HOSPITAL PHARMACY

QUALITY CONTROL

Pharmacy Manual

Presented by:

Rana Itani; Rph, Hospital Pharmacist- RHUH

Mona Baalbaki; Rph, Head of Pharmacy - RHUH
THE PURPOSE OF THE MANUAL

The pharmacy manual is designed to be a reference for all

Hospital staff in order to identify:

Pharmacy Policies & Operational

Procedures Responsibilities

&
Insure Safe and accurate medication ordering, preparation,
Departmental
distribution and control
Relationships
Relationships
 PHARMACY MANUAL

The Pharmacy Manual is reviewed

annually and whenever needed for any
kind of modification.
HOW TO DESIGN YOUR OWN PHARMACY
MANUAL?
 Pharmacy Manual Includes all the
following

●
Hospital Organization.
●
Pharmacy Department Functions.
●
Services provided.
●
Pharmacy Organization.
●
Human resources Functions.
●
Safety and occupational Hazards.
 HOSPITAL ORGANIZATION
FUNCTIONAL ORGANIZATION OF THE HOSPITAL

RHUH is a university hospital providing services for several

nursing units

ICU
PHARMACY CCU

Supportive Services: Blood bank, Radiology, Dietitians, Nursing…

Oncology Surgery
 HOSPITAL ORGANIZATION
ORGANIZATIONAL CHART OF HOSPITAL

Information
Technology
Material &
Purchasing
- Biomedical - Logistics
- Eng. & Maint. - HR
- Material Mngt Finance &
- Finance
Admin.

Management
Nursing
Pharmacy

Internal
audit
 HOSPITAL ORGANIZATION

• Pharmacy Map:
A-Reception
B&C offices for pharmacy staff
E-Purchasing office
D&F- Dispensing room
G- Compounding room
H- Pharmacy store
I- WC
J- Changing room
K- Library
L- Kitchen

Head of pharmacy office is located in

the ground floor.
PHARMACY DEPARTMENT FUNCTIONS

 PHARMACY MISSION.

 PHARMACY VISION.

 PHARMACY PHILOSOPHY.

 PHARMACY GOALS AND OBJECTIVES.

 CODE OF ETHICS.
SERVICES PROVIDED

Central IV Admixture Unit

 PHARMACY ORGANIZATION

Functional
Location &
Organization
Operating
PharmacyPersonnel
of the Hours
Extensions
pharmacy

ResponsibilityGeneral
& rules &
Job Description
duties Regulations
 PHARMACY ORGANIZATION
FUNCTIONAL ORGANIZATION OF THE PHARMACY

Head of Pharmacy

Acting Supervisor Oncology team Acting Supervisor

Purchasing Team
Pharmacists
Pharmacist Assistants
Pha rmacy Technicians

On co l o g y Ph a rm a c ists
Ass ista nt O P
Onco lo g y Tech nic ia n s
 PHARMACY ORGANIZATION
LOCATION AND PHARMACY EXTENSIONS

 The main pharmacy is located in the basement of the

hospital. It consists of the following areas:

Reception and Secretary  1190

Library  1198

Pharmacists Office  1192, 1193, 1194, 1195, 1197

Chemotherapy Preparation Unit  1937

Drug preparation/ Dispensing Area  1196

PHARMACY ORGANIZATION
OPERATING HOURS & PERSONNEL

Operating hours
8-7 during the week
8-4 on Saturdays
8-3 on Sundays

The pharmacy Staff should be sufficient to meet goals and

objective of RHUH hospital
 PHARMACY ORGANIZATION
AFTER PHARMACY OPENING HOURS

 Nursing Units  Emergency carriage & floor stock

(replenished daily).

 Pharmacist On-Call is available after closing hours.

 Nursing and medical staff is are informed by a memo of the

pharmacist on-call during pharmacy closing hours.

 Pharmacy on call sheet should be filled including dispensed

medication and duration of dispensing.
PHARMACY ORGANIZATION
RESPONSIBILITIES & DUTIES

Head of
pharmacy

Pharmacist
Pharmacy
-Oncology
Secretary
Pharmacist

Pharmacy
Technician
Oncology
Technician
 PHARMACY ORGANIZATION
RESPONSIBILITIES & DUTIES

e.g. Head of Pharmacy

Specifying all duties assigned to the assistant of the head, supervisor

pharmacists, pharmacist, assistant pharmacist, technician, secretary.
PHARMACY ORGANIZATION
GENERAL RULES & REGULATIONS

●
Pharmacy Rooms should be clean at all times.
e.g.
●

●
● Offices should be organized especially before leaving.

●
Lab coats should be worn without exceptions.
e.g.
●

●
● The schedule work time should be requested.

●
● Work
Work hours
hours in
in holidays
holidays are
are rewarded
rewarded in
in a
a similar
similar manner
manner within
within aa
month.
e.g. ●
● Pharmacist on-call should be available after closing hours to provide
life-saving medications.
HUMAN RESOURCES FUNCTIONS

Performance
Appraisal

Studen
Orient t
ation Mento
rship

Continuing
Educations
HUMAN RESOURCES FUNCTIONS
ORIENTATION
 HUMAN RESOURCES FUNCTIONS
PERFORMANCE APPRAISAL

Regular evaluation of Annual competency

personnel validation plan

erformance appraisal is done

q 6 month & retraining is Anecdotal Report
done regularly.
HUMAN RESOURCES FUNCTIONS
In-service CONTINUING EDUCATION
Educatio
n
program

Interventio
ns &
monthly
Roundtable
s
Pharmaceutical
& Medical
lectures
Competency
tests & Quizzes
HUMAN RESOURCES FUNCTIONS
STUDENT/TRAINING MENTORSHIP

Students from
Approval all
form universities
university &
Head

Training
Application

Training Certificate
 SAFETY AND OCCUPATIONAL
HAZARDS

●
Drug Preparation:
●
Personal preparation Protective Equipments.
●
Preparation Area.
●
Preparation Equipments.
●
Work Practices in the preparation:
●
Handling vials.
●
Handling ampoules.
●
Waste Disposal.
●
Spills.
●
Medical. surveillance
 SAFETY AND OCCUPATIONAL
HAZARDS
Hazardous Drug Safety
Glass ware Safety
Use a dustpan and brush
to pick up broken glass.
Discard broken glass in a
rigid container separate
from regular garbage
(label).
Hazardous materials
include chemotherapeutic
agents, strong acids or
alkali, Corrosives,
flammable items, poisonous
items, human serum
derived drugs, Infectious
agents
SAFETY AND OCCUPATIONAL
HAZARDS
●
● No
Genera ●
● Minimiz Preven
e the
smoking l quantity
ting
,
running
Safety of Fire
or flamma
jumping ble
liquids
shall be
kept in
permitte
the
d.
pharmac
●
● Dressin
y.
g shall ●
● Keep
be in
flamma
accorda
ble
nce with
liquids
policy.
in
●
● Keep approve
exits d
and flamma
passage ble
s clear at liquid
all storage
times. cabinets.
 SAFETY AND OCCUPATIONAL
HAZARDS
●
Immediately activate the building
fire alarm system.
●
Learn how to use extinguisher.
●
Do not use elevators; use building
stairs.

Treating Fire

●
All electrical equipments should be
wired with a grounding plug.
●
Electrical cords or other lines shall
not be suspended unsupported
across rooms or passageways.

Electrical Safety
SAFETY AND OCCUPATIONAL
HAZARDS
●
Prevention of Medical
injuries should Emergencies
be a major
emphasis of
pharmacy safety
program.
●
Proper training
will prevent
injuries from
glassware,
hazardous
material, burns
and electrical
shock.
●
First aid should
be provided
immediately.
THANK YOU…