Institutional pharmacy practice

The followings I’d like to introduce

the symbolic hospital and main GPP training center: Taipei Veterans General Hospital This hospital is established in 1958, located in northern part of Taiwan. We have 7 branch hospitals in north and eastern parts of Taiwan We have 3000 inpatient bed. Every day we have 10 thousand ambulatory patients, the pharmacy have to deal with 8 thousand prescriptions per day. We have more than 6 thousand staffs, the pharmacy has more than 200 staffs. In Gazette Review published in September 2016, Taipei Veterans General Hospital was ranked as top 15 hospitals in the world!

This diagram describe the Institutional Pharmacy Practice Process: From the left, the medicine is purchased from the supplier, then pharmacy has to manage the procurement process and control the inventory. In the prescribing process, the pharmacist need to manage the clinical decision support system to prevent inappropriate order by the physician and also, pharmacist is responsible for verifying the appropriateness of the order. In the dispensing process, pharmacist need to ensure the rationale of the prescription and dispense the right drugs to the patient. At least double checked in the process. In the administration process, pharmacist should provide sufficient information to the nurses, for example, comprehensive instruction of administration, IV fluids, compatibility issues, etc.

After administration, the pharmacist is responsible to monitor the efficacy and side effects of medication therapy. In the whole process of medication therapy, pharmacists are responsible for preventing and solving drug related problems.

There are three main processes in Pharmaceutical care: assessment, care plan, and follow up. There forms a never-ending cycle in caring patient drug therapy. The safety system and quality assurance are also imperative in building up an ideal pharmaceutical care environment. The core elements including IT Infrastructure, Error Proofing Measures and Accreditation Mechanisms.

To fulfill the need of sound management of institutional pharmacy. We should set up a well-organized team. Let me show you an example- the organizational histogram of Taipei Veterans General Hospital Pharmacy. The pharmacy department operate independently and provide with sound organized structure. It comprises three divisions, Dispensing, Compounding, and Clinical Pharmacy. Dispensing division provides prescription dispensing and basic counseling service. Compounding division provides chemotherapy and total parenteral nutrition prescription dispensing, along with clinical pharmacy services, teaching and research. Clinical Pharmacy division provides clinical pharmacy services, drug information services, teaching and research. We take charge in Pharmacy Service Administration and Medication Safety.

And we have also been assigned as the secretary and executive department of Pharmacy and Therapeutics Committee as well as Controlled Drugs Committee in the hospital. Furthermore, we participate in Quality Care and Patient Safety Committee and Infection Control Committee.

The following slide I will show you the Major Achievement of Hospital Pharmacy Practice in Taiwan

I will use TVGH as a symbolic pharmacy model: In the Management of medication storage, TVGH use fully barcode control system to manage the medicine inventory. I will show you picture later. The Unit Dose System was introduced in TVGH in 1981, we also are pioneer in Taiwan in using UD System. Now most of the medicine are packed in meal package with barcode embraced. The pharmacist use iPAD to dispense. I will show you some pictures later.

As I mentioned earlier, the Computerized Physician Order Entry system was introduced in Taiwan in 1987. Now almost 100% hospital in Taiwan use CPOE. Furthermore, most CPOE system linked to multiple query functions to support physician as they prescribe. More sophisticated system incorporated with Electronic Medication Safety Systems, which build up prescription error proofing mechanism.

Medicines storage and shelf life management are achieved by barcode system. And vaccines are keep separately from other medicines. As for refrigerators, they are equipped with a 24 hour temperature recorder and Un-interruptible Power Supply system. The recorder can automatically call the authorized pharmacist when abnormal temperature occurred. This is the screen of computerized physician order entry system in TVGH We provide a user-friendly query system for physicians. For example, physician can click query button to check electronic formulary, package inserts, drug appearance and classifications. On the drug lists, we remark the special usage, and highlight solutions with a green background. We also describe the clinical uses and stock status. We have developed numerous Prescription Error-Proofing Mechanisms on our Computerized Physician Order Entry System.

To give physicians instant information, we embed many information in CPOE system for query, such as formulary, package inserts, drug image, lists of drug classification, clinical indication, substitution advice for drug in shortage. Auto-checking system can auto-check duplications, dosage, inappropriate split or crush, interactions, pregnancy, contraindication, allergy and also adverse drug reactions. The demo screens are in the following slides. As you can see here, the drug allergy warning can notify physician about the allergy history. The adverse drug reactions Warning is designed to remind physician to be more careful when prescribing. The dosage form check can prevent the drugs that should not be split or crushed from being administered by inappropriate routes, such as nasal gastric tube.

Warning of prescribing antibiotics in the Upper Respiratory Infection patients, helps to limit antibiotic abuse.