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Hospital and Clinical Pharmacy

In Easy English
Prepared By S R Pharmacy
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According to New Syllabus released by Pharmacy Council of India

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Contents
S.N. Chapters P.N.
1 Hospital Pharmacy 3

2 Different Committees In The Hospital 10

3 Supply Chain and Inventory Control 13

4 Drug Distribution 26

5 Compounding in Hospitals 34

6 Radiopharmaceuticals 39

7 Application of Computers in hospital 42

Pharmacy practice
8 Clinical Pharmacy 44

9 Clinical Laboratory Tests 53

10 Poisoning 63

11 Pharmacovigilance ( Overview ) 69

12 Medication Errors and Drug Interaction 71

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Hospital And Clinical Pharmacy Chapter 1
Hospital Pharmacy

Hospital
Hospital is a complex organization .It provides health care services with the
help of trained , well educated staffs and special scientific equipments .

Hospital Pharmacy
Hospital Pharmacy is a healthcare service provider in which medicines storing
, compounding , dispensing are performed and medical devices and advices
are provided to patients with safe and effective manner .
Scope Of Hospital Pharmacy
1) It inspects ( check ) the medical items are received and maintains an
inventory ( record ) .
2) It dispenses drugs and other pharmaceutical products to patients .
3) It has a record of each dispensed m edicine .
4) It has a record of narcotic and alcoholic drugs received and issued .
5) It manufactures the drugs in case of shortage and drugs available in high
cost .
6) It helps in minimising the illness and promotes the health .
7) It provides drug related information to the health care team and patients .
8) It helps in quality control of drugs .

National And International Scenario Of Hospital Pharmacy

1)The pharmacists are the third largest group of healthcare professional in

the world , and along the growth of Pharmacists the hospital Pharmacy is also
growing steady .
2) The main job of pharmacist is to manufacture and dispense the drugs , but
this role is evolved now and they are playing an important role in the care of
patients ..
3) Many of countries are not accepting the pharmacists as healthcare team ,
although they are capable to work in this field .
4) In India a hospital Pharmacist has a limited role in comparison to western
countries .

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5) Many of countries granted the pharmacists to prescrib e drugs for patients .
6) Hospital pharmacy is a important part of hospitals to provide
Pharmaceutical preparations .
7) Developed countries have clearly defined the role of hospital pharmacist ,
but many of countries have not defined their roles .

Organisational structure Of Hospital Pharmacy

Administrator

Pharmacy OPD Emergency

Chief Pharmacist
secretary
Pharmacy staff
Pharmacy Students
Clerks
works and qualifications

Dispensing Quality cont. storage manufacturing clerk clinical trail

( D. Pharm) ( M.Pharma ) ( B & D Pharma ) ( M Pharma ) ( d Pharm) ( B Pharma )

Professional Responsibilities of a Hospital Pharmacist

1) To follow the hospital's policies and co vey other for that .
2) To maintain accuracy of dosage are prescribed .
3) to provide drug information and way of administration to new staff or of
new drugs to all staffs .
4) to remain updated about new drugs ( effect , side effect etc ) .
5) to give instructions to the patients for self administrated drugs .
6) to take parts in new research and development .

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7) to educate and make trained the Pharmacists and pharmacy students are
taking practical training .

Qualifications And Experience Required for a H ospital Pharmacist

* The chief Pharmacist must have minimum postgraduate degree in pharmacy
, especially in Pharmacology or Hospital Pharmacy .
* Manufacturing chemist should have graduate degree in pharmacy with
minimum 18 month experience in drug manuf acturing .
* dispensing pharmacist should have minimum diploma in pharmacy .
* Ph.D degree holder is preferred in all categories .

A Chief Pharmacist must have these qualities

1) Administrative and Management Ability :

a) A pharmacist should have the abi lity of planning , implementing the
pharmacy policies and ability of making budget , stock control .
b) He / she should have ability to interview and select staff for pharmacies .
c) He / she should have ability to manage staffs and distribute works betwe en
them .
2) Manufacturing Ability : He should be able to manufacture drug in case of
shortage or high cost of drugs than normal .
3) Knowledge : He / she must have complete knowledge about drug action ,
side effect , routes of administration , and quality control .
4) research ability : he should have ability to research and develop new drugs
.
5) Teaching Ability : he should have ability to give lecture to the nursing staff
and students are under training .

Job specifications for a Hospital Pharmacist

A job specification is the list of recommended qualities for a person to qualify
a position .
A Pharmacist Should have the quality and experiences in " dispensing drug ,
performing quality check , formulating and reformulating dosage form
,monitoring and reporting drug safety , creating medications budgets, storing
medication and in planning of drug qualities for hospital " .

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Work-load Requirement for a hospital pharmacist
work load means how much work can a person do in a specific time .
The work-load of pharmacist is observed / analyzed by work characteristic .
some characteristics are following :
1) working hours per week .
2) numbers of hours that a person spent working alone in his or her
department .
3) numbers of prescription filled by a pharmaci st daily .
The number of pharmacist needed for a hospital is determined using the
number of beds .
Up to 50 beds 3 Pharmacists
Up to 100 beds 5 Pharmacists
Up to 200 beds 8 Pharmacists
Up to 300 beds 10 Pharmacists
Up to 500 beds 15 Pharmacists
They may be increased and reduced as required .

Inter-professional Relationships of a Hospital Pharmacist

The relationship between two or more professionals is called Inter-
professional relationship .
To get good result it is necessary to maintain positive relationship between
various professionals , as doctor prescribed drugs , pharmacist dispenses , and
nurses give to patients .

Good Pharmacy Practice In Hospital

It is a pharmacy Practice that responds to the need of people who use the
pharmacist 's services , to provide them optimal ( best ) and evidence based
care at standard level .
Requirements Of Good Pharmacy Practice
The main Important part of pharmacy activity to help patients through :
* the supply of medicines and healthcare products .
* the provision of appropriate information and advices to the patients .
* the administration of medicines .

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Roles of Pharmacists In Good Pharmacy Practice
Roles of pharmacists in GPP are to prepare , obtain , secure , distribute ,
administer , dispense and dispose of medical products at the standard level .

Hospital Pharmacy Standards ( standards of good pharmacy practice in

hospitals )
1) FIP ( International Pharmaceutical Federation ) Basel Statements
FIP is a global organisation that represent and assist Pharmacy ,
Pharmaceutical science , and pharmaceutical education worldwide .
In 2008 , a conference was conducted in Basel, Switzerland by FIP which
included hospital pharmacist from all over the world and discussed about the
future of hospital pharmacy .

FIP Basel Statement

1) procurement
2) Influence On Prescribing (doctor's choice , cost , marketing influence the
prescription)
3) Preparation and delivery of medicines
4) administration of medicine
5) monitoring of medicine use
6) Human resources , training and development

2) ASHP ( American society Of Health System pharmacy )

The American Society Of health System Pharmacists represent all pharma cists
who provide health care service . This organisation is made up of more than
60,000 member including Pharmacy technicians , pharmacists in training and
professional Pharmacists .

Minimum Standards required

1) The pharmacist should have appropriate k nowledge of pharmacy
department .
2) Knowledge of abbreviation .
3) Knowledge of dosage calculation
4) Knowledge of procurement and inventory
5) Knowledge of administration
6) Knowledge of production , packaging and labeling .

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NQAS(National Quality Assurance Standards)Guidelines

Introduction
NQAS is a organization, it was made up by Ministry of health and Family
Welfare to highlight top performing facilities and to increase the trust of
people on public hospitals .
Organisational structure
NQAC SQAC DQAC
Some Area where they focus
1) Service Provision , Patient right , infection control , quality management ,
2) hand washing Facilities .
3) Postpartum care ( hormonal level and uterus size return to a non pregnant
state after 6 weeks of childbirth )
4) oxytocin administration within 60 seconds of childbirth .
5) Availability of curtains etc .

NABH ( National Accreditation board for Hospitals & Healthcare Provider )

Accreditation
NABH is a constituent ( part ) of Quality Council Of India ( QCI ) . It is made
up to operate hospital accreditation ( approval ) program for health care
organizations . This board give approval the hospitals and health care
providers after completing certain standards ( criteria ) .
NABH Standards For Hospital Pharmacy
1) Legal requirements :
a) Qualified Pharmacists should have their certificate displayed in the
pharmacy .
b) Schedule H and X drug should only be sold by retailer , when they
prescribed by a licenced medical professional .
c) The pharmacy should not sold the physician samples .
d) the NDPS medications should be kept in locked container and a register
should be available to keep record of every issue of NDPS medications .
e) All the legal document should be updated during valid time .
2) Access to Medications :
a) The pharmacy should stock only those medicines which are listed on the
hospital's formulary ( list of medicines ) .

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b) The pharmacy in-charge should be aware of the procedure for obtaining
medications
c) the room and area where the medications are kept should be clean and free
from vermin and bugs .
d) the proper security like CCTV and entry restriction should be available in
pharmacy .
3) medicine Safety :
a) Refrigerator should be available for the drugs are not stable i n room
temperature .
b) personal items like food drinks should not be kept in the refrigerator is
used for drugs
c) LASA drugs should be stored separately or colour - coded.
d) A list of high risk drugs should be identified and made easy available .
4) other safety :
a) Fire safety like fire extinguisher should be available .

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Hospital And Clinical Pharmacy Chapter 2
Different Committees In The Hospital

Pharmacy and Therapeutic Committee (PTC)

Introduction
PTC is an advisory group of physicians , Pharmacists , and other medical staff . They make
policies regarding the drug used in hospital .
Objectives Of PTC
1) Advisory Objectives
a) To make policies regarding drugs to evaluate and select the best drugs for therapeutic
usage in hospital .
b) To provide guidance to Pharmacists about drug distribution in an efficient way ( without
mistake and wasting time and energy )
c) To aware the hospital administration and medical staff about the problems are related
drug usage , especially experimental drugs .

2) Educational Objectives
a) to examine adverse effects of the drugs and offer new formulary system .
b) To provide up-to dated information about drugs and their usage to satisfy the demand of
policy maker professionals .
c) to plan training program for staff regarding the drug usage .
Composition Of PTC

Medical staff Pharmacy staff

Pharmacy and Therapeutic Committee

Sub- Committee Sub- Committee Sub- Committee
1)neo-plastic 4) Anti-infective 7) Gastrointestinal
2) Cardiovascular 5) Diuretics 8) endocrinology agents
3) Hypotensive 6) Laxatives 9) Analgesic & anti-pyretic

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Functions Of PTC
1) It acts as an advisory council to the medical staff and hospital administration regarding
the therapeutic use of drugs.
2) It develops a formulary of drugs and prescriptions to be used in hospitals.
3) It suggests written policies and procedures regarding the selection, procurement,
storage, distribution, and therapeutic use of drugs.
4) It establishes suitable educational schemes for the hospital staff regarding the
therapeutic use of drugs .
5) it studies the problems related to drug distribution and administration .
Role Of Pharmacist In PTC
1) Pharmacists are important to make the formulary, because they can ensure safe,
effective, and affordable drug use.
2) They examine scientific , clinical , and economical data .
3) they convey the staff to obey the decision taken .
4) they create a schedule for committee meeting .

Hospital Formulary

The Hospital Formulary is a list of evaluated and selected drugs with their important
information to use or distribute in a hospital .
Procedure for development of Hospital Formulary
To make a hospital formulary the first step is to form a good PTC . The PTC develop a
formulary in written form . This committee take decision on
1) the type of publication of formulary ( Hospital's won formulary or purchased formulary
services ) .
2) Fixation of rules which the PTC required during evaluating and selecting the drug for
formulary .
3) Addition of other content like,
a) Prescription writing
b) uses of drug
c) Table of metric weight ( 1g = 1000 mg )
d) table of common laboratory values ( BP 120/80 )
e) Calculation of dosage ( for children )
4) type of format of formulary ( size , loose leaf , bounded ) .

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Addition and Deletion of Drugs from Hospital Formulary
It is a important step in maintenance of Hospital formulary .

Criteria For addition and deletion are :

1) The medical staff should approved the drug to be added in formulary .
2) the drug should be reccognised by the Pharmacopoeias .
3) the drug manufacturer should hold a license , and he should not have been punished for
any serious offence under any law of Drug and medicine .
4) There should not be used secret ingredient in drug which is not labeled .
5) The drug containing multiple ingredients should not be added in formulary , if the same
therapeutic effect can be obtained by a single ingredient drug .

Infection Control Committee ( ICC )

It is a committee to prevent and control healthcare related infections by making infection

control policies and monitoring practices to reduce these risks .
Nosocomial In fection = Patient get infection inside the hospital
Objectives Of ICC
1) To understand the methods of infection control .
2) to understand the reason of nosocomial infection .
3) to reduce the danger of infection for patients , medical personnel , and gests .
4) to conduct antimicrobial program and instruct the medical staff , patients , and gests .
* Function , same the objectives
Role Of Pharmacist In Preventing Antimicrobial Resistance
Anti-Microbial Resistance is a ability of microorganisms to protect them from the effect of
antimicrobial drugs .
This resistance ability they develop themselves or developed naturally . overuse of
antibiotics is the main reason of AMR .( Anti-Microbial Resistance ) .
Role of Pharmacist in preventing AMR .
1) He / she should distribute medicine in safe and appropriate manner .
2) he / she raises awareness on the risk of inappropriate drug use .
3) he control the infection by decreasing the infection transmission .
4) he guide hospitals on the selection and use of suitable antibiotics , disinfectants , and
sterilants.

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Hospital and Clinical Pharmacy chapter 3
Supply Chain and Inventory Control

Supply Chain Of Drugs

A drug supply chain is the network of all the individuals , organisations , resources and
technologies are involved in manufacturing and sale of a product .

Following Chart can help to understand the supply chain of drug to hospital

Manufacturing Distributor Wholesaler Retailer

Hospital Pharmacy

Preparation training
* It is a process to categories the drug with their generic names , strength and form .
* It is prepared by country 's pharmacist , chemical and pharmaceutical staff.
Some Drug lists :
* High Risk drugs
* Emergency drugs ,
* Schedule H1 Drugs ,
* NDPS ( narcotic drugs and psychotropic substances .
*Reserve Antibiotics .

High Risk Drugs

High risk drugs are those drugs which cause significant ( serious ) harm to patients if they
are used incorrectly .
1) adrenergic agonists IV ( Epinephrine , norepinephrine , )
2) ) adrenergic antagonists IV ( propranolol , prazosin , atenolol )
3) anaesthetic agents ( general ) inhaled and IV ,( Ketamine , propofol )
4) anti Arrhythmic agents ( lidocaine , procainamide ) .
5) antithrombotic agent ( anticoagulants) : heparin , argatroban
6) Hypoglycemic Agents ( metfomin .)

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7) sedative agents ( alprazolam , diazepam )
8) narcotic drugs : Codeine , morphine
9) neuromuscular blocking agents : succinylcholine
10) Insulin IV and subcutaneous .

Emergency Drugs
These are the drugs which may be required immediately in emergency conditions to
prevent the risk or harm to patients and can save their life ,
these drugs have onset of action , and are administered by such route which facilitate onset
of action like : Epinephrine in cardiac arrest .

Emergency drugs
1) Adrenaline
2) Inj Lidocaine
3) Inj. Delanettasone
4) Adenosine
(6) Inj Deriphyllin
7) Inj. Nor-adrenaline
8) Inj. Hydrocortisone
(9) Inj. Avil
10) Inj. Calculuconate
11) inj Vascogressin
12) Inj Diclofenac
13) Inj. Sodium bicarbonate

(14) Inj. Midazolam

15) Inj Ethamsylate
16) Inj. Flumazenil
17) Inj. Amiodarone 25% Dextrose
18) Inj. Naloxone
19 ) Inj. Nitroglycerin
20) Inj. Diazepam
21) Inj. Potassium chloride

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22) Inj Succinylcholine
23) Inj. Paracetamol
24) Inj. Digoxin
25) Inj. Dopamine
26) Inj. Methylprednisolone
27) Inj. PAM
28) Inj. dobutamine
29) Inj. Heparin
30 Inj. Mephentermine
(31) inj. Lasix .
(32) Inj. Aminophylline
33) Inj.Phenergan

Schedule H1 Drugs
These are the sensitive antibiotics and habit forming drugs , which are not allowed to sale or
distribute without a prescription of a registered Physician or pharmacist . like Alprazolam .
1) Alprazolam
2) Balofloxacin
3) Buprenorphine
4) Capreomycin
5) Cefdinir
6) Cefditoren)
7) Cefepime
8) Cefetamet
9) Cefixime
10) Cefoperazone
11) Cefotaxime
12) Cefpirome
13) Cefpodoxime
14) Ceftazidime
15) Rifampicin
16) Tramadol

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17) Ceftibuten
18)Ceftizoxime
19) Ceftriaxone
20) Chlordiazepoxide
21) Clofazimine
22) Sodium codeine
23) Cycloserine
24) Diazepam
25) Diphenoxylate
26) Doripenem
27) Ertapenem
28) Ethambutol
29) Hydrochloride
30) Ethionamide
31) Sparfloxacin
32) Zolpidem
33)Feropenam
34) Gemifloxacin
35) Imipenem
36) Isoniazid
37) Levofloxacin
38) Meropenem
39) Midazolam
40) Moxifloxacin
41) Nitrazepam
41) Para-aminosalicylate
42) Pentazocine
43) Prulifloxacin
44) Pyrazinamide
45) Rifabutin
46) Thiacetazonedol

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NDPS ( Narcotic drugs And Psychotropic substances )
Narcotic Drugs : the opioids and their derivatives are called narcotic drugs .
psychotropic substances : psychotropic substances are chemical substances which change
the function of nervous system , and alter the mood , perception , consciousness like
alcohol , marijuana , nicotine .
The NDPS Act, 1985 forbids cultivation, production, possession, sale, purchase, trade, use
and consumption of narcotic drugs and psychotropic substances, except for medical and
scientific purposes under license.

NDPS Drugs
Alprazolam, Amfepramone, Barbital, Benzphetamine, Bromazepam, Camazepam,
Chlordiazepoxide, Clobazam. Clonazepam, Clorazepate, Clotiazepam, Cloxazolam,
Delorazepam, Diazepam, Estazolam, Ethchlorvynol, Ethinamate, Ethyloflazepate,
Fludiazepam, Flunitrazepam, Flurazepam, Halazepam, Haloxazolam, Ketazolam, Lefetamine,
Loprazolam, Lorazepam, Lormetazepam, Mazindol, Medazepam, Meprobamate,
Methylphenobarbital, Methyprylon, Nimetazepam, Nitrazepam, Nordazepam, Oxazepam,
Oxazolam, Phendimetrazine, Phenobarbital, Phentermine, Pinazempam, Prazepam,
Temazepam, Tatazepam, Triazolam, Cathione, DMA, MDMA, 4 Methylaminorex, MMDA, N-
Ethyl MDA, N-Hydroxy MDA, PMA, TMA, Fenethylline, Levamfetamine, Metamfetamine,
Racemate, Byprenorphine, Butalbital, Cathine, Allobarbital, Methylamfetamine,
Fencamfamine, Penproporex, Mefenorex, Midazolam, Pemoline, Pyrovderone, Sec
butabarbital, Vinylbital, Butobarbital, Etryptamine, Methacathinone, Zipeprol, Aminorex,
Brotizolam, Mesocarb.
DET, DMHP, DMT, (+)-Lysergide, (LSD, LSD25), Mescaline, Parahexyl, Eticyclidine,
Rolicyclidine, Psilocine, Psilostin, Psilocybine, STP, DOM, Tenocyclidine, THC, DOB, MDA,
Dexamphetamine, Mecloqualone,
Amphetamine, Methamphetamine, Methaqualone, Methylphenidate, Phen cyclidine,
Glutethimide, Phenmetrazine, Amobarbital, Cyclobarbital,Pentazoxine, Pentobarbital,
Secobarbital,

Reserved Antibiotics
The reserved antibiotics are those antibiotics which are reserved for the treatment of
suspected or diagnosed infection caused by multi -resistant organism , and they are used
when all other antibiotics have failed .
1) Aztreonam
2) Carumonam

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3) Colistin (Oral)
4) Ceftaroline
5) Cefiderocol
6) Ceftobiprole
7) Ceftazidime + Avibactam
8) Ceftolozane + Tazobactam
9) Colistin (Injection)
10) Dalbavancin
11) Dalfopristin + Quinupristin
12) Eravacycline
13) Fosfomycin (Injection)
14) Imipenem + Cilastatin + Relebactam
15) linezolid
16) Minocycline (Injection)
17) Oritavancin
18) Polymyxin B (Injection)
19) Tedizolid
20)Daptomycin
21) Faropenem
22) Iclaprim
23) lefamulin
24)Meropenem + Vaborbactam
25) Omadacycline
26)Plazomicin
27) Polymyxin B (Oral)
28)Telavancin
29) Tigecycline

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Procedure Of drug Purchase

Drug Purchase : means to obtain or get different types of medicines from external network.
procedure for purchase
1) purchase request form / Purchase requisition :
a) the pharmacist prepares the drug list to be buy and fills purchase request form .
b) This form provides information regarding required drugs , their quality and quantity .
c) this form will be sent to administration for approval , after approval it will sent to
purchasing officer .

2) Quotation Invitation :
Now the Purchasing officer send this form to different suppliers and ask their quotations

3) Purchase form :
The purchasing officer check all the quotations and select suppliers on the price , quality
etc. and place the purchase orders .

4) Receipt of good products :

When the ordered products delivered to the purchasing department , their quality ,
quantity and prices are checked . If the any product miss the desired quality , quantity ,or
price they should retuned to supplier .

5) Payment :
After satisfactory completion all these process , the purchasing officer pay the amount to
the suppliers .
Tender /e-tender
It is a process in which a person or organisation , who need goods / services etc. invites the
other parties to submit a proposal to provide their goods or services .
E tender : If this process is done by electronic machinery without using paper then it called
E-tender .

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Inventory Control

Inventory : All the items , goods , materials and manufactured product a company have for
sell is called Inventory .
inventory Control : Inventory control is a process of maintaining a business stock level to
fulfill the customer 's demand and to minimize cost .
Inventory control techniques
1) ABC analysis : It is a inventory management technique that determine the value of
inventory items on the basis of their importance to the business .
2) VED Analysis : It is also an inventory management strategy that classifies the materials
according to their importance .
No. Expenses Rs Need of care
Goods
V. Vital A 10% 70% 70 Rs Good care, Good Storage,
Evaluation
E.Essensial B 20% 20 % 20 Rs General care ,general storage no
evaluation
D . Desirable C 70% 10% 10 Rs No care, no storage , no
evaluation

ABC = Always Better Good

3) Economy Order Quantity ( EOQ) : It is a method to purchase appropriate quantity of row
material for manufacturing at one time , to minimize ordering and caring cost .
Ordering Cost : It includes all those expenses are related to ordering , like traveling cost
expenses during traveling etc .
Caring Cost : It includes all those expenses are related to goods like transportation charge ,
insurance , room rent , storage expenses etc.
Formula EOQ = √ 2x A.D. x O.C. A. D. = annual demand , O.C.= ordering cost
C.C . C.C . = Caring Cost

Key Points of inventory Control :

* Minimum level of stock
* Maximum level of Stock
* Average requirement
* Dangerous level of stock
* Re-ordering Quantity .

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Lead Time : It denote the time gap up between placement of an order and its delivered time
.
Reorder Quantity Level :
It is a process of inventory control , when the level of stock material reach at specific level ,
then new order is placed to maintain stock level .
Reordering Level = maximum consumption x maximum reorder period
Inventory Turnover :
it means how many times an inventory of a company is sold or used in a particular time
period .
It is calculated to see if a business has an excessive inventory in comparison to its sales .
cost of goods sold
Inventory Turnover = average inventory
Cost Of goods sold : It is the value of goods sold during a particular time period . Average
Inventory : It is a estimated value of goods used in a specific time periods . it includes total
amount of raw material and products are manufactured .
beginning inventory + Ending inventory
average turnover = 2

cost of goods sold ( 50 cr )

Inventory Turnover =
average inventory (3 cr )

50 cr
= = 16.66 times
3 cr
it means a company has sold its inventory 16.66 times in last year .

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Inventory Management of central Drug Store

Inventory Management :
It is a process in which different types of actions are taken place like ordering , storing ,
using , and selling a company 's inventory .
It has a record of each new and returned product enters in warehouse or out from here .

Some key points of Inventory management :

1) Storage conditions

2) FIFO , FEFO methods

3) Expiry drug removal

4) Documentation
Storage Conditions
considering protection , drugs are kept in the storage room under different conditions like
in different temperature , darkness , dryness . various Storage conditions on the basis of
temperature :
1) Room Temperature : majority of pharmaceuticals are stored at room temperature , room
temperature is considered between 20-25 ° C
2) Cool Storage Condition : It defined between 8-15 ° C , Antibiotics and hormone etc are
stored in this temperature .
3) Cold Storage condition : It is defined between 2-8 ° C , Vitamins , Vaccines etc are stored
in this temperature .
4)Fridge Storage condition : It is defined between - 4 to 2 ° C , Insulin and some types of eye
drops etc. are stored in this temperature .

Methods Of Storage
All the medicines must be stored according to the guidelines are provided on the label .
like that storage instructions should be provided on label .

Storage of Tablets
Store in a cool and dry place , protected from light and moisture .

Storage of Capsule
Store in a cool and dry place , protected from light and moisture .

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Storage of Emulsion
It needs to be protected from light , stored in cool and well closed container .
Storage of suspension
Store in cool and dry place protect from heat and light .
Storage of Ointment
It needs to be protected from light and heat , stored in cool and well closed container .
Storage of Syrup
Store in cool and dry place protect from heat and light .
Storage of Injection
store below 25 ° C , protect from light .
Distribution Of Drug
It means providing drugs to the patients , they may of tow types in hospital .
Indoor or in- patients , outdoor or out-patients .
Maintaining Cold chain
It means to provide 2-8 ° C temperature to any product like vaccines , during manufacturing
, storing , transporting ,and distribution , to maintain their potency .
Devices Used for Cold Storage :
1) Refrigerator
2) Thermometer which indicate the temperature level .
3) cold boxes for storage and transportation .
4) ice packs
ILRs ( ice lined refrigerator )
Ice lined refrigerator is a type of refrigerator which has an extra function where cold ice
water , or ice packs are filled . they maintain the inside temperature at a safe level in case
of electricity fails .
Walk In Cold Rooms ( WIC )
Walk- in cold room is a cold storage condition on a large scale and it provide a constant an
comfortable temperature throughout the space .
FIFO and FEFO
FIFO : Means First In, First Out It is a method in which the product came first in the
warehouse is taken out first , to avoid expiration .
FEFO : It means First Expire, First Out . In this method the products whose expiry is closest
are out first , to avoid expiration .

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Expiry Drug Removal and Handling and Disposal

Expiry
There is a time period and condition in which a drug is good for use , and ending this time
period or missing the specific condition ( temperature , darkness ) in which a drug is good
, called Expiry .
Removal and Handling of expired Drugs
It is a process of store management to remove the expired drugs from store and to handle
properly so that they should not be given to use .

Following actions can be taken for handling expired drugs

1) the expired drugs must be separated from usable drugs .
2) where these drugs are kept , there should be a notice like " out of Use "
3) The expired drugs must be destroyed as recommendation of local waste management .
Disposal Of Expiry Drugs
Disposal of expiry drugs means destroying the expired drugs so they can not used .
Disposal methods recommended by the International Authorities
1) Returning to the Manufacturing : The Manufacturer has good disposal method at its
disposal .
2) landfill : This is the oldest and best way for disposal of solid waste ,In this method the
waste materials are placed into land . The municipal waste should be used to cover this site
.
3) Waste Immobilisation ( Encapsulation ) : In this method , the pharmaceuticals are packed
in a plastic or steel drum , solid and semi solid materials are filled 75 % of drum , then
mixture of lime , cement and water in 15: 15: 5 ratio is filled , then mouth of drum sealed
and placed in landfill and cover with municipal solid waste .
4) Sewer : Syrups and IV fluids are diluted with water and flushed into sewer , in small
quantity , over a time period .
5) Incineration : In this methods the waste material are given high temperature heat to be
destroyed .
6) Chemical Disposal : In this chemicals are used to destroy the expired drugs .
Disposal Of Narcotics
Narcotics drugs should be disposed in supervision of a pharmacist or the police , and public
should not be allowed to prevent abuse .

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Disposal Of Cytotoxic Drugs
Anti cancer drugs are also known as Cytotoxic Drugs .

disposal methods of Cytotoxic wastes

1) Return to supplier
2) Incineration at high temperature
3) Encapsulation
4) disposed to landfill
Documentation of purchase and Inventory
documentation means to write every purchase, inventory retuned products .

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Hospital And Clinical Pharmacy Chapter 4
Drug Distribution

Definition
Drug distribution is a process to provide drugs to the patient or patient's attendant .
Types of Drug Distribution
1) to Indoor or in patients
2) To outdoor or out patients .

Methods of drug distribution to in patients

1) Individual prescription order method ,
2) Floor stock method
3) Unit dose drug distribution method
4) Drug Basket Method
Individual Prescription Order Method
In this method the physician writes a prescription and ask the patient to get the medicines
from a licensed medical store .
Advantages
1) All the prescribed medicines are directly revived by a pharmacist .
2) Less number of staff required in hospital .
3) It may be cheaper than hospital pharmacy .
Disadvantages
1) chances for increasing medication errors due to
a) wrong scheduling .
b) wrong administration
2) Greater chances for drug interaction .
3) there may be delay in obtaining required drugs .
Floor Stock Method
In this method , the drugs are stored in the chief stock room , and are supplied to the
wards at nursing station ( which may at every floor ) and stored there , and from there
administered to a patient by a nurse according to the chart order of physicians .
It is divided in two types

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1) Charge drugs ( Envelop method ) : these are expensive drugs , obtained from the
pharmacy store and cost of these drugs are billed in the patient account .
2) Non Charge Drugs ( Drug Basket Method ) : These are cheaper and commonly used drugs
, their costs are not directly billed in patient 's account , but included in the per day cost of
hospital ward .
Advantages
1) Drugs are readily available for use
2) reduced the number of staffs .
3) the number of drug order by nurses is also reduced
4) reduced the number of drug returned to the pharmacy .
Disadvantages
1) medicine errors may increase .
2) degradation of drugs may increase .
3) There is need of extra investment to maintain storage facilities in every ward or floor .
Drug Basket Method
It is a type of floor drug distribution method , in this method , nurses verify the availability
of medicines in all rooms and refrigerators with the help of master list of pharmacy , then
fill demand form for the delivery of drugs to floors .
* If they found any empty container , they put it in the drug basket .
* after completing the round in all rooms , they send the demand form and container to the
pharmacy .
Advantages
1) Drugs are readily available for use
2) reduced the number of staffs .
3) the number of drug order by nurses is also reduced
4) reduced the number of drug returned to the pharmacy .
Disadvantages
1) medicine errors may increase .
2) degradation of drugs may increase .
3) There is need of extra investment to maintain storage facilities in every ward or floor .
Unit Dose Drug Distribution Method
In this method drugs are prepared and distributed in a single dose to use once

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Types of Unit Dose Drug Distribution Method

1 ) Centralised Unit Dose Dispensing ( CUDD) : In this method the drugs are stored in the
main pharmacy and dispensed when any dose is required to give a patient ( by dumb waiter
) with medication card .

2) Decentralised Unit Dose Dispensing ( DUDD) : In this method a small pharmacy is made
on each floor of the hospital , and drugs are supplied to this pharmacy from main pharmacy
on receiving the demand . from this small pharmacy drugs are dispensed in unit dose when
required to give a patient .
Advantages
1) pharmacist checks the physician 's prescription before administration of drugs by a nurse
.
2) lees chances for stolen of drugs .
3) Low investment , because storage facility is not required at each floor or ward .
4) Nurses have more time to care patients because all doses are prepared in pharmacy .
Disadvantages
1) Time consuming : - A Pharmacist has to give more time in handling each dose individually
than sending the bulk drugs to a ward .
2) Increased staff : This system requires a large number of staff to manage the system .
3) Increased Cost : This system additional equipments to deliver drugs like dumb waiter .

Drug Distribution to Out patients

In this type of drug distribution , drugs are provided to the patients are not admitted in
hospital and are given general or emergency treatment .
Steps for dispensing drugs to out-patients
* The patient name is registered by registration staff and patient is send to the physician
with registration form .
* the Physician Checks the patient and write a prescription .
* The patient takes the prescription to the pharmacy .
* The pharmacist reviews the prescription carefully and records the prescription and
provides the drugs.

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Distribution of Drugs to ICCU/ ICU /NICU / Emergency Wards
There are some specialised units ( department ) in hospital which are reserved
for those patients are in serious condition and require close monitoring and
extensive ( big) treatment .
some specialized units are given below :
1) ICU ( Intensive Care unit ) : It is also called Intensive treatment unit ,ICU is
a specific department for critically ill patients who require intensive and
constant care .
2) ICCU ( Intensive coronary Care Unit ) : It is also called Intensive Cardiac
care Unit . ICCU department is reserved for patients having Heart related
problems like heart failure , coronary heart diseases etc.
3) NICU ( Neonatal Or Newborn Intensive Care Unit ) : it is also called ICN (
Intensive Care Nursery ) NICU Department is reserved for care of sick or
preterm newborn babies .
4) Emergency Ward : This department provides emergency medication for
patients arrive without an appointment .
Drug Distribution to these Departments
In Intensive care Units drugs are available already . Only some certain ,
limited quantity of drugs stored there . They are packed in single unit
container . And location are fixed for storage of IV solution for certain drugs .
Automated Drug Dispensing System and Devices
Introduction
Automated drug dispensing is a pharmacy process in which a machine or a
robot fills the prescription at the place of human being .
Advantages
1) Reduced Pharmacy staff and work load .
2)It Provides Automatic In ventory facility .
3) It saves a lots of time .
4) Decreased mistake .
5) It provides safety .
Disadvantages
1) It Requires Extra training and technical knowledge .
2) Dispensing may be stopped in case of failure of any part of automatic
system .
3) It requires extra budget and space .

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Devices Used in automated drug dispensing system
1) Automated Dispensing Cabinet (ADC) : It is a computerised medication
cabinet (Cupboard ) used in hospitals
Some Features of it :
1) It provides Automatic Inventory control .
2) It provides a drug storage environment.
3) It Provides safety of drug .
4) It provides safety of patients via bar code verification .
5) It provides a fast service .
6) It provides a EMR ( Electronic Medical record ) .
7) It provides MAR ( Medication Administration Record ) support .

2) Computer : Using computer Following Facilities can be used .

a) ADS ( Active Directory System ) Sever System : It a feature of Microsoft
Window . It allows administrators to handle and manage all the computers
and devices are connected to this server (network) , from a single location ,
and other users can use the information and date are provided here .

b) Medication Administration Record ( MAR) : It provides a list of prescription

, prescribed for each individual patient , and list of medication with
administration timing and signature of nurse .

c) Coputerised Physician Order Entry : It is a clinical information system in

which by a physician , through computer system an order is placed for
dispensing of drug , laboratory test , or treatment to a patient .

d) Clinical Decision support system : This system provides a real time clinical
decision , including dose , alternative drug information , drug -drug and drug
food interaction information guidanc e .
3) Robotic dispensing : It is a computer controlled automated dispensing device ,
it can store and fills the prescription . It can counts pills , ampoule and bottles
etc. and ensure accuracy .
Advantages
1) Reduced Pharmacy staff and work load .
2) It saves the time of pharmacists and patients .

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3) Safe distribution of drugs .
4) it provides fast services .
5) It can distribute up to 12 prescriptions per minute and store up to 3500
medicines .

Distribution of Narcotics and Psychotropic Substances and Storage

According to Drugs and Cosmetics Act 1945 , Narcotics and Psychotropic

substances are can't be sold without a valid prescription for non ward and ,
and can 't be dispensed without a requisition form for wards in hospital .
These are also called controlled Substances .
So It is the responsibilities of Hospitals and Pharmacies to control their use
without a valid prescription .
Hospital Control procedures
These Procedures are developed by American Government Authorities and can
apply in India also :
1) Responsibilities for Controlled Substances in a hospital :
I. The administrator of hospital should properly handle the controlled
substances .
II. The Medical superintendent should manage properly .
III. The Chief Pharmacist : He should Look After the pu rchase , storage and
dispensing of controlled substances .
IV. the Head Nurse should look after the storage and use of Controlled
substances in nursing unit.

V. While Ordering Demand of controlled substances for ward stock the

nurse should fill a requisition for and should mention the name , desired
strength and quantity of controlled substances .
Sample of requisition form
Apollo Hospital Delhi
Ward No ... Floor ... Date .....
Quantity Items needed Price
20 Codeine sulphate tabs. 15mg
30 Morphine sulphate ampoules .15mg

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The Nurses should also record the use of controlled substances on daily basis

Apollo Hospital Delhi

Date .... Ward No .______ floor no .______
Patient's Name No. of Strength Ordered Adm. by Time
name of drug tabs . or by doctor nurse
injec.

signature of Nurse ......

2) Prescribing Controlled drugs for out patient department : the prescription
prescribed for out patient pharmacy , the prescription should have following
information :
I. full anme of patient
II. hospital number or address
III. date
IV. name and strength of prescribed controlled drugs.
V. quantity of drug
VI. frequency and rout of administration
VII. signature of Physician .
3) Procedure In Case of Waste , Destruction , contamination etc.
I. Aliquot part of narcotic solution unused : The remaining part of solution
in ampoule which is not used should be thrown into sink by nurse .
II. Prepared dose refuse by patient or cancelled by doctor : In this case the
solution should be discarded into sink , and record the reason for drug
not being administrated .
III. Accidental destruction of drugs : in case of accidental destruction of drug in
nursing unit , the responsible person should inform the head nurse
about that .
4) Control of Narcotics on the ward by nurses :
 when Controlled drugs dispensed to nursing unit , Now it is
responsibility of nurses for administration , looking after , and
documentation .

5) Delivery of Controlled drugs to ward : The narcotics drugs from main

pharmacy should be delivered to ward / nursing station by a faithful person
working in hospital .

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6 ) Storage of narcotics and psychotropic drugs :
a) These substances should be under lock and key all the times .
b) There should be a different register to register them .
c) No other objects should be kept with Narcotics .
d) They should not be bought and sold to unauthorised person .

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Hospital and Clinical Pharmacy Chapter 5
Compounding In Hospital

Definition
Compounding is a process of combining , mixing or altering in drug
ingredients for developing a drug to fulfill t he specific need of a patient .
It is done when no approved drug is appropriate for patient .
Objectives
1) To convert solid form to liquid .
2) to avoid an allergic ingredient like coloured dyes .
3) To provide an exact dose that is not available in ma rket .
4) To mask an unpleasant taste .
5) Two minimize multiple dosing .
Bulk Compound
when any drug compounded in bulk ( big amount ) it is called bulk
compounding it is required when same medication are prescribed more and
more in a specific area .
Requirements for bulk compounding in hospital
1) Manufacturing facilities : the place where drug are being compound should
be clean at high degree . it should be smooth construction specially walls and
floor which are easy to clean .

2) Raw Materials : after deciding the drug to be compounded , its raw

materials should be bought of good quality and in sufficient quantity .
3) Equipments : the equipments are required for specific drugs should be
available .
4) Staff : there should be enough staff acco rding to workload .
Control Systems In Compounding
1) Compounding process control : during compounding the standard process
should be applied to obtain good strength , quality and purity of drug .
2) Quality control : it is a process to check the qual ity , purity or strength of
a developed product .
3) Budgetary control : the budget of hospital should also be considered
during making a program for bulk compounding .

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I V Admixture Services

Definition
Combination of one or more sterile products in to bottle of IV Fluid is called
IV Admixture .
Preparation Of IV Admixture
1) The admixture should be prepared according to the directions of physician
.
2) According to the physicians order a label should be prepared including
a) name and address o f patient and location
b) name of physician .
c) name of drug with quantities.
d) date of compounding and expiry date
e) name of pharmacist who prepared Admixture .
3)The admixture should be prepared under laminar flow hood / cabinet using
sterile needles and syringe .
4) After adding the drugs the solution should be mixed properly .
5) Before using the admixture solution , it should be checked carefully to
satisfy that there is no incompatibility .
6) Before dispensing the final admixture preparati on to use ,the pharmacist
should inspect the label and calculation etc .
Incompatibility of IV Admixture
Incompatibility is an unwanted reaction that occurs between the drug to drug
, fluid or containers . and unable to show required effect. like :
1) Synergism ( increase in drug efficiency )
2) antagonism
3) New effects like toxic effect .
Types of Incompatibility of IV Admixture
 Physical Incompatibility
 chemical Incompatibility
 therapeutic Incompatibility
1) Physical incompatibility : when visible changes occurs after mixing two or
more drugs , it is called physical incompatibility for example change in colour
, formation of precipitate etc.

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2) Chemical incompatibility : when chemical degradation occurs after mixing
true or more products , it is called chemical incompatibility e. g. oxidation
,reduction ,decomposition ,complexation .
3) therapeutic Incompatibility : when drugs are administered and show
unwanted effect like antagonism ,synergistic or toxic effect , it is called
therapeutic incompatibility .
Consequences of Incompatibility of IV Admixture
Irritation , Multiple organ failure , toxicity , Embolus . etc.

Preventing Incompatibility of IV Admixture

 Preparing admixture under strict indications of Physician .
 Separating the drug dose by time and place and by rinsing the IV setup
/ system with a natural solution .
 by using in-line filter for infusion .
 Proper mixing of drugs added in IV fluid .
 Reducing the number of drugs in a single IV bag .
 avoiding the administration of Admixture just after the mixing .
 Discarding / should not used the admixture solution after 24 hours
 Observing the running of IV fluid to detect the physical change .
 Observing the patient to detect the therapeutic Incompatibility .
Role of Pharmacist in IV admixture Administration
 Pharmacist should provide proper supervision during preparation of
IV admixture
 He should provide proper guidance for staff to avoid incompatibility
.
 he should use latest research information to avoid incompatibilit y.
 he should use colour coding to avoid incompatibility .
 He should provide labelling on bags
 he should use alternate administration route .
 He should use in-line filter .

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Total parental Nutrition ( TPN )
Definition
It is a method to provide es sential nutrition without using GIT . In this
method nutrients are provided in the form of IV Fluid to meet the body needs
.
This method is used when someone unable to take nutrients orally . or in an
emergency condition .
Types of TPN
1) Central Parental Nutrition ( CPN ) : In this method fluids are delivered
through a central vein ., Mainly through the superior vena cava , It is present
beneath the collarbone and directly goes to the heart .
2) peripheral Parental Nutrition ( PPN ) : In this method fluids are delivered
through a smaller vein .
Composition of TPN
TPN is a mixture of all the essential nutritional components , which are
required for normal body functions like carbohydrates , proteins , fat and
minerals .
Macronutrients provided by TPN
Proteins
200 ml bottles containing 8-9 % amino acids are available in market for IV use
.
1.5 g protein /kg/day is needed for normal hepatic and renal function .

Calories ( carbohydrates )
Calories are administered as 20 -25% dextrose in water .
2000- 2500 calories are needed daily normally .

Fat
fatty acid deficiency may occur within 3 weeks of fat -free TPN .
milky emulsions of soyabean or safflower oil are availabl e for lipid
administration .
Micronutrients provided by TPN
Vitamins
Multivitamin Preparation which contain essential Vitamins is available in
market

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Minerals
Copper , zinc , selenium , and chromium are commonly added in TPN .
Indications of TPN
1) TPN is administered if the digestive system is not working properly .
2) if GIT needs a complete rest .
3) Abdominal surgery
4) Chemotherapy
5) Intestinal Ischemia
6) GIT bleeding
7) Extremely Premature Birth
Complication of TPN
o Bacterial Infection Through the IV Catheter .
o Blood Clots can form at catheter .
o GI atrophy ( weakening of GI ) after 2 weeks .
o Liver disease can be develop after long term use of TPN .
o Gallbladder problems

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HCP Chapter 6
Radiopharmaceutical

Definition
Those Compounds or Substances that emits / release radiation and are used
for therapeutic or diagnostic purpose are called Radiopharmaceuticals .

Handling and storage of Radiopharmaceuticals

 When Radiopharmaceuticals are not in use , must be kept in sealed
container .
 The radioactive materials must not contaminate the working area .
 Unnecessary movement of persons and radioactive materials must be
avoided .
 all the radiation workers must wear suitable protective clothing and
surgical gloves and should have radiation monitoring device .
 to carry liquid Radiopharmaceutic als , the trays should be used with
absorbent tissue paper for absorbing any accidental spillage .
 Smoking , eating , drinking and like that activities are strictly
prohibited in the area of radioactive work .
Storage
 Radiopharmaceuticals must be stor ed in well closed , air tight
containers .
 The containers should be dark
 they should be stored in a sealed place .
 They should be stored for short time of periods .
 Staffs should not expose themselves to Radiopharmaceuticals .

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Dispensing of Radiopharmaceuticals
 Dispensing of Radiopharmaceuticals should be safe, simple , and reliable .
 Radiopharmaceuticals should not be dispensed to patients , but
dispensed to healthcare providers and from there administered to patients
.
 The recommended dose should be determined by the pharmacist on the
basis of patients history , age , weight etc.
 These drugs should be dispensed only on the valid prescription .
 necessary records should be maintained .
Disposal Of Radiopharmaceuticals
 Radiopharmaceuticals are not disposed just like other drugs ,
 Low level radioactive wastes are disposed into land at 10 meter depth
.
 High level radioactive wastes are stored for about 50 years before
disposal . and they are disposed into at depth of 500 to 1000 meter

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Steps before disposal
 They are put in yellow color plastic in a separate place ,
 solid should be free from liquids and liquids from solids .
 Radio Active symbol should be labeled on the bags .
 attach a dangerous tag .
 seal the bag when it is full
 sealed it in a clear plastic bag
 moved it waste storage area

Types of Disposal
1) Incineration 2) In water 3) Burial 4) Deep Burial 5) recycle and reuse

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HCP Chapter 7
Application of Computers in hospital Pharmacy practice
Introduction
Computers are used in Pharmacy Practice to perform various type of works . It
reduce the work load of pharmacists. Using computer many of time
consuming and difficult works can be done easily , paying less time and
efforts . It reduce the paper work and expenses of Hospital Pharmacy .
Nowadays mobile phones are also used at the place of computers in many
aspects .
Some specific Applications of Computer in Hospital Pharmacy .
I. Patient Record Data base
II. Patient Medication Profile
III. Inventory management (Purchasing and selling of drugs )
IV. Formation of drug formulary
V. Entry of medication order
VI. Entry of returned drugs .
VII. Billing Procedure .
VIII. to provide Drug related information data
IX. maintaining prescription record
X. help in automated dispensing system .
XI. calculation of drug dosage .
XII. easy to search any recorded data .
XIII. to maintain financial record

Electronic Health record (EHR )

It is an electronic health record of patient which maintained by the health
care providers, it contain all the essential clinical data related to patient care
for example disease , medication , immunization , laboratory reports,
radiology reports , disease history .
And it can be up-to-dated and shared to patient and to other healthcare
providers through electronic medium .

Components of EHR
1. patient contact details
2. details of consultation with medical exports
3. allergies
4. insurance information
5. family history

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6. vaccination history
7. information regarding any illness
8. medicine list
9. hospitalisation record
10. Details regarding any previous surgeries or procedures

Advantages Of EHR
 It provides patient's complete , accurate , and up -to-date information
during providing health care .
 It shares patient 's data through electronic medium to the patient and
other health care providers .
 It helps to prevent medical errors .
 it makes easy to provide health care services .
 It decrease costs by reducing paperwork and repeated laboratory and
radiology tests .

Softwares Used in Hospital Pharmacy

Various softwares are available in market that help the pharmacist and
community pharmacy that decrease the efforts of Pharmacists and save a lot
of time
some examples of softwares are following :
1) EHR : It provides complete patients 's medical records in electronic form
which can be updated and shared to patients and other health care providers
.
2) Medical Billing Software : It provides Health care billings name of some of
them : NextGen Healthcare HER , Kareo , Therapy notes etc.
3) E-Prescribing : This software is used to create and send a prescription to
the pharmacy in electronic form .
4) Telemedicine software : This software helps medical professionals to
schedule patient appointments online , using a web browser or a mobile
application .
5) Therapeutic Drug Monitoring : ( TDM) This software is used to calculate
drug dosages according to patient age , weight etc.
6) Drug Information Data Storage : This software provides a complete drug
information that a pharmacist requires , like Uses , drug , interaction to drugs
or food , dosage , adverse effects , Toxicity etc .

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Hospital and Clinical Pharmacy chapter 8
Clinical Pharmacy

Definition
Clinical pharmacy is a branch of Pharmacy which provide healthcare services
using rational and appropriate pharma ceutical products and devices.
Scope of clinical pharmacy
A Clinical pharmacist has many scope some of them are following:
I. Patient monitoring : a clinical pharmacist monitors the symptoms of a patient if the
disease is under control of pharmacist he tries to treat otherwise refer the patient to
a senior doctor or physician.
II. Medication history: the pharmacist interviews the patients and
prepares their medication history which helps a doctor in treatment of
those patient and save the doctor's time to i nterview the patient.
III. Treatment of patient : a clinical pharmacist treats the minor ailments
without performing a big surgery procedure.
IV. Preparation of IV Admixture : they prepare the IV admixtures under
specific condition.
V. Training : a clinical pharmacist trains the new pharmacist ( fresher) .
VI. Retail Pharmacy Store : a clinical pharmacist can sale drugs after getting
license .
VII. Patient Counselling : clinical pharmacist can perform patient counselling
service .
VIII. Clinical research and development : A clinical takes parts in clinical
research and development .
IX. Drug formulary: pharmacist helps in formation of hospital formulary.
X. Drug consultant : a clinical pharmacist can offer his services as a drug
consultant .
Development of clinical pharmacy
The term "clinical pharmacy " is being used from 1953 . Before 1960s the
work area of pharmacist was limited to drug relative services only (like
production Compounding distribution , sale etc. ) , they were not permitted
to participate in patient care but in late 1960 the status and function of
pharmacist revised and developed and involvement of pharmacist in patient
care started .

In India
 Pharmacy education was started after implementation of drug and
cosmetic act but these pharmacist were oriented towards production
distribution and sale of drugs.

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 During 1980s and 1990s many of drug misuse and poor health outcome
and economic loss to patient are recorded , due to bad performance by
both pharmacy and medical profession and according to population
doctors were not sufficient.
 Now it is realized that the pharmacist should given those knowledge
and skills that they can contribute in patient care effectively like
pathophysiology , therapeutics , pharmacokinetics , patient counsellin
etc.
 So in 1991 the education regulation was revised and hospital and clinical
pharmacy , community pharmacy , health education and drug store and
business management subjects were added in diploma in pharmacy.
 Seeing Lake of teaching personnel for clinical pharmacy first master i n
pharmacy practice program started at JSS College of Pharmacy Mysore
and Ooty with the support of Overseas academy In 1997 .
 Now there are numbers of institution in India which offer a clinical
pharmacy degree .
In other countries
 During 1960 to 1970 in UK after many efforts it was possible for
pharmacist to participate in patient care
 Harve A .K. and Paul Parker started clinical pharmacy in USA
 Graham Calder started ward pharmacy services in United Kingdom.

Technical Definitions and Common terminologies used in Clinical Pharmacy

and their significance
1. Antenatal Care : Care for protecting the health of women and their
unborn children .
2. Post natal Care : Care given to the mother and her newborn baby just
after birth for the first six weeks .
3. Paediatrics : Branch of medicine dealing with children and diseases .
4. Geriatrics : Branch of medicine dealing with the diseases of old age .
5. Achlorhydria : Absence of HCL in stomach .
6. Anorexia : Lake of appetite .
7. Antibody : a substance of body which fight against diseases or
Causative agent .
8. Antibiotics : a substance that kill or prevent the growth of bacteria .
9. Vaccine : a substance that stimulate the immune system to make
antibody .
10. Anticeptic : a antimicrobial substance that work on living tissues .

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11. Disinfectant : and antimicrobial substance that work on non -living
things .
12. Appendectomy : removal of Appendix .
13. Asthenia : General weakness .
14. Dyspnea : Difficulty in breathing .
15. Dysmenorrhea : Difficult and painful menstruation
16. Congenital : existing before birth, in born error
17. Atherosclerosis : deposition of fat and harding of arteries
18. Bradycardia : low heart rate than normal.
19. tachycardia : Increased heart rate .
20. Angian : Chest pain
21. Arrhythmia : Abnormal heart rhythm .
22. Leukamia : Increase in White Blood Cells .
23. Amnesia : Loss of Memory .
24. Endogenous : developing a disease from within body , and cause
is
unknown .
25. Exogenous : Developing from outside the body and cause is
known .
26. Diastol : resting phase of heartbeat during which the chambers fill
with
blood
27. Systole : The time when heart contracts . and pump the blood .
28. Haematemesis : vomiting of blood .
29. Haematuria : blood in urine .
30. Haemoptysis : Blood in coughing .
31. Myocarditis : Inflammation of heart muscles .
32. Myopathy : Degeneration of muscles .
33. Necrosis : localised death of tissues .
34. Oedema : Presence of abnormal amount of fluids in tissues.
35. Pathogenic : disease causing .
36. prophylaxis : Steps taken for prevention .
37. Stenosis : permanent narrowing of a hollow organ .
38. Syndrome : presence of a lots of symptoms .
39. trauma : Injury
40. polyuria : Excess frequency of urination .
41. Allergy : abnormal reaction of the body to certain prod ucts .
42. Dermatitis : inflammation of skin .

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43. Eczema : Acute or chronic inflammation of Skin .
44. Anuria : failure to excrete urine .
45. Dysuria : Painful or abnormal urination .
46. Nephroctomy : Removal of Kidney .
47. Pyuria : Pus in urine .
48. Arthritis : Inflammation in joints .
49. ostalgia : Pain in bone .
50. hypochromic : lake of Haemoglobin .

Daily Activity of Clinical Pharmacist

flowing activities a pharmacist should perform :
1) Ward Round Participation .
2) Treatment chart review .
3) Adverse drug reaction monitoring .
4) Drug Information and poisons information .
5) Medication history .
6) Patient Counselling .
7) Inter - Professional Collaboration .

Ward Round Participation .

Definition
A ward round is a visit of medical practitioner (Alone or with a team of Health
care professionals and medical student) to hospital inpatient at their bedside
to review and increase the progress in their health.

Goals
 To review the patient and understand the patient condition
 to improve the patient health
 to provide appropriate drug related information on drugs availability ,
optimum and cost effective or alternate drug .
 To identify the medication compliance .
 For patient discharge planning .

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Procedure
1) Pre-Ward Round preparation : the doctor / pharmac ist should prepare
before participating in ward round , they should get up to date information on
patient disease , disease management and patient medical history .
2) During ward round the physician or pharmacist interview the patient and
observe their symptoms and current status .
3) The physician also consults the pharmacist regarding the effective and
cheap drugs.
4) A detailed medication history should be collected from a new inpatient .
5) If required the patient existing profile can be updated .
Treatment Chart Review
Definition
Treatment chart review is a process to review the patient Drug Treatment
during hospital admission .
Goals
1) to minimize the risk of medication errors , that might occur during
prescription writing or during drug administr ation .
2) To provide economical and rational drugs .
Procedure
1) First of all he should try to get information about patient
2) He should verify that the medication order is completed or not or is there
any mistake such as in terminologies used , dru gs name , administration
route.
3) He should identify Drug Related Disorders if find he should record them in
patient medication profile .
4) he should provide medication care information to nurses who take care of
the patient.
5) when medication therapy supposed to finish , the pharmacist should double
check that the order is cancelled in all part of the Drug administration record
.
Adverse Drug Reaction Monitoring
Definition
it is a process of continuously monitoring of undesirable effects suspected
(maybe occur) due to use of medical product.
Goals
1) to detect adverse drug reaction in a early stage.

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2) To control the adverse drug reaction.
3) To inform the drug regulatory authority to identify the risk factors that can
cause severe health damage.
Procedure
1) information about the patient
2) continuous monitoring the suspected patient
5) Recording and informing the drug regulatory authority.

Drug Information and poisons information

Drug information : it is the current , relevant and critically examine data
about drug used in given situation .
Poison information
It covers the information on toxic effect of chemicals , drugs , overdose of
drugs , and animal toxins such a snake , spider and other vanomous creature
bite.
Goals
1) to prevent patient from poisoning effect of drugs or animals
2) To provide appropriate and exact drug to patient to increase the
therapeutic effect .
Procedure
1) the pharmacist should get information about the drugs are going to be
administered.
2) the physician can consult the pharmacist about drug and poisons
information.
3) Pharmacist can get these information from manufacturers through leaflet
or electronic medium or any other authentic sources .
Medication History
Definition
Medication history is a detailed , accurate and complete recoded data of all
prescribed and non prescribed medications that a patient had taken or is
currently taking .
Goals
1) It provides the patient's previous History which helps the physician for
choosing appropriate drug therapy .
2) It can reduce drug reaction , ( if patient is staking a drug before ) .
3) it provides an information about drug related allergies .

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Procedure
1) pharmacist should introduce himself to patient .
2) He should get details on diseases , prescribed and non prescribed
treatment. and record all the information .
3) He should notice the duration of therapy .
4) He should understand the patient's behaviour regarding taking drug

Patient Counselling
Definition
Patient Counseling is a process in Pharmacist gives information to the patients
or their attendant orally or in written form regarding proper use of
medications.
Goals
1) to provide a better knowledge to the patient about disease and drugs .
2) To make treatment more effective .
3) to reduce chances of drug reaction .
Procedure
1) preparation for Counselling session
in this stage pharmacist collects information about patients disease and the
drugs prescribed for patients.
2) Opening Session .
In this stage Pharmacist start taking with patient s and ask questions , to
know their understanding about disease .
3) Counselleng Content
In this session Pharmacist gives information to the patients or their attendant
orally or in written form regarding proper use of medications.
4) Closing Session
In this session Pharmacist get Feedback , to know if patients have any doubt .
Inter-professional Collaboration
Definition
the process of developing and maintaining effective working relationship with
learners , practitioner , patients or attender to giv e optimal health outcomes
.

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Pharmaceutical Care
Definition
Pharmaceutical care is specific services and activities by which pharmacist
Cooperates with a patients and other Healthcare professionals in designing ,
Implementing , monitoring a therapeutic plan to produce best therapeutic
outcomes ( results) for patients .
Principles to provide pharmaceutical care
1) Knowledge and skillful staffs .
2) Equipment and Resources .
3) Communication skill
4) proper data collection and documentation system .
5) Collaboration with patient and other healthcare Professionals .
6) effective workflow management .
Procedure to provide Pharmaceutical Care
1) Interaction with patient must be maintained to get patient's important
information .
2) Patient' s medical information should be collected and a record should be
maintained .
3) Evaluation( Check out ) of medical information Collected by patient .
4) Formation of Therapeutic Plan .
5) Determination of patient' s Consent that patient is ready or not for the
therapy planned for him/ her .
6) Implementation of Plane .
7) Pharmacist Reviews , Monitoring , and modification of therapeutic plan if
needs .
Classification of Drug Related Problems (DRPs)

Drugs Choice Dosing Adverse Drug Interaction Drug Use Other

reaction
Need for Too High Allergic NSAIDs with Drug Lake of
additional or reaction due Furosemide administered Monitoring
drug Too Low to antibiotics (Decrease by Health
e.g. rashes Diuretic professional
effect) Or Drug
administered
by patient.

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Medication therapy Management (MTM)
Definition
MTM is a set of services provided by a pharmacist which maximizes the
therapeutic results for Certain patients , through using safe and effective
Medication .
MTM promotes Collaboration between the pharmacist , patient and Prescriber
for better therapeutic outcomes .

Goals
 To Solve medication related problems .
 to reduce adverse drug effects .
 To help those patients who have multiple healthcare problems , and
taking multiple medication and require a close monitoring , and have
queries regarding medication .

Home Medication Review ( HMR)

Definition It is a set of Medical services which are provided by a pharmacist .
Under the HMR a pharmacist visits patient at his home , in which pharmaci st
provides drug related information to patient and some time patient's family
members .

Goals
 to improve patients medication Knowledge .
 To reduce the adverse drug effects .
 to solve the patient's drug related queries .

Need Of HMR
It requires when patient :
1) takes maore than five medication per day .
2) He forgets to take medication or has some confusion .
3) Requires a close monitoring

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Hospital and Clinical Pharmacy Chapter 9
Clinical Laboratory Tests
Haematological Tests
The Tests are related to blood are called "Haematological Tests "
1) Haemoglobin Test : (Hb test )
This Test is performed to check Haemoglobine level of the body .

Normal Range
Male : 13.2 to 16.6 g/dl
Female : 11.6 to 15 g /dl
Children 6-12 years : 11.2 to 14.5 g /dl

Significance and interpretation

Normal level is necessary for enough oxygen supply to tissues and transport
of CO2 to lungs .
Low level than normal range indicates Anaemia , Leukemia . and High level of
haemoglobin indicates polycythemia .( High concentration of RBCs).
2) RBCs Count : RBCs Contain Haemoglobin which transports O 2 and CO 2 , it
hlps in Blood clotting . This Test is performed to check Count of RBCs in blood
.

Normal range
Male : 4.5- 5.5 million/mm 3
Female : 3.5 - 5.5 million /mm 3
Children : 4.0-5.5 Million /mm 3
Significance :
Low level of RBCs than normal range in blood indicates Anaemia and
leukemia .
High rage of RBCs indicates Polycythemia .

3) Hematocrit (Hct) :
this test Indicates percentage of RBCs in whole blood sample. For example
40% Hct indicates that a 100ml sample has 40ml of red blood cells .

Normal range
Male : 40-50%
Female : 37 - 47 %

Reason for high RBCs , High haemoglobine , and hematocrit .

1) Dehydration
2) lake of Oxygen ( due to lungs problems , smoking )

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3) Kidney problems ( kidneys makes a hormone erythropoietin which trigger
the Bone marrow to make more red blood cells ) .

Reason for low RBCs , High haemoglobine , and hematocrit .

1) Heavy Blood loss .
2) Bone marrow failure .( Infection , tumor )
3) Any kind of Cancer treatment .
4) leukemia
5) Haematolysis ( break down of RBCs )
6) Kidney problems
4) White Blood Cell or Total Leucocyte Count (TLC) : This test is performed to
check conditions like : Infection , allergic reaction , Inflammation , Blood
cancer ( leukemia

Normal Range
male : 4500 to 11000 / ml
Female : 4500 to 11000 / ml

Significance :
 High Level of WBCs indicates Infection like( Appendicitis (
inflammation of appendix ) , Leukemia , Pneumonia , , meningitis etc. )
Allergic reaction , Inflammation , Blood cancer.
 High level may be due to theses reason also : Certain drugs ( antibiotics )
,Smoking , Removal of spleen , blood cancer , Inflammation .
 Low level of WBCs is called Leucopenia it indicates typhoid , Hepatitis ,
influenza , measles , anxiety .
 Low level of WBCs is may be due to these reasons also Bone marrow
problems , Cancer treatment , certain viral illness etc.

5) Different Leucocyte Count : (DLC)

Neutrophils 60-70%
Eosinophils 1-4%
Granulocytes Basophils 0-2%
Monocytes 5-10%
Lymphocytes 20-30%
Significance :
 High Neutrophils count(Neutrophilia) indicates severe bacte rial
infection , whooping Cough ,UTI ( Urinary Tract Infection )
 High Eosinophils Count ( Eosinophilia ) Indicates Intestinal Parasites ,
allergic condition .

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 High basophils Count indicates granulocyte leukemia .
 High monocyte Count indicates bacterial In fection like malaria , and
Monocytic Leukemia .
 High Lymphocite Count indicates bacterial , viral or other infection(
whooping cough , mumps , Influenza , tuberculosis ) autoimmune
disorder .
6) Erythrocyte Sedimentation Rate ( ESR )
It indicates the rate at which eryrocytes sediment ( settle ) to the bottom ,
this rate of settlement is called RSR . the distance they cover in 1 hour is
recorded .
Normal range
Male : 0-15 mm/hr
female : 0-20 mm/hr

significance :
This test is performed to estimate inflammation in body , or infection .
if it is more than normal range indicates Inflammation in the body .

7) Platelets Count : they are necessary for blood clotting

Normal range
1.5 lac to 4.5 lac

Significant :
 this test is performed to check number of platelets . and before surgery
procedure this test is performed
 Low range than normal indicates bone marrow problems , leukemia , or
infection such as Hepatitis C , Dengue fever , Chikungunya , HIV . etc
a minor reduction occurs in pregnancy .
 High count of Platelets indicates Bleeding , Cancer, iron Deficiency
,bone marrow problems .

8) Coagulation or Blood Clotting Time :

this test indicates the time blood takes to clot .
Normal Range
1) Slide method : 2-6 minutes
2) Capillary method : 2-6 minutes

Significance :
Increased clotting time indicates Haemopholia , Vitamin K Deficiency ,
increased heparin level and pneumonia .

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Decreased clotting indicates thrombosis and embolism .

9) Blood Sugar level

Normal range
Fasting : 70 - 99 mg /dl
after two hrs meals : less than 180 mg /dl
Random : 110-140 mg/dl

10) Blood Uric acid test :

Normal range
2-6 mg /100 ml
Significance : High uric acid indicates gout .renal failure .

Liver Function Tests (LFT Test)

Liver function test is performed to estimate the dysfunctions of liver several
testes are performed under liver function test .Like Serum Bilirubin , serum
(Plasma) proteins , Alkaline Phosphatase ( ALP) , Serum Glutamic Oxaloacetic
transaminase (SGOT) or Aspartate transaminase (AST), Serum Glutamate
Pyruvate Transaminase ( ALT) etc.
1 ) Serum Bilirubin : It is the breakdown product of haemoglobin and a major
pigment in bile .
Normal Range
Indirect Bilirubin : 0.3-1.3 mg/dl
Direct Bilirubin : 0.1- 0.4 mg /dl
Significance :
high level indicates haemolysis , jaundice ( liver problem ) .
2) Serum (plasma ) protein : Albumins and globulins proteins are major
protein of plasma and produced by Liver .
Normal Range
Albumins : 3.5-5.1 gm/dl
globulins : 1.8-3.1 gm /dl

Significance
Increased level indicates dehydration Liver problems .
Deceased level Indicate Oedema, haemorrhage , Increased protein break
down .
3) alkaline Phosphatase ( ALP) : This enzyme produced in liver , bones , sm all
intestine and kidneys , It catalyses splitting of phosphate group from
monophosphoric ester .
Normal range : 29-92 IU/L
High level indicates Rikets , Osteomlacia , abnormal absorption of vitamin D .

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Low level indicates Hypophosphatacia .
4) Serum Glutamic Oxaloacetic transaminase (SGOT) or Aspartate
transaminase (AST) : this enzyme is produced by liver and it helps in energy
production .
Normal range : 0.40 U/L

significance :
Increased level of SGOT indicates liver disease ( hepatitis , cirrhosis )
5) Serum Glutamate Pyruvate Transaminase ( ALT) : this enzyme produced by
liver and helps in formation of alanine .
Normal Range : 5-36 U/L
significance : Its increased level indicates Liver cell damage .
6) Serum Cholesterol test( Lipid Profile ) : this test is performed to check
triglyceride and Cholesterol level in blood .
Normal Range
a) Total cholesterol level is < 200 mg /dl
b) LDL cholesterol level < 100 mg/dl
c) HDL Cholesterol level is equal or more than 60 mg/dl
d) Triglycerides level is < 150 mg/dl

Significance :
increased level of LDL and triglyceride indicates the risk of heart diseases ,
blockage of arteries .

Renal Function Tests (KFT Test)

Kidney or renal function tests are performed using urine ( and some test a re
performed using blood like urea clearance test) , and the presence of
different substances in abnormal amount in urine or in blood indicates the
kidney problems .
Physical examination of urine

Colour :

Odour

pH ( 4.5-8 )

Turbidity

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Chemical examination of Urine
1 ) Proteins : Globulin less than 5 mg/dl and albuline less than 30 mg/dl .
2) Abnormal Glucose level : normal is 0-0.8 mmol /L .
3) Ketone Bodies : Under normal condition , < 1 mg of Ketone Bodies is
excreted in 24 hours .
4) Blood : blood in urine indicates Sore of kidneys , UTI and nephritis .
5) Urine Osmolality Test : Urine osmolality is the number of dissolved
particles in urine( creatinine , urea, potassium , sodium etc.) . Normal Range :
500-850 mOsm/kg .
Significance :
Increased level indicates Kidney problems and congestive heart failure . and
cause dehydration .
6) Urine Concentration Test : kidneys maintain the osmolarity of body fluid (
290-300 mOsmol/L) , and excrete urine with average 500 -850 mOsm/l
normally

significance :
High concentrated urine indicates Kidney problems , dehydartion , heart
failure .

some blood sample test are performed to Evaluate kidney function .

1) Blood Urea nitrogen test ( BUN ) : Urea is obtained as a by-Product of
protein metabolism . It is formed in liver and excreted out in urine through
filtration of blood by kidneys.
Normal range 10-12mg /dl
significancec : increased level of Blood urea nitrogen indicates kidney problems
.
2)Creatinine Test : Creatinine is a waste product of body me tabolism which
present in blood excreted out by Kidneys .
Normal Range Creatinine in blood
1-2mg/dl or 0.6-1.2 mg/dl

Significance
Increased level in blood and low level in urine indicates kidneys dysfunction .
Urine Creatinine normal Range
for adult man : 0.74 - 1.35 mg/dl
For adult woman : 0.59 - 1.04 mg/dl

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3) Creatinine Clearance Test
This test shows the ability of kidneys to clear( Excrete out) creatinine from
blood through urine. In this test 24 hours collected urine sample is taken.
along this test blood creatinine level also examined .
Normal Range of Creatinine clearance /min in urine
in adult men : 90-139 ml/min
In adult women : 80- 125 ml / min

Significance :
Lower than normal creatinine excretion indicates the kidney problems .

4) Urea Clearance test

This test is also performed to check the kidneys functions . In this test using
blood , the amount of urea in blood Checked , and along with two urine
sample are collected with a gap of one hour to determine the amount of urea
filtered by the kidneys into urine .

Normal Range of urea clearance

12-20 gm/24 hours

Significance
Low level of urea than normal range indicates kidney problems , Protein deficiency in diet .
High level than normal range indicates excessive protein metabolism , or too much protein
intake in diet .

Thyroid Function Tests ( TFT test )

There are many different blood tests which are performed to check thyroid
gland functioning . some of them are following
1) TSH ( thyroid stimulating Hormone ) test :
This test is performed using blood to check Level of TSH pituitary gland
makes this hormone which stimulates the thyroid gland to produce thyroid
hormones

Normal range of TSH in blood

0.5 - 5.0 mU/L

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Significance
High level than normal indicates low production of thyroid hormone ( primary
Hypothyrodism ) , low level of TSH indicates too much thyroid hormone
production ( Hyperthyrodism ) .
2) T3 or Triiodothyronine test : this test is used to check production level of
thyroid hormone T3 in blood .
Normal range : 100- 200 ng /dl
significance
High level indicates Hyperthyrodism , when low level indicates Hypothyrodism
.

3) T4 or thyroxine Test :
It is also a Thyroid hormone , it is found in two forms free and bounded with
proteins , Normal range of T4 (free and bounded with protein) for adult
5.0-11.0 ng/dl

Significance
High TSH and low T4 indicates the Hypothyrodism ( due to problems in thyroid
gland) , Normal TSH and High T4 indicates Hyperthyrodism ( due to problems
in thyroid gland )

Tests Associated with cardiac Disorder

1) Blood cholesterol Level
Normal Blood cholesterol level of different ages
Neonates : 45-100mg/dl
In children : less than 170 mg/dl
in adults : less than 200 mg /dl
Significance
Increased level indicates Heart related problems , Obesity , Obstructive
Jaundice .
2) Creatine Phosphokinase (CPK ) or Creatine Kinase (CK) test : CPK is a
enzyme which found in heart muscle , skeletal Muscles and brain tissues , it
plays an key role in the intracellular energy transport from mitochondria to
the sites of energy utilization .
Note : when muscles damage occurs the CPK leaks to blood stream .
Normal range of CPK in blood : 10 -120 mcg /L

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Significance
High level than normal range indicates In jury of Heat Muscles , skeletal
muscles or brain tissues , Myocardial Infarction .
3) lactic Acid Dehydrogenase ( LDH or LD ) Test : LDH enzyme found in all
metabolising Cells and catalyses inter -conversion of Lactate and pyruvate .
Five type of LDH are found , LDH 1 and LDH 2 found in Heart .
Normal Range
Male : 135 -225 U /L
Female : 135 -214 U/L

Significance
High level of LDH 1 and LDH 2 indicates myocardial infarction .

Fluid And Electrolyte Balance

1) Osmolarity of Body Fluids : this test is performed to check level of Water in
Body fluid or fluid balance .
Normal Range : 275 - 300 mmole /Kg

Significance
High Osmolarity than normal range of body fluid Indicates dehydration which causes many
of body function problems .
Low Osmolarity than normal range of body fluid indicates water intoxication
( Nausea , fatigue , Headache , seizure )
2) Serum Electrolyte test : This test is performed to check the amount of
electrolytes of blood . They are important to balance water in body f luids .

Normal range
sodium : 136 - 145 m moles /L
Potassium : 3.5 to 5 m moles/L
Chloride : 98 to 106 m moles/L

Significance
High level than normal range indicates
Sodium : Hypernatremia
Potassium : Hyperkalemia
Chloride : Hyperchloremia

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Pulmonary Function test ( PFT)
Pulmonary Function tests are a group of tests that measure how well lugs
work , How well lungs takes in and out air ( Inhale and exhale ) and how
efficiently they transfer oxygen into the blood .
1) Tidal volume(TV) : The amount of air inhaled and exhaled during normal
breathing
Normal Value : 500 ml
2) Inspiratory Reserve Volume(IRV) : the amount of air Inhaled by forceful
Inhalation above the tidal volume .
Normal Value : 1800-2000ml
3) Expiratory Reserve volume (ERV): The amount of air Breathed out by forceful
Expiration above the tidal volume .
Normal Value : 1400 ml .
4) Residual Volume (RV): The amount of air remains in the lungs after forceful
expiration is called residual Volume .
Normal value : 1200-1500 ml
5) Vital Capacity(VC) : The amount of air that inhaled and Exhaled by most
powerful inspiration and expiration is known as vital Capacity .
Normal value : 3-5 liters
6) Total Lungs Capacity( TLC) : The sum of Vital capacity and residual capacity is
called TLC.
Note : Spirometry is an instrument that used for measuring air capacity.

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Hospital and Clinical Pharmacy Chapter 10
Poisoning

Introduction
Poison: Poison is a substance which when consumed , Inhaled , applied to
skin , injected or created within body and produces a harm effect to the body
. It may be heavy metals, Drugs , animal poisons and Bacterial Contaminated
food or drink .
A Poison change the cellular metabolism and chemical activity and damage
the cell from functioning and then diseases and death occurs .
Poisoning : injury or death of cell due to poison is called poisoning
It may be acute or chronic .
Antidotes : antidote is a substance which neutralise the poison and reduce
its harm effects to the body .
Types
1) Physiological Antidote : It Counteracts the poison effects by Producing
opposite Effects For example caffeine is used in morphine Poisoning .
2) Chemical antidotes : It change the chemical nature of Poison For example
Sodium Thiosulphate is used in Cyanide Poisoning .
3) Mechanical Antidote : It prevents the absorption of poison in the body , For
example Kaolin and Charcoal absorb the poison and prevent absorption into
body , albumin of eggs , it makes a layer on intestine lining and prevent
absorption .
General Principles of Poisoning treatment
1) Removal of Unabsorbed Poison
2) Removal of Absorbed poison
3) Antidotes
Removal of Unabsorbed Poison
1) Emetics : 15 g of Sodium Chloride ( salt ) dissolved in a glass of wa ter and
given to patient to produce Vomiting . and this process should be repeated till
vomiting .
If it fails 1-2 g of ipecacunha powder is given , if it does not work
Apomorphine hydrochloride injection is given but it does not given in
morphine Poisoning .
2) Diarrhoea : this method is used to remove the poison from GIT through
stool
Sodium Bicarbonate solution 5% w/v , other purgatives can be used .

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Removal of absorbed Poisoning
diuretics are used to remove absorbed poison .
removal of Gaseous Poison ( Carbon monoxide )
Fresh air and O 2 is used to remove gaseous poison , Ventilator can be used .

Types Of Poisoning
1) Heavy Metal Poisoning : heavy metal poisoning occurs when certain metals
accumulate in the body , through foods , water or air . Following are some
metals which cause Poisoning effects .
a) Arsenic Poisoning :-
Clinical manifestation
Burning sensation in mouth ,lips , thirst , Inflammation of Gum and mouth ,
vomiting , and Diarrhoea .
In Severe Condition
weakness of body , Fall in body temperature , rapid pulse , cardiac failure and
death .
Antidotes : 1) Dimercaprol injection via i.m.
b) Lead Poisoning
Clinical Manifestation
Loss of Appetite and sleep , Pain in joints , Muscles and abdomen and
Headache and CNS system disturbed .
Antidotes
1) Sodium or Potassium iodide is given Orally , it excrete through Kidney .
2) Dimercaprol .
c) Mercury
Clinical Manifestation
Sore Throat , Burning Sensation in abdomen , Bone marrow problems , Blood
in vomiting and Urine , renal failure .
Antidotes
1) Dimercaprol injection . 2) Penicillamine is also effective in Mercury
Poisoning .
2) Narcotic Drug Poisoning : The poisoning occurs due to overdoes of opioid
Drugs is called Opium Poisoning .
Clinical Manifestation
1) excitation : restlessness , Redness of face , heart rate Increased .
2) Stupor : starts unconscious , headache , Fatigue , Contraction of eye pupils
.

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3) Coma : muscles becomes relaxed , reflexes stopped , respiration depressed
and pulse becomes very slow .
Antidotes
1) if it is confirm that the poisoning is due to opiates Nalorphine injection is
given I.V . route .
2) The patient's body be kept warm .
3) CNS stimulant should be given like Nikethamide ( Coramine ) .
3) Cannabis poisoning: is same to opioid in manifestation and treatment
4) Barbiturate Poisoning :
Clinical Manifestation
Respiratory Depression , Hypotenssion , renal function slowdown , Coma and
death may be occur due to respiratory failure .
Antidotes
1) Picroxin injection via i.v.
2) CNS Stimulant : Nikethmide .

5) Snake Bites
Snakes have Poisonous gland on both side of Head , their saliva is venom
( poison ) which is a complex mixture of proteins and enzymes : Which are
following
1) Neurotoxin-A ( it affects cardiac and respiratory center and central
nervous system .
2) Neurotoxin-B ( it causes paralysis )
3) Enzymes ( Cholinestrase , Phosphatase etc.
clinical manifestation
1) Two puncture Wounds 2) loss of sensation of face .
3) Increased heart rate 4) Blurred vision a nd headache
5) Excessive sweating 6) Vomiting 7) Unconsciousness 8)
Diarrhoea
9) Fever 10) Convulsion

Antidotes
1) antibiotics : Q6H IV ampicillin , Doxacillin and me tronidazole should be
given
2) Atropine 1.2 mg and neostigmine are given to remove Paralysis .
3) Snake Venom Antiserum I.P.

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3) Polyvalent Crotalidae .
Hydrocortisone and pheneramine maleate injection is used before antivenin
injection to prevent allergic reaction .

6) Insecticide Poisoning
Insecticides are substances used for destroying insects like :
1) Organochlorine insecticides e.g. Chlordane , Heptachlore , DDT (
Dichlorodiphenyltrichloroethane )
2) Organophosphorus 3) Carbamate
Clinical manifestation
1) Abnormal sensation in tongue , lips , face
2) dizziness and tremor
3) convulsion
Antidotes
1) Atropine 2) Parlidoxime
7) Food Poisoning
this type of poisoning Occurs due to microorganism which are enter in the
body with food or Beverages .
Clinical Manifestation
1) cramping in stomach 2) Vomiting 3) Loss of appetite 4) Fever
5) fatigue 6 ) headache
Antidotes
Antibiotics are used according to specific microorganism .

Drug Information center and Services

Definition
Drug Information Center is a place from where drugs and drugs therapy
related information are provided to those demand ( Ask) like Healthcare
professionals , organisation , patients , etc.
Requirements
 A drug information center requires Computer which has drug
information data base( Softwares ) and Internet Connection to access
different Websites .
 Printed Materials ( Books , Bound Journals )
 Subscription to some national and international Journals of medicine
.like British Medical Journal , Indian medical Journal etc.

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Information Resources
1) Primary Sources : Primary Sources consist of Original research written by
an author in his own words , research , studies and scientific Results .
Secondary and tertiary resources Based on these sources .
The readers analyses the given information and make an opinion . Some
Examples of primary Resources :
1) British Medical Journal
2) New England Journal of Medicine
4) American Journal of Health Systems pharmacy .
4) Indian Medical Journal .
Advantages
1) They provide latest Information .
2) They provide Original information in author's word .
Disadvantages
1) Chances for fault Conclusion .
2) It takes time to search any specific topic .
3) The information provided by Primar y sources are not accepted by
community easily , because of newer .
2) Secondary Sources : The Primary sources information are provided in the
form of Indexing and abstracting ( main content ) .
The indexing system provides topic wise information and Imp ortant points .
Some Examples of secondary Resources
1) Medline
2) International Pharmaceutical Abstracts
3) Index Medicus
4) WHO Drug Information
Advantages
1) They provide quick access to the topic
2) They provide updated information weekly or m onthly
3) they provide Concise( a lot of information in some words ) and concluded
information .
Disadvantages
1) There should be Mistake because it is not in the author's words.
2) It don't provides detailed information .
3) Tertiary Resources : They provide Information of Primary Sources but these
information are approved and accepted by FDA and has labelled Indication .

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Examples of tertiary Resources
1) Remington's text Book
2) Handbook of Non Prescription drugs
3) martindale Drug Reference
4) Micromedex
Advantages
 These are available on internet and can be used easily .
 Low chances for mistake because they are approved by FDA.
 They are widely accepted in medical practice .
 It don't take time for conclusion .
 They Provide concise information
Disadvantages
1) It takes a long time to come in Tertiary stage .
2) Author may deny to use his content for FDA approval .
Poison Information Center (PIC)
Definition
Poison Information Center or Poison Control Center (PCC) is a specific
Department which gives Information management and Immediate diagnosis
and treatment and prevent of effects of poisoning .
Information Resources
1) Clinical Toxicology
2) Indian Journal Of toxicology
3) Poisindex
4) Hypertox .
Requirements
1) Legal Permission : a Poison Information center should have Legal
permission from government and WHO .
2) They should have a well defined Policies for carry out the procedure .
3) trained Staffs : This center must have trained Staff , and it should conduct
training program .
4) They should have Computer database information , internet access and
Printed materials .
Functions
1) They provide poison related information services.
2) They treat the patients have poisoning effects .
3) They conduct training program to manage poi soning .

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Hospital and Clinical Pharmacy Chapter 11
Pharmacovigilance ( Overview )

Definition
Pharmacovigilance is made up of Two words one Greek word " Pharmcon " =
Drug or medical substance , and second Latin word " Vigilare "= To keep
watch
according to WHO Pharmacovigilance is defined as " the science and
activities relating to the detection, assessment, understanding, and
prevention of adverse effect or any other drug related problem".
Aims
 to make the treatment of a patient effective.
 To improve the patient care and safety related with the use of medicine
and all medical and Paramedical intervention ( The activities done by a
non fully qualified doctor to support medical treatment like ultrasound
CBC ) .
 To improve the public health an d safety related to use of medicine.
 For early detection of adverse drug reaction.
 For Identification of risk factors.

Scope Of Pharmacovigilance
 Patient Monitoring: the person has knowledge of pharmacovigilance can
provide his services in hospital for m onitoring the patients
 Immunization( vaccination ): pharmacovigilance plays an important role in
vaccination because there are some certain vaccines which show serious
adverse reaction so a person has knowledge of pharmacovigilance ,
required to monitor and control the adverse reactions
 Herbal Medicine : safety and efficacy of herbal medicine is necessary so
pharmacovigilance required in herbal medicine practice
 Disease Control Public Health Program :The person has knowledge of
pharmacovigilance can take a part in disease control programs to aware
the public about safety and proper use of medicine to prevent adverse
drug reaction
 Academy: a person has pharmacovigilance knowledge can go in academic
field.

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Pharmacovigilance in India
 In India pharmacovigilance was introduced in 1986 with the formal
introduction of adverse drug reaction monitoring system , under the
guidance of drug controller
 At that time there was only 12 main centre and district and primary
Health care hospitals were affiliated to these main centres.
 In 1997 India become a part of WHO program for international drug
monitoring
 On first January 2005 WHO sponsored and World Bank funded and
National Pharmacovigilance Program of India, was started .

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Hospital and Clinical Pharmacy Chapter 12

Medication Errors and Drug Interaction

Definition
Medication error is a Preventable Event that may cause or lead to inappropriate
medication use or harm to Patient , while the medication is in the Control of the
healthcare professional , patient or consumer .

Types Of Medication Errors

1) Prescribing Error : this error occurs when due to mistake of prescriber (
Doctor ) , such as wrong drug , dosage , administration route etc .
2) Omission Error : this error occurs when patient is not given a scheduled
prescribed drug in health care control , like hospit al , nursing home etc.
3) Improper Dose Error : this error occurs when a patient is given a higher
or lower dose in comparison to prescribed dose .
4) Deteriorated (Expired) Drug error : This error occurs when expired
drug is administrated .
5) Prescription Filling(Dispensing) Error : This error occurs when drugs
are not dispensed properly according to the prescription .
6) Unauthorised Drug error : This error occurs when patient is given a
medication without consent(willing ) of prescriber .
7) Wrong Time Error : this error occurs when drug is not administered at
appropriate time . (too soon or too late )
8) Wrong dosage Error
9) wrong drug preparation error
10) Wrong administration technique error
11) Monitoring Error
12) Compliance Error : This error occurs when patient do not complete a
prescribed medication course .

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Consequences of Medication Error
1) Medication error leads to a serious adverse effect .
2) Causes allergic reaction .
3) some time causes a new healthcare problem .
4) some time leads to death ( in united states 700-900 people die per year due
to medication error ) .
5) The trust of patient decrease on health care system .

Strategies to Minimize Medication Error

1) Separate prescription should be written for each medication
2) Before signing the prescription the prescriber should recheck every parts of
the prescription
3) Abbreviation of drug names should be avoided
4) The patient age should be mentioned in the prescription
5) The pharmacist should read the prescription carefully and should follow every
steps of dispensing of the drugs
6) The pharmacist should check, if the doges are adequate or not , according to
patient age
7) The nurses Should administered the right drug to the right patient in right
dose at right time.
8) Multitask should be avoided during prescribing dispensing and administrating
the drug.
9) The health care professional should be stress free .
10) The workload of healthcare professionals should be in limit
11) LASA drugs should be handled carefully
12) Prescriber should write the prescription himself and should avoid dictation .

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LASA Drugs
LASA means looks like and sounds alike . These are the drugs which have similar
appearance(looks same ) or similar spelling or pronunciation , whether in brand
name or generic name . Examples
Folic Acid Fonilic acid
Retrovir Ritonavir
Chlorpropamide Chlorpromazine
Doxorubicin Daunorubicin .

Tall Man Lettering as per ISMP

The term " Tall Man Lettering " is discovered by the Institute for Safe Medication
Practices (ISMP).
Tall Man Lettering is a technique to differentiate ( distinguish ) the similar drug
names and cause mistake during dispensing , handling administrating . In this
technique the main part of the drug names is written in Upper Case Lettering
( In Capital letter ) and the parts of the drug names similar to the other drug
names are written in Lower Case ( Small letter ) . this technique highlights the
distinctive part of the drug names and reduces the chances of mistake .
Examples
Drug Name with Tall Man Letters Confused with
chloproMAZINE chlorproPAMIDE
DOPamine DOBUTamine
cycloSPORINE cycloSERINE
vinBLAStine vinCRIStine

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Drug Interaction

Definition
Drug Interaction is a condition in which an another drug or food affects the drug action (
Increases or decreases the effect )
Types
1) Drug-Drug interaction
2) Drug-food Interaction Examples of Drug to drug Interaction

Analgesics
Drugs Interaction with Possible effect
Opioids Phenoxybenzamine Effect of opioids increased
Salicylates Alkalinisers and antacisds The Concentration of salicylates decrease
because reabsorption of Salicylates reduced
in kidney .
Salicylates Indomethacine The Concentration of salicylates decrease
because absorption of Salicylates from GIT
reduced.
Salicylates Acidifires The Concentration of salicylates iecrease
because reabsorption of Salicylates from in
kidney increase.
Phenylbutazone Tobutamide Tolbutamide metabolism inhibited and so its
half-life increased and chances of
Hypoglycemia increased .

Diuretics
SN Drugs Interacting Drugs Possible effects
1 Furosemide , Sulfonylureas The effect of Sulfonylureas decreased
Thiazides .
2 Thiaxzides Methyldopa , The antihypertenssive effects are
Guanethidine , and increased and may cause Hypotension
reserpine
3 Furosemide , Digoxin The cardiac effect and toxicity
Thiazides increased
4 Furosemide Phenytoin The diuretic effect decreases
5 Spironolectone Potassium Hyperkalemia occurs
Chloride

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Cardiovascular Drugs
Drugs Foods Possible Effects
1 Digitalis Magnesium , calcium and Digitalis absorption decrease in GIT
aluminium salts containing
antacids
2 Digitoxin Barbiturates Digitoxin effect decreases
3 Digitalis Quinidine Cardiac and effect and toxicity of digitalis
increase

Gastrointestinal Drugs
Drugs Foods Possible Effects
1 Antacids Aspirin The absorption of aspirin decreases
2 Aluminium Hydroxide gel Isoniazid The absorption of isoniazid decreases
3 Metoclopramide Levodopa The absorption of Levodopa decreases
( antiemetic)
4 Kaolin-pectin Mixture Digoxin The absorption of digoxin decreases

Vitamins
Drugs Foods Possible Effects
1 Vitamin Chloramphenicol Effect of Vitamin B12 decreases
B12
2 Vitamin B Levodopa The effectiveness of levodopa decreases
6
3 Vitamin D Phenytoin and Blood Calcium level decreases
Phenobarbital
4 Vitamin Oral Contraseptives Deficiency of Vitamin B 12 , B 6 ,B9 and
Vitamin C occurs .

Hypoglycemic Drugs
Drugs Foods Possible Effects
1 Hypoglycemic Alcohol Causes Hypoglycemia
Drugs
2 Hypoglycemic Oral Contraseptives Blood glucose level increases
Drugs

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3 Insulin Propranolol Insulin effect increases
4 Sulfonylurea Anticoagulant Causes Hypoglycemia
5 Sulfonylurea Rifampin Causes Hypoglycemia

Drug - Food Interactions

Some Commonly occurring Drug-Food Interaction
Drugs Foods Possible Effects
1 Antacids Avoid High Protein Decrease the neutralising capacity of
Meals antacids
2 Calcium Channel Avoid Grapes Juice Increase the effect of Calcium Channel
Blockers Blockers and may cause adverse
effects
3 Carbamazepine Avoid Grapes Juice Increase the effect of Carbamazepine
and may cause adverse effects
4 Sephalosporine ( Avoid alcohol Can cause Disulfiram reaction (
Cefoetan Vomiting , Increase heart rate ,
Cefoperazone) etc. Shortness of breathing )
5 Disulfiram Avoid alcohol Can cause Disulfiram reaction (
Vomiting , Increase heart rate ,
Shortness of breathing )
6 Iron (ferrous Take Vitamin C rich food Increase iron absorption
sulphate) etc.
7 Iron (ferrous Avoid dairy products Decrease Iron absorption from GIT
sulphate) etc.
8 Fluoroquinolones Avoid calcium rich food , decrease the absorption the drugs
(ciprofloxacin ) etc. minerals supplement
and caffeine
9 Isoniazid 1)Avoid tyramine 1) show severe adverse reaction 2)
containing food 2) causes disulfiram reaction 3) decrease
Alcohol 3) avoid food absorption
with this drug
10 Ketoconazole Avoid alcohol causes disulfiram reaction
11 Metronidazole Avoid alcohol causes disulfiram reaction
12 Oral Diabetic Avoid alcohol causes disulfiram reaction
agents (
Glimepiride ,
Glibenclamide ,

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Metfomin )
13 Levodopa Avoid protein rich food Decrease drug effect
14 Theophylline Avoid high amount of It causes nervousness and insomnia
caffeine
15 Tetracycline Avoid dairy products They decrease the effectiveness of the
high amount of calcium , drug
magnesium and iron

Clinical Significance of Drug interaction

1) They can cause severe adverse effects .
2) they can increase or decrease the effect of Drug .
3) They can alter the treatment .
4) they can cause death
5) drug interaction should be avoided for better drug response .

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