Sub.
-Hospital and clinical Pharmacy
Chapter-3 Drug distribution system in hospital
Drug distribution system in hospital is categorised in two parts:
1) Out patients/Ambulatory patient
2) Inpatients.
Out Patient :An outpatient receives general or emergency treatment, which could be diagnostic,
therapeutic or preventive without being admitted in hospital. OR
It is defined as patient who is not occupying a bed in the hospital.
Reasons for the development of outpatient services:
1) The demand by the community.
2) To achieve control over patients receiving drugs after investigation.
3) The lack of sufficient number of physician in some areas.
4) The need of hospital to support its inpatient teaching programme.
5) The hospitals more active role in the community heath programme.
The main advantages of dispensing medicines to out patients:
1) Treatment commences immediately
2) Medicines may be prescribed as a part of clinical trials.
3) Medicines prescribed may be restricted to the hospital service.
Classification:
1) General outpatient :The patient who come to hospital for treatment of general symptoms like
fever, cough, cold etc. And medicine is prescribed. They may undergo minor surgery and
superficial surfing dressing at the hospital.
2) Referred patient-He is referred directly to outpatient department by his attending medical/
dental practitioner for specific treatment, other than an emergency treatment, and who later
returns to the practitioner for further treatment.
3) Emergency outpatient: A Patient who need emergency care in situation like accident ,burn
which calls for emergency medical attention. 24hr. Services are given to those patients who
requires immediate care for survival.
Location and layout of outpatient department
Out patient department should be located near the office and entrance of the hospital .
It must be on ground floor.
It should have pleasant look.
The floor should be salient, smooth and easily washable.
For the location of out patient dispensing service three provisions are made:
1) A separate outpatient dispensing service
2) A combined unit service for inpatients and outpatients from same windows.
3) A combined unit service for inpatients and outpatients from different windows.
Layout outpatient department:
The unit should be provided with two windows, one for receiving the prescription and other for
delivery. A waiting area should be provided as the patient have to wait for same time while the
prescription is being compounded. The waiting room should be clean and ventilated with
sufficient number of comfortable seats. In waiting room general publications regarding
pharmacy and medicines should be provided .It should also includes newspapers and magazines.
The waiting period should be kept minimum to avoid overcrowding. In the waiting room
posters of family planning and general hygiene should be displayed. In such way the waiting
room is utilised for educating the patients on matters relating to health and hygiene.
1. Table and chair 2.Preparation table 3.Storage rack
4. Sink with tap 5.Medicine platform 6.Dispensing window
Explain the Receipt and Issue system to outpatient. OR explain the process of dispensing
drug to out patient in typical hospital.
Receipt system in OPD:
Drug in hospital pharmacy department may receives from following sources:
1.Directly from manufacturer.
2.Directly from wholesaler
3.From local retail pharmacy
4.By inviting the tenders.
5.From inhouse production and manufacture unit in hospital purchase department.
For ordering the medicines for out patient department , complete description of medicine ,or drug
must be given with full specification, quantity needed, price, quality should also be noted on the
purchase requisition (bills).
3 copies of purchase requisition must be made one for out patient department ,one for the account
section and one for the purchase department
Issue system in OPD/ Process of dispensing the drugs:
1. Patient in his first visit to OPD goes to registration counter .Take case paper after paying
nominal fees.
2. Then patient goes to general check-up counter –guided for medical department on the basis of
clinical symptom.
3.Physician write the prescription for patient and he submit to pharmacy department , where
prescription is compounded and dispensed by pharmacist.
4.Pharmacist number the prescription, monitor it and assemble the material and equipment for
compounding.
5.Pharmacist give token to the patient so the patients prescription can be identify.
6.Compounded prescription fill in the suitable container, packed, label and price resealable.
7.Pharmacist record the prescription in register for accounting purpose while dispensing and
compounding drug is adequate.
8.Delivery is ensure by checking token number and for next visit of patient and prescription is
given back to the patient.
Drug distribution system for in patient department:
(Describe in short how the drug is distributed OR Define inpatient and classify drug distribution
system)
• In patient : In patient is as the patient who get admitted in ward of the hospital and occupies the
bed in the hospital .
• Distribution of drug to IPD can be carried out from outside dispensing area.IPD may be located
on the ground floor or 1st floor but it should be closed to the OPD.
• IPD contains storage , dispensing and manufacturing of I.V. fluids and parenteral also.
• General methods are used in hospital for dispensing medicine to IPD.
Classification of Inpatient drug distribution system/ methods of drug distribution
system:
1.Individual prescription method
2. Complete floor stock system
i) Charge floor stock
ii) Non charge floor stock system/ drug basket method
3. Combination of individual prescription order and complete floor stock system
4. Unit drug distribution system/Unit dose dispensing
i) Centralised unit dose system
ii) Decentralised unit dose system /Satellite pharmacy
1) Individual prescription method :In this method the physician writes a prescription for
patient, who is admitted in the hospital. According to the name of this method, pharmacist
arranges a medicine in a container of each patient and personally visit the wards and keeps it
near each patients bed. Then nurse administers / give medicine to patient. In this system
physician has to write prescription in triplicate .Each copy of different colors. The ward boy
sends these prescriptions to pharmacy at fixed time intervals. The nursing station receive
packet of medicine and middle copy of a prescription, the one copy of prescription is given to
the patient treatment record and the original copy sent to accounts section for billing.
Advantages:
1 All medicines are reviewed by the pharmacist personally.
2. The method provides close contact among the pharmacist ,nurse, patient and doctor.
3 The method provide accurate inventory of medicine in pharmacy .
4.There are fewer chances of medication error .
Disadvantages:
1.Delay in Administration of medicine to patient.
2. Increases in the cost of drug to patient.
3.The method is not useful or suitable for small and Private Hospital and also not possible for
large Hospital..
2) Complete floor stock system:
( what do you mean by complete system or give the criteria for selection of non charge floor stock
system, or how they are dispensed or define floor stock system, write advantages disadvantages
complete floor stock system.)
The medicine or drugs are stored in pharmacy and supplied or distributed to the wards or rooms
on order and are kept under supervision of registered nurse at nursing station.
Criteria for selection of charge floor stock drug:
1. pharmacy and selection committee decides about the selection of drugs to be kept in the
charge floor stock.
2. After fixing the floor stock, it is the responsibility of hospital pharmacist to make the drug
available and also to resubmit the list of drugs for re-evaluation of newer needs of the
committee
3. Types of the drugs are usually stocked at hospital
Criteria for selection of non charge floor stock drug:
1. Cost of product
2. Quantity of used,
3. Effect on Hospital budget
4. Inventory control for cost and cheaper drug
Complete floor stock system classified as follows:
i) Charge floor stock system: It means the drug which are placed on the nursing station at all
time and are charged to the patient accounts after their administration.
ii) Non charge floor stock system:
It means the drug which are placed at the nursing station for the use of all patient who are
admitted in wards and there may not be direct charge to the patient account. The cost of this
group of drugs is calculated in the per day cost of hospital room
Procedure for dispensing drug by charge floor stock system:
1 The costly drug obtained from either medical Store or through wholesalers are made available
upon the receipt of prescription then the cost of drug is billed to the patient accounts.
2 Envelopes are used to dispense these drugs
3. Specific drugs in determined quantity are placed in envelopes .The envelopes are labeled.
4.When the drugs are administered, the patient's name, room number are mentioned on the
envelopes and sent to the pharmacy record.
Procedure for dispensing drug by non charge stock system
1 In this system, medicaments are placed at nursing station .For this medicament no direct charges
paid by the patient.
Two methods are used for the dispensing of non charge drugs.
i)Drug basket method :
In this method, the nurse checks all the medicine closet, all wards refrigerator and after
completing procedure, the empty containers and requisition for floor stock supplies and is sent
to the pharmacy department.
4 Immediately, early in the morning, pharmacy staff fill each container in a basket with drug and
it is delivered in the every wards through the ward boy.
ii) Mobile dispensing unit:
It is specifically constructed stainless steel trunk of the dimensions :Height -60 inches Width 48
inches Depth 25 inches .The body is fitted on six 8-inch balloon tiers, four of which are swivel
type. The pharmacist controlling the mobile unit checks the items and quantity of supplies left in
the pavilion drug cabinets.
The carbon copy of the requisition for floor stock supplies is left on the on the pavilion as a
record of the delivery and the original is returned to the pharmacy for the following purpose
i. To determine the rate of consumption of drugs.
ii. To restock the mobile unit.
iii. To serve as a charge document for the internal application of costs.
Advantages of Mobile dispensing unit
1. The deteriorated, out dated and on-approved drugs and drug samples may be renowned
quickly through the routine checking of the medicine cabinets. Thus it eliminates the drug
returns.
2. The pharmacist is available for spot consultation by the clinical and nursing staff.
3. Ready availability of required drugs
Disadvantages Mobile dispensing unit
1. More load on pharmacist.
2. Less involvement of nursing in charge.
3. Required proper drug storage facility at nursing station.
Advantages of Complete floor stock system:
1 Ready availability of medicine for administration.
2. Minimum retention of drugs to the pharmacy
3. Less number of pharmacist staff is required.
4. The nursing station of drug cabinet are under the continuous supervision of the pharmacist.
5. Minimization in patient prescription order.
Disadvantages Complete floor stock system:
1. Chances of medication error may increase.
2. Increased drug inventory at wards and nursing units.
3. Greater opportunity for spoilage of the drug as they are stored in large quantity.
4. Increased hazards associated with drug deterioration.
5. Special facilities are required in nursing station for storage of drugs.
3)Combination of individual prescription order and complete floor stock system:
This system is applicable when patients admitted in wards on each floor. prescription written
by a doctor is handed to the patient personally through nurse. The prescriptions are shown to
the pharmacist who then arranges the medicine as per prescription. The attending nurse then
administers it to the patients.
4)Unit dose drug distribution system: ( Define unit dose, Write note on satellite pharmacy,
Write advantages and disadvantages of Unit dose drug distribution system, Write the
benefits of Unit dose drug distribution system)
Unit: It means pharmacist make each and every dose ready for administration. Each unit dose is
repacked and relabelled with their strength, ingredient mention on it.
Unit dose: Those medications which are ordered, packed, handled, administered and charged in
the form of multiples of single dose unit containing a predetermined amount of drug sufficient
for one regular use of application is called Unit dose dispensing.
This is the most accepted method of dispensing drugs to hospitalized patients. In this system, the
pharmacist prepares every dose of medication ready for administration rather than issuing
containers of drugs to nursing units where the nurse must prepare the drug for administration.
For example, tablets and capsules are labeled for each patient, liquid premeasured, freeze dried
injections diluted and measured accurately into sterile syringes, parenteral drug admixtures added
to intravenous solutions prior to use, other unusual dosage forms measured and mixed
appropriately his unit dose dispensing concept has changed many of the traditional functions of
hospital pharmacist. For example, strip packaging for tablets and capsules. Labeling machines and
liquid unit dose packaging equipments are replacing traditional prepackaging of multiple doses of
drugs. Free and charge floor stock drug activities are eliminated.
Classification of Unit dose drug distribution system:
1) Centralized Unit dose distribution system
2) Decentralized Unit dose distribution system
1) Centralized Unit dose distribution system:
All inpatients are dispensed in unit doses. The drugs which are included under unit dose system
are stored in centrally located pharmacy and are dispensed at the time of dose is due to be given
the patient. This system which provides unit dose drugs to the patients from central pharmacy of
the hospital then it is known as Centralized Unit dose dispensing system.
2) Satellite Pharmacy OR Decentralized Unit dose distribution system( DUDDS)-
1.This system consist of Satellite pharmacies located on each floor of the hospital. The main
pharmacy in this system is also a central pharmacy but the drugs are stored and delivered from
Satellite.
2.This type of system can be used for hospitals with number of floors.
3.Satellite Pharmacy provide patient profile record (PPC) for every patient in the ward .PPC
contains admission date, name of disease and diagnosis made by the doctor.
4.The prescriptions are carried directly to the pharmacist through an assistant and
entered in the patient profile card.
5.The pharmacist checks the prescription containing drugs or medicines ordered by
the physician .Then he checks for their allergies if any, any probable drug interactions,
drug laboratory tests, side effects, contraindications etc.
6.Then the pharmacist decides the dosages schedule and coordinates with the nurse
in-charge for administration.
7.Then patient profile card and prescription ordered is filled by pharmacy technician.
8.The attending pharmacist checks the card before its release and hands it over to the
nursing staff.
9.Nurses administer the drugs and make the entries accordingly, in their record .
10.The card is returns to the pharmacy and rechecked by the pharmacist.
Advantages of satellite pharmacy:
1. Satellite pharmacies satisfactorily provide the required medication for a patient's current
clinical trials.
2. The pharmacist of satellite pharmacy is available to patients and nursingprofessionals not just
as a dispenser, but for clinical purposes also.
3 The pharmacist is present at the nursing station to perform the following:
a) Dispense unit doses and intravenous products.
b) Maintain patient drug policies.
(c) Take patient drug histories.
d) Monitor patient for drug reactions and toxicity.
Advantages of Unit dose distribution system:
1. This system minimizes the wastage drugs.
2. Each dose is readily available , hence the patient receives medicines round the clock.
3. Less chances of medication errors
4. It reduces the contamination of drugs as they are properly re- packed.
5. Less paper work , so that , more space is available on nursing station and pharmacy.
6. Patients are charged only for the dose they receive.
7. Keeping an account of drugs becomes easier at the pharmacy.
8. Reduction in the nursing time and maintenance of record is simple.
9. Accurate delivery of medicines due to repacked of drug with name , strength expiry date helps
in avoiding wrong administration.
Disadvantages of Unit dose distribution system:
1. It requires large number of technically skill pharmacy person.
2. The method being lengthy makes it expensive to the patients.
Benefits:
1. The patients are charged for those which are administered to them.
2. It reduces the medication error since the pharmacist checks the copy of physician’s original
order.
3. It avoids drug losses, no pilferage of drug.
4. Less space is required as compared to bulky floor stock.
5. Patients receive the nursing service 24 hrs a day.
6. It avoids duplication of orders and extra paper work.
7. It enhances more efficient utilization of personnel
8. It eliminates labelling error.
9. Drug accounting become easier.
10. Better financial control means credits are eliminated.
Bed side pharmacy:
(Write in brief about bed side pharmacy. Give its importance.)
Hospital pharmacy is becoming increasingly patient oriented now a day. Hence Pharmacist must
work in close association with the nursing and medical staff. Personally each pharmacist in the
hospital should visit the wards, go to each patient’s bed side and discuss with them regarding the
illness and drugs they take. This is called as Bed Side pharmacy.
Importance or role of pharmacist in bedside pharmacy
1. The pharmacist should build an inter-professional team of the physicians, nurses and
pharmacists.
2. Ward visit:-Daily in the morning, he visits the wards and enquires about the progress of
health etc.
3 Take medication history of each patient during the visits.
4. He interacts with the physicians about medicine and with nurses regarding storage,
handling and safe use of the medicine.
5. Pharmacist carrying out such visits must have thorough knowledge about drug food
reactions, allergies, side effects and adverse reactions of drugs.
6. He/she should give counselling to the patients regarding their food habits and ways of
administration of drug.
7. He/she guides the patient about the treatment to be continued after discharge and how the
drugs should be stored at home to avoid its degradation.
8. Medication at Bed-Side: Lifesaving drug--Nitro-glycerine tablet is kept at bedside, if ordered by
physician. Not more than one strip/10 tablet shall be left with the patient.
Central sterile service room/department ( CSSR) / (CSSD)
(Describe the location and layout of central sterile service room, What is CSSR)
CSSR/CSSD: A Central sterile service room in the hospital is one which receives used goods,
processes to make them sterile and distributes and controls the sterile supplies to all units of
hospital for the care and safety of the patients. The materials supplied includes syringes, needles,
catheters , IV set and gloves etc.
Location: It should be centrally located in the hospital or near a place where bulk of the
supplies are required as operation theatres which contributes about 75% of the work of
this department. The store and laundry should be very near.
It consists of series of working station in dirty, non sterile area which are separated from sterile
by Autoclaving and different sterilizing equipment. In layout, sterile area is established having
different sterilizers.
Objectives:
1. To supply necessary equipments and material to operation theatre (OT).
2. Cleaning and sterilization of hospital sulies by following the standard operating procedures
(SOP )
3. To take complete and accurate inventory of all hospital sulies and equipments.
4. To participate in educative programme in hospital specially in sterilization process.
5. To develop cost effective ,economic and simple programme by proper analysis personnel sulies
and equipments.
Procedure:
i) At the entrance, Non sterile items like gloves, syringe and needle, rubber gloves, surgical
instrument and dressing, urine and blood collection sets, etc are received.
ii)The Non sterile item then passes for sorting and disassembly purpose
iii) It goes for general clean-up process for washing purpose, powdering process for gloves
and all this assembled according to types of items. Linen material goes to the linen storage
section
iv) Then these items pass through partition zone to sterile area for sterilization in different
sterilizer.
v) Finally the sterilized item comes to the sterile storage area.
vi) From this area, these items are issued or distributed to various departments through clear
area.
The purpose of such layout is to minimize cross flow of non-sterile item with sterile item
thereby eliminating the possibility of error of contamination.
Advantages of CSSD:
· Processing issue and control Infection free atmosphere
· Economic efficient and uniform source
· Maintains Standards
· Reduces burden on nursing staff Prevents cross infection
· Shortens patients stay
· Ensures safe environment
· Inventory maintenance & quality one.
Give administrative pattern of central sterile service. OR Write three administrative
patterns of central sterile service department.
1- Department as a part of Nursing services-
The majority of items to be dispensed are used by the nurses for the patients care. She should
therefore be work as head of this department.
2- Department under a pharmacist-
Pharmacist by taking training is competent to handle the functions of this department i.e purchase,
storage and distribution of supplies and also the preparation of sterile solution.
3- Department under dual control of pharmacist as well as nurse-
Some functions of the department like cleaning, packaging and distribution of medical supplies
and equipments should be placed in charge of nurse whereas manufacturing of sterile solutions
should be placed in charge of pharmacist.
Pre-packaging:
It is the process of packaging of drugs into small packages which are procured in bulk quantity
in hospital and make it readily available.
Repackaging left up the standard of dispensing practice in hospital. It is suitable for fastest
moving item ( frequently used medicine ) whose consumption is very quickly and also those items
which takes long time for compounding and packaging .The tablet and capsules are repacked in
the small container of 12’s,24’s,48’s and 100’s. The size of the package is the result of
consultation of pharmacy department and nursing staff of the hospital.
Hospital formularies may give definite guarantee of the quantity to be prescribed for certain
categories of drug. The date for various doses form and therapeutic categories is the gaining factor
to determine the pack size.
Advantages:
To increase standard of dispensing in hospital.
It helps to save labour and less time is consumed.
Disadvantages:
Once a packed medicine is given to patient the remaining quantity in the package will be
wasted.
Questions:
1. What is individual prescription order. State its merit and demerits
2. What are free floor stock drugs and charge floor stock drugs.
3. Give advantages and disadvantages of complete floor stock system
4. Write note on unit dose dispensing.
5. Write a note on location of out patient pharmacy.
6. Write the advantages of CSSD and also state layout of CSSD.
7. Define ambulatory patients and referred patient.
8. Explain bed side pharmacy.
9.Write advantages and disadvantages of unit drug distribution system.
10.Exlain satellite pharmacy.
11.Write location and layout of outpatient department.
