall expectation (t=2.707, P=0.007) and
satisfaction (t=2.260, P=0.024).13
A large number of participants were satisfied with the cleanliness and conveniences in the
pharmacy. They also received their medicines during visit to the pharmacy and they rated it
fairly good. Although there might be variation among settings, medication availability can be
a major factor in determining patient satisfaction. The poor access to medication has remained
major compliant among patients
A cross-sectional study design was employed from March 8 to 24, 2016. A semistructured
questionnaire was used to assess clients' perception and satisfaction toward service provided
by pharmacy professionals. Among 384 respondents, 53.1% were male. Of the total
participants, 63.8% had good perception and 36.2% had poor perception toward pharmacy
services. With regard to satisfaction, 52.6% of the respondents were satisfied and 47.4% were
unsatisfied by the pharmaceutical services. Sociodemographic variables such as educational
level (p=0.000), occupation (p=0.031), payment for service (p=0.002), and reasons the
respondents seek service (p=0.001) showed statistically significant association with the level
of perception. Clients' satisfaction was found to be significantly associated with educational
level (p=0.002) and reason for seeking service (p=0.016).14
Most of them were satisfied with the behavior of the pharmacist and other staff.
However, some areas still need attention. There is no arrangement in the pharmacy about any
help regarding health problems of the patients. They are not guided about healthy life style,
physical activities and exercises or quit smoking to avoid hypertension, diabetes and ischemic
heart diseases. There is no facility available in the pharmacy to guide about the usage of
medication and their disposal if needed.
An institution-based cross-sectional study was conducted involving 400 clients who had
prescriptions/orders filled at the outpatient pharmacy of the hospital during the period of 5th to
25th of November 2013. The data on the level of satisfaction of clients with the services of the
outpatient pharmacy in the hospital was collected using a structured interview guide adopted
from an instrument translated into Amharic and validated. The overall mean score the
respondents gave to satisfaction with the pharmaceutical services was 2.48 out of a maximum
of 5.00 score. The mean scores for all the individual parameters rated were less than 3.00.
Maximum mean scores were given for parameters asking about the promptness of prescription
medication service (2.99), and professionalism of the pharmacy staff (2.96) with the lowest
being scored for information given to clients about the storage of medication (1.25), and
explanations of possible side effects (1.27).15
A cross-sectional study was conducted on 287 patients, who were served in five pharmacies of
Gondar University Hospital in May 2015. Data regarding socio-demographic characteristics
and parameters that measure patients' expectation and satisfaction were collected through
interview using the Amharic version of the questionnaire. Among 287 respondents involved in
the study, 149 (51.9%) claimed to be satisfied with the pharmacy service and setting. Two
hundred and twenty-nine (79.4%) respondents have high expectation toward gaining good
services. Even though significant association was observed between the pharmacy type and
patients level of satisfaction, sociodemographic characteristics of a patient were not found to
predict the level of satisfaction.16

Nevertheless, a large number of participants prefer to visit the POF hospital’s pharmacy and
were content with the services provided to them.
A cross-sectional design, using an interview-administered questionnaire, was employed in this
study. Data were analyzed in SPSS, continuous and categorical data were computed
descriptively. Main outcome measure Patients satisfaction with pharmaceutical services
provided in public hospitals in Sierra Leone. Results Overall, 797 questionnaires were
analyzed. The majority of patients seeking free pharmaceutical services were satisfied (n =
470, 56%) or very satisfied (n = 229, 28.7%) with the services they received. Pharmacy staff
which includes pharmacists and pharmacy techincians demonstrated good communication
skills while delivering services, but lacked technical details like; how to handle (n = 187,
23.5%) and store (n = 135, 16.9%) drugs and their potential side effects (n = 253, 31.8%).
Low satisfaction was observed with the lack of private area for patients counseling (n = 474,
60.1%), and a convenient waiting area (n = 229, 28.7%). Respondents also thought the
pharmacy was too small (n = 191, 24.6%) and with less than optimal lighting system (n = 120,
15.0%). Dissatisfaction was associated with college/university students or graduates [AOR:
0.211 (0.083-0.537), p = 0.001] and those with household incomes less than SLL 1,000,000
[AOR: 0.391 (0.155-0.987) p = 0.047].17
There are multitudes of studies indicating the determinants for patient satisfaction, although
the findings are often indecisive and vary from setting to setting. Although there are
conflicting reports, demographic characteristics such as age, gender, standard of living,
education, and occupation have been linked with patient satisfaction. Apart from demographic
characteristics, the association between patients’ health-care experience and satisfaction is
well- documented. For example, waiting time, pharmacist’s attitude and medication
availability are often reported to have strong association with patient satisfaction.
A CRITICAL VIEW OF POF HOSPITAL PHARMACY:
POF Hospital is a large tertiary care hospital with the bed occupancy of 650 beds. The
pharmacy is located in the basement of the main hospital building. It is quite at a distance
from the main OPD block. All the outdoor patients who are prescribed treatment either from
the OPD or Staff Surgeon have to report to the pharmacy for issuance of medicines. All the
patients who are prescribed continuous treatment for longer duration and those who only
require injection insulin have to come to the pharmacy for issue of medicines. This is quite
cumbersome and inconvenient for most of the patients as most of them are either sick or
elderly patients.

Dispensing Procedures:
Patients reporting in the pharmacy go through the following procedure:
a) All the patients reporting in the pharmacy get their prescription signed by Medical
Officer in charge. Patients with prescription of injection insulin go to the pharmacist
for signatures.
b) After signatures patients report to separate windows for issuance of medicines:
 Routine medicines are issued from retail store
 LP medicines are issued from LP stores
 Injection Insulin is issued from a separate counter
c) Uniform persons (nursing assistants/ dispensers) dispense the medicines to the
patients.
d) A JCO is detailed to look over the whole process and to monitor and guide the
patients.
e) In case LP medicines are not available then patient is issued a balanced chit to collect
the medicines either in the evening or in the next morning.
f) Although the working in the pharmacy is very smooth but unfortunately there is no
proper waiting room for the patients in the pharmacy. There are some sitting areas
specifically in the corridor for convenience. Moreover, the time to receive medicines is
not more then 10-15minites

Observations:
1. The pharmacy is running short of adequate space and manpower.
2. The area dedicated to pharmacy is not purpose build and quite old now.
3. Due to shortage of staff guidance and supervision of the operative procedures undergoing
 in the pharmacy are also compromised.
4. The pharmacy is opened from 0730 hours to 1430 hours every working day, but there are
no arrangements for dispensing of medicines after working hours.
5. The pharmacy lacks professional outlook to some amount. There is stacking of medicines
in all the windows because of makeshift arrangements due to lack of space.
6. Pharmacy staff gives inadequate verbal instructions to patients about their prescriptions
due to heavy workload.
7. An important salient feature of the POF Hospital pharmacy is thatit has been
computerized and HMIS and PACS system have already been facilitated. These systems
provide readily eligible presumptions. Necessary corrections can be done there and then
by the pharmacist.
8. Rapid changing of pharmacy staff due to posting out to next station.

Recommendations:

Keeping in view the findings of the study, recommendations are

1. Human resource at work is considered the most important factor and their efficient and
effective management is key to achieve objects for any department as well as the
organization. It is necessary to utilize the manpower in the pharmacy.
2. Constructive supervision improves the efficiency considerably. This includes random
checking of medicines from the patients while leaving the pharmacy to counter the
dispensing errors.
3. CCTV monitoring can be a good option for supervision in an efficacious manner.
4. Diversity of people visiting the pharmacy demands skilled public dealing. Pharmacy
staff needs to be trained in their interpersonal and communication skills.
5. There should be adequate space for stocking and dispensing the medication.
6. Design of the infrastructure has the ability to influence the outcome. A new space for the
pharmacy should be decided and proper design should be followed for storage of
medicine as well as convenience of patients.
7. A satellite pharmacy should be established near or in the OPD block. This will not only
facilitate the patients but will also decrease the workload in the pharmacy. This satellite
pharmacy can also cater the patients who only come to receive medicines on their
continued treatment forms.
8. An electronic queuing system will also be beneficial and will solve many problems
 associated with queuing and waiting.
9. A comfortable waiting area is the need of the time. It should also have drinking water
facility and television for the patients who wait in the pharmacy for their prescriptions to
be made.
10. There should be a separate counter for senior citizens for their convenience.
11. Professional outlook of the pharmacy adds to the trust and confidence of the patients.
Provision of medicine in proper paper bags, avoiding counting of tablets with bare hands
are small but noteworthy and essential measures.
12. It is a good opportunity to promote health education and awareness among patients while
waiting fr their turn in the pharmacy. For this purpose, relevant information can be
displayed on LED screens placed in the hospital pharmacy, with internet facility. Other
measures like leaflets and handouts with simple language and colourful pictures may
also be used.
13. Boosting the morale of pharmacy staff through monitary benefits and other incentives
like good performance certificates and reports will create pride in jobs and increase
efficiency in performance of duty.
14. Last but not the least, regular feedback survey regarding pharmacy services from
patients as well as doctors for quality improvement will also play an important role
 CONCLUSION

Healthcare organizations all over the world are trying to improve the pharmacy services
through various strategies. The main aim is to improve the quality of services and achieve
safe and an effective system.
POF Hospital pharmacy is facilitating the patients who approach the pharmacy in high
hopes of getting remedy of their ailments and suffering. This study shows that although
majority of the patients reporting in the pharmacy are satisfied with the working and
facilities available there but, there are always some areas which need improvement and
change.
Even though the staff of the pharmacy, pharmacist and MOI/C medical stores are doing
their best but incompatible infrastructure, insufficient human resources and unresolved
dilemmas which may lead to lack of optimum efficiency of the pharmacy at times.
Nevertheless, continuous appraisals and unremitting efforts are required to resolve these
impediments within available resources. Moreover, patient satisfaction is an important
humanistic outcome. This study helped to find not only the working of the pharmacy, but
also the level of satisfaction of patients visiting there. It is essential to constantly monitor
needs of the patients and address their expectations, because patient satisfaction is not just
an indicator of service quality but also a predictor of health-related behaviour.
Moreover, international best practices and standards need to be incorporated into the
system with more vigor in order to bring the system at par with best international
 practices.

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INSTITUTIONAL REVIEW BOARD (IRB) APPROVAL FORM

(It will be submitted after approval of the synopsis)

 Annexure ‘A’

INFORMED CONSENT FORM

QUALITY OF PHARMACY SERVICES IN P.O.F HOSPITAL

Introduction
1. You are requested to participate in a study about quality of pharmacy services in P.O.F
Hospital. Your contribution will require responding to the attached questionnaire. You are
likely to require 15-20 minutes to indicate your answers.
Purpose of the study
2. The purpose of this study is to review existing pharmacy services as well as level of
patient satisfaction and to improve the quality of services.

Confidentiality and Right of Refusal

3. Your responses to the questionnaire will remain confidential, and your name will not
be associated with the research findings. Your identity will not be disclosed. The decision to
participate in this study is entirely up to you. You may refuse to take part or may withdraw
from the study at any time.

Additional Information
4. Please do not hesitate to ask anything before participating or during the study. I,
Dr._____________, may be contacted by phone on ______________ and my email address is
__________________________.

Consent
1. Your signatures below confirm that you have read and understood the information
provided in this form and that you are willing to participate in the study.

Signature

_____________________

Date

Name (Optional)___________________________
 Annexure ‘B’

QUESTIONNAIRE FOR PATIENT’S REPORTING IN POF PHARMACY

Serial No.

INTRODUCTION
This questionnaire is designed specifically to assess the status of pharmacy services in
terms of patient’s satisfaction level.
DEMOGRAPHIC DETAILS

1. Please fill in your gender

O Male
O Female
2. Please choose your age group
O Below 26 years
O 26 - 35 years
O 36 - 45 years
O 46 - 55 years
O 56 - 65 years
O Over 65 years
3. Please indicate the highest education level you have achieved
O No formal education
O Secondary School
O Bachelor’s Degree
O Master’s Degree
O Higher Degree
4. Please indicate your form of employment. (You can choose more than 1 box for example
if you have a regular paid employment and are also self-employed)
O POF employee
O Dependent POF employee
O Retired POF employee
O Army personnel
 O Other, please specify

Community Pharmacy Patient Questionnaire

This section is about why you visited the pharmacy today

Q1 Why did you visit this pharmacy today?
To collect a prescription for: Yourself  Someone else  Both  OR
For some other reason (please write in the reason for your visit):

If you did not collect a prescription, please go to Q3.

Q2 If you collected a prescription today, were you able to collect it straight away, did you
have to wait in the pharmacy or did you come back later to collect it?

Straight away  Waited in pharmacy  Came back later 

Q3 How satisfied were you with the time it took to provide your prescription and/or any
other pharmacy services you required?

Not at all satisfied  Not very satisfied  Fairly satisfied  Very Satisfied 

This section is about the pharmacy and the staff who

work there more generally, not just for today's visit

Q4 Thinking about any previous visits as well as today's, how would you rate the pharmacy
on the following factors? Please tick one box for each aspect of the pharmacy listed below, to
show how good or poor you think it is:

ANSWERS: very fairly fairly very don’t

poor poor good good know
a) The cleanliness of the pharmacy ………………….     
b) The comfort and convenience of the
waiting areas (e.g., seating or standing room) …..     
c) Availability the medicines/appliances
you need ……………………………………………..     
d) Offering a clear and well-organized layout ……….     
e) Privacy/confidentiality available or not………     

Q5 How would you rate the pharmacist and the other staff who work there? Please tick one
box for each aspect of the service listed below, to show how good or poor you think it is:
ANSWERS:

Very fairly fairly very don’t

a) Being polite and taking the time to listen poor poor good good know
to what you want …………………………………….     
b) Answering any queries you may have…..…….. …     
c) The service you received from the
pharmacist …………………………………………..     
d) The service you received from the other
pharmacy staff ………………………………………     

e) Providing an efficient service ……………………...     

f) The staff overall attitude…………………………...     

Q6, How well do you think the pharmacy provides each of the following services?
ANSWERS:
Not Not Fairly Very Never
at all very well well used
well well
a) Providing advice on a current health problem
or a longer-term health condition…………………..     
b) Providing general advice on leading a more
healthy lifestyle ……………………………………...     
c) Disposing of medicines you no longer need ……..     
d) Providing advice on health services or
information available elsewhere …………………...     

Q7 Have you ever been given advice about any of the following by the pharmacist or
pharmacy staff?
Stopping smoking……......  Yes  No
Healthy eating…………….  Yes  No
Physical exercise…………  Yes  No

Q8 Which of the following best describes your preference about this pharmacy?
This is the pharmacy that you choose to visit every time………………………… 
This is the only pharmacy available that you use when you need to………… 
This pharmacy was just convenient for you today ……………………………….. 

Q9 Finally, taking everything into account - the staff, the shop and the service provided -
how would you rate the pharmacy where you received this questionnaire?
Poor  Fair  Good  Very Good  Excellent 

[Insert here, if required, additional questions relating to healthcare service provision]