DRUG

DISTRIBUTION
SYSTEM
 Objectives:

● To identify different Drug Distribution System

● To discuss each type of Drug Distribution System
● To discuss the importance the of DDS
Definition of Terms

DRUG DISTRIBUTION SYSTEM

→a system that has its purpose in the selection,

acquisition (from the manufacturer), control
storage, dispensing, delivery, preparation and
administration of drug products in health care
institutions in response to the order of an
authorized prescriber
● DRUG DISTRBUTION SYSTEM

Syn:
Medication Distribution System
Drug Management System
Drug Delivery System
DISPENSING

→ The act of a pharmacist in supplying one or

more drug products to a patient, usually in
response to an order form an authorized
prescriber, utilizing his professional knowledge,
judgement, and skills to assess the patient and the
drug and then plan, develop, control and monitor
the maintenance and delivery of the drug along
with the information needed for its proper storage
and administration
UNIT DOSE

→ a physical quantity of a drug product

ordered by a prescriber to be
administered to a specified patient at
one time, in ready-to-administer form
with no further physical or chemical
alterations required
●UNIT DOSE PACKAGE
→ a package containing one dose

● SINGE UNIT PACKAGE

→ a package which contains one discrete
pharmaceutical dosage form e.g. one tablet,
one 5 mL volume of liquid
STEPS IN DRUG DISTRIBUTION

● The overall drug distribution and utilization process in

the hospital involves an infinite number of procedures,
personnel, departments, equipment and storage.

● As an illustration, the drug distribution system can be

summarized as a chain of twelve steps from
procurement to administration to the patient.
● At the manufacturer:
1. Order processing
2. Production and filling
3. Shipping

● At the Pharmacy:
4. Ordering/Receiving
5. Storing
6. Prep’n for dispensing (compounding,
measuring, packaging, labelling)
7. Dispensing
8. Transportation to the Nursing Unit
● On the Nursing Unit
9. Order/Receiving
10. Storing
11. Preparation for administration
12. Administration to the patient

● Within the hospital, steps 4-12 constitute the hospital

drug distribution system
METHODS USED IN TRANSMITTING PHYSICIAN’S MEDICATION
ORDER TO THE PHARMACY

The physician writes the medication order on a

(1)

separate blank.

(2) The medical record has a duplicate copy so that

the pharmacy can obtain a carbon copy of the
physicians’ original medication order.
(3) The physician’s order is transcribed by the
nursing personnel into an inpatient prescription or
requisition form.

(4) The order is transmitted to the pharmacy by

the physician inputting the order in a computer
terminal.
TYPES OF DRUG DISTRIBUTION

1. Individual prescription for each patient

2. A complete Floor Stock System
3. A combination of 1 and 2
4. Unit dose dispensing either centralized in the
pharmacy or decentralized at the nursing unit
level.
5. A pharmacy coordinated unit-dose dispensing
and drug administration system
 1. INDIVIDUAL PRESCRIPTION ORDER SYSTEM

→ Drug distribution system in which medications

are dispensed by a pharmacist on receipt of
individual medication orders

→ This system is generally used by the small

and/or private hospitals because of the reduced
manpower requirements and the desirability for
individualized service
 INDIVIDUAL PRESCRIPTION ORDER SYSTEM

ADVANTAGES:
1. All medication orders are directly reviewed
by the pharmacist
2. Provides for the interaction of pharmacist,
doctor, nurse and patient
3. Provides closer control of inventory
 INDIVIDUAL PRESCRIPTION ORDER SYSTEM

DISADVANTAGES:

1. Possible delay in obtaining the required

medication

2. Increase cost to the patient

2. FLOOR STOCK SYSTEM

→ drug distribution system in which drug supplies

are stocked on nursing units

→ Rarely used or particularly expensive drugs are

omitted from floor stock but are dispensed upon
the receipt of a prescription or medication order
for the individual patient
FLOOR STOCK SYSTEM

→ Although this system is used most often in

governmental and other hospitals in which charges
are not made to the patient or when the all
inclusive rate is used for charging, it does have
applicability to the general hospital
DRUGS ON THE NURSING UNIT MAY BE DIVIDED
INTO:
1. CHARGE FLOOR STOCK DRUGS

→ May be defined as those medications that are

stocked on the nursing station at all times and are
charged to the patient’s account, after they have
been administered to him
DRUGS ON THE NURSING NIT MAY BE DIVIDED INTO:

2. NON-CHARGE FLOOR STOCK DRUGS

→represents that group of medications that are placed at
the nursing station for the use of all patient on the ward
and for which there may be no direct charge to the
patient’s account

→ The cost of these group of drugs is usually calculated in

the per diem cost of the hospital room
FLOOR STOCK SYSTEM

ADVANTAGES:

1. Ready availability of the required drugs

2. Elimination of drug returns
3. Reduction in number of drug order
transcriptions for the pharmacy
4. Reduction in the number of pharmacy
personnel required
FLOOR STOCK SYSTEM

DISADVANTAGES:

1. Medication errors may increase because the

review of medication orders is eliminated
2. Increase drug inventory on the wards
3. Greater opportunity for pilferage
4. Increased hazards associated with drug
deterioration
5. Lack of proper storage facilities on the ward
may require capital outlay to provide them
6. Greater inroads are made upon the nurses’ time
3. COMBINATION OF INDIVIDUAL DRUG ORDER AND
FLOOR STOCK SYSTEMS
● In this system, drugs which are free floor stock
are charged against the nursing service and, in
the final analysis, the patient does pay for the
drugs since the cost is included as a part of the
nursing service portion of the daily room and
board rate
4. UNIT-DOSE DISPENSING SYSTEM

● The unit dose drug distribution is a pharmacy

coordinated system of dispensing and
controlling medications in health care
institutions

● Medications are contained in single-unit

packages and are dispensed in ready-to-
administer form as possible
UNIT-DOSE DISPENSING SYSTEM

● For most medications, not more than a 24-hour

supply of doses is delivered or available at the
patient care area at any time

● A medication profile is maintained for each

patient
UNIT-DOSE DISPENSING SYSTEM

ADVANTAGES:
1. Patients receive improved pharmaceutical
service 24 hours a day and are charged for
only those doses which are administered to
them.

2. All doses of medications required a the

nursing station are prepared by the
pharmacy thus allowing the nurse more
time for direct patient care.
3. Allows the pharmacist to interpret or check a copy of the
physician’s original order thus reducing medication errors.

4. Eliminates excessive duplication of orders and paper work

at the nursing station and pharmacy

5. Eliminates credit

6. Transfers IV preparation and dry reconstitution procedures

to the pharmacy

7. Promotes more efficient utilization of professional and non-

professional personnel
8. Reduces revenue losses

9. Conserves space in nursing units by eliminating bulky floor

stock

10. Eliminates pilferage

11. Extends pharmacy coverage and control throughout the

hospital from the time the physician writes the order to the
time the patient receives the unit dose

12. The pharmacist can get out of the pharmacy and into the
wards where they perform their intended functions as drug
consultants and help provide the team effort that is needed
for better patient care
The Unit Dose Dispensing may be introduced into
the hospital in either of two ways:

1. Centralized Unit Dose Distribution System (CUDD)

→ All drugs are stored in a central area pharmacy and

dispensed at the time the dose is due to be given to
the patient
2. Decentralized Unit Dose Drug Distribution (DUDD)

→Sub-pharmacies that receive their supplies from the main

pharmacy but have the advantage of being able to respond
to the clinical needs of the patient on a current basis

→ In addition, such a system makes available to the

patient, physician and nurse the services of a pharmacist in
a clinical capacity rather than a dispenser of medications.
A PHARMACY-COORDINATED UNIT DOSE DISPENSING AND
DRUG ADMINISTRATION SYSTEM

● This system differs from the others in that pharmacy

technicians have been trained to administer the drugs
instead of registered nurses.

● These pharmacy technicians assist in the unit-dose

dispensing phase as well as the drug administration phase
of the coordinated system which is directly controlled and
supervised by registered pharmacists.
● Pharmacists work directly with physicians on the nursing
unit to carry out pharmacy’s mainstream function of the
safe and appropriate use of drugs in patients.

● This system reduce significantly the incidence of

medication errors in comparison with the other drug
distribution systems in existence.
 PATIENT SELF-ADMINISTRATION OF DRUGS IN
HOSPITALS
● Pharmacists generally have considered a unit-dose
dispensing system as a panacea for hospital drug
problems.

● However, unit-dose dispensing systems primarily have

been “pharmacy-centered” rather than “patient-
centered”.
● The new direction in hospital pharmacy is to develop
patient-oriented services as the focal point in drug-
distribution systems.

● The self-administration of drugs by patients in the

hospital offers many advantages.

✓ It allows the patient to assume more responsibility for

his direct care and allows him to learn how to use drugs
properly, and be able to anticipate potential side effects
and other drug-created problems.
● It provides a salient opportunity for the pharmacist to
help educate patients on the safe and proper use of
drugs and thereby alleviates much time spent by nurses
and physicians in this essential pharmct’l function.
● A procedural manual should be prepared which outlines the
methods used to implement a patient self-administration program
as part of a unit-dose distribution system.

● A self-administration medication program gives the patient

possession of his medication and makes the patient responsible for
its administration. Both the nurse and pharmacist will make rounds
to insure that the patient is using his medication properly.
● The self-administration program enables the nurse to
use her time better.

● The patient should become more knowledgeable bout

his medication, thus enhancing proper and safe use of
drugs during hospitalization and after discharge.
● This program is used for patients who are not capable of self-
administering their medications and for those medications which
the patient cannot administer to himself. This is the interacting role
which hospital pharmacists have developed under the umbrella
term, “clinical pharmacy”.
NEW CONCEPTS IN DISPENSING

○ Placing a pharmacist on the nursing station to assume

all responsibility concerning the ordering, stocking and
preparation of drugs for administration as well as to be
readily available for consultation by the clinical and
nursing staffs.

○ Ensures drug safety through marked reduction in

medication errors.
● On the pavilion, the pharmacist may help the physician
in the selection of the most therapeutically beneficial
drug, assist the nurse by interpreting the physician’s
order as well as the preparation of each dose for
administration, and the ordering, storage, charging and
control of all drugs and related products on the nursing
station.
DISPENSING TO AMBULATORY PATIENTS

● As ambulatory-care activities continue to increase within the

institutional setting, the hospital pharmacist becomes more and
more involved in providing services to these patients.

● This includes special patient information brochures, patient-dosing

calendars, special packaging, patient education audio-visual and
home-care programs.
LOCATION OF OUT-PATIENT DISPENSING AREA

● There is no set rule as to the best area to locate an out-

patient dispensing pharmacy. This is evidenced by the
fact that in today’s practice three equally suitable
provisions are made for this area:

a. Separate out-patient pharmacy is available

b. A combined in-patient and out-patient unit

with service provided from the same “window”

c. A combined in-patient and out-patient unit with

service provided from separate “window”
● A separate out-patient pharmacy is usually
established whenever the out-patient
department and the pharmacy are
geographically widely separated.
Disadvantage:

● requiring a separate staff

● consuming a great deal of time
● transporting supplies and drugs to the area.
 TYPES OF PRESCRIPTION RECEIVED

● Depending upon the location and kind of hospital, the prescriptions

received in the out-patient department pharmacy will generally
include those of private patients, indigent patients, non-indigent
patients, employees, and patients being discharged from the
hospital.
THE DISPENSING ROUTINE

● The dispensing pattern involved in providing clinic

patients as well as those patients being discharged with
“take home drugs” is identical with that carried on by a
community pharmacy.
● For internal audit purposes, hospital
prescriptions are separated into out-patient and
in-patient discharges and therefore may utilize
two different colored blanks.
DISPENSING ANCILLARY SUPPLIES

● A recent trend in hospital pharmacy is the assumption of

responsibility for the purchase, stocking and distribution
of the various ancillary medical, surgical and laboratory
supplies.
● These may consist of surgical instruments, catheter,
sutures, needles, syringes, sphygmomanometers and
laboratory things.
● Central Sterile Supplies
● The purchasing of the supplies should not be mixed with
the purchasing of pharmaceuticals and separate records
and inventories should be maintained.
Combined Pharmacy-Central
Sterile Supply Room
Central Supply Department
 as that service, with in the hospital, catering
for the sterile supplies to all departments ,
both to specialized units as well as general
wards and OPDs.
 Also known as: CSSR;CSR and sterile supply
room
 AIMS
 To provide sterilized material from
a central department where
sterilizing process is carried out
under properly controlled conditions

 To alleviate the burden of work of

the nursing personnel, there by
enabling them to devote more of
their time to patient care .
ITEMS COMMONLY HANDLED BY
CSSD STORES
Central Supply Departments
Central Supply
 Receives Purchase Request
from Department Heads
 Shops for the best price and
best quality on items requested.
 Awards Purchase Order to
Company that met the above
criteria.
 Receives items on purchase
order catalogs them into
inventory and releases money
to pay for purchases.
Central Sterile
 Receives equipment from
purchasing.
 It is cleaned, tagged and placed
in the clean storage area
awaiting a request form.
 Equipment is sent out of
Central Supply to the floors
after receiving a request
 After patient who needed the
equipment has been discharged
or no long need it, the
equipment is sent to the C.S.
Decontamination room
Central Supply Departments
Central Supply Continued
 Central Supply Continues
to keep records of supplies
ordered , received, and
supplies sent out to patients
or the floors of the hospital.
 Inventories are done
frequently to make sure the
items in the computer are
on the shelves.
Central Sterile Continued
 When items come into the
decontamination room or
dirty side, they are cleaned
and processed and sent to
the clean side for storage .
 The Central Sterile “clean
side” wraps instruments,
surgical trays, etc.. And
sterilizes them. They are
then sent to the
departments that uses them
for storage
1. Syringes

2. Procedure Sets
Lumbar puncture ; sternal puncture ;
venesection ; paracentesis ; aspiration ;
catheterization ; tracheotomy ; suturing ;
dressing ; biopsy ; incision & drainage ;
aortography ; cardiac resuscitation ; etc
3. Needles
4. Gloves
5. I.V.Fluids.
6. Treatment Trays.
7. Instruments.
8. Linen
9. Infusion Fluids for Renal Dialysis.

NB: Diet , drugs , bedpans & urinals are

not included by convention .
 All items are received into the Central Sterile
decontamination area for cleaning before being
sent to the clean area. In the clean area items
are stored or processed if necessary and
sterilized.

Central Sterile Technician is

Central Sterile Technician
receiving clean instruments
is loading the Autoclave
Aseptic Technique, Sterile Compounding:
Intravenous and Admixture
 Aseptic Technique

“Aseptic technique is the term used

for all procedures and techniques
performed to keep a sterile product
from becoming contaminated.”
 Parenteral Drug Administration
 Basic Intravenous Therapy
- Intravenous (IV) route of administrations is the most
common route that parenteral dose are administered
today.

- Other parenteral dosage forms are:

1. intramuscular (IM)
2. subcutaneous (SubQ)
3. intradermal (ID)
4. epidural

- IV fluid is in a large-volume parenteral (LVP), usually

more than 100 mL
Basic IV Therapy cont…
- Hang on an IV pole
approximately 36 inches higher
than
the patient’s bed.

- The LVP is usually a simple

solution of dilute dextrose,
sodium chloride or both.

- Solution is infused continually

to keep blood from clotting
in the catheter and plugging the
line.
Basic IV Therapy cont…
- Primary IV set – attaches to the LVP. Most IV sets that
flow by the force of gravity have several common features:
1. Drip chambers are typically classified as macrodrip
or minidrip based on the size of the drop that is
formed in the drip chamber.
a. Macrodrip – deliver 10 to 20 drops/mL
b. Minidrop or Microdrip – deliver 60 drops/mL

2. Electronic infusion devices are usually used in fluid

restricted patients or when the LVP contains a drug
that must be administered at a precise rate that
cannot be monitored by using the gravity method.
Continued…
- Secondary IV sets – drugs that are routinely delivered
through the same basic IV setup are usually attached to
a “secondary IV set” connected to the primary set.

- Catheters – typically inserted into a peripheral vein (arm,

leg, or hand) or a central vein (in the chest near the
heart).
1. Where the catheter is inserted depends on the
contents of the IV
2. Peripheral insertion is more common than central
insertion
3. The central catheter is more complicated and riskier
to insert and maintain, but has fewer restrictions with
respect to type and rate of administration
Continued…

4. Types of peripheral catheters:

a. Plastic – most common
b. Steel – commonly referred to as a scalp vein or
butterfly. Used in patients that require IV therapy
who are still capable of eating and drinking, do not
require supplemental fluids, and might be ambulatory.

5. Central catheters can be temporary; used for days or weeks

(such as during a hospital stay) or permanent, when used
for months or years (such as home care or cancer patients)
Continued…

6. The central catheter gives direct access into a vein that

that has a high flow of blood.

7. Peripheral inserted central catheter (PICC) offers some of

the benefits of both central and peripheral catheters.
Inserted peripherally it is a long flexible catheter that
travels through the vein and its tip ends near the heart
where there is a high volume of blood flow.
 Risks of Intravenous Therapy
 Infection – results if a product contaminated with bacteria
is infused into a patient.
- human touch contamination continues to be the most
common source of IV related contamination.

 Air embolus – incidence is low, because many solutions

are administered using infusion pumps equipped with an
alarm that sound when air is in the IV line. These are
called air-in-line alarms.
- in adults it takes 150 or 200 mL of air (much less in
infants or pediatric patient) given quickly to result in
harm.
Risks continued…
 Bleeding – when the IV catheter is removed, bleeding may
occur around the catheter site.

 Allergic reaction – when a patient has an allergic reaction to

a substance given parenterally the reaction is usually more
severe than if the same substance was given by another
route (e.g. mouth, topically, or rectally)
- one reason for this is that substances given parenterally
cannot be retrieved like substances given by other routes.

 Incompatibilities – if an incompatibility exists, the drug

might precipitate, be inactivated, or adhere to the container.
Incompatible solutions should not be administered to
patients.
Risks continued…
 Extravasation – occurs when the catheter punctures and
exits the vein under the skin, causing drugs to infuse or
infiltrate into the tissue.

 Particulate matter – refers to particles present in

parenteral products. When injected into the bloodstream
can cause adverse effects to the patient. Examples:
- microscopic glass fragments
- hair
- lint or cotton fibers
- cardboard fragments
- undissolved drug particles
- fragments of rubber stoppers
Risks continued…
 Pyrogens – the by-products or remnants of bacteria, can
cause reactions (e.g. fever and chills) if injected in large
enough amounts.

 Phlebitis – Irritation of the vein. Caused by:

- the drug being administered (due to it chemical properties
or its concentration)
- the location of the IV site
- a fast rate of administration
- the presence of particulate matter
- the patient usually feels pain or discomfort along the path
of the vein (often severe) and red streaking may also
occur
 Aseptic Preparation of Parenteral
Products
 Aseptic Technique
- Programs designed to ensure the aseptic preparation of
sterile products.

- The main elements these programs focus on are:

1. the development and maintenance of good aseptic
technique in the personnel who prepare and
administer sterile products.
2. Development and maintenance of a sterile
compounding are complete with sterilized equipment
and supplies.
3. Development and maintenance of the skills needed to
properly use a laminar flood hood (LAH).
Aseptic Technique continued…

 Aseptic technique is a means of manipulating sterile

products without contaminating them.

 Proper use of a LAH and strict aseptic technique are the

most important factors in preventing the contamination of
sterile products.
 Sterile Compounding Area

 Sterile parenteral solutions must be free of living

microorganisms and relatively free of particles and
pyrogens.

 A sterile compounding area should be cleaned daily and

segregated from normal pharmacy operations, patient
specimens, nonessential equipment, and other materials
that produce particles. Examples:
- cardboard into the clean environment should be avoided.
- traffic flow should be minimized.
- floors should be disinfected periodically.
- trash should be removed frequently and regularly.
Compounding Area continued…

 Sterile products should be prepared in a Class 100

environment, which contains no more than 100 particles
per cubic foot that are 0.5 micron or larger in size.

 LAHs are frequently used to achieve a Class 100

environment.
Laminar Airflow Hoods (LAH)
 Underlying principle of LAHs is that twice-filtered layers of aseptic
air continuously sweep the work area inside the hood to prevent
the entry of contaminated room air.

 Two common types:

- Horizontal LAH – sweeps filtered air from the back of the
hood to the front.
1. use an electrical blower to draw contaminated room
air through a prefilter.
2. The prefilter, which is similar to a furnace filter, only
removes gross contaminants and needs to be cleaned
or replaced on a regular basis.
3. The high efficiency particulate air or (HEPA) filter
removes 99.9% of particles that are 0.3 micron or
larger.
Laminar Airflow Hoods continued…
 Vertical LAH – HEPA filtered air emerges from the top and
passes downward through the work area.
- used for antineoplastic (anticancer) drugs.
- the risk of exposure to airborne drug particulates is
minimized.
- the type of vertical LAH used for the preparation of
antioneoplastics contains airflow within the hood and are
referred to as biological safety cabinets (BSCs).

 The critical principle of using LAHs is that nothing interrupts

the flow of air between the HEPA filter and the sterile object.
The space between the HEPA filter and the sterile object is
known as the critical area.
Hoods continued…
 To maintain sterility, nothing should pass behind a sterile
object in a horizontal flow hood or above a sterile object in
a vertical flow hood.

 Materials placed within the laminar flow hood disturb the

patterned flow of air blowing from the HEPA filter. This
“zone of turbulence” created behind an object could
potentially extend outside the hood pulling or allowing
contaminated room air into the aseptic working area.

 It is advisable to work with objects at least six inches

from the sides and front edge of the hood without blocking
air vents, so that unobstructed airflow is maintained
between the HEPA filter and sterile objects.
Hoods continued…
 The following are general principles for operating LAHs
properly:
- A LAH should be positioned away from excess traffic,
doors, air vents, or anything that could produce air currents.
- If turned off, it should be allowed to run for 15-30 minutes
before use.
- Before use, all interior working surfaces of the laminar
flow hood should be cleaned with 70% isopropyl alcohol or
other appropriated disinfecting agent and a clean, lint-free
cloth. Cleaning should be performed from the HEPA filter
toward the front of the LAH (in a horizontal LAH) so that
contaminants are moved out of the hood.
Hood Criteria continued…
 Nothing should be permitted to come in contact with the
HEPA filter. This includes cleaning solution, aspirate from
syringes, or glass from ampules. Ampules should not be
opened directly toward the filter.

 Do not put paper, pens, labels, or trays into the hood.

 Jewelry should not be worn on the hands or wrists when

working in the LAH since it may introduce bacteria or
particles into the clean work area.

 Actions such as talking and coughing should be directed

away from the LAH working area, and any unnecessary
motion within the hood should be avoided to minimize the
turbulence of air flow.
Hood Criteria continued…
 Smoking, eating or drinking are prohibited in the aseptic
environment.

 All aseptic manipulations should be performed at least six

inches within the hood to prevent the possibility of
potential contamination caused by the closeness of the
worker’s body and backwash contamination resulting from
turbulent air patterns developing where LAH air meets
room air.

 LAHs should be tested by qualified personnel every six

months, whenever the hood is moved, or if filter damage
is suspected.
 Personal Attire
 The first component of good aseptic technique is proper
personal attire.

 Clean garments, which are relatively particulate free,

should be worn when preparing sterile products.

 Many facilities provide clean scrub suits or gowns for this

purpose.

 Hair covers and shoe covers help reduce particulate or

bacterial contamination, and some experts claim that the
use of surgical masks and gloves is warranted as well.
 Handwashing
 Touching sterile products while compounding is the most
common source of contamination of pharmacy prepared
sterile products.

 Scrub your hands, nails, wrists, and forearms thoroughly

for at least 30 seconds with a brush, warm water, and
appropriate bactericidal soap before performing aseptic
manipulations. Wash your hands frequently and every
time you re-enter the sterile compounding area.

 Workers who have open sores on their hands or have an

upper respiratory tract infection should inform their
supervisor and/or consult the institutions quality assurance
procedures. Wear sterile gloves and mask is needed.
Equipment and Supplies
 Another important factor in aseptic preparation of sterile
products is the correct use of appropriate sterile
equipment and supplies, including syringes and needles.

 Syringes:
- made of either glass or plastic
- most drugs are more stable in glass, so glass syringes
are most often used when medication is to be stored in
the syringe for an extended period of time.
- Composed of a barrel and plunger. To maintain sterility
of the product, do not touch the syringe tip or plunger.
Many syringes have a locking mechanism at the tip:
Leur-lock, which secures the needle within a threaded
ring.
Syringes continued…
 Available in numerous sizes ranging from 0.5 to 60 mL.
Usually the larger the syringe capacity, the larger the
interval between calibration lines.

 Ideally, the volume of solution should only take up ½ to

2/3 of the syringe capacity. This avoids inadvertent touch
contamination caused when the syringe plunger is pulled
all the way back.

 When measuring with a syringe, lineup the final edge

(closest to the tip of the syringe) of the plunger piston,
which comes in contact with the syringe barrel, to the
calibration mark on the barrel which corresponds to the
volume desired.
Syringes continued…

 The syringe package should be opened within the laminar

flow hood in order to maintain sterility.

 The wrapper should be peeled apart and not ripped or

torn.

 To minimize particulate contamination, do not lay

discarded packaging on the LAH work surface.

 The syringe tip protector should be left in place until it is

time to attach the needle.
Needles
 Sizes are described by two numbers:
- Gauge: corresponds to the diameter of its bore, which is
the diameter of the inside of the shaft. The larger the
gauge the smaller the needle bore.
Ex: the smallest needles have a gauge of 27, the
largest needles have a gauge of 13.

- Length: the needle shaft is measured in inches and

usually ranges from 3/8 to 3 ½ inches.
Needles continued…
 Components of a simple needle:
- Hub: attached the needle to the syringe and is often
color-coded to correspond to a specific gauge.

- Shaft: the tip of the needle shaft is slanted to form a

point. The slant is called the bevel, the point is called the
bevel tip. The opposite end of the slant is termed the
bevel heel.

 No part of the needle itself should be touched. Needles

should be manipulated by their over-wrap and protective
covers only. The protective cover should be left in place
until the needle and/or syringe are ready to be used.
Needles continued…

 A needle shaft is usually metal and is lubricated with a

sterile silicone coating.

- For this reason, needles should never be swabbed with

alcohol.

 Some needles have built in filters and are meant to be

used with products requiring frequent such as drugs
removed from a glass ampule.
Drug Additive Containers
 Ampules
- Composed entirely of glass and once broken (opened)
become open-system containers

- Since air or fluid may now pass freely in and out of the
container, it is not necessary to replace the volume or
fluid to be withdrawn with air.

- Before an ampule is opened, any solution visible in the

top portion (head) should be moved to the bottom (body)
by swirling the ampule in an upright position, tapping the
ampule with your finger or inverting the ampule and then
quickly swinging it into an upright position.
Ampule continued…
 To break an ampule properly, the head must be broken
from the body of the ampule. To make the break properly,
the ampule neck is cleansed with an alcohol swab and the
swab should be left in place.

 To withdraw medication from an ampule, the ampule should

be tilted and the bevel of the needle placed in the corner
space (or shoulder) near the opening.

 To withdraw the solution, either use a flter needle and

change to a regular needle BEFORE expelling the contents.
Ampules continued…

 Usually the medication is withdrawn

from the ampule with a regular
needle and then the needle is
changed to a filter needle before
pushing drug out of the syringe.
Vials
 Is a glass or plastic container with a rubber stopper
secured to its top, usually by an aluminum cover.

 They are used to hold powders and liquids.

 The rubber stopper is usually protected by a flip-top cap or

aluminum cover.

 Most protective covers do not guarantee sterility of the

rubber stopper; therefore, before the stopper is
penetrated, it must be swabbed with 70% isopropyl
alcohol and allowed to dry.
Vials continued…
 Swabbing helps achieve sterility in two ways:
- the alcohol acts as a disinfecting agent
- the physical act of swabbing in one direction removes
particles.

 When piercing vials with needles, avoid coring fragments

out of the rubber stopper with the needle.
- a core is carved out of the rubber stopper when the
bevel tip and the bevel heel do not penetrate the stopper
at the same point.

 Vials are closed-system containers since air or fluid

cannot pass freely in or out of them.
Vials continued…

 In most cases, air pressure inside the vial is similar to that

of room air.

 In order to prevent the formation of a vacuum inside the

vial (less pressure inside the vial than room air) the used
should normalize pressure by first injecting into the vial a
volume of air equal to the volume of fluid that is going to
be withdrawn.

 If the drug is in powdered form, it has to be reconstituted.

Inject the desired volume of sterile diluting solution (the
diluent), such as sterile water for injection, into the vial
containing the powdered drug.
Vials continued…
 An equal volume of air must be removed in order to
prevent a positive pressure from developing inside the
vial.

 Vials with drugs in solution are classified as multiple-

dose (also called multiple use) or single-dose.

 Multiple-dose vials contain a small amount of a

preservative agent, added to retard the growth of bacteria
or other organisms that inadvertently contaminate a
product.

 Single-dose vials have no preservative and are intended to

be used one time only. Once a vial is entered with a
needle, it should be discarded.
Pre-filled Syringes

 Drugs commonly given IM or IV are packaged this way to

make them convenient for the health care provider.

 It is also done if the drug is commonly used in emergency

situations because a pre-filled syringe saves time.
Preparation of Intravenous Admixtures
 Before compounding – assemble all materials and visually
inspect vials, ampules, and IV solution containers for signs
of cloudiness, particulate matter, cracks and punctures,
expiration dates, and anything else that may indicate that
the product is defective.
Preparation continued…
 Next, disinfect all injection surfaces and allow them to dry.
- Flexible plastic bag – made of polyvinyl chloride (PVC)
are frequently used.
- Easier to store, less breakable than glass bottles, and
eliminates the need to vent the container when
removing fluid.
- The protective overwrap should not be removed from
a PVC bag until it is ready to be used.
- To minimize air turbulence in the critical area, position
the injection port of a PVC bag, which is covered by an
outside latex tip diaphragm, toward the HEPA filter
when preparing an IV admixture.
Disposal of Supplies

 Syringes and uncapped needles should be discarded

according to institutional policy.

 Never recap a needle. Lay the syringe horizontally and

slide the cap onto the needle. Or place the syringe
vertically and drop the cap onto the needle.

 In some institutions supplies are discarded in puncture-

resistant, sealable containers often called sharps
containers.
Labeling
 Properly label the IV with the following information:
- Patient name, ID number and room number (if inpatient)
- Bottle or bag sequence number, when appropriate
- Name and amount of drugs(s) added
- Name and volume of admixture solution- Auxiliary labeling
- Approximate final total volume of the admixture, when
applicable
- Prescribed flow rate (in mLs per hour)
- Date and time of scheduled administration
- Date and time of preparation
- Expiration date
- Initials of person who prepared and person who checked
the IV admixture
- Auxiliary labeling – supplemental instructions and precautions
- Typically drugs are considered stable as long as they are
within 10% of their labeled potency.
Bulk and Sterile
 Hospital pharmacies operating manufacturing
program which prepare galenicals, sterile
pharmaceuticals such as oinments,
injectables, surgical irrigating fluids.
 To have an adequate budgetary control over
the manufacturing program, the pharmacist
is required to give an inventory and
consumption rate for the following:
 Finished products
 Raw materials
 Manufacturing capacity
 Personnel and operating cost
 In able to determine the requirements in
manufacturing program it will be helpful to
review the records of the previous years and
comparing this figure to the present.
 When the pharmacist determined what
products he intends to manufacture and the
quantity, he must next arrange the necessary
supplies such as the containers, labels and
the ancillary materials (i.e. filter paper, boxes)
which will be used in the manufacturing.
 Two important consideration in
compounding:
 First, the kind of equipment necessary to
produce the selected formulas is available
 Second, the machinery is capable of
producing the desired quantity.
Note: the selection of equipment should be
made from the basis of variety of uses to
which a single piece of equipment can be put.
 vary from institution to institution
 Given to the scope of the manufacturing
program
 quantities to be produced during any
production run as well to the length of time
that will be required to consume the product
 The availability of personnel
 The ability of the physical facilities
 Most important consideration in bulk
compounding program
 Too many personnel= raise the cost of
product
 Too little= inadequate production schedule
and potential errors
 Supervised by a Pharmacist
 Must be supported with ancillary personnel
 Direct cost only
 Direct labor
 Cost of materials
 Both direct and indirect costs
 Ex: Space rental, insurance, equipment,
maintenance, housekeeping
QUALITY CONTROL
• THE TERM “QUALITY CONTROL” SHOULD NOT BE
CONFUSED WITH THE “STATISTICAL QUALITY CONTROL”
WHICH INVOLVES THE APPLICATION OF STATISTICS FOR
THE CONTROL SIZES, WEIGHTS, AND OTHER PHYSICAL
CHARACTERISTICS OF ARTICLES UNDERGOING MASS
PRODUCTION.

• WHAT IS MORE IMPORTANT TO HOSPITALS IS A Q.C

THAT WILL ENSURE THE INTEGRITY OF THE LABEL. THIS
CAN BEST BE ACCOMPLISHED BY DEVELOPING A SERIES OF
CROSS CHECKS AND LABORATORY ANALYSES.
THE WORK SHEET
 THE MASTER FORMULA CARD AND THE WORK
SHEET MUST NEVER BE REMOVED FROM THE CONTROL OF
THE PHARMACY OFFICE.

• THEREFORE A MEANS MUST BE DEVISED WHEREBY

THE MANUFACTURING PHARMACIST WILL HAVE
AVAILABLE ALL OF THE NECESSARY DATA FOR THE
PRODUCTION AND PACKAGING OF THE FINISHED
PRODUCT, AS WELL AS HAVING A FORM TO RECORD THE
NECESSARY INFORMATION OBTAINED FROM THE
CONTROL LAB.
 A good control system record will
provide the hospital pharmacist with the
following information on each product
manufactured:
❑NAME
❑STRENGTH
❑DATE OF MANUFACTURE
❑FORMULA
❑INGREDIENTS
A.MANUFACTURER
B. LOT NUMBER
❑ METHOD OF COMPOUNDING
❑PERSON WHO PREPARED FINISHED PRODUCT
❑PERSON WHO CHECKED THE MATERIALS AND PROCESS
❑THE HOSPITAL LOT NUMBER ASSIGNED TO THE PRODUCT
❑ITS DISPOSITION
❑ITS PACKAGING
❑LABORATORY CONTROL DATA
❑PERCENTAGE YIELD
❑TIME CONSUMED IN ITS PREPARATION
❑RAW MATERIAL COST
❑PACKAGING COST
 one or more sterile products are added to
an IV fluid for administration.

 a unit dose
• Health care personnel who are professionally best qualified to prepare
intravenous admixtures
• Trained to provide such service
 Successfully have organized, developed and operated a centralized
pharmacy intravenous-admixtures service that:

1. Saves nursing time for other professional nursing roles

2. Provides a system for screening physical-chemical
incompatibilities and dispensing of stable preparations
3. Minimizes pharmaceutical calculations errors
4. Reduces the risk of medication error by providing
additional checks
5. Centralizes responsibility for preparation of parenteral
admixtures.
6. Labels admixtures with rate of infusion as prescribed by
the physician and provides a standardized label format.
7. Provides an aseptic environment for the preparation of
admixtures
8. Provides a mechanism for charging patients for IV
therapy and creating revenue.
9. Insures more effective use of professional personnel in
the hospital.
10. Minimizes the potential for medical-legal liability.
11. Provides for the preparation of solutions which are not
commercially available.
• A pharmacy-controlled intravenous-admixture service
demonstrates that a hospital is fulfilling its responsibilities
to patients
• An intravenous admixture is a unit dose
• The intravenous-admixture service can serve as a base for
other pharmacy services such as chemotherapy
compounding, allergy extract preparation and parenteral
home-care programs.
 Intravenous
Additive Program
and
Preparation Of IV
Additive Solutions
 Intravenous Additive Program
◼ Consist of policies and procedures for both the
preparation and administration of intravenous
fluids to which drugs are to be added under
aseptic conditions, on an around-the-clock basis,
and controlled as to location and person
preparing the product.
 IV Additive Service
◼ Refers only to the preparation of the product by
individuals who may not necessarily be the same
as those who will administer them and assume
the responsibility for the monitoring of its
clinical effects.
Through the implementation of
an IV service, the hospital
pharmacist expected to achieve
the ff. objectives:
A. that the preparation of the final
product be accomplished under
aseptic conditions.
B. that drug interactions be avoided
through the judicious choice of
additive and mixing techniques; and
C. that the final product is
appropriately labeled, dispensed and
stored.
◼ The preparation of IV solutions with their additives was
a task performed on the nursing floor by nurses or
interns and residents.

◼ The preparation of these products requires the skills of

the pharmacist has raised many other questions not the
least of which is availability of the product at the odd
hours particularly if the site of the preparation is moved
to main pharmacy. Thus, has evolved the satellite
pharmacy, staffed by a clinical pharmacist and the
pharmacy technicians.
Preparation of IV additive Solutions
◼ In the preparation of these solutions, the
pharmacist should work the physician’s original
order sheet or from a direct copy.
◼ Upon receipt of the order, a pressure-sensitive
label must be prepared which provides the ff.
information:
A. patient identification
B. patient location
C. physician’s name
D. name of drugs with quantities added
E. date of compounding
F. expiration date
G. identification of the pharmacist preparing the
product
◼ When applying the label to the container, it must be positioned
in an upside down position in order to facilitate reading when
the container is hung from an intravenous solution pole on the
patient’s bed.
◼ Preparation of the solution should always take place
under a laminar flow hood using sterile needles and
syringes or double ended transfer needles.

◼ Once the transfer is made, the metal disc must be

replaced and a new seal crimped on to container. A
safety device, a different colored seal should be used in
view of the fact that warns individuals that drugs have
been added.
Before permitting the admixture to leave his
control, the pharmacist must carry out a final
inspection of the product. The inspection
should include a review of the label, clarity of
the solution and the mathematics involved in the
preparation.
INTRAVENOUS ADMIXTURE
PREPARATIONS & TOTAL
PARENTERAL
NUTRITION/HYPER-
ALIMENTATION
Flow chart for IV admixture preparation
❖ Writesadmixture order& includes IV fluids
wanted, additives & their concentration, rate
of flow, starting time and length of therapy.
❖ Theorder is checked for proper dosage,
incomplatibility, drugs allergies, and stability.
❖ Label (contains bottle no.,patient’s name&room
no., date prepared& exp. Date, IV & additives w/
amounts, total time for infusion, ml/hr & gtts/min,
and space for name of nurse who hangs the
container are included).

❖ and profile worksheet

❖ In handling sterile products, aseptic
techniques involved must maintain the
characteristics & integrity of product. Additive
caps are affixed before delivery to floor/
wards.
❖ Label is checked w/ original order.
❖ Empty containers are checked to confirm the
additives. It is also checked for color changes,
or particular matter..
❖ Completed admixture may be delivered by a
messenger or by the pharmacist on a
centralized unit.
❖ STAT orders are usually picked-up by the
nursing staff.
❖ If the admixture is not to be infused
immediately, (w/in 1 hour) storage under
refrigeration is requires; if refrigerated, it
must be used w/in 24 hours.
❖ The nurse checks for the correctness of the
patient’s:
▪ Name
▪ Drugs & concentration + solution
▪ Expiration date
▪ Time started
▪ And clarity

*infusion of admixtures can run ahead

of or behind schedule, necessitating the pharmacist
to modify the preparation of continued orders.
1.Strict asepsis must be used in inserting and
maintaining catheters.
2.Withdrawal of blood or direct administration
of medication of medication through the
infusion catheter is discouraged.
3. Patient should be weighed daily for strict
intake and output measurement.
4. Appropriate hemoglobin and hematocrit
levels should be maintained at appropriate
intervals.
 5. Laboratory studies of the following must be
done:
a. Urine test for sugar four (4) times a day.
b. Electrolytes checked twice a week.
c. Blood sugar twice a week.
d. Blood cultures as indicated.
e. Blood Urea Nitrogen (BUN) and Complete
Blood Count (CBC) once a week.
f. Occasional urine and serum osmolality, as
indicated
 Is the intravenous administration of calories,
nitrogen, and other nutrients in sufficient
quantities to achieve tissue synthesis and
anabolism.
 The term hyper- alimentation was originally
used to describe the procedure, but it is now
replaced by TPN, the term being more
descriptive of the technique.
 The normal calorie requirement for an adult
is approximately 2,500 calories per day.

 If these provide totally by Dextrose Injection,

five percent (5%), approximately 15 liters
would be required.

 Each liter contains 50 grams dextrose, which

equivalent to 170 calories.

 However , it is only possible to administer

three or four liters per day without causing
fluid overload.
 Fluid for TPN may be administered through
the subclavian vein the superior vena cava
where the solution is rapidly diluted by the
large volume of blood available.

 This technique developed minimizes the

hypertonicity of the solution.

 For administration of the TPN fluids, a

catheter is inserted and retained in the place
in the subclavian vein.
◦ TPN is indicated in patients who are unable to
ingest food due into carcinoma or extensive burns;
patients who refuse to eat, as in the case of
depressed geriatrics or young patients sufferings
from anorexia nervosa; and surgical patients who
should not be fed orally
 Carbohydrate dextrose is preferred source for
calories in TPN.
 Although fat emulsions and alcohol are
caloric source, they are not used in TPN fluids
 Commercially available preparation of the
TPN solution:
 Fifty percent 50% of dextrose injection is
provided.
 For dilution with protein hydrolysate or amino
acid injection- the resulting concentration is
approximately 25%.
1. Protein hydolysate- obtained from casein or
fibrin and contain polypeptide which must
be broken down before they can utilized.
 Advantage over crystalline amino acid is
available at lower cost
 Disadvantage, contain higher amounts of
ammonia and free chloride.
 For optimum utilization of amino acids for
promoting tissue regeneration, the nitrogen-
to calorie ratio should be 1:150.

 Calories are needed to provide energy for

metabolism of nitrogen.
 Contains all essential and nonessential amino
acids in the L-form.
 More expensive than protein hydrolysate but
contain lesser ammonia and free chloride.
 Electrolyte requirements varies for every
individual patient.
 Present in protein hydrolysate injection or
amino acid injection are given on the label
and must be taken into consideration when
determining the quantities to be added.
Electrolyte Normal range
Sodium 100-200 mEq
Potassium 80-120 mEq
Magnesium 8-16 mEq
Calcium 5-10 mEq
Chloride 100-200 mEq
Phosphate 40-60 mEq
 It is better to keep a 1:1 ratio between
sodium and chloride ions.
 In adding potassium, the acetate salt is
preferred over the chloride type.
 If the combination of calcium and phosphate
ions exceeds 20 mEq, precipitation occurs
 In the addition to the electrolytes, the daily
requirements for both water-soluble and fat
soluble vitamins may be added, usually in the
form of a multivitamin infusion concentrate.
 Iron
 Folic acid
 Vitamin B12
should be administered separately from
the TPN fluids.
 Zinc
 Copper
 Manganese
 Iodide
are a concern only in long term cases and
can be added when required.
  TypicalIV Order
(Parenteral Prescription)
 Sodium chloride injection (normal
saline solution) 1000 ml, is to be
administered at the flow-rate of
125 ml per hour. It will require
approximately eight hours.
 Continuous Infusions

- More effective and less toxic than when given

intermittently.

- Includes:
1. Basic fluid and electrolyte therapy
2. Blood products
3. Specific drugs that require tight administration
control to minimize adverse effects
 Intermittent Injections

- Used to administer medications that work better when

infused at defined time intervals rather than when
infused continuously.

- Examples of drugs commonly given intermittently are:

1. antibiotics
2. drugs used to treat or prevent gastrointestinal
ulcers
- Types of systems for intermittent injections:
1. Large Volume Parenterals (PVC)
a. Usually defined as those IV solutions containing
more than 100 mL
b. Usually infused as solutions of dilute dextrose
and/or sodium chloride as continuous infusions
with or without additives, but they can be used
for intermittent infusions as well.

- Commercially Available
1. Preparations with additives are used in standard
concentrations, are stable in solution for long periods of
time.
2. Available in a variety of sizes and containers
3. Ready-to-use products are advantageous because they reduce
handling by the pharmacy, - the potential for contamination.
 Small Volume Parenterals (“Piggyback” Systems)
1. Common method for drug additives to a small
volume parenteral or piggyback (< 100 mL)
 Definition:
- Total parenteral nutrition (also known as hyperalimentation,
hyperal or TPN) is the IV administration of nutrients needed
to sustain life: carbohydrates, protein, fats, water,
electrolytes, vitamins, and trace elements.

- Usually initiated in patients who cannot meet their

nutritional needs from other sources for an extended period
of time.

- TPN is used for patients who cannot eat (e.g. head & neck surgery,
comatose, or before or after surgery), who will not eat (e.g.
patients with esophageal obstruction or inflammatory bowel
disease or who cannot eat enough (e.g. patients with cancer,
burns or trauma).
 Contain base components and additives
- Base components are usually mixed first and make up
much of the volume of the TPN. Composed of dextrose
(carbohydrates) and amino acids (protein) and may
include fat and water.

- Additives are usually mixed with the base components and

include life-sustaining nutrients, electrolytes, vitamins,
trace elements as well as heparin, insulin and H2
antagonists.
 Carbohydrates – usually administered in the form of
dextrose because of its low cost and easy availability.
Usually a 50 – 70% solution is used in TPN preparation,
and the final dextrose concentration in the TPN is usually
around 25% for solutions administered via central vein.

 Protein – required for tissue synthesis and repair, transport

of body nutrients and waste, and maintenance of immune
function. These solutions are available in concentrated
form, such as 8.5 – 10% and diluted in the compounding
process.
 Fats – (lipids) are usually administered as fat emulsions.
Administered as a source of calories. Available as 10 to
20% emulsions dispensed in a separate container given
through a peripheral IV line. Fats can be added to the TPN
solution (3-in-1 solution or total nutrient admixture).
Considered a third base component along with dextrose
and amino acids.

 Water – in all preparations and is usually derived from the

components used in the preparation. The purpose of adding
water is to offset normal bodily losses and prevent
dehydration.
 Electrolytes – needed to meet daily metabolic needs and
correct deficiencies. Usually include sodium, potassium,
chloride, acetate, phosphate, magnesium, and calcium.

 Vitamins – usually administered in a standard formulation o

fat and water-soluble vitamins and are often abbreviated as
“MVI.” When vitamin K (phytonadione) is needed it is
usually given separately as an IM injection.

 Trace elements – required for proper enzymatic reations

and for use of energy sources in the body. Typical elements
administered are copper, zinc. Chromium, manganese,
selenium and iron.
 The proper order of mixing is:

- add the fats first (adding concentrated dextrose may “oil

out” or crack the emulsion)
- the amino acid second
- the dextrose last
- remember the acronym “FAD” fats, amino acids, dextrose
- this mixing order dilutes and buffers the fat emulsion with
amino acids before the highly concentrated and acidic
dextrose is added.
 Most TPN solutions are made for administration
through a central line.

 This route is used because it results in immediate

dilution of the solution being administered and
therefore a very concentrated solution can be
administered.
 Administering a concentrated solution often
allows the medical team to completely meet an
adult patient’s daily nutritional needs with 2000
to 3000 mL of TPN solution.

 Occasionally, TPNs are administered through a

peripheral IV line – can contain same ingredient,
but diluted to a lower osmolarity. Since the
solution is more dilute, they do not meet al the
patient’s nutritional needs. May need
supplements for caloric intake.
 Standardization of doses is not as common in pediatric
patients as it is in adults.

 Their doses are usually calculated based on their body

weight, resulting in much smaller dose than most adults
receive.

 The volume of solution also is limited since their blood

volume is considerably less than that of an adult.

 Intermittent doses are usually given by syringe through a

volume control chamber or by using a syringe pump.
 The ASHP technical assistance bulletin describes three
different levels of risk for products.

 Products are classified into one of the three risk levels

based on:

- How they are prepared

- How long they can be stored
- Whether they are prepared for a single patient or as part
of a batch, whether they are from a sterile or non-sterile
source.
 Risk Level 1
- Sterile products w/o preservatives for individual patients
or batch prepared with preservatives for multiple
patients.

- These are sterile products transferred into a sterile

container (e.g. syringe, IV bag or bottle).

- Storage time for these products, including administration

time, should not exceed 28 hours at room temperature,
7 days under refrigeration, or 30 days if frozen.
 Risk Level II
- These products are batch-prepared w/o preservatives for
multiple patients.

- These include products that require multiple sterile ingredients

that are combined in a sterile container through a closed system
transfer that are then subdivided into multiple parts.

- Storage time for these products, including administration time,

can exceed 28 hours at room temperature, 7 days under
refrigeration, or 30 day frozen.
 Risk Level III
- These products are compounded from nonsterile
ingredients, containers or equipment or prepared from
sterile or nonsterile ingredients in an open system.

 The pharmacist is likely to be responsible for ensuring

compliance with the guidelines and other standards of
practice.

 Areas of the document that affect the technician include

training, policies and procedures, garb, aseptic technique,
process validation, and end-product evaluation.
 Means procedures that ensure that the processes used in
sterile product preparation consistently result in sterile
products of acceptable quality.

 For most aseptic processes, validation is actually a method

for evaluating the aseptic technique of personnel.

 Validation may be accomplished through process

simulation.

 Process simulation is carried out just like a normal sterile

product preparation process except that a microbial growth
medium is substituted fro the products that would normally
be used.
 Once the sterile product is prepared, the growth medium is
incubated and evaluated for microbial growth over a period
of time.

 No microbial growth indicates that the person performing

the preparation did not contaminated the product.

 Individuals should complete a process validation program

before being allowed to prepare sterile products, and
technique should be re-evaluated regularly.
 End-product evaluation is the final inspection made by the
pharmacist before the product is allowed to leave the
pharmacy.

 It includes an inspection for leaks, cloudiness, particulate

matter, color, solution volume, and container integrity.

 The pharmacist also verifies compounding accuracy with

respect to the correct ingredients and quantities.

 This check of the technician’s work is an important step in

ensuring that only quality products are sent for patient use.
Introduction to Clinical
Pharmacy
 To identify the roles or functions of a
Clinical Pharmacist
 To discuss the importance of Clinical
Pharmacy

Objectives:
 “Patient Oriented”
 The American College of Clinical Pharmacy
(ACCP) defines clinical pharmacy as an
area of pharmacy concerned with the
science and practice of rational medication
use.

Clinical Pharmacy
 Clinical pharmacy is a health science
discipline in which pharmacists provide
patient care that optimizes medication
therapy and promotes health, and disease
prevention.

Clinical Pharmacy
 The practice of clinical pharmacy
embraces the philosophy of
pharmaceutical care, blending a caring
orientation with specialized therapeutic
knowledge, experience, and judgment to
ensure optimal patient outcomes.
 As a discipline, clinical pharmacy also has
an obligation to contribute to the
generation of new knowledge that
advances health and quality of life.

Clinical Pharmacy
 Work directly with physicians, other health
professionals, and patients to ensure that the
medications prescribed for patients
contribute to the best possible health
outcomes.
 Clinical pharmacists practice in health care
settings where they have frequent and
regular interactions with physicians and other
health professionals, contributing to better
coordination of care.

Clinical Pharmacy
 Clinical Problem Solving, Judgment, and
Decision Making
 Communication and Education
 Medical Information Evaluation and
Management
 Management of Patient Populations
 Therapeutic Knowledge

Competencies of a Clinical Ph
 Assess the status of the patient’s health problems and
determine whether the prescribed medications are
optimally meeting the patient’s needs and goals of
care.

 Evaluate the appropriateness and effectiveness of the

patient’s medications.

 Recognize untreated health problems that could be

improved or resolved with appropriate medication
therapy.

 Follow the patient’s progress to determine the effects

of the patient’s medications on his or her health.

Roles of Clinical Ph
 Consult with the patient’s physicians and other health
care providers in selecting the medication therapy that
best meets the patient’s needs and contributes
effectively to the overall therapy goals.

 Advise the patient on how to best take his or her

medications.

 Support the health care team’s efforts to educate the

patient on other important steps to improve or maintain
health, such as exercise, diet, and preventive steps like
immunization.

 Refer the patient to his or her physician or other health

professionals to address specific health, wellness, or
social services concerns as they arise.

Roles of Clinical Ph
 Provide a consistent process of patient
care that ensures the appropriateness,
effectiveness, and safety of the patient’s
medication use.

 Consult with the patient’s physicians and

other health care providers to develop
and implement a medication plan that can
meet the overall goals of patient care
established by the health care team.

Clinical Pharmacy Services

 Apply specialized knowledge of the
scientific and clinical use of medications,
including medication action, dosing,
adverse effects, and drug interactions, in
performing their patient care activities in
collaboration with other members of the
health care team.

Clinical Pharmacy Services

 Call on their clinical experience to solve
health problems through the rational use
of medications.

 Rely on their professional relationships

with patients to tailor their advice to best
meet individual patient needs and desires.

Clinical Pharmacy Services

Hospital Codes
 OBJECTIVES:

 To identify different hospital codes in the Philippines

 To discuss conditions on activating different
emergency codes.
 To discuss the importance of emergency codes.
 To review the drugs found in emergency cart.
 Hospital emergency and disaster codes are codes,
usually using colors, being used in hospitals
worldwide to convey essential information quickly
to staff during times of potential and actual
emergencies and disasters.
 Prevent stress or panic among patients and visitors
in the hospitals during response to actual
emergencies and disasters.
 What are the uses of hospital emergency
and disaster codes?

1. to convey need to be alert or ready

2. to convey type of emergency or disaster occurring
in the hospital that needs a corresponding
response.
 In the Philippines, for the hospitals under the
Department of Health (DOH), because of the
Administrative Orders 182 s 2001 and 2008 – 0024,
there is a standardized code alert system which
consists of Code White, Code Blue, and Code Red.
 Importance:

 There is really a need to standardize the emergency

and disaster codes being used in government and
private hospitals in the Philippines to facilitate
collaborative networking and responses during
emergencies and disasters in the country and in a
specific community.
How are hospital emergency and disaster
codes classified?

 Hospital emergency and disaster codes can be

classified into
❑ alert codes
❑ response codes
 Hospital alert codes

 are mainly used in anticipation of surge of patients

from an emergency or disaster occurring outside the
hospital.

 they can also be used for anticipated emergencies

and disasters involving the hospital itself, such as
when there is a forecast typhoon.
 Response codes

 mainly used in response to emergencies and

disasters occurring within the hospital such as fire,
earthquake, flood, and sudden cardiopulmonary
arrest of patients, staff, and guests.

 they can also be used in response to external.

emergencies and disasters.
 The recommendation is for all hospitals to adopt the
alert codes being used by DOH hospitals, as long as
the word “Alert” is incorporated in the code, like so,
Code White Alert, Code Blue Alert, and Code Red
Alert.
 Color codes without the word “Alert” being used in
hospitals shall be considered as response codes.
 Response codes can make use of colors also.
 If there are two similar colors being used in the alert
and response codes, the presence of “Alert” makes
for the distinction.
 Example

 Code Red is a response code in cases of fire in the

hospital. Code Red Alert is an alert code for more
manpower and supplies in preparation for an
anticipated extensive surge of patients.

 Code Blue is a response code in case of sudden

cardiopulmonary arrest in the hospital.
 What are the DOH alert codes and the codes
that are being recommended for all hospitals,
both government and private, to adopt for
alignment purposes?

 Color White Alert

 Code Blue Alert
 Code Red Alert
 Conditions in which Code WHITE Alert
can be adopted:

 Strong possibility of a military operation within the

area/region, e.g., coup attempt
 Any planned mass action or demonstration within the
catchment area
 Forecast typhoons (Signal No. 2 up) the path of which will
affect the area
 National or local elections and other political exercises
 National events, holidays, or celebrations in the area with
potential for mass casualty incidents
 Any emergency with potential 10-50 casualties (deaths,
injuries)
 Any other hazard that may result in emergency
 Unconfirmed report of reemerging diseases, e.g., bird fl u,
SARS
Conditions in which Code BLUE Alert can
be adopted:
 When 20-50 casualties (red tags) are suddenly brought
to the hospital.
 Any internal emergency/ disaster in the hospital which
brings down their operating capacity (i.e., vital areas) to
50% or which would require evacuation of patients and
setting up of a Field Hospital.
 For conditions other than mass casualty incidents, the
influx of patients is beyond the capacity of the hospital to
handle.
 Confirmed/documented report of reemerging diseases
(SARS, human to human avian flu) within the catchment
area.
Conditions in which Code RED Alert can
be adopted:

 When more than 50 (red tag) casualties are suddenly

brought to the hospital.
 An emergency wherein the services of the hospital is
paralyzed since 50% of the manpower are themselves
victims of the disaster.
 Hospital is structurally damaged requiring
evacuation and/or transfer of patients.
 Conditions requiring mandatory quarantine of
hospital and its personnel (e.g.,SARS, avian fl u);
uncontrolled human to human transmission of
SARS/avian flu within the catchment area.
 What are the general sequential steps in the
activation and deactivation of alert codes?

 Monitoring of news of potential emergency and

disaster that may create a surge of patient incident or
event in the hospital.
 Assessment of the potential incident or event with a
determination on what alert code to activate.
 Securing of permission for activation of an alert code
from the Hospital Director by the Hospital Disaster
Control Director.
 Activation of an alert code approved by the Hospital
Director to be implemented through the Hospital
Disaster Control Director.
 Surveillance for occurrence of actual emergency and
disaster with corresponding response.
 Maintenance of readiness of out-of-hospital stand-by
staff such that they proceed promptly to the
hospital when needed.
 Securing of permission for deactivation of an alert
code from the Hospital Director by the Hospital
Disaster Control Director.
 Deactivation of an alert code approved by the
Hospital Director to be implemented through the
Hospital Disaster Control Director.
Drugs in Emergency Cart