Professional Documents
Culture Documents
Chapter 2
a Well-documented accounts of the development of hospital pharmacy practice in the United States were published by the
American Society of Health-System Pharmacists (ASHP) in conjunction with anniversaries of its 1942 founding.
Particularly noteworthy are the “decennial issue” of the Bulletin on the American Society of Hospital Pharmacists and articles
that marked ASHP’s 50th anniversary.1–3 Readers who have an interest in more detail are encouraged to seek out those ref-
erences and others.4 This section of the chapter is based closely on Reference 2.
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the mid-1800s, the medical elite avoided drug use or characterized pharmacy practices in hospitals as
used newer alkaloidal drugs such as morphine, strych- “chaotic” and commented, “Few departments in hospi-
nine, and quinine. An organized pharmacy service was tal performance have been given less attention by and
not seen as necessary in hospitals, except in the largest large than the hospital pharmacy.” In the committee’s
facilities. The situation changed somewhat during the view, “…any hospital larger than one hundred beds
Civil War when hospital directors sought out pharma- warrants the employment of a registered pharmacist….
cists for their experience in extemporaneous manufac- Unregistered or incompetent service should not be
turing and in purchasing medical goods.2 countenanced, not only because of legal complications
In the 1870s and 1880s, responding to the influx of but to insure absolute safety to the patient.”9 The pro-
immigrants, the number of hospitals in cities doubled. liferation of unapproved and proprietary drug products
Most immigrants in this period were Roman Catholic, in hospitals was the target of extensive criticism by the
and they built Catholic hospitals. This was significant committee.
for two reasons—Catholic hospitals charged patients a
small fee (which allowed services to be improved) and
they were willing to train, or obtain training for, nuns
A Fifty-Year Perspective
in pharmacy. This era of hospital expansion coincided There is much that can be learned by comparing con-
with reforms in nursing, development of germ theories, temporary hospital pharmacy with practice of 50 years
and the rise of scientific medicine and surgery. The ago. Fifty years is a comprehensible period of time for
general adoption of aseptic surgery in the 1890s made most people and, in hospital pharmacy’s case, the past
the hospital the center of medical care. Advances in half century was a period of astonishing advancement.
surgery led to growth of community hospitals, most of The data sources for making such a comparison are
which were small and relied on community pharmacies remarkably good. A major study of hospital pharmacy
to supply medicines.2 was conducted between 1957 and 1960—the Audit of
By the early twentieth century, hospitals had devel- Pharmaceutical Services in Hospitals—under the direc-
oped to the point of having more division of labor, more tion of Donald E. Francke and supported by a federal
specialization in medical practice, a greater need for grant (see Figure 2-2). The results were published in a
professional pharmaceutical services for handling com- book, Mirror to Hospital Pharmacy, which remains a
plex therapies, and recognition that it was more eco- reference of monumental importance.10 In more recent
nomical to fill inpatient orders in-house. Hospital times, ASHP has conducted an annual survey of hospi-
pharmacists retained the traditional role of compound- tal pharmacy, yielding contemporary data for compari-
ing, which fostered a sense of camaraderie among them son with the figures of an earlier era.
and an impetus to improve product quality and stan- Four major themes emerge from an examination of
dardization. The advent of the hospital formulary con- changes over this period:
cept persuaded many hospital leaders about the value 1. Hospitals have recognized universally that
of professional pharmaceutical services. An important pharmacists must be in charge of drug product
reason for hiring a hospital pharmacist in the 1920s acquisition, distribution, and control.
was Prohibition—alcohol was commonly prescribed, 2. Hospital pharmacy departments have assumed
and a pharmacist was needed for both inventory control a major role in patient safety.
and to manufacture alcohol-containing preparations,
3. Hospital pharmacy departments have assumed
which were expensive to obtain commercially.2
a major role in promoting rational drug therapy.
By the 1930s, pharmacy-related issues in hospitals
had coalesced to the point that the American Hospital 4. Hospital pharmacy departments have come to
Association (AHA) created a Committee of Pharmacy see their mission as fostering optimal patient
to analyze the problems and make recommendations. outcomes from medication use.
The 1937 report of that committee was considered so It is important to keep in mind what was happening
seminal by hospital pharmacy leaders that even a over this period in the United States as a whole. Since
decade later they saw value in republishing it.9 The 1950, the U.S. population has grown 86%. Expendi-
aim of the committee was to develop minimum stan- tures for health care services have grown from about
dards for hospital pharmacy departments and to pre- 5% of gross domestic product to 14%. This growth has
pare a manual of pharmacy operations. The committee fostered an endless stream of public and private initia-
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b Throughout this chapter, pharmacy data from recent ASHP surveys refer to U.S. nonfederal short-term hospitals.
c Calculated based on data in Reference 11.
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2. A pharmacist reviews the medication order as a whole, ASHP estimates that about 80% of IV
before the first dose is dispensed. admixtures are now prepared by the pharmacy depart-
3. Medications are contained in single-unit ment.19
packaging. ASHP’s 2002 survey showed that most hospitals
regularly engage in a number of programs designed to
4. Medications are dispensed in as ready-to-
increase the safety of injectable medications, including
administer form as possible.
educational programs on IV administration equipment
5. Not more than a 24-hour supply of doses is (82%), administration and precautions associated with
delivered or available at the patient-care area at high-risk therapies (71%), and administration of IV
any time. push medications (62%); promulgating lists of approved
6. A patient medication profile is concurrently IV push medications (57%); and affixing supplemental
maintained for each patient.18 labels for IV push medications (53%).19
These precepts for state-of-the-art drug distribution There is immense interest in U.S. hospitals in
are met widely in U.S. hospitals today. For example, in applying computer technology to improve the safety of
a 2002 survey, in 79% of hospitals, pharmacists medication prescribing, dispensing, and administration.
reviewed and approved all medication orders before Computer-generated medication administration records
the drug was administered to patients. The figure for are used in 64% of all hospitals and in 75% of the
the largest hospitals (≥400 beds) was 92%.19 largest hospitals.19 The foregoing data notwithstanding,
There has been much debate in hospital pharmacy the cost of such technology is having a decided moder-
over the years about the virtues of centralized versus ating effect on the rate of adoption. For example, in
decentralized drug distribution. With a decentralized 2002, only about 2% of hospitals used computer-
system, pharmacists come in contact more regularly readable coding technology to improve accuracy of
with physicians, nurses, and patients, which is consis- medication administration, and, in 2004, only about
tent with contemporary views about how the profession 3% of hospitals used a computerized prescriber order
should be practiced. Among all hospitals, 20% use a entry system that was linked to a decision support sys-
decentralized system; the figure is 41% for the largest tem.13,19
hospitals.19 Many hospitals indicate that they would Because of the concerns of groups such as the
like to move toward decentralized pharmacy services in Institute of Medicine and various federal agencies,
the future (see Table 2-2). improving patient safety is now a major national priori-
U.S. hospitals have shown a remarkable rate of ty.21 When that general interest in patient safety
adoption of point-of-use automated storage and distri- embraces medication-use safety, hospital pharmacists
bution devices, which are now used to some extent in have cheered and felt “it’s about time!” Further break-
58% of facilities. Point-of-use dispensing is now the through advances in medication-use safety will depend
primary method of dose delivery in about one-fourth on a fundamental reengineering of the entire medica-
of U.S. hospitals.19 tion-use process, a shift toward a true team culture in
Pharmacy-based IV admixture services have been providing care, and wider application of computer
widely adopted by U.S. hospitals. Development of such technology.22 As new technologies or new patterns of
services, as a professional imperative, was a topic of health professional behavior evolve, history suggests
intense interest in the 1960s.20 For short-term hospitals that hospital pharmacists will be at the leading edge of
those advances.
Table 2-2
Promoting Rational Drug Use
Hospitals with Decentralized Drug
In U.S. hospitals, the concept of a pharmacy and thera-
Product Distribution19 peutics (P&T) committee, as a formal mechanism for
Year 2002 Future Desire the pharmacy department and the medical staff to
communicate on drug-use issues, was first promulgated
All hospitals 20% 44%
in 1936 by Edward Spease (dean of the School of
Largest hospitals (≥ 400 beds) 41% 56%
Pharmacy at Western Reserve University) (Figure 2-5)
and Robert Porter (chief pharmacist at the University’s
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ism in drugstores, the more I felt that if profes- actualization of the professional ideals and aspirations
sional pharmacy was to exist, let alone grow to an of hospital pharmacists. In its early years, ASHP con-
ideal state, it would have to be in the hospital ducted a series of educational institutes that were very
where the health professions were trained…. influential in enhancing knowledge and skills and in
Good pharmacy is as important in hospitals away building esprit de corps among hospital pharmacists.33
from teaching centers as it is in the teaching and Also noteworthy, especially as the organization has
research hospital. It can be developed to a high grown in size and diversity, is ASHP’s efforts to devel-
degree of perfection there, too, if the pharmacist op consensus about the direction of practice.25,26
can get the picture in his mind.” (Emphasis The second essential act of ASHP has been its cre-
added.)31 ations of resources to assist practitioners in fostering
“…if the pharmacist can get the picture in his the development of hospital pharmacy practice. One
mind.” Those are key words that reflect that early hos- example is the AHFS Drug Information reference book
pital pharmacy leaders were trying to create a new (and, in recent times, electronic versions for central
model for pharmacy practice in hospitals and not allow information systems, desktop computers, and hand-
this practice setting to become an extension of the type held devices), which is the most widely used independ-
of practice that prevailed in community pharmacies. ent source of drug information in U.S. hospitals.
These leaders were change agents with a missionary Another example is the American Journal of Health-
zeal, and they were blessed with the ability to infect
others with their passion.
Figure 2-7
It is noteworthy that the Mirror to Hospital Phar-
macy framed the entire Audit project in the context of A Leading Force in the Creation of
professional advancement. The report laid out the ASHP—Harvey A. K. Whitney
essential characteristics of a profession and articulated
goals for hospital pharmacy that would bring pharmacy
(1894–1957) circa, 1940a
as a whole into better alignment with those character-
istics.
Professional Associations
The national organization of hospital pharmacists—
the American Society of Health-System Pharmacists
(ASHP)—has had a profound effect on the advance-
ment of the field. The visionary hospital pharmacists
of the early 1900s focused much of their energies on
the creation of an organizational structure for hospital
pharmacy. One landmark event was the creation of the
Hospital Pharmacy Association of Southern California
in 1925. On a national level, organizational efforts
were funneled through the American Pharmaceutical
Association (APhA), the oldest national pharmacist
organization in the country. For years, hospital phar-
macists participated in various committee activities of
APhA focused on their particular interest. Then, in
1936, a formal APhA subsection on hospital pharmacy a HarveyA. K. Whitney took the lead in organizing hospital pharmacists in the
was created. This modest achievement evolved to the United States. He was chief pharmacist at the University of Michigan Hospitals
creation of ASHP in 1942 as an independent organiza- when he became ASHP’s first chairman (president) in 1942. Whitney was also
tion affiliated with APhA32 (see Figure 2-7). a pioneer in developing postgraduate training in hospital pharmacy.
There are two essential things that ASHP has done Source: ASHP Archives.
for the advancement of hospital pharmacy. One is to
serve as a vehicle for the nurturing, expression, and
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System Pharmacy. These two publications, and other grade the pharmacy curriculum, to make it more con-
ASHP activities such as the Midyear Clinical Meeting, sistent with the needs in hospital practice. This is sig-
have produced a source of funds beyond membership nificant because practice demands have always been
dues that ASHP has used to develop a broad array of far more intense in hospitals than in community phar-
services that help members advance practice. macy, so pressure to meet the demands in hospitals
The original objectives of ASHP were as follows: served to elevate education for all pharmacists. Also,
■ Establish minimum standards of pharmaceutical beginning in the 1970s, corresponding with increased
service in hospitals emphasis on clinical pharmacy in the curriculum, hos-
pital pharmacies played a much larger role in pharma-
■ Ensure an adequate supply of qualified hospital
cy education as clerkship rotation sites for pharmacy
pharmacists by providing standardized hospital
students. Third, in the early days of clinical education,
pharmacy training for four-year pharmacy
faculty members from schools of pharmacy began
graduates
establishing practice sites in hospitals, which often had
■ Arrange for interchange of information among a large impact on the nature of the hospital’s pharmacy
hospital pharmacists service.
■ Aid the medical profession in the economic Table 2-4 shows how the minimum requirements
and rational use of medicines for pharmacy education have evolved over the years. It
The core strengths of ASHP today are as follows: took a very long time for pharmacy in the U.S. to set-
tle on the Pharm.D. as the sole degree for pharmacy
■ Practice standards and professional policy
practice. Many bitter fights—between educators,
■ Advocacy (government affairs and public between practitioners, among educators and practition-
relations) ers, and among educators and the retail employers of
■ Residency and technician training accreditation pharmacists—occurred over this issue. Now that the
■ Drug information matter is settled, everyone seems to be moving on with
the intention of making the best application of the
■ Practitioner education pharmacist’s excellent education.
■ Publications and communications Over the past 20 years, pharmacy education in the
One of the reasons for ASHP’s success has been its U.S. has been transformed completely from teaching
clarity about objectives and its concentrated focus on primarily about the science of drug products to teach-
a limited number of goals. It is a testament to the wis- ing primarily about the science of drug therapy. Trans-
dom of ASHP’s early leaders that the goals expressed
in 1942 still serve to guide the organization, although
Table 2-4
different words are used today to express the same
ideas, and some other points have been added. The Evolution of Minimum
organization continues as a powerful force in the Requirements for Pharmacist
ongoing efforts to align pharmacists with the needs
that patients, health professionals, and administrators
Education in the United States
in hospitals have related to the appropriate use of Year Minimum Requirement (Length of Curriculum
medicines. and Degree Awarded)
1907 2 years (Graduate in Pharmacy)
Pharmacy Education 1925 3 years (Graduate in Pharmacy or Pharmaceutical
There are three important points about the role of Chemist)
pharmacy education in transforming hospital pharmacy. 1932 4 years (B.S. or B.S. in Pharmacy)
First, as pharmacy education as a whole has been 1960 5 years (B.S. or B.S. in Pharmacy)a
upgraded over the years, hospital pharmacy has bene-
fited by gaining practitioners who are better educated 2004 6 years (Pharm.D.)
and better prepared to meet the demands in hospital a Transition
period; some schools offered only the B.S. or the Pharm.D. degree; many
practice. Second, hospital pharmacy leaders have put schools offered both degrees, with the Pharm.D. considered an advanced degree.
considerable pressure on pharmacy educators to up-
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formation of hospital pharmacy practice from a prod- spectrum are various federal laws governing drug prod-
uct orientation to a patient orientation could not have ucts and state practice acts governing how the phar-
occurred without this change in education. macist behaves and how pharmacies are operated. At
the opposite end of the spectrum are voluntary practice
standards promulgated by organizations such as ASHP.
Postgraduate Residency Education and A practice standard is an authoritative advisory
Training document, issued by an expert body, that offers advice
Stemming from its early concerns about the inadequa- on the minimum requirements or optimal method for
cy of pharmacy education for hospital practice, ASHP addressing an important issue or problem. A practice
leaders advocated internships in hospitals and worked standard does not generally have the force of law.
for years to establish standards for such training. This Methods used to foster compliance with practice stan-
led to the concept of residency training in hospital dards include education and peer pressure. ASHP’s
pharmacy and a related ASHP accreditation pro- practice standards have been very important in elevat-
gram.33–35 ing hospital pharmacy in the United States.
Early hospital pharmacy leaders noted the following The origins of hospital pharmacy practice standards
imperatives for hospital pharmacy residency training36: go back to 1936 when the American College of
■ Hospitals were expanding, thereby creating a Surgeons adopted the Minimum Standard for Pharma-
growing unmet need for pharmacists who had cies in Hospitals. This document was semidormant for
been educated and trained in hospital pharmacy. a number of years, but it served as a rallying point for
■ Pharmaceutical education was out of touch with hospital pharmacists and revision and promulgation of
the needs in hospital pharmacy. the Standard became a priority for ASHP.37
The revision pursued by ASHP in the 1940s speci-
■ The internship training required by state boards fied the following minimum requirements:
for licensure was not adequate preparation for a
■ An organized pharmacy department under the
career in hospital pharmacy practice.
direction of a professionally competent, legally
■ Hospital pharmacists required specialized train- qualified pharmacist
ing in manufacturing, sterile solutions, and phar-
■ Pharmacist authority to develop administrative
macy department administration.
policies for the department
■ Organized effort was needed to achieve improve- ■ Development of professional policies for the
ments in hospital pharmacy internships or resi-
department with the approval of the pharmacy
dencies.
and therapeutics committee
There are well over 10,000 pharmacists in practice
■ Ample number of qualified personnel in the
who have completed accredited residency training.
department
These individuals have been trained as change agents
and practice leaders. Early in their careers, they came ■ Adequate facilities
to understand the complexity of hospital pharmacy, ■ Expanded scope of pharmacist’s responsibilities:
including inpatient operations, outpatient services, - Maintain a drug information service
drug product technology and quality, and medication- - Nurse and physician teaching
use policy. Residency training is the height of mentor- - File periodic progress reports with
ship in professionalism in American pharmacy. Dreams administrator
are fostered in residency training—dreams of the pro-
■ P&T committee must establish a formulary
fession becoming an ever more vital force in health
care; dreams of patients improving their health status From this modest beginning, ASHP has developed
more readily because pharmacists are there to help more than 60 practice standards that deal with most
them. aspects of hospital pharmacy operations and several
major controversies in therapeutics.38
ASHP practice standards have been used effectively
Practice Standards over the years as a lever for raising the quality of hos-
Numerous legal and quasi-legal requirements affect pital pharmacy services. The standards have been used
hospital pharmacy practice. On the legal end of the in the following ways:
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■ Requirements for pharmacy practice sites that 4. It is important to regularly and honestly assess
conduct accredited residency programs progress and embark on a new approach if the
■ Guidance to practitioners who desire to volun- existing plan for constructive change is not
tarily comply with national standards working or has run its course. This requires
open-mindedness and a good sense of timing.
■ Guidance to the Joint Commission on Accredi-
tation of Healthcare Organizations in developing Today’s challenges in hospital pharmacy are no
standards for pharmacy and the medication-use more daunting than those that faced hospital pharma-
process cy’s leaders and innovators in the past. Fortunately,
hospital pharmacy is imbued with a culture of taking
■ Tools for pharmacy directors who are seeking
stock, setting goals, making and executing plans, meas-
administrative approval for practice changes
uring results, and refining plans. If hospital pharmacy
■ Guidance to regulatory bodies and courts of law sticks to this time-tested formula, it will continue to be
■ Guidance to curriculum committees of schools a beacon for the profession as a whole.
of pharmacy
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