DIPLOMA IN PHARMACY

ASSIGNMENTS PHFB 4112

PHARMACY SERVICES IN HOSPITAL &

COMMUNITY PHARMACY

COHORT 43

NAME: SHARMILA A/P RAVICHANDRAN

MATRIX NUMBER: 2042222020
LECTURER: PN. HJH HAZIAN HJ. MOHD NOR

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Table of contents

BIL CONTENTS PAGE

1 Introduction of pharmacy services in Hospital 3-4

2 In patient Pharmacy 5
Sample Picture 6

3 Out patient Pharmacy 7-8

Sample Picture 8

4 Cytotoxic Drug Reconstitute Unit 9

Sample Picture 10

5 TPN (Total Parenteral Nutrition) Unit 11

Sample Picture 12

6 Ward Supply/ Pharmacy satellite Unit 13

Sample Picture 14

7 Others (TDM, Tele info… 15

Sample Picture 16

8 Community Pharmacy Services 17- 18

Sample Picture 19

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Conclusion 20

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References 21

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Introduction of pharmacy services in hospital
The pharmacy profession comprising the industry and practice sectors is undergoing
a rapid change. While Indian Pharma industry has registered a spectacular progress ranking
3rd in volume and 13th in value in the global pharmaceutical market, the visibility and
recognition of pharmacists in health sector has still a long way to go. The pharmacist in
healthcare sector has to evolve from a mere dispenser of medicines to a more crucial role in
medicine management and as overall health care programmer. While community pharmacy is
largely dominated by mere dispensing of medicines without paying any attention to “patient
information while dispensing”, the hospital pharmacy offers an emerging opportunity for the
pharmacists to demonstrate their capabilities in view of the proliferation of corporate
hospitals along with private hospitals aspiring for accreditation from National Accreditation
Board for Hospitals & Healthcare (NABH) or JSI and by many accreditation boards in other
countries. Among many stipulated requirements for the accreditation, medication
management through a functional Drug and Therapeutics Committee (DTC) which is also
referred to as Pharmacy & Therapeutics Committee (PTC), can provide an effective structure
and tool to bring together all the relevant people to work jointly for promoting more efficient
and rational use of medicines. Besides, playing a pivotal under the functioning of DTCs,
pharmacists can also provide relevant “patient information” related to medicines being
dispensed in the hospitals as a service. This would definitely lead to his recognition by the
society as “competent health professional”.

Pharmaceuticals/medicines have always remained and would continue to remain as

core in the healthcare. It constitute second highest item of expenditure after the manpower in
any given health facility/hospital. Medicines save lives and improve quality of life, but can be
dangerous with adverse drug reactions (ADR) and medication errors which would be
expensive. Medicines have often been misused and abused. Irrational use of medicines is
prevalent at all levels of health care leading to wastage of scarce resources as well as reduced
medication safety in patients. Emergence of antimicrobial resistance continues to pose a
global problem in handling the management of infections. Common drug related problems
encountered in most hospitals are selection of medicines is not evidence based, quantification
of demand of medicines is not scientific, supply is not regular, standard Treatment

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Guidelines (STGs) are not developed or used, over enthusiasm in using newer & expensive
medicines, rampant use of combination product, over use of antimicrobials and no system for
monitoring use of medicines.

Majority of hospitals do not have system /committee to tackle these problems.

Pharmaceutical management in hospitals can be one of the most cost effective measures for
appropriate use of scarce health care resources. Medication safety in patients can be best
ensured if rational and appropriate uses of medicines are practiced. The efficacy and
therapeutic benefits of medicines is often not grasped during the treatment which happens
due to problems with medicine selection and dosages, improper administration of medicines
and lack of adherence by patients to prescribed treatment, medicine–medicine and medicine–
food interactions, and adverse medicine events. To reduce these healthcare burdens, the
following pharmaceutical services in hospitals can contribute towards health improvement
and to help patients:

• Formulary management

• Quality assurance of medicines

• Medicines safety & Pharmacovigilance

• Preventing, identifying, and resolving medication errors

• Patient education and counseling

• Prescription audit

• Monitoring medicines use

• Supply Chain Management of Pharmaceuticals including

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In patient Pharmacy

Pharmaceutical care is an area in the health care system which has yet to be fully
developed in Malaysia although it has generated tremendous impact worldwide. Since its
inception in the 1990's, Malaysian pharmacists have embarked on a bold and dramatic leap
forward to embrace its philosophy in all areas of pharmaceutical care services. Much effort
has been put into exploring ways in which to instil and initiate pharmaceutical care activities
in both the outpatient and inpatient settings.

Ward pharmacy activities encompass issues on all aspects of pharmacotherapy.

During ward rounds, input pertaining to appropriateness of therapy, counselling of patients on
medication therapy and the monitoring of unwanted side effects are the major services
provided. Often time, the input given is not documented. Thus, a mechanism to document
these activities is crucial and urgently required.

The pharmaceutical needs of a patient refer to his or her requirements for

pharmaceutical products or services. Pharmaceutical needs may be identified by any member
of the health care team or by the patient him/herself. Once a targeted patient group has been
assigned to the responsibility of a clinical pharmacist, a function of the delivery of the service
is to prioritise the individual patient in the group according to his/her potential
pharmaceutical care issues (PCI).

It is important to document the outcomes of the pharmaceutical care intervention for

the purpose of individual patient records as well as information for the management.

Information on issues such as drug availability, dosage form, procurement and

storage should be managed in liaison with colleagues in other units. Pharmacists require both
knowledge and clinical experience to be a useful member of the health care team. Therefore,
the clinical pharmacist serves as a liaison person between patients, doctors, nurses and fellow
pharmacists.

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Diagram shows the Inpatient pharmacy services in hospital

Diagram shows the the Inpatient Resident Service

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Outpatient pharmacy
An outpatient pharmacy is a pharmacy which fills prescriptions for patients affiliated
with the pharmacy's parent medical institution, typically a hospital or clinic. Usually, these
facilities will only fill prescriptions related to medical treatment at the parent facility or one
of its outpatient clinics, by contrast with a more conventional pharmacy, which fills
prescriptions for anyone. Hospitals usually offer outpatient pharmacy services as a
convenience to their patients, and sometimes to staff as well.

The rules about who may get prescriptions filled at an outpatient pharmacy vary,
depending on the pharmacy's policies. Usually, people who are hospitalized may fill their
prescriptions there, along with people who have just been discharged with prescriptions
which need to be filled. In addition, the pharmacy handles prescriptions from people
in outpatient therapy, and many also fill prescriptions for the staff of the hospital.

As with other types of pharmacies, an outpatient pharmacy can usually handle written
prescriptions as well as prescriptions which are phoned in. Due to the need to compound
complex drugs in a hospital facility, these pharmacies may also be able to offer specialty
drugs and preparations to their patients, rather than having to special-order them.

There are several advantages for patients who use an outpatient pharmacy as opposed
to a regular pharmacy. The first is that the pharmacy is on the same site where they receive
medical treatment, so they do not need to make an extra trip to the pharmacy to pick up
prescriptions. The second is that the pharmacy staff is usually very knowledgeable about the
patient's condition, and the staff can quickly catch potential drug conflicts and other issues
which may arise. The pharmacy may also offer discounts on prescriptions.

Hospital staffs may also take advantage of outpatient pharmacy services, picking up
the prescriptions they need at work. Pharmacy services may also be a part of employee
benefits, with employees receiving prescriptions at reduced cost as part of their health plans.
Employees who choose to fill prescriptions elsewhere may certainly do so, but they may be
obliged to pay full cost for the drugs.

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In addition to an outpatient pharmacy, some hospitals also have an inpatient pharmacy, which
specifically fills prescriptions for people who are hospitalized. The inpatient pharmacy is
often in a different area of the hospital than the outpatient one, and it may only be open to
authorized personnel, with doctors and nurses picking up prescriptions for their patients. This
pharmacy also synchronizes its records with the outpatient pharmacy to ensure that the
patient's data is always up to date.

Diagram shows the outpatient pharmacy services in hospital

Diagram shows the outpatient pharmacy services in hospital 8

Cytotoxic Drug Reconstitute Unit

This unit was established in January 2000 to prepare safe and sterile chemotherapy
drugs for patients. Now, this unit has become the cytotoxic reconstitution center for
Daycare Hematology, Oncology, and Pediatrics Hematology /Oncology in HCTM. The
services includes patient review including body weight, height, allergy status, pre- and
post- medications history, and lab result monitoring for optimum dose of medication,
answering specific questions regarding cytotoxic drugs, collaborations with medical
specialists in developing trial protocols, providing patient counselling regarding
medication regimen and possible side effects, providing basic training and knowledge
to final year students attachment, organizing training programmes for local and
international trainee and annual audit for Cytotoxic Drug Reconstitutions in HCTM.

Pharmaceutical Services Division, Ministry of Health has developed the policy for CDR
service which is intended to safeguard patients and staff by defining standards of CDR practice
from pharmacists perspective. It is worth noting that all the local policies involving prescribing,
handling, and administering the cytotoxic drugs must be developed by a multi-professional
team and complies with the scope of the service:

1. The pharmacy department of the hospital will operate the CDR service providing
customised chemotherapy regimen suits to every patient's needs.

2. Preparation, reconstitution, administration and disposal of hazardous drugs should be

performed by trained personnel to protect the handler, the drug and the environment.

3. The reconstitution should take place in the pharmacy aseptic unit (qualified clean room).

4. However for those hospitals without the CDR facility on site, preparation may be outsourced

to any nearby hospitals with qualified clean rooms or option for the closed-system-drug-
transfer device.

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Diagram shows the Cytotoxic Drug Reconstitute

Diagram shows the Cytotoxic Drug preparation

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TPN (total parenteral nutrition) unit

Total parenteral nutrition (TPN), also known as parenteral nutrition (PN) is a form
of nutritional support given completely via the bloodstream, intravenously with an IV pump.
TPN administers proteins, carbohydrates, fats, vitamins, and minerals. It aims to prevent and
restore nutritional deficits, allowing bowel rest while supplying adequate caloric intake and
essential nutrients, and removing antigenic mucosal stimuli.

TPN may be short-term or long-term nutritional therapy, and may be administered

on acute medical floors as well as in critical care areas. The caloric requirements of each
patient are individualized according to the degree of stress, organ failure, and percentage of
ideal body weight. TPN is used with patients who cannot orally ingest or digest nutrition.
TPN may be administered as peripheral parenteral nutrition (PPN) or via a central line,
depending on the components and osmolality. Central veins are usually the veins of choice
because there is less risk of thrombophlebitis and vessel damage.

TPN is made up of two components such as amino acid/dextrose solution and a

lipid emulsion solution. It is ordered by a physician, in consultation with a dietitian,
depending on the patient’s metabolic needs, clinical history, and blood work. The amino
acid/dextrose solution is usually in a large volume bag (1,000 to 2,000 ml), and can be
standard or custom-made. It is often yellow in colour due to the multivitamins it contains.
The ingredients listed on the bag must be confirmed by the health care provider hanging the
IV bag. The solution may also include medication, such as insulin and heparin. The amino
acid/dextrose solution is reviewed and adjusted each day based on the patient’s blood work.
Lipid emulsions are prepared in 100 to 250 ml bags or glass bottles and contain the essential
fatty acids that are milky in appearance. At times, the lipid emulsion may be added to the
amino acid/dextrose solution. It is then called 3 in 1 or total nutrition admixture.

TPN is prepared by a pharmacy, where the calories are calculated using a formula,
and is usually mixed for a 24-hour continuous infusion to prevent vascular trauma and
metabolic instability (North York Hospital, 2013). TPN orders should be reviewed each day,
so that changes in electrolytes or the acid-base balance can be addressed appropriately
without wasting costly TPN solutions.

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Diagram shows the total parenteral nutrition high resolution stock

Diagram shows the Intravenous Feeding

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Ward Supply/ Pharmacy satellite Unit

The in-patient pharmacy supplies drugs to patients in the wards and specialised units / clinics
in Hospital. The in-patient Pharmacy has its own store which is easily accessible and
spacious enough to hold adequate stocks of drugs. This unit is divided into two sections
namely Ward Supply Pharmacy and Satellite Pharmacy. These two sections use two different
supply systems known as 'traditional' system (as practised in the Ward Supply Pharmacy) and
'unit of use' system (as practised in the Satellite Pharmacy). In Hospital, the Ward Supply
Pharmacy section supplies intravenous solutions and disinfectants directly to all the wards
and clinics. This section also supplying medicine to the wards / units based on the requests in
the indent books.

The Satellite Pharmacy is a special unit located near the wards and practises 'unit of use'
supply system. Under this system, the supply of medicines is based on the needs of the
individual patient which is requested using patient drug profiles. Medicines for each patient
are kept in individual drawers and transported to the wards by means of a medication trolley.
Medicine is supplied for individual patient for a fixed period of time. The supply of
medicines will be faster and more efficient. Any query on prescription or any information
about the medication will be easily conveyed to the ward staff by the Pharmacy staff.
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Diagram shows the Ward Supply Pharmacy

Diagram shows the Pharmacy Satellite Unit

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Therapeutic drug monitoring (TDM)

Therapeutic drug monitoring (TDM) refers to the clinical practice of measuring drugs and/or
metabolites in blood or serum/plasma at a specific time point to determine if a patient’s drug
concentrations are within the therapeutic range and confirm concentrations are neither
subtherapeutic nor potentially toxic. The purpose of TDM is to optimize dosing to target a
therapeutic plasma drug concentration while minimizing toxicity. TDM is often influenced by
pharmacogenetics (PGx) factors. Refer to the ARUP Consult Germline Pharmacogenetics
PGx topic for detailed information about PGx testing and recommendations.

The purpose of TDM is effective drug treatment is dependent on patient adherence

compliance to prescribed medications. Drug treatment and dosage should be personalized for
each patient due to interindividual variability in response to therapy. Therapeutic drug
monitoring (TDM) allows for personalization of drug selection and dose, evaluation of
adherence, and investigation of changes in pharmacokinetics (eg, drug-drug interactions). In
many cases, germline pharmacogenetics (PGx) testing can inform TDM testing.Therapeutic
drug monitoring (TDM) should be performed when the patient has achieved steady-state
concentration, has changed drug therapy, or has had a change in response to treatment.

Whole blood, serum, and plasma specimens can be used to assess whether the drug dosage
achieved the targeted therapeutic range and to evaluate patient adherence. Urine drug and
metabolite concentrations do not correlate with signs and symptoms of drug therapy or
toxicity and should not be used for therapeutic drug monitoring (TDM).

Test results should be interpreted relative to the established therapeutic range, dose-related
range, or toxic range (if applicable); timing of specimen collection; specimen type; and the
patient’s clinical response to treatment. Results can be affected by several variables. Incorrect
timing of specimen collection relative to the therapeutic range can be misleading. Response
to drug therapy is also influenced by the patient’s pharmacogenetics (PGx), examples,
whether they demonstrate normal, rapid, or poor drug metabolism; physical conditions such
as pregnancy, comorbidities; and drug-drug or food-drug interactions that could lead to an
increase, decrease, or inhibited response to therapy.
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Diagram shows the Therapeutic drug monitoring (TDM)

Diagram shows the Fundamentals of Therapeutic Drug Monitoring

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Community Pharmacy Services

Community pharmacies, also known as retail pharmacies, play a critical role in the provision
of health services and function as a health centre which provides clinical interventions, drug
reviews, medical examinations, treatment of acute illnesses, lifestyle modification
counselling, and drug supply. Most of these facilities are located close to communities, have
extended opening hours, and are accessible to all. Community pharmacists in Malaysia are
involved in several regular health promotion activities such as weight-management, diabetes
counselling, as well as diet and physical activity counselling. Studies have shown that the
services provided by community pharmacies have led to better patient care and optimal
medical outcomes. Based on availability, access, convenience, and cost, some have suggested
that using community pharmacies to treat minor illnesses could help optimise health
resources and provide more healthcare options to the public. Public healthcare services are
often congested, and utilisation of community pharmacy for minor illnesses reduces the need
for medical care at the primary health clinics or hospitals.

In Malaysia, primary healthcare services are mainly provided by two sectors: the tax-funded
and government-run public primary healthcare sector and the non-subsidised, fee-for-service
private sector which includes the private clinics and community pharmacies. Traditional
healers, such as Chinese medicine practitioners, Indian ayurvedic healers and Malay
traditional healers also prescribe traditional medicine as part of their practice.

Roles of community pharmacists have evolved in many parts of the world, from dispensing
medicine to being healthcare professionals who are involved directly in patient care services.
Pharmacists have the ability to provide a comprehensive analysis of medication for patients,
recognise problems relevant to clinical treatment, as well as offer suggestions and alternatives
for drug administration and drug compatibility. However, the transition and evolution of the
pharmaceutical care practice towards a more dynamic role amongst the community pharmacy
in Malaysia were limited by the lack of dispensing separation policy in private primary
healthcare. In Malaysia, the 1952 Poison Act allows registered private general practitioners to
prescribe and dispense medication in their clinics.

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In order to improve the relevance of community pharmacies in Malaysia, extended basic

health services such as early detection of general health problems as well as health promotion
and health counselling services were provided, in addition to the supply of non-prescription
medications and health supplements.

Community pharmacies provide an alternative for the public to obtain medicines and get
access to basic, minor health related services, in addition to mainstream hospitals and primary
healthcare services in Malaysia. Previous study found that the general public in Malaysia
utilised community pharmacies to purchase a medication or health supplement and to seek
advice on minor health problems. However, national data on the prevalence of community
pharmacy utilisation among adults in Malaysia is currently unavailable and association
between community pharmacy utilisation and the demographic, socioeconomic and health
related characteristics of the population in Malaysia have not been explored from a national
perspective. Determining the prevalence and identifying the factors associated with
community pharmacy utilisation allows better planning of community pharmacy services
which may enhance the professional roles of community pharmacists in Malaysia.
Diagram shows the Community Pharmacists In Self-Care

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Diagram shows the community pharmacy services

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Conclusion
Overall, patient satisfaction is high across pharmacy services; however, this satisfaction is
related to prior patient exposure to services and their level of expectation. Pharmacists have
multiple opportunities to improve the services they provide, and there are additional services
pharmacists may consider offering to expand their role within the health care system.

Pharmacy services , the science and art concerned with the preparation and standardization
of drugs. Its scope includes the cultivation of plants that are used as drugs, the synthesis of
chemical compounds of medicinal value, and the analysis of medicinal agents. Pharmacists
are responsible for the preparation of the dosage forms of drugs, such as tablets, capsules, and
sterile solutions for injection. They compound physicians’, dentists’, and veterinarians’
prescriptions for drugs. The science that embraces knowledge of drugs with special reference
to the mechanism of their action in the treatment of disease is pharmacology.

We conclude that TDM is highly cost-avoidant. Furthermore, the implementation costs of

TDM by the pharmaceutical services are clearly lower than the benefit achieved. In future
studies, it will be important to measure the translation of this cost avoidance into direct
savings, use this methodology in other settings, and populate the probability matrix with real-
world evidence from local centers.

This study has identified the current barriers towards the transformation of community
pharmacy practice in Malaysia. Future actions including planning, developing and
implementing new policies are much needed.

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References:
1. https://www.pharmacy.gov.my/v2/sites/default/files/document-upload/guidelines-
inpatient-pharmacy-practice.pdf

2. https://www.thehealthboard.com/what-is-an-outpatient-pharmacy.htm

3. https://hctm.ukm.my/farmasi/cytotoxic-drug-reconstitution-cdr-
unit/#:~:text=This%20unit%20was%20established%20in,Pediatrics%20Hematology
%2FOncology%20in%20HCTM.

4. https://opentextbc.ca/clinicalskills/

5. Horvat N, Kos M. Slovenian pharmacy performance: A patient-centred approach to

patient satisfaction survey content development. Int J Clin Pharm. 2011;33:985–96

6. https://qehpharmacy.tripod.com/qehpharmacy6.html

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