Orientation To The Hospital Pharmacy At The Townsville Hospital

Services provided at The Townsville Hospital

Section ONE: Orientation to the Hospital Pharmacy

a). Describe the services provided at The Townsville Hospital, including the scope of the area that the hospital seryices and the number of patient beds.

b). Describe the function of the Main Dispensary and the Pharmacy Distribution Centre. What general seruice does each department provide? 

c). How many staff are employed in the Pharmacy?

d). How are medications stored within the pharmacy? What are the advantages of this system?

e). What is an imprest supply ?

f). What is a Pyxis Machine? What is an advantage and disadvantage of these machines?

g). Where does the hospital pharmacy get supplies of the medications from? What is an advantage and disadvantage of this system? 

h). Describe the different roles of a hospital pharmacist (using the web resources listed) and your obseruations on the placement.

Section TWO: Outpatient Services 

1.Queensland Health prescriptions have three copies associated with them. What is the purpose of the largest'red'copy of the prescription?

2. The'SHPA Standards of Practice for Clinical Pharmacy Seruices'Chapter 12 outlines the practice standards to which Pharmacy Assistants and Technicians suppott Clinical Pharmacy Seruices. This document will assist you when answering the following
questions:
a. What duties are suitable for a pharmacy technician to pelform? 

b. What duties would not be suitable for a pharmacy assistant to perform? 

3. Highly Specialised Drugs are very expensive and patients must meet strict criteria to be eligible to be treated with these medications.
a. Give TWO examples of typical medical conditions that require ongoing treatment with medications supplied through the outpatients depaftment. 

b. Give ONE example of a Highly Specialised Drug and a condition it is used to treat. 

Section THREE: Clinical Pharmacy Seruices

1. What are the THREE clinical pharmacy activities that should be completed when a patient is transferred to a healthcare provider (e.9. Hospital)? (Hint: Refer to Figure 2 in the'SHPA Standards of Practice for Clinical Pharmacy Overuiew).

2. List FOUR examples of information that should be obtained during a medication history interview. 

3. What is a Discharge Medication Record? What are the advantages of these? 

4.  Give an example of an abbreviation that should never be used in medical tfd communication. Explain the potential errors that could result if this abbreviation is used.

Section FOUR: Specialty Area of Practice: Oncology

1. What does the term'cytotoxic' mean?

2. Why are chemotherapy drugs prepared in cytotoxic cabinets?

3. What sort of Personal Protective Equipment (PPE) should be worn when preparing lU l chemotherapy?

4.  List the details required for the safe labelling of chemotherapy (Hint: Refer to the tl:J Clinical Oncological Society of Australia guidelines listed in the resource section) 

Services provided at The Townsville Hospital

Section 1: Orientation to the hospital pharmacy

a). Townsville is a public tertiary care hospital situated in Douglas, Townsville, Queensland, Australia. It is the largest health care facility in the Townsville HHS. It comprises of 20 facilities including a community health, aged care facility and rural hospital. It is the only tertiary hospital of Northern Queensland. It has got a cardiac surgery unit, coronary care unit, diabetes unit, domiciliary care unit, hospice care unit and infectious disease care unit.  It sees 336 people in the emergency department, 1913 people through the specialist outpatient clinic and almost performs 40 operations. Currently Townsville hospital has about 775 beds (1).

b). The hospital pharmacy is responsible for the dispensing of the outpatients and discharge prescriptions, supply and the distribution of the inpatient mediations and maintenance of the medication needed in the hospital ward, for providing a clinical pharmacy review services to the inpatient areas. They are responsible for the preparation of specialized sterile medications, reconstitution of the cytotoxic drugs and also support the conduction of any clinical trials of medication(1).

c. Staffs employed in the pharmacy

Pharmacist
Intern-pharmacist
Pharmacy assistant	34
Support staffs	7

d. Storage of medications- Themedications are stored within the pharmacy in an alphabetical order or  by the generic drug name. The schedule 2, 3 and 4 drugs are stored together on the shelves while the schedule 8 drugs are stored in the safe. The stock in the pharmacy is adequate for one week.

Advantages and disadvantages of storage of medications- One of the advantage of storing medicine in this way is that it eases the way to locate the drugs. One of the disadvantage is that, since the drugs are stored together, any electricity malfunction and temperature fluctuation might affect all the stored drugs at once, especially the ones that are heat sensitive.

e. An imprest system is a process by which the medicines are supplied from the pharmacy of a clinical setting such as a hospital or by any authorized seller to a licensed health service or wards, departments of clinics in containers of the original manufacturers for establishing and maintaining a stock of medications at a predetermined level. An imprest license is normally granted to the facilities where patients resides for greater than one day (3).

f. Pyxis machine-Pyxis machine is an automated system for dispensing medications supporting the decentralized medication management with various features for the efficiency and safety (4).

Function of the Main Dispensary and the Pharmacy Distribution Centre

Advantages-The system helps in the accurate dispensing of the medications supporting the workflow of the pharmacy. It also reduces the turnaround time of the orders. A study had also shown that such machines reduces the time to the first dose and the number of the missing doses. It helps the hospital to keep a track on what is being used, keeps a close monitoring on the controlled substance and keeps an accurate documentation of the medications (4).

Disadvantages- The main disadvantages are long queues to get the medications, medications not used within the timeframe, easy overriding of the controlled substance.

g. The Townsville hospital pharmacy gets its supply of medication from the central medication pharmacy in Brisbane (1).

The advantage in using this pharmacy is that this pharmacy is approved to supply the subsidized medicines under the Pharmaceutical Benefits Scheme (PBS) and provides a wide range of medicines required for s full-fledged hospital pharmacy (1).

One of disadvantage is in relation to the transport cost. The transport cost for the medicines are quite high and the time consumed in the transportation is also more.

h. Different roles of a hospital pharmacist

• As a hospital pharmacist one needs to check the prescriptions for the errors, ensuring that they are appropriate and safe for each and every patient.
• To provide advice on the medicine dosages and the appropriate route for administration (1).
• To participate in the inward rounds for taking the drug history of the patients.
• To make sure that the medications are stored securely and appropriately.
• To remain updated and contribute to the research and development by searching and evaluating the current pharmaceutical and the medical journals for providing answers to the enquiries from the doctors, nurses, patients and their families (6).
• Pharmacist are often responsible for the coordination and the monitoring of the clinical trials.
• Give information regarding the expenditure on medications, prepare and quality check he sterile medications (7).

Apart from this, hospital pharmacists are scientific minded and have excellent communication skills for engaging with the public and focus on the details while working in a lab (6).

References:

Martin ED, Burgess NG, Doecke CJ. Evaluation of an Automated Drug Distribution System in an Australian Teaching Hospital: Part 1. Implementation. The Australian Journal of Hospital Pharmacy. 2000 Jun;30(3):94-7.

Vottero BA. Proof of concept: virtual reality simulation of a Pyxis machine for medication administration. Clinical Simulation in Nursing. 2014 Jun 1;10(6):e325-31.

SHPA Standards of Practice for Clinical Pharmacy Services[cited 21 October 2018]. Available from: https://www.researchgate.net/publication/286802694_SHPA_Standards_of_Practice_for_Clinical_Pharmacy

de Clifford JM, Blewitt P, Lam SS, Leung BK. How do Clinical Pharmacists spend their Working Day? A Time?and?Motion Study. Journal of Pharmacy Practice and Research. 2012 Jun;42(2):134-9.

Mak VS, Clark A, Poulsen JH, Udengaard KU, Gilbert AL. Pharmacists' awareness of Australia's health care reforms and their beliefs and attitudes about their current and future roles. International Journal of Pharmacy Practice. 2012 Feb;20(1):33-40.

Section 2: Outpatient services

1. Red prescription-

2. a) Duties of a pharmacy technician

• The duties of a pharmacist technician includes medication reconciliation, medication management , detecting the admission of the new patients, screen them communicate about the medicine supply information, ensuring all the medicines are available in the store, communicating with the external health professional and the community pharmacist.
• They are responsible for checking the orders in compliance with the legal and the local requirements, annotation of the medication chart, accessing and recording the patient specific laboratory data and access for any abnormal results (1).
• They are also responsible for therapeutic drug monitoring , providing medication information to the patient and about their contraindications and the preventive measures
• Assist the pharmacist with the documentation and the processing of the ADR reports (1)
• Gathering of information about the consumer medicine information.
• Identification of the patients requiring further supply of the medications on discharge.
• Assisting the patient in the preparation of the medication list (1).

2. b) Duties not suitable for the pharmacy assistants

• Pharmacists are not accountable for interviewing patients to obtain medication history.
• Interview the patients to obtain information about allergies.
• Investigate about any medication related problems (1).
• They should not decide any changes in medication without consulting with the physician.
• Assessment of the medications
• Educate the medical staffs about writing of the prescriptions
• They are not liable to ensure that the medication order is appropriate with respect to the previous medical history of the patient.
• They are not accountable to provide any information about medicines other than the supply.
• They are not accountable to label the drugs Standards of Practice for (1)

Number of staff employed in the Pharmacy

3. a) TWO examples of typical medical conditions that require ongoing treatment with medications supplied through the outpatients department are-

• Pain management- pain management are often categorized as outpatient services where patients do not have to stay overnight and are discharged within a day (2).  
• Drug rehabilitation treatment often are included in outpatients services involving prescribing of medications and counselling. For severe cases the patient has to be admitted (2).

3. b) Example of a highly specialized drug- Azithromycin (4).

It is used for treating a number of bacterial infections like bronchitis, pneumonia, lung sinuses, and infections of skin, throat and reproductive organs.  It does so by interfering with the protein synthesis in the bacteria, by binding to the 50 S subunit of the ribosome of the bacteria. This leads to the inhibition of the translation of the mRNA, thus inhibiting the protein synthesis (3).

References:

SHPA Standards of Practice for Clinical Pharmacy Services[cited 21 October 2018]. Available from: https://www.researchgate.net/publication/286802694_SHPA_Standards_of_Practice_for_Clinical_Pharmacy

McQuay HJ, Moore RA, Eccleston C, Morley S, Williams AC. Systematic review of outpatient services for chronic pain control. Health technology assessment (Winchester, England). 1997;1(6):i-v.

Bakheit AH, Al-Hadiya BM, Abd-Elgalil AA. Azithromycin. In Profiles of Drug Substances, Excipients and Related Methodology 2014 Jan 1 (Vol. 39, pp. 1-40). Academic Press.

Department of Human Services Australia. .Highly specialized drugs. 2015. https://www.humanservices.gov.au/organisations/health-professionals/services/medicare/highly-specialised-drugs

Section 3 : Clinical Pharmacy Services

1. The three activities that are being carried out when a patient is transferred to the health care provider are as follows-

• Compiling the medical history of the patient accurately (1)
• Reconciliation of the medications between the currently prescribed medicines and the medications used in past (1).
• Assessing the current medications given, the medical history of the patient and the current health status of the patient (1).

2. Four information that should be obtained at the time of medication history interview are:-

• Type of medications obtained over time (1)
• Duration of the use  of  the medication
• History of any past adverse drug reaction.
• History of any change in the prescribed medication and the reason for the change.

3. Discharge medication record- Reconciliation of the medicines in a form before the transition of care from one facility to the other or at the time of the discharge is discharge medication record (2).

Advantages: One of the advantage of this is that such a record provides a complete instruction of medications in use or that had been withdrawn, or information regarding the occurrence of any adverse drug reaction or the treatment carried out before the discharge. Such a record serves useful to the next care setting where the patient has been transferred (2).

4. Abbreviations that should never be used in medication communication are- QD whose intended meaning is every day but Period after the Q is mistaken for I and the O is mistaken for I (3).

Errors that might occur- Wrong abbreviations might lead to medication error related to the dosage and the duration of application of the medications. Over dosage of medications can not only cause adverse reactions and can also cause mortality and morbidity. Wrong abbreviations can be confusing for the informal caregivers or the personal carers, having no prior knowledge of medical abbreviations and jargons (4).

Medication storage and its advantages and disadvantages

References:

SHPA Standards of Practice for Clinical Pharmacy Services[cited 21 October 2018]. Available from: https://www.researchgate.net/publication/286802694_SHPA_Standards_of_Practice_for_Clinical_Pharmacy

Pronovost P, Weast B, Schwarz M, Wyskiel RM, Prow D, Milanovich SN, Berenholtz S, Dorman T, Lipsett P.Medicationreconciliation: a practical tool to reduce the risk of medication errors. Journal of critical care. 2003 Dec 1;18(4):205.

Institute for Safe Medication Practices (ISMP). List of Error-Prone Abbreviations. 2016. https://www.ismp.org/recommendations/error-prone-abbreviations-list

Australian Commission on Safety and Quality in Healthcare. Recommendations for terminology, abbreviations and symbols used in medicines documentation. https://www.safetyandquality.gov.au/wp-content/uploads/2017/01/Recommendations-for-terminology-abbreviations-and-symbols-used-in-medicines-December-2016.pdf

Section FOUR: Specialty Area of Practice: Oncology

1. The term “cytotoxic” can referred to something that is toxic to the living cells. Cytotoxic drugs are drugs that are used to destroy the unprecedented proliferation of the cancer cells. The cytotoxicity of the chemotherapeutic agents not only destroy the cancer cells but also the immune cells and thus impairs the ability of the adaptive immunity of the body (1).

2. Chemotherapeutic drugs are often found to have adverse effects upon the research professionals or the health care professionals. Diffusion of the drugs through direct skin contact or inhalation of the aerosolized drugs might give rise to cytotoxicity. Furthermore, the unique demand of the cytotoxic drugs requires specialized cabinets hat is exhausted through the HEPA filters to the outer atmosphere that prevents any recirculation in the inside area. It has got an exhaust and a ventilation system that remains in operation for a sufficient period of time for ensuring that the contaminants do not escape the biologically safety cabinets. It also contains a continuous monitoring device that detects the performance of the cabinets and continuous airflow (1).

3. Due to the associated cytotoxicity with chemotherapy, personal protective equipment should be worn during the preparation. The PPE recommendations include gowns, gloves, face shield and goggles. Gowns made up of high density polyethylene has been found to effective against any kind of spillage or aerosolization of the cytotoxic drugs. Surgical nitrile gloves can be used. Other suitable materials are polyurethane and neoprene. Plastic face shields can be useful, safety glasses should be used. The eye protectors should be cleaned after using each time (2).

4. Safe labelling of the chemotherapy drugs

The general components of the chemotherapy drugs are- The identifying information such as the names of the patient, the drug name, the amount of drug present in a containers, the route of administration, the amount of the drug to be used per dose, the volume of the chemotherapeutic agent to be administered, the duration of the infusion, instructions for supplemental administrations, the numbering of the containers, the rate of the administration in mL/hour. In relation to the general formatting the labels, the color of the labels should be readable. Differently colored labels can be used to draw attention towards high alert chemotherapy drugs. Regarding the printing of the abbreviations and the dosage designation, Institute for Safe Medication Practices (ISMP) guidelines for abbreviations and dose expressions should be followed (3). Proper space should be provided between the name of the drug, dosage form, and the strength. The label information can be used in the following format- generic name, brand name, patient dose, dosage units, and route of administration.

References:

Galioto M, Bonelli KR, McCorkle MR. American society of clinical oncology/oncology nursing society chemotherapy administration safety standards. InOncology nursing forum 2009 Nov (Vol. 36, No. 6, p. 1).

Rizalar S, Tural E, Altay B. Nurses' protective measures during chemotherapy preparation and administration in Turkey. International journal of nursing practice. 2012 Feb;18(1):91-8.

The Clinical Oncology Society of Australia (COSA). Guidelines for the Safe Prescribing, Dispensing and Administration of Cancer Chemotherapy’. The role the pharmacist.2015https://www.cosa.org.au/publications/guidelines/