Inpatient pharmacy

Hello, I am Chia-Lin Chou from Taipei Veterans General Hospital. In last lecture, I have introduced the evolution of 4 types of medication distribution systems, which are Floor Stock System, Patient Prescription System, Unit Dose System, and Automated Dispensing System. We have discussed the advantages and disadvantages of each system, and staff’s responsibilities in each system. In the real world, all of these systems are still adopted in hospital pharmacies. We may adopt one or two systems in different situations or adopt a mixed type of distribution system to meet our clinical needs. In today’s program, I will introduce current pharmacy practice in Taiwan.

I will take our pharmacy in Taipei Veterans General Hospital as an example to introduce how we adopt these distribution systems with new technologies.

This is today’s outline. First, I will introduce our pharmacy and then introduce the working process in different setting of pharmacies and on nursing unit. After this lecture, you may understand current practice of medication distribution system in Taiwan and may able to adopt a suitable medication distribution system to meet the need in hospital pharmacies in your hometown. Let’s move on to introduce our hospital and pharmacy. Our hospital is one of the largest national medical center in north Taiwan since 1959. Now we have 7 branch hospitals in north and east Taiwan. The annual medical revenue is about 780 million US dollars. The total hospital beds is around 3000 beds. In Taiwan, we serve large amount of outpatients even in a medical center.

So, the total outpatient visits is about 10,000 per day. And the emergency visit is about 200 per day. The total prescription is up to 15 million drug items per year. So pharmacists have lots of workload, we indeed need an efficient distribution system to help us preparing medication safely. For outpatient department, we have 2 outpatient pharmacies, and for inpatients, we have 3 inpatient pharmacies, so basically we adopt a centralized pharmacy model. And we have 1 emergency pharmacy and 1 chemotherapy and total parenteral nutrition pharmacy. We have 190 pharmacists. In Taiwan, pharmacy technician is not allowed by law, so all dispensing practice is performed by pharmacists. In Taiwan, almost all inpatient pharmacies adopt Unit Dose System.

However, in different situation, we also adopt different medication distribution system. In inpatient pharmacy, we mainly adopt Unit Dose System with automated dispensing machine support. In emergency pharmacy, we adopt Patient Prescription System. And we still allow some drugs stored at each nursing unit using Floor Stock System. In our inpatient pharmacy, we mainly adopt Unit Dose System. First, physicians prescribe orders through computerized order entry system, then the computer system sends orders to pharmacy, so pharmacists can receive and review the same orders and preparing medication carts. Orders are sent to the pharmacy in various ways. For regular drugs, computer system printed patient daily drug profile every day, so pharmacists basically review and dispense regular drugs by using daily drug profile.

For new drugs, computer system link to the pharmacy printer and print out the prescriptions. Pharmacists dispense new drugs by using the printed prescriptions.

In addition, pharmacists also review those orders through pharmacy information system which link to hospital system. Our pharmacy also use automated dispensing machines to assist dispensing practice. All orders can be sent to automated dispensing machine and the machine dispense medications automatically. Pharmacists only need to recheck these medications. Then the filled medication carts are sent to nursing unit, the nurses receive and administer medications by orders and record the medication administration record. This is our working flow in inpatient pharmacy. The Patient Drug Profiles are printed at midnight. Patient Drug Profile shows essential patient information and latest lab data and current regular drug list. Drug lists include drug name, brand name, dose, and frequency, quantity, and duration.

For some drugs need to be adjusted the dosage based on patients’ renal or liver function, the Patient Drug Profile could also show R or L marks on those drugs. Thus, pharmacists could pay more attention to recheck the dose and patient’s latest data while reviewing prescriptions. Then pharmacists can reviewing drug profile for regular medications and dispensing medications and put in patient-specific pillbox. The second pharmacist will recheck medications before exchanging carts. In addition, for some infusion bags with large volume, we may dispense several infusion bags and put on the bottom drawer of the carts, so pharmacists should print out patient-specific labels and stick them on the medications. Thus the nurse could identify the correct infusion bags and administer to correct patient.

On the other hand, clinical pharmacists verify new prescriptions via pharmacy information system. Then drug carts are delivered to ward

and exchange the empty carts at 3:30 pm in the afternoon. The unused drugs also return to the pharmacy along with the empty carts. Then pharmacists return unused drugs and amend the balance. At the ward, the nurse also administer medications according to prescriptions after they receive medications. In our hospital, we use barcode assistant administration record, so the nurse can complete their record very quickly. I will introduce the process in the next lecture.