hospital pharmacy manual (final)

7/31/2019 Hospital Pharmacy Manual (Final)

1/29


2/29

The pharmacy manual is designed to be a reference for allHospital staff in order to identify:

&

Insure Safe and accurate medication ordering, preparation,distribution and control

PharmacyPolicies &Procedures

OperationalResponsibilities

DepartmentalRelationships


3/29


4/29


5/29


6/29

Supportive Services: Blood bank, Radiology, Dietitians, Nursing

RHUH is a university hospital providing services for severalnursing units

ICU CCU Oncology

Surgery Pediatrics OBS & GYN

PHARMACY


7/29

InformationTechnology

Finance &Admin.

InternalauditNursing

Material &Purchasing

Pharmacy

- Logistics- HR- Finance

- Biomedical- Eng. & Maint.- Material Mngt

Management


8/29

Pharmacy Map:

A-ReceptionB&C offices for pharmacy staffE-Purchasing officeD&F- Dispensing roomG- Compounding roomH- Pharmacy storeI- WCJ- Changing roomK- LibraryL- Kitchen

Head of pharmacy office is located inthe ground floor.


9/29


10/29

Central IVAdmixture

Unit

TotalParenteral

Nutrition Unit

ChemotherapyUnit

Dispensingby Unit Dose

System


11/29

FunctionalOrganization

of thepharmacy

Location &PharmacyExtensions

OperatingHours

Personnel

JobDescription

Responsibility& duties

General rules&Regulations


12/29


13/29

The main pharmacy is located in the basement of thehospital. 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


14/29

Operating hours

8-7 during the week8-4 on Saturdays

8-3 on Sundays


15/29

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 thepharmacist on-call during pharmacy closing hours.

Pharmacy on call sheet should be filled including dispensedmedication and duration of dispensing.


16/29


17/29

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

technician, secretary.

- Formulating and applying pharmacy policies.

- Updating hospital formulary.

- Controlling stock level.

- Intervening in any medical or pharmaceutical problem.

e.g. Head of Pharmacy


18/29

e.g.

Pharmacy Rooms should be clean at all times.

Offices should be organized especially before leaving.

e.g.

Lab coats should be worn without exceptions.The schedule work time should be requested.

e.g.

Work hours in holidays are rewarded in a similar mannerwithin a month.

Pharmacist on-call should be available after closing hoursto provide life-saving medications.


19/29

PerformanceAppraisal

StudentMentorship

ContinuingEducations

Orientation


20/29


21/29

Regular evaluation ofpersonnel

Annual competencyvalidation plan

Performance appraisal isdone q 6 month &retraining is done

regularly.

Anecdotal ReportEmployee of the month


22/29

Pharmaceutical &

Medical lecturesCompetency tests

& Quizzes

Interventions& monthly

Roundtables

In-serviceEducationprogram


23/29

Training Certificate

TrainingApplication

Approvalform

university &

Head

Studentsfrom all

universities


24/29

Cytotoxic/Anti-Neoplastic Drugs

Drug Preparation:

Personal preparation Protective Equipments.

Preparation Area.

Preparation Equipments.

Work Practices in the preparation:

Handling vials.Handling ampoules.

Waste Disposal.

Spills.

Medical. surveillance


25/29

Glass ware Safety

Use a dustpan and brush topick up broken glass.

Discard broken glass in a rigidcontainer separate fromregular garbage (label).

Hazardous Drug Safety

Hazardous materials includechemotherapeutic agents,strong acids or alkali,Corrosives, flammable items,poisonous items, humanserum derived drugs,

Infectious agents


26/29

GeneralSafety

No smoking, running

or jumping shall bepermitted.

Dressing shall be inaccordance withpolicy.

Keep exits andpassages clear at alltimes.

P

reventingFire Minimize the

quantity offlammable liquidskept in the pharmacy.

Keep flammableliquids in approved

flammable liquidstorage cabinets.


27/29

Immediately activate thebuilding fire alarm system.

Learn how to useextinguisher.

Do not use elevators; usebuilding stairs.

Treating Fire

All electrical equipmentsshould be wired with agrounding plug.

Electrical cords or other linesshall not be suspendedunsupported across roomsor passageways.

Electrical Safety


28/29

MedicalEmergencies Prevention of injuries should 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.


29/29

hospital pharmacy manual (final)

Documents