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Introduction to acute ambulatory care pharmacy practice
Second Edition David A. Holdford (Editor) Digital Instant
Download
Author(s): David A. Holdford (editor);
ISBN(s): 9781585285457, 1585285455
Edition: Second
File Details: PDF, 8.77 MB
Year: 2017
Language: english
 Second
SecondEdition
Edition
Introduction to
Introduction to

Acute
Acute &&
Ambulatory
Ambulatory
Care
Care PHARMACY
PHARMACY
PRACTICE
PRACTICE
Previously published as Introduction to Hospital
and Health-System Pharmacy Practice

DAVID A. HOLDFORD, RPh, MS, PhD, FAPhA

Professor, Department of Pharmacotherapy and Outcomes Science
Virginia Commonwealth University School of Pharmacy
Richmond, Virginia
Any correspondence regarding this publication should be sent to the publisher, American Society of Health-System
Pharmacists, 4500 East-West Highway, Bethesda, MD 20814, attention: Special Publishing.

The information presented herein reflects the opinions of the contributors and advisors. It should not be inter-
preted as an official policy of ASHP or as an endorsement of any product.

Because of ongoing research and improvements in technology, the information and its applications contained in
this text are constantly evolving and are subject to the professional judgment and interpretation of the practitioner
due to the uniqueness of a clinical situation. The editors and ASHP have made reasonable efforts to ensure the
accuracy and appropriateness of the information presented in this document. However, any user of this informa-
tion is advised that the editors and ASHP are not responsible for the continued currency of the information, for any
errors or omissions, and/or for any consequences arising from the use of the information in the document in any
and all practice settings. Any reader of this document is cautioned that ASHP makes no representation, guarantee,
or warranty, express or implied, as to the accuracy and appropriateness of the information contained in this docu-
ment and specifically disclaims any liability to any party for the accuracy and/or completeness of the material or
for any damages arising out of the use or non-use of any of the information contained in this document.

Editorial Project Manager: Ruth Bloom

Production Manager: Johnna Hershey
Cover & Page Design: David Wade

Library of Congress Cataloging-in-Publication Data

Names: Holdford, David A., editor. | American Society of Health-System
Pharmacists, issuing body.
Title: Introduction to acute and ambulatory care pharmacy practice / [edited
by] David A. Holdford.
Other titles: Introduction to hospital & health-system pharmacy practice
Description: Second edition. | Bethesda, MD : ASHP Publications, [2017] |
Preceded by Introduction to hospital & health-system pharmacy practice /
[edited by] David A. Holdford, Thomas R. Brown. c2010. | Includes
bibliographical references and index.
Identifiers: LCCN 2017001189 | ISBN 9781585285457
Subjects: | MESH: Pharmacy Service, Hospital--organization & administration |
Ambulatory Care Facilities--organization & administration | United States
Classification: LCC RS152 | NLM WX 179 | DDC 362.17/82--dc23
LC record available at [Link]

© 2017, American Society of Health-System Pharmacists, Inc. All rights reserved.

No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechan-
ical, including photocopying, microfilming, and recording, or by any information storage and retrieval system,
without written permission from the American Society of Health-System Pharmacists.

ASHP is a service mark of the American Society of Health-System Pharmacists, Inc.; registered in the U.S. Patent
and Trademark Office.

ISBN: 978-1-58528-545-7

10 9 8 7 6 5 4 3 2 1
 TA B L E O F C O N T E N T S

Preface......................................................................................................................................................................................... v
Contributors............................................................................................................................................................................. viii

PART I: INTRODUCTION
CHAPTER 1: Introduction to Acute and Ambulatory Care Health-System Pharmacy Practice ....... 1
Douglas J. Scheckelhoff and Kasey K. Thompson

CHAPTER 2: Overview of the History of Hospital Pharmacy in the United States............................. 19

William A. Zellmer

CHAPTER 3: Key Legal and Regulatory Issues in Health-System Pharmacy Practice......................... 43

John P. Uselton and Lee B. Murdaugh

PART II: MANAGING MEDICATION USE

CHAPTER 4: Medication Management......................................................................................................... 67
Kathy A. Chase

CHAPTER 5: Clinical Pharmacy....................................................................................................................... 89

John E. Murphy

CHAPTER 6: Medication Safety...................................................................................................................... 107

David A. Holdford

PART III: MANAGING MEDICATION DISTRIBUTION

CHAPTER 7: Medication Distribution Systems........................................................................................... 129
Stephen F. Eckel, Jami E. Mann, and Fred M. Eckel

CHAPTER 8: Controlled Substances Management.................................................................................... 151

George J. Dydek and David J. Tomich

PART IV: USING TECHNOLOGY

CHAPTER 9: Informatics................................................................................................................................... 167
Bruce W. Chaffee

CHAPTER 10: Electronic Data Management: Electronic Health Record Systems and
Computerized Provider Order Entry Systems...................................................................................... 195
Asli Ozdas Weitkamp, Scott D. Nelson, Shane Stenner, and S. Trent Rosenbloom

CHAPTER 11: Automation in Practice............................................................................................................ 213

Brad Ludwig and Jack Temple

PART V: FINANCIAL MANAGEMENT

CHAPTER 12: Purchasing and Inventory Control........................................................................................ 239
Jerrod Milton

CHAPTER 13: Basics of Financial Management and Cost Control.......................................................... 269

Andrew L. Wilson

CHAPTER 14: Providing Sustainable Pharmacy Services in Ambulatory Care..................................... 291

David A. Holdford

I N T R O D U C T I O N T O A C U T E A N D A M B U L AT O R Y C A R E P H A R M A C Y P R A C T I C E    iii
TA B L E O F C O N T E N T S

PART VI: STERILE PRODUCT PREPARATION AND ADMINISTRATION

CHAPTER 15: Sterile Preparations and Admixture Programs.................................................................. 311
Ryan A. Forrey and Philip J. Schneider

CHAPTER 16: Parenteral Therapy................................................................................................................... 335

Julie A. Patterson and David A. Holdford

PART VII: MANAGING PEOPLE

CHAPTER 17: Leadership and Management................................................................................................. 359
David A. Holdford

CHAPTER 18: Recruiting, Selecting, and Managing Pharmacy Personnel............................................. 381

David A. Holdford and Emily C. Prabhu

PART VIII: CAREERS IN HEALTH-SYSTEM PHARMACY PRACTICE

CHAPTER 19: Preparing for Careers in Hospitals and Health Systems.................................................... 405
Thomas P. Reinders and David A. Holdford

CHAPTER 20: Career Options for Technicians in Hospitals and Health Systems................................ 423
Jennifer Phillips and Carrie A. Sincak

Index ..................................................................................................................................................................... 435

i v    I N T R O D U C T I O N T O A C U T E A N D A M B U L AT O R Y C A R E P H A R M A C Y P R A C T I C E
 P R E FAC E

W
hen I was a child living in Mount Vernon, Ohio, I visited my father at his workplace in the
pharmacy of Mercy Hospital, a small Catholic hospital serving the rural community. My
dad, Arthur A. Holdford, RPh, was the director of pharmacy services. In fact, he was the
only pharmacist employed by Mercy Hospital at the time. Large pharmacy staffs were not common
when he first took the job at the hospital. Over time, he was able to hire employees to support the
expansion of pharmacy services.
The hospital where my father worked was very different from today’s hospitals. Back then,
there were no computers, no Internet, and no automated dispensing cabinets. Handling, storage,
and administration of sterile products and other medicines were primitive compared to today.
Nurses prepared intravenous drugs on the floors using subpar aseptic technique. Oral medications
were typically sent in bulk bottles to nursing units to be administered, with little pharmacy over-
sight or input. Medication-use systems were neither very safe, nor were they really systems.
Clinical pharmacy, as we now know it, was in its infancy back then. Clinical pharmacists were
rarely seen in hospitals. Today’s most commonly used drugs had not yet been invented. Major
diseases, including AIDS, were not known either.
The hospital where my father worked was not part of an integrated health system, so it did
not coordinate its care with a network of outpatient clinics, physicians’ offices, pharmacy benefits
management, long-term care facilities, home health agencies, and the like. My father worked in a
hospital, not a health system.
Medicare and Medicaid were just in their infancy at that time. Pharmacy benefits managers
and many other forms of managed care were virtually nonexistent. Pharmacists were not as well
paid as today’s pharmacists. Pharmacist training was also different. Pharmacists needed fewer
years of schooling, and their education revolved around the product versus the patient. In short, a
lot has changed since my father’s days.
Individuals entering the pharmacy profession today will see some truly amazing changes in
healthcare and pharmacy practice during their career. It is impossible to accurately predict the
exact nature of those changes, just as it would have been impossible for my father to imagine the
changes that would occur over his lifetime. The only certainty is that change will continue, and
pharmacists will be a part of it.

Origin of this Text

The first edition of this text, Introduction to Hospital and Health-System Pharmacy Practice, origi-
nated from another, Handbook of Institutional Pharmacy Practice. The Handbook, first published
in 1979 by Drs. Thomas Brown and Mickey Smith, went through four editions before sparking the
origin of this book.
Introduction to Hospital and Health-System Pharmacy Practice covered many of the same
topics and concepts as the original Handbook, but it was written for a new audience—pharmacy
students, educators, technicians, and new pharmacy graduates. Content and pedagogy were devel-
oped to focus on the needs of these audiences. The first edition offered learning tools (e.g., review
questions, discussion questions, additional readings) to assist readers in building on the text’s
basic terminology and concepts.
This second edition evolved from the first edition with a number of significant changes. The
first and most visible change is the new title, Introduction to Acute & Ambulatory Care Pharmacy
Practice. This new title explicitly acknowledges the growing importance of ambulatory care prac-
tice in health-system settings and is line with the direction of ASHP.

I N T R O D U C T I O N T O A C U T E A N D A M B U L AT O R Y C A R E P H A R M A C Y P R A C T I C E    v
P R E FAC E
In addition to the new title, the second edition has two new chapters. The first, Providing
Sustainable Pharmacy Services in Ambulatory Care, discusses how to make ambulatory pharmacy
services financially sustainable by using new, innovative business models. The second new chapter,
Career Options for Technicians in Hospitals and Health Systems, explores the evolving roles of
pharmacy technicians and discusses career and training opportunities in acute and ambulatory
settings. All of the remaining chapters have been updated with new content. Of note are the
following:
■■ A discussion about the Affordable Care Act in Chapter 1: Introduction to Acute and Ambu-
latory Care Health-System Pharmacy Practice
■■ Further analysis of the history of institutional pharmacy in Chapter 2: Overview of the
History of Hospital Pharmacy in the United States
■■ An explanation of Lean Management practices in Chapter 6: Medication Safety
■■ A description of 340B/contract pharmacy, billing, and financial compliance in Chapter 13:
Basics of Financial Management and Cost Control
■■ Introduction of the topic of employee engagement in Chapter 18: Recruiting, Selecting,
and Managing Pharmacy Personnel
■■ An extensive update of Chapter 19: Preparing for Careers in Hospitals and Health Systems

Approach and Organization

This text presents an overview of essential terms, concepts, and processes in acute and ambula-
tory care pharmacy practice in a concise, practical, and understandable way. Content comes from
recognized topic experts. Emphasis is on explaining, developing comprehension, and encouraging
application.
The book consists of 20 chapters divided into eight parts. Part I, Introduction, answers the
question, “What Is Health-System Pharmacy Practice?” It provides an overview, describes its
history, and discusses key legal and regulatory issues. Part II, Managing Medication Use, describes
how the medication-use process is controlled through formularies, clinical pharmacy practice, and
medication safety practices. Part III, Managing Medication Distribution, describes systems for
managing the distribution of medications (including controlled substances) throughout health
systems. Part IV, Using Technology, discusses the role of automation, technology, and informa-
tion systems in health systems. Part V, Financial Management, reviews key management responsi-
bilities of the pharmacy department including revenue generation, inventory control, budgeting,
and cost control. Part VI, Sterile Product Preparation and Administration, discusses key systems,
practices, and terms in preparing and administering sterile products. Part VII, Managing People,
addresses leadership and human resources management in health systems. Finally, Part VIII,
Careers in Health-System Pharmacy Practice, discusses different training options for careers in
health systems.
Prior knowledge of health-system practice is not necessary to use this text, because it is
written in an easy-to-read style and provides definitions for unfamiliar vocabulary. Some of the
major highlights of this book include:
■■ Learning objectives for each chapter
■■ Key terms highlighted and defined within chapters
■■ Key points highlighted and then explained by answering “so what?”
■■ Graphics and visual aids used throughout to illustrate key concepts
■■ Review questions provided at the end of each chapter for self-assessment
■■ Discussion questions provided in each chapter to initiate dialogue and debate

v i    I N T R O D U C T I O N T O A C U T E A N D A M B U L AT O R Y C A R E P H A R M A C Y P R A C T I C E
 P R E FAC E
Intended Readers
This book is written for anyone interested in health-system pharmacy practice, especially students
in PharmD and pharmacy technician programs. This book provides a foundation for introductory
and advanced pharmacy practice experiences (APPEs) and on-the-job training in hospitals and
health systems. Mastery of the book’s terms and concepts will be particularly useful for students
who plan to seek residencies.
The book can also be useful for students who plan to practice in community settings by
helping them understand how health systems work. Not all community pharmacists understand
health-system practice, although a general understanding of those systems can be valuable when
interacting with pharmacists in them. Interactions often occur as patients move in and out of
hospitals and other settings. Greater contact and understanding will also be needed across prac-
tice settings if integrated therapeutic interventions such as medication therapy management and
specialty medicine are going to succeed in achieving positive patient outcomes.
Practicing pharmacists who read this book can gain insight into health-system practice.
Non–health-system pharmacists working in community settings or other jobs will learn about the
various financial, clinical, technological, and distributional systems in healthcare institutions. This
can be especially useful for individuals seeking new career opportunities.

For Educators
This book can be used as the core text around which an elective or required course in health-
system pharmacy practice can be built. It can also serve as a text for the integration of health-
system pharmacy across the curriculum.
For a standalone elective or required course, educators can build learning experiences around
individual chapters. The chapters can form the backbone of the course. Chapters can be supple-
mented with presentations by practitioners, classroom assignments, and active learning projects.
A textbook would also help guide the presentations of different faculty involved in team-taught
courses. For instance, Part I, Introduction, can be used to provide an overview of health systems
and pharmacy practice within them. Faculty and guest speakers can describe common types of
health-system settings and the types of patients treated in each as well as the pharmacist’s roles
and models of practice, the history of hospital pharmacy, and the various accreditation, regula-
tion, practice standards, and policies and procedures influencing practice. Clarification of concepts
within the related chapters can occur, and problem-based learning activities can be used to apply
and synthesize ideas covered in the book and class.
Use of the text could also occur across the curriculum as part of an integrated, multidisci-
plinary education. This could be accomplished by mapping health-system pharmacy topics across
curriculum, identifying the desired learning objectives for various courses, and matching book
chapters to the learning objectives. For instance, chapters from the Managing Medication Use and
Managing Medication Distribution sections of the book could be assigned as part of hospital intro-
ductory pharmacy practice experiences (IPPEs). Part VI, Sterile Product Preparation and Admin-
istration, could accompany laboratory classes that teach compounding of intravenous solutions.
Financial management could be part of a pharmacy management course, while careers in health-
system pharmacy practice could be part of career training. Students who complete all of the text’s
learning objectives would have much richer APPEs.

David A. Holdford

I N T R O D U C T I O N T O A C U T E A N D A M B U L AT O R Y C A R E P H A R M A C Y P R A C T I C E    vii
EDITOR AND CONTRIBUTOR
David A. Holdford, RPh, MS, PhD, FAPhA
Virginia Commonwealth University
Richmond, Virginia

CONTRIBUTORS

Bruce W. Chaffee, PharmD, FASHP Jami E. Mann, PharmD, MBA, MS, BCPS
Assistant Director of Quality, Safety & Regulatory Clinical Manager
Michigan Medicine, Department of Pharmacy Central Inpatient Pharmacy
Services University of North Carolina Medical Center
Adjunct Clinical Associate Professor of Pharmacy Department of Pharmacy
The University of Michigan College of Pharmacy, Chapel Hill, North Carolina
Department of Clinical Pharmacy
Ann Arbor, Michigan Jerrod Milton, BSc, PharmD, RPh
Vice President, Operations
Kathy A. Chase, PharmD Professional Services Division
Cardinal Health Children’s Hospital Colorado
Prairie Village, Kansas Anschutz Medical Campus
Aurora, Colorado
George J. Dydek, PharmD, BCPS, CDE, FASHP
Clinical Pharmacist, Family Medicine Clinic Lee B. Murdaugh, RPh, PhD
Department of Pharmacy Director, Quality and Regulatory Affairs
Madigan Army Medical Center Cardinal Health
Joint Base Lewis McChord Knoxville, Tennessee
Tacoma, Washington
John E. Murphy, PharmD, FASHP, FCCP
Fred M. Eckel, MS, FASHP, FAAAS, DNAP Professor of Pharmacy Practice and Science
North Carolina Association of Pharmacists Associate Dean, College of Pharmacy
Chapel Hill, North Carolina Professor of Clinical, Family and Community
Medicine
Stephen F. Eckel, PharmD, MHA, BCPS College of Medicine, The University of Arizona
Clinical Associate Professor Tucson, Arizona
University of North Carolina Eshelman School of
Pharmacy Scott D. Nelson, PharmD
Chapel Hill, North Carolina Vanderbilt University School of Medicine
Nashville, Tennessee
Ryan A. Forrey, PharmD, MS, FASHP
Senior Manager, Market Development for Julie A. Patterson, BS, PharmD, PhD
Hazardous Drug Safety Department of Pharmacotherapy and Outcomes
Becton, Dickinson, and Company Science
Franklin Lakes, New Jersey Virginia Commonwealth University School of
Pharmacy
Brad Ludwig, RPh, MS Richmond, Virginia
Assistant Director of Pharmacy
University of Wisconsin Hospital and Clinics Jennifer Phillips, PharmD, BCPS, FCCP
Madison, Wisconsin Midwestern University
Downers Grove, Illinois

v i i i    I N T R O D U C T I O N T O A C U T E A N D A M B U L AT O R Y C A R E P H A R M A C Y P R A C T I C E
 CONTRIBUTORS

Emily C. Prabhu, PharmD Kasey K. Thompson, PharmD

University of Virginia Health System Chief Operating Officer & Senior Vice President
Charlottesville, Virginia Office of Policy, Planning and Communications
ASHP
Thomas P. Reinders, PharmD Bethesda, Maryland
Virginia Commonwealth University
Richmond, Virginia David J. Tomich, PharmD, FASHP
Chief of Clinical Pharmacy Service
S. Trent Rosenbloom, MD, MPH, FACMI Department of Pharmacy
Vanderbilt University School of Medicine Madigan Army Medical Center
Nashville, Tennessee Joint Base Lewis McChord
Tacoma, Washington
Douglas J. Scheckelhoff, MS
Senior Vice President John P. Uselton, RPh
Office of Practice Advancement Vice President
ASHP Operations Improvement
Bethesda, Maryland Cardinal Health
Houston, Texas
Philip J. Schneider, MS, FASHP, FASPEN, FFIP
Professor and Associate Dean Asli Ozdas Weitkamp, PhD
University of Arizona College of Pharmacy Assistant Professor
Phoenix, Arizona Department of Biomedical Informatics
Director
Carrie A. Sincak, PharmD, BCPS, FASHP Clinical Decision Support and Knowledge
Assistant Dean for Clinical Affairs Engineering, HealthIT
Professor of Pharmacy Practice Nashville, Tennessee
Midwestern University Chicago College of Pharmacy
Downers Grove, Illinois Andrew L. Wilson, PharmD, FASHP
Vice President, 340B Solutions
Shane Stenner, MD, MS McKesson, U.S. Pharmaceutical
Vanderbilt University Medical Center Richmond, Virginia
Nashville, Tennessee
William A. Zellmer, BSPharm, MPH
Jack Temple, MS, PharmD President
Manager Pharmacy Foresight Consulting
Information Technology and Medication Use Bethesda, Maryland
Systems
UW Health
Madison, Wisconsin

I N T R O D U C T I O N T O A C U T E A N D A M B U L AT O R Y C A R E P H A R M A C Y P R A C T I C E    ix
 PA RT I : I N T R O D U C T I O N

CHAPTER
1
Introduction to Acute and Ambulatory Care
Health-System Pharmacy Practice
Douglas J. Scheckelhoff and Kasey K. Thompson

provide more timely care, prevent

n n n duplication, and reduce cost.
LEARNING OBJECTIVES ■■ Accreditation: Determination by
an accrediting body that an eligible
After completing this chapter, readers
healthcare organization complies
should be able to: with the accrediting body’s applicable
1. Describe the most common types of standards.
acute and ambulatory health-system ■■ Health-system pharmacy practice:
settings and the types of patients Practice that includes the provision of
treated in each. distributional and clinical pharmacy
2. Describe the pharmacist’s role in services at a broad range of health-
the medication-use process and system settings including hospitals,
specifically how pharmacists improve ambulatory clinics, ACOs, patient-
outcomes, reduce cost, and improve centered medical homes, long-term
safety. care, hospice, home infusion, specialty
pharmacy, and correctional facilities.
3. Contrast the pharmacist’s role in acute
and ambulatory settings. ■■ Integrated health systems: Systems
that integrate all care under the
4. Identify the four primary practice
umbrella of a central organization and
models seen in acute and ambulatory
often include inpatient/acute care,
care health-system settings.
primary care/ambulatory clinics care,
5. List the types of automation and long-term care, and home care settings.
technology common in today’s health
■■ Patient-centered medical home
systems used to improve safety and
(PCMH): A care delivery model
efficiency of medication use.
designed to provide patient-centered
6. List the other disciplines care coordinated through a primary
usually present when providing care physician, with better and more
interdisciplinary team-based care. timely access to services that results in
better overall quality outcomes.
n n n ■■ Practice guidelines: Tools that describe
processes found by clinical trials or
KEY TERMS AND DEFINITIONS by consensus opinion of experts to be
■■ Accountable care organization (ACO): the most effective in evaluating and/
A collaboration of hospitals, doctors, or treating a patient who has a specific
and other providers who work symptom, condition, or diagnosis, or
together voluntarily with the purpose that describe a specific procedure.
of providing better coordinated care Synonyms include clinical practice
for Medicare patients. The goal is to guideline, practice parameter, protocol,
preferred practice pattern, and guideline.

1
2 I N T R O D U C T I O N T O A C U T E A N D A M B U L AT O R Y C A R E P H A R M A C Y P R A C T I C E

■■ Practice model: The operational structure that defines how and where pharmacists
practice including the type of drug distribution system used, the layout and design of
the department, how pharmacists spend their time, practice functions, and practice
priorities. The predominant practice models include the drug-distribution-centered
model, the clinical-pharmacist-centered model, the patient-centered integrated model,
and the comprehensive model.
■■ Privileging: The process by which an oversight body of a healthcare organization or
other appropriate provider body, having reviewed an individual healthcare provider’s
credentials and performance and found them satisfactory, authorizes that individual
to perform a specific scope of patient care services within that setting.
■■ Regulation: Governmental order having the force of law.

n n n
INTRODUCTION
This chapter describes the unique and diverse practice of pharmacy in acute and ambulatory
settings, with an emphasis on hospitals and integrated health systems. The purpose of this
chapter is to introduce the concept of health-system pharmacy practice and key issues that
will be discussed throughout this book.

WHAT IS HEALTH-SYSTEM PHARMACY PRACTICE?

Health-system pharmacy practice is the provision of distributional and clinical pharmacy
services at a broad range of health-system settings including hospitals, accountable care
organizations (ACOs), patient-centered medical homes (PCMHs), ambulatory clinics,
long-term care, hospice, home infusion, specialty pharmacy, and correctional facilities.
Typically, the institutions that pharmacists serve are linked together formally or informally
into integrated health systems. As the term implies, integrated health systems blend all
care under the umbrella of a central organization and often include inpatient/acute care,
primary care/outpatient care, long-term care, and home care.
Health systems are a collection of organizations and institutions whose mission
is to positively impact health outcomes. Although health systems may be made up of
independent entities, they are systems because the entities are interdependent and unified.
The integrated model creates the potential to provide enhanced levels of patient care
continuity through access to medical records and patient care providers. At the completion
of this chapter, the student will have a general understanding of the unique attributes that
comprise the practice of pharmacy in hospitals and health systems, including the various
factors that influence practice in these settings.

TYPES OF HOSPITALS
At one time, health-system pharmacy practice referred almost exclusively to service in
hospital pharmacies; hospitals are still the biggest component of health-system practice.
There are approximately 5,600 hospitals in the United States.1
Hospitals traditionally employ a team of highly skilled nurses, physicians, pharmacists,
and other healthcare practitioners to provide the required care and specialized services for
acutely ill patients who require constant care. Hospitals are often differentiated by factors
such as location, size, and specialization. Location-related factors can include whether a
hospital is situated in a large urban area or small rural setting. Hospitals may be located in
a single building or spread across a campus complex. Some hospitals have a distinct mission
to educate and train healthcare professionals. These hospitals are termed university teach-
 C H A P T E R 1 INTRODUCTION TO ACUTE AND AMBULATORY CARE HEALTH-SYSTEM PHARMACY PRACTICE 3

ing hospitals. Other hospitals emphasize dis-

tinct specialties such as cardiac surgery and KEY POINT . . .
oncology. The following are some common There are approximately 5,600
labels assigned to hospitals:
hospitals in the United States.
■■ Community hospital — Community
hospitals are what most people . . . SO WHAT?
think of when they hear the term Hospitals exist in almost any location
hospital. They are the most com- in the country—each employing
mon type and are designed to deal pharmacists. Opportunities in
with an assortment of diseases and health-system pharmacy practice are
injuries. Community hospitals typi-
everywhere.
cally have emergency services for
treating trauma and other immi-
nent threats to health. They also have inpatients that need surgical, intensive care,
obstetrics, long-term care, medical, and other services to treat a broad group of
medical conditions.
■■ Specialized hospital — Specialized hospitals serve the needs of patients suffering
from some particular disease (e.g., cancer, psychiatric illness), or affecting a spe-
cific organ system (e.g., eyes, lungs) or type of patient (e.g., children, seniors).
■■ Teaching hospital — Teaching hospitals have two missions—serving patients’ needs
and training future healthcare professionals. Teaching hospitals often have some
association with medical schools and sometimes conduct medical research.
■■ For-profit hospital — For-profit hospitals are differentiated from nonprofit hospi-
tals by their ownership. For-profit hospitals are owned by corporations or groups
of private investors. They differ from nonprofit hospitals, which do not seek a
return on investment for owners. Nonprofit hospitals often operate under reli-
gious, volunteer (e.g., Shriners), community, or other voluntary patronages. Any
additional revenue generated after expenses is put back into the hospital.
■■ Government hospitals — These hospitals are owned or heavily supported by fed-
eral, state, county, or other governmental entities such as the Veterans Adminis-
tration, U.S. Public Health Service (e.g., Bureau of Prisons, Indian Health Service),
and the Armed Services (e.g., Army, Air Force, Navy). Various states, counties, and
cities have hospitals for underserved populations such as indigent and psychiatric
patients.
■■ Multihospital system — A multihospital system is formed when a central organiza-
tion owns, leases, sponsors, or contract manages two or more hospitals. Over 60%
of hospitals are part of multihospital systems.

PHARMACY’S ROLES IN THE MEDICATION-USE PROCESS

The role of pharmacists is to lead and influence the safety and quality of all aspects of the
medication-use process. This means that pharmacists should be involved in controlling or
influencing any step of the medication-use process that can impact patient health outcomes
or costs. Pharmacists have important direct or indirect roles in prescribing, transcribing,
dispensing, administration, monitoring, and modifying as well as discontinuing therapy.

Prescribing
The prescribing of medications is often viewed as something that only physicians are
authorized to do. The reality is that many other healthcare professionals are authorized
4 I N T R O D U C T I O N T O A C U T E A N D A M B U L AT O R Y C A R E P H A R M A C Y P R A C T I C E

to prescribe by state law (e.g., dentists,

nurse practitioners, optometrists, podia- KEY POINT . . .
trists) or through a formalized process in Pharmacists have important direct or
hospitals known as privileging. “Privi-
indirect roles in prescribing, transcribing,
leging is the process by which a health-
dispensing, administration, monitoring,
care organization, having reviewed an
modifying, and discontinuing therapy.
individual healthcare provider’s creden-
tials and performance and found them . . . SO WHAT?
satisfactory, authorizes that individual to
The pharmacist’s role in drug-use control
perform a specific scope of patient care
does not end once a medication leaves
services within that organization.”2 Phar-
macists who have prescribing privileges the pharmacy. That role often includes
in hospitals are typically authorized to helping others in their roles within the
do so through the formalized privileging drug-use process. Indeed, a pharmacist’s
process. greatest impact often lies in ensuring
A more common role for pharmacists the quality of the physicians prescribing
beyond actually prescribing is the phar- and the nurses administering the
macist’s duty to influence the prescribing medications.
of other health professionals. Pharmacists
indirectly influence prescribing by acting
as information resources about medica-
tions. They also provide feedback about the quality of prescribing and manage prescribing
through the formulary system.

Transcribing
Transcribing is the process by which a prescriber’s written order is copied and either manu-
ally or electronically entered into pharmacy records. The transcribing process represents an
opportunity for error, especially when done manually. Pharmacists must understand poten-
tial breakdowns in the transcribing process and help find ways to minimize errors. The
problem of manual transcription has diminished greatly because of the movement toward
computerized prescriber order entry, resulting in an electronic transmission of the order.3

Dispensing
Dispensing is the act of physically transferring the drug product following review and
approval of the prescription to the area responsible for administering the medication to
the patient. Dispensing is also an area where medication errors can occur including, but not
limited to, wrong drug, wrong dose, or wrong dosage form errors.

Administration
In hospitals, nurses typically manage the medication administration to the patients. This
phase of the medication-use process is the last step before patients are given their medica-
tions, and errors at this point cannot be corrected. When errors do occur in the medication-
use process, studies have shown that upwards of 34% are in the administration phase.4
Nurses usually serve as the final check in the medication-use process. Pharmacists help
improve the safety of medication administration by clearly labeling medications, using bar-
coding systems and unit dose packaging, reducing the time and effort involved in accessing
drugs (e.g., through the use of decentralized automated dispensing devices), and using tech-
nology that reduces administration errors (e.g., smart infusion pumps).
 C H A P T E R 1 INTRODUCTION TO ACUTE AND AMBULATORY CARE HEALTH-SYSTEM PHARMACY PRACTICE 5

Monitoring
Monitoring the patient’s response to the medication is a critical phase where pharmacists
play a vital role. Monitoring includes reviewing laboratory values, which are correlated with
the expected medication-therapy outcomes as well as other objective and subjective factors
that indicate whether the therapy is effective, or may be having a toxic effect.

Modifying and Discontinuing

Modifying drug therapy occurs when a dosage change is required, or when one therapy is
discontinued and a new therapy is initiated based on the patient’s clinical response to the
drug.

PRACTICE MODELS
Health-system pharmacists comprise their roles in practice models. A practice model can
be defined as the
operational structure that defines how and where pharmacists practice, including
the type of drug distribution system used, the layout and design of the department,
how pharmacists spend their time, practice functions, and practice priorities. The
practice model is probably the most important factor determining the role and effec-
tiveness of the pharmacy department. It sets the stage and defines the roles.5

The term practice model describes how pharmacists, pharmacy technicians, and automation
interrelate to provide pharmacy services. Practice models used vary based on the hospital
type (e.g., community versus academic), institution size (e.g., large versus small), patient
population (e.g., chronic versus critical care), or philosophy of how pharmacy services
should be delivered. There are four major pharmacy practice models6:

■■ Drug-distribution-centered model — In this model, pharmacists primarily distrib-

ute drugs and process new medication orders. The pharmacist’s role is reactive, in
that he or she responds to requests of physicians and nurses but rarely initiates
major changes in therapy. In this model, the pharmacist is not actively involved
with the healthcare team or in development of therapeutic plans for the patient.
Consequently, pharmacists are not accountable for the health outcomes of patients
and exert little leadership in influencing the medication-use process.

■■ Clinical-pharmacist-centered model — There are two types of pharmacists in this

model who serve separate roles in the medication-use process. Clinical pharmacists
work with medical teams on the nursing units to provide services. In its extreme
form, clinical pharmacists in this model are not accountable for drug distribution
or delivery systems. Their primary responsibility is assisting physicians and other
health professionals in avoiding and solving clinical problems exclusive of the dis-
tribution process. Drug distribution is managed by a second type of pharmacist—
the distribution pharmacist. These pharmacists spend most of their time managing
technicians in the dispensing and distribution of medications. Limited collabora-
tion occurs between clinical and distributive pharmacists in the extreme of this
model, so these pharmacists are selectively accountable for the medication-use
process.

■■ Patient-centered integrated model — In this model, all pharmacists in the depart-

ment accept responsibility for all elements of the medication-use process and,
therefore, spend their time on both clinical and distributive functions. Pharma-
cists’ roles in drug distribution are often limited, because many distribution tasks
6 I N T R O D U C T I O N T O A C U T E A N D A M B U L AT O R Y C A R E P H A R M A C Y P R A C T I C E

are delegated to well-trained pharmacy technicians. Therefore, pharmacists are

able to expand their clinical roles to more active engagement in medication selec-
tion and drug use as part of an interdisciplinary team. In this model, pharmacists
exhibit a high degree of ownership of and accountability for the entire medication-
use process.
■■ Comprehensive model — A fourth model is emerging in practice, which can be
called the comprehensive model. It combines elements of the clinical-pharmacist-
centered model and the patient-centered integrated model. The comprehensive
model includes a majority of pharmacists spending their time on both clinical and
distributive functions, but it also has clinical pharmacy specialists assigned to spe-
cific locations or disease states. This way, the benefits of both models is realized.
The resource requirements of this model are such that it is often seen only in
larger academic settings.
The models above are generalizations of what
might be seen in practice, but they describe KEY POINT . . .
the tension between clinical and distributional
The culture of the department
roles of pharmacists. The degree to which a
health-system pharmacy resembles any model influences the success of any
depends on a variety of factors including its particular practice model.
leadership; the relationships it develops with . . . SO WHAT?
medicine, nursing, and the hospital adminis-
tration; its involvement with colleges of phar- A culture where individuals are
macy; the drug distribution model; variations discouraged from trying new things
in regional practice and work force; the pres- often hinders the ability to advance
ence or absence of pharmacy residency training the practice of pharmacy. In many
programs; and department culture (e.g., staff instances, a change in culture is
members’ willingness to accept responsibility necessary for evolution to a new
for patient outcomes).6 practice model.
The culture of the department influences
the success of any particular practice model.
The individuals who make up a pharmacy department will ultimately determine the deliv-
ery of services. Indeed, practice models must be understood and accepted by everyone
within the organization. Pharmacists, technicians, and other individuals must appreciate
how their individual efforts contribute to the department’s mission. Unless the members
develop a common vision, they will not work well as a team. And without teamwork, fac-
tions can develop within the pharmacy leading to “us-versus-them” attitudes.
Whatever the model of pharmacy practice, the following common features are likely
to emerge as key7:
■■ Practice will need to be interdisciplinary and team based as will education and
training of pharmacists.
■■ Medication preparation and distribution must be made more efficient with auto-
mation, centralization, and the use of trained technicians.
■■ Pharmacists’ contributions to the medication-use process are going to increase in
direct patient care and decrease in medication distribution.
■■ Health information technology will give pharmacists much greater ability to posi-
tively influence the medication-use process.
■■ Pharmacists will need to justify their value because allocation of healthcare
resources will be heavily driven by metrics. The benefits of pharmacy services
must be justified against their costs.
 C H A P T E R 1 INTRODUCTION TO ACUTE AND AMBULATORY CARE HEALTH-SYSTEM PHARMACY PRACTICE 7

■■ A pharmacotherapy plan should be developed for every patient. That plan should
be comprehensive, multidisciplinary, accessible, and transferable to any provider
or location. Primary responsibility for this plan should rest with the pharmacist.
■■ Pharmacists will need continuous training to practice pharmacy. Credentialing and
privileging of pharmacists may be requirements for practice in general and spe-
cialty practice areas.
■■ Pharmacists in health systems will need to collaborate better with community
pharmacists to coordinate care as patients transition from one practice setting to
the next.
Although there are health-system pharmacists who have purely distributional respon-
sibilities, most are increasingly involved in direct patient care. Direct patient care typically
occurs with the pharmacist being part of an interdisciplinary patient care team, where
diverse professionals are each responsible for patient care within their scope of practice
and expertise. Teams typically include physicians, nurses, and pharmacists, and they may
also include others such as respiratory therapists and social workers. These teams are syner-
gistic, enabling the patient to benefit from their individual and collective skills in the most
efficient way possible. The team concept has contributed to the pharmacist’s clinical role
through providing a portal for pharmacist recommendations on drug therapy and monitor-
ing, and puts the pharmacist into daily contact with the patient. Because these models are
becoming integral to experiential education models, most new graduates feel comfortable
moving into these roles and often seek out these types of positions upon graduation.

KEY INDIVIDUALS
Importance of Pharmacy Leadership
Possessing good leadership skills and providing leadership is important for virtually
all pharmacist roles, but it is especially crucial for those individuals responsible for the
oversight of pharmacy services. This includes the primary pharmacist in charge and other
pharmacy managers who have responsibility for specific aspects of pharmacy services.
The primary pharmacist in charge, usually referred to as the Director of Pharmacy,
has ultimate responsibility and accountability for all aspects of the pharmacy service.
This includes the safety of medication use, quality of drug information provided,
financial budgeting and management, human resources, drug procurement, technology
implementation, education and qualifications of their staff, regulatory compliance, and
adherence to accreditation standards.8,9 The quality of services depends on strong leadership
in these types of positions as well as the advancement of pharmacy practice.

Pharmacists
Pharmacists can fill a number of different roles in acute and ambulatory settings. The most
traditional role is that of the dispensing pharmacist. These individuals are responsible for
preparation of medications, either directly or through supervising the preparatory work
of pharmacy technicians. Dispensing pharmacists play an important role in verifying
that medications are prepared correctly and are dispensed accurately. But because of the
increasing use of technicians, coupled with greater use of automation and technology and
more dosage forms being commercially available, positions for dispensing pharmacists are
declining in some institutions. While the dispensing pharmacist is less common, pharmacist
oversight of the dispensing and preparation process remains critical. Fortunately,
pharmacy education is preparing new pharmacy graduates to fulfill both dispensing and
non-dispensing roles.
8 I N T R O D U C T I O N T O A C U T E A N D A M B U L AT O R Y C A R E P H A R M A C Y P R A C T I C E

Clinical pharmacy practice is another role for pharmacists. Clinical pharmacists are
likely to serve on interdisciplinary patient care teams and interact directly with patients.
Clinical pharmacists usually have clinical pharmacy training and often have completed a
pharmacy residency. Clinical pharmacists may be generalists and provide clinical pharmacy
services to a wide range of patients, or they may be specialists who have a defined expertise
in one or more areas (e.g., critical care, oncology). The prevalence of these clinical pharmacy
roles continues to increase, and this trend will likely continue.
The most prevalent role in health-system practice is one where the pharmacist has both
dispensing and clinical roles, usually referred
to as an integrated practice.3 This type of
role may involve the pharmacist spending a KEY POINT . . .
designated amount of time in each area (e.g., Pharmacy education is preparing new
1 month spent dispensing alternating with 1 pharmacy graduates to fulfill both
month of clinical practice) or time split in dispensing and non-dispensing roles.
a given day (e.g., mornings spent in patient
care areas rounding and providing order . . . SO WHAT?
review followed by afternoons in the phar- Educators still struggle with the
macy verifying technician-prepared medica- decision about the exact role of
tions). For the most part, these pharmacists
pharmacists within health-system
are considered generalists in both dispens-
practice. Some advocate for the
ing and clinical activities.
clinical-pharmacist-centered practice
Pharmacists in management usually
model, while other educators
serve as the supervisor for pharmacy activi-
emphasize drug-distribution-centered
ties or as the director for the pharmacy
department. These roles require an under-
or integrated practice models. This
standing of the practice of pharmacy and textbook takes the position that
how medications are used; a good knowl- regardless of the preferred practice
edge of regulations and laws that govern model, both dispensing and non-
pharmacy practice; and basic skills in human dispensing roles are important.
resource management, leadership, and bud-
get management as well as ensuring quality
of medication use. Good managers are especially important because the effectiveness of
pharmacy services often depends on how well the department is managed and led.
Other pharmacist roles are evolving. Examples include pharmacists who are responsi-
ble for informatics, investigational drug services, research, sterile compounding, and emer-
gency care.

Pharmacy Technicians
Pharmacy technicians continue to play an expanding role in virtually all practice
models. Technicians have been integral in the purchasing, stocking, preparation, and
compounding of medications. This has been and continues to be under the pharmacist’s
direct supervision. The scope of this role varies depending on the pharmacy technician’s
experience, training, and skills. The scope and responsibility often vary because technicians
do not have consistent and standardized training requirements. Because technicians play
an increasingly important role in drug preparation and dispensing, technician training
standards are being established. This will allow greater responsibility to be transferred to
pharmacy technicians because each will meet a defined training and certification standard.
Pharmacy technicians are also taking on new and expanded roles beyond preparation
and dispensing. Some technicians are assuming roles that involve the maintenance of
automated dispensing technology and other information technology systems. Others are
 C H A P T E R 1 INTRODUCTION TO ACUTE AND AMBULATORY CARE HEALTH-SYSTEM PHARMACY PRACTICE 9

assuming roles that assist clinical pharmacists in the collection of laboratory values or
other clinical data. In some organizations, pharmacy technicians are interviewing patients
and reconciling medication regimens at home with those ordered during their hospital stay.
Regardless of whether technicians are in traditional medication preparation roles or in one
of these new capacities, their importance in freeing the pharmacist for more direct patient
care responsibilities is increasing, and so is the need for training and certification.

Importance of Automation and Technology

Automation and technology have been used in pharmacy for many years, but use has grown
considerably in the past 10–15 years. Pharmacy automation serves to increase efficiency and
accuracy of dispensing. Medication-related technology used outside of the pharmacy (e.g.,
bar-coded medication administration, smart pumps, computerized prescriber order entry) is
usually focused on safety. Pharmacy automation is important to the practice model because
utilization of many available technologies can influence what the pharmacist and pharmacy
technician do in support of medication dispensing. Full use of automation can redirect staff
time away from routine technical tasks and toward more direct patient care activities.
The most common type of pharmacy automation is the unit-based dispensing cabinet.
These cabinet-based technologies are usually located strategically in the patient care area
and contain compartments where individual medications are stored. The compartments
open and give access only to authorized users of the medication. Usually this authorization
is based on the computer in the cabinet verifying that the medication has been approved
through an interface with the pharmacy computer system. These systems have been suc-
cessful because they place medications much closer to the user, but still allow electronic
verification that the medication and dose are correct for the patient. They also simplify
billing and documentation of medication administration.
The second most common type of pharmacy automation is the pharmacy robot. These
systems contain hundreds of bar-coded packages placed in designated spaces on long rods.
The robot moves to the designated space, verifies that it is the correct medication using the
bar code, and removes the number of doses needed. The robot is usually used to prepare a
24-hour supply of oral and prepackaged injectable medications. Using this technology greatly
reduces the pharmacist and technician time needed to prepare and check medications.
Automation used in sterile compounding ranges from small pumps used to fill syringes
and prepare parenteral nutrition solutions to large systems with robotic arms capable
of preparing all types of sterile intravenous (IV) solutions and infusions. These systems
improve the efficiency of sterile product preparation while improving the accuracy of the
preparation and minimize potential contamination. Other systems help manage pharmacy
IV workflow and verify accuracy through a bar-code scan and gravimetric means.
Many medication-related technologies are used outside of the pharmacy to improve
safety. These systems have a direct impact on the pharmacy and require active involvement
by the pharmacy in making sure that systems are designed and used optimally to realize
their safety benefits. Examples of medication-related technologies include:
■■ Bar-coded medication administration (BCMA) systems (see Chapter 9 for more
information on BCMA), requiring pharmacy involvement in ensuring that drug
packages have appropriate, readable bar codes and that information systems cap-
ture and document information.
■■ Computerized provider order entry (CPOE) systems (see Chapter 10 for more infor-
mation on CPOE) require an interface or integration with pharmacy information
systems so that medication ordering information is able to transfer between the
Discovering Diverse Content Through
Random Scribd Documents
 Transcriber’s Note
The printer employed the diaeresis in words like
‘coördination’ or ‘coöperation’. On p. 157, the first
syllable of ‘coöperating’ fell on the line break, and the
word was hyphenated as ‘co-operating’, since the
diaeresis was not needed. The word has been joined
here and the diaeresis employed as ‘coöperating’.
The following words appear both with and without a
hyphen: to-day, non-entity, half-way, inter-connected,
non-entity.
Errors deemed most likely to be the printer’s have
been corrected, and are noted here. The references are
to the page and line in the original.
20.10 restraining g[i/o]vernment. Replaced.
21.31 is kept in contact w[ti/it]h Transposed.
57.30 Now the scientific philosop[h]y Inserted.
69.9 no other way of putting[s] Removed.
things
77.6 these relationships Added.
constitute[s] nature.
157.20 societies of c[o-/ö]perating Replaced.
organisms.
160.8 These divis[i]ons are Inserted.
176.3 extends beyond[s] the spatio- Removed.
temporal continuum
177.6 by the reali[z/s]ation of pattern Consistency.
177.25 character of spatio-temporal [of Removed.
]extension
183.5 radiate its energy i[s/n] an Replaced.
integral number
195.4 history of the Christi[o/a]n Replaced.
Church
195.7 apocalyptic forecast[e]s Removed.
202.21 This divis[i]on of territory Inserted.
213.10 what anything is in i[t]self. Inserted.
245.27 even [al]though any such Removed.
discrimination
274.14 its sta[k/t]e of rapid Replaced.
development
276.17 The task of coö[r]dination is left Inserted.
279.22 What I mean is art [(]and Removed.
aesthetic education.
288.33 mutually coö[o]perate. Removed.
290.3 it bars coö[o]peration. Removed.
*** END OF THE PROJECT GUTENBERG EBOOK SCIENCE AND
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