Drug distribution in Hospital Pharmacy, relationship b/w purchasing and drug distribution & relationship b/w purchasing and clinical services.

2. DRUG DISTRIBUTION,
RELATIONSHIP B/W
PURCHASING, DISTRIBUTION &
CLINICAL PHARMACY SERVICES
KAINAT MALIK, ANOOSH ZAHID, ANOOSHA KHAN & AREEJ ALI
4TH PROF. LCWU

3. DRUG DISTRIBUTION
 The supply, delivery & transitory storage of drugs at patient-care areas(nursing stations) other than main
hospital pharmacy for subsequent patient’s utilization is called distribution.
 It occurs in two ways:
 Directly; issue to the patients on doctors prescription
 Indirectly; issue to the patients as ward & department stock

4.  Once prescribed by a doctor, inside a hospital, the drug, or more precisely the decision of its prescription
will follow a complex circuit, involving numerous intermediates (human and technical) leading to drug
dispensation and follow-up.
 Regulatory guidelines and rules harmonise and standardise this drug pathway in hospitals. Any
weakness in this distribution system will be the source of nosocomial drug iatrogenic.
 The goal is to ensure that each dose of medication administered to each patient is exactly that which
was intended by the prescriber.

5. CLASSIFICATION
For in-patients
For out-patients

6. DRUG DISTRIBUTION FOR IN-PATIENTS
 An inpatient (or in-patient), on the other hand, is "admitted" to the hospital and stays overnight or for an
indeterminate time, usually several days or weeks, though in some extreme cases, such as with coma for
years.
 Treatment provided in this fashion is called inpatient care.
 The admission to the hospital involves the production of an admission note. The leaving of the hospital
is officially termed discharge, and involves a corresponding discharge note.

7. IN PATIENTS

8. METHODS OF DRUG DISTRIBUTION FOR IN-PATIENTS
 Individual drug order system
 Floor stock system
 Complete floor stock system
 Combined individual drug order-floor stock system
 Unit dose distribution system

9. INDIVIDUAL DRUG ORDER SYSTEM
 It is also termed as individual prescription order system.
 It is used by small or private hospitals due to desirability of an individualized service & for availability of
a reduced manpower.
 It provides better interaction among physician, patient & pharmacist.

10.  Advantages
 All medication orders are directly reviewed by pharmacist .
 It provides closer control of inventory.
 Disadvantages
 There may be possible delay in obtaining the required medications for administration to the patient .
 Increase in the cost to the patient

11. Individual
prescription orders
This Photo by Unknown Author is licensed under CC BY-SA

12. FLOOR STOCK SYSTEM
 It is a traditional system, involves separate storage facility at each floor.
 The nursing area has limited (10 to 100) dosage forms
 It may include many bulk supply of medications
 All selection is approved by pharmacy & therapeutic committee.
 The medications include;
 Charge floor stock drugs
 Non-charge floor stock drugs

13. CHARGE FLOOR STOCK DRUGS
 These are drugs for which patient is charged for every single dose administered to him •
 Selection of these drugs is made by PTC •
 Charge floor stock drugs are stored at various nursing stations •
 An envelope is used to dispense such drugs.
 Examples;
 Anti-allergies; Prednisolone tablet
 Antibiotics Penicillin G inj.
 Anticoagulant heparin

14. NON-CHARGE FLOOR STOCK DRUGS
 These drugs are placed at nursing stations for use without direct charging to patient’s account but
costing in per day cost of the hospital room.
 The selection of these drugs is based on cost of drugs, frequency & quantity of drugs used.
 Examples;
 Glucose
 Normal saline
 Paracetamol

15. METHODS OF DISPENSING NCFSD
 Drug basket method;
 The night nurse check the medicine cabinet, fill
the requisition & place the empty containers in
the drug basket & sent it to the pharmacy.
 In the morning the pharmacy fill the containers
& dispense them.

16. MOBILE DISPENSARY UNIT
 It is also called medication cart system, made of stainless steel with
appropriate dimensions to hold all sort of drugs & is equipped
with wheels.
 The main compartment is provided with locking, sliding doors with
a handle.
 The interior consists of shelves

17.  When one unit is in use the other is being serviced.
 It is not necessary for the night nurse to check the pharmacy inventory & sent the empty containers to
the pharmacy
 It is the duty of the pharmacist or his nominee to check the inventory & check off items & quantity of
supplies left.
 A duplicate requisition form is filled for floor stock supplies & original is sent to the pharmacy.
 This method allows a better supervision by the pharmacist.

18. DIFFERENCE B/W CHARGE & NON-CHARGE DRUGS
Charge drugs
 The charges are included in patient’s account
after the drugs have been administered from the
stock drugs.
 Every dose of the drug administered to the
patients is charged.
 Floor stock list is prepared which is sent to the
pharmacy to make the drugs available at all
nursing station.
Non-charge drugs
 The drugs are not charged in the account
directly even after the drug has been
administered .
 The charges are made indirectly to the patient's
account .
 The cost of the drugs are not high as they are
mostly tablets, capsules.
 A pre-determined list is prepared by nursing
station

19. COMPLETE FLOOR STOCK SYSTEM
 The nursing station pharmacy caries both charged & non-charged medicines.
 It operates in two ways;
 Floor stock system under supervision of a nurse
 Satellite pharmacy

20. FLOOR STOCK SYSTEM UNDER SUPERVISION OF A NURSE
 The supply, delivery & transitory storage of drugs at nursing station are requisitioned by nursing service
& are distributed by pharmacy personnel.
 Expensive drugs are only dispensed upon the receipt of a prescription
 It reduces the workload of pharmacy.
 It increases the chances of medication errors due to elimination of pharmacist review.

21. SATELLITE PHARMACY
 A satellite pharmacy is defined as a pharmacy in an institution which provides specialized services for the
patients of the institution and which is dependent upon the centrally located pharmacy for
administrative control, staffing, and drug procurement.
 The patient care satellites operate to provide pharmaceutical care to our patients. Each satellite is
designed to meet the special needs of select patient populations.
 Pharmacists in patient care areas provide drug information, individualized medication dosing, as well as
assist in designing intravenous nutritional support, and provide education to patients and other
members of the healthcare team.
 Pharmacists in the patient care satellites participate in patient care rounds as an integral member of the
multidisciplinary healthcare team. All pharmacists attend cardiac/respiratory arrests and assisting in drug
dosing and preparation, and other services as needed.

22.  Pharmacists in the Critical Care Satellite are
skilled in providing pharmaceutical care
services for patients in our Surgical/Trauma,
Neurosurgery, and Medical/Surgery Intensive
Care Units

23. COMBINED INDIVIDUAL DRUG ORDER-FLOOR STOCK SYSTEM
 It is a type of drug distribution system that uses individual prescription or medication order system as
their primary means of dispensing along with a limited floor stock system.
 It is commonly used in hospitals.

24. UNIT DOSE DISTRIBUTION SYSTEM
 A unit-dose drug distribution system is in place for all dosage forms to provide patient-specific,
individually packaged medications, which minimizes nurse/caregiver drug product manipulation (e.g.,
cutting in half) in order to arrive at the correct dose prior to administration.
 These unit doses of medication are also dispensed with individually labelled bar code packaging to
enable nurse scanning of the medication at the bedside just prior to medication administration.

25.  ADVANTAGES:
 Patient receives improved services and are
charged for only those doses which are
administered •
 Medication errors are reduced •
 More space is available in nursing station by
eliminating bulky floor stock •
 It eliminates wastage of drug.
 A pharmacist directly review the physician’s
medication order, it eliminates the chances of
drug related problems.

26. METHODS OF UNIT DOSE DISTRIBUTION
Centralized unit dose
distribution system
De-centralized unit
dose distribution
system

27. CENTRALIZED UNIT DOSE DISTRIBUTION
 The drugs are stored at central pharmacy & distributed in unit doses while receiving the medication
order.
 DECENTRALIZED UNIT DOSE DISTRIBUTION:
 In this system the distribution operates through small satellite pharmacies at each floor.
 The central pharmacy is involved in procurement, storage, manufacturing & packaging services.
 The medication order is received by the Pharmacist who check it for interactions & allergies, then the
drugs are sent to the nursing stations for administration.

28. COMPUTER AIDED DISPENSING
 To save the time of all personnels, computerized dispensing system is used.
 Under this system computer of Physician, Pharmacist & nursing station are networked with each other,
the prescriber enters the prescription received by the pharmacist.
 He check it for interactions, after checking , at nursing station a nurse receives the order for
administration.
 Different softwares are available to alert the personal if the drug is not in inventory or not prescribed
according to dose/route of administration recommended in hospital formulary.

29. DRUG DISTRIBUTION FOR OUT PATIENTS
 An outpatient (or out-patient) is a patient who is hospitalized for less than 24 hours. Even if the patient
will not be formally admitted with a note as an outpatient.
 Treatment provided for out patient is called ambulatory care. Sometimes surgery is performed without
the need f.or a formal hospital admission or an overnight stay. This is called outpatient surgery.

30. OUT-PATIENT

31. AMBULATORY CARE
 Ambulatory care or outpatient care is medical care provided on an outpatient basis, including diagnosis,
observation, consultation, treatment, intervention, and rehabilitation services.
 It has three categories:
 Primary care
 Emergency care
 Referral /tertiary care

32.  Primary care:
 Primary care is the day-to-day healthcare given by a health care provider. Common chronic illnesses
usually treated in primary care may include, for example: hypertension, angina, diabetes, asthma,
depression and anxiety, back pain, arthritis or thyroid dysfunction.
 Emergency care:
 The emergency department must provide initial treatment for a broad spectrum of illnesses and
some of which may be life-threatening and require immediate attention.
 Referral/ tertiary care:
 In medicine, referral is the transfer of care for a patient from one clinician or clinic to another by
 Tertiary care is usually done by referral from primary or secondary medical care personnel.

33. LOCATION OF OUT-PATIENT DRUG DISTRIBUTION AREA
INDEPENDENT OUT-
PATIENT PHARMACY
IN & OUT-PATIENT
COMBINED PHARMACY

34. INDEPENDENT
OUT-PATIENT
PHARMACY
 A separate set up with
specialized function for
provision of out-patient
pharmaceutical services
operating under the main
pharmacy.
 Disadvantages;
 Need of separate staff &
consumption of time .

35. IN & OUT-PATIENT COMBINED PHARMACY:
 In this type of pharmacy both in & out-patients services are provided.
 It eliminates the disadvantages of independent pharmacy & there is a greater degree of supervision.
 TYPES;
 Combined pharmacy with one window; where both in & out patients can be served.
 Combined pharmacy with separate windows; separate windows for in & out patients.

36. DISTRIBUTION OF NARCOTICS:
 It follows the same procedure but requires
more strict control, it is needed in stocking,
handling & distribution of controlled
substances.
 The delivery of narcotics from hospital
pharmacy to nursing station needs a reliable
person supervision
 Record keeping of all activities during handling
& distribution of controlled substances help to
avoid their abuse
 A nurse may be wholly or partially responsible
for violation of any regulations described
above.

37. DISTRIBUTION OF SURGICAL ITEMS:
 The service may consists of supplying surgical items as sutures, surgical dressings & other equipments
employed by the surgeon prior to, during & after a surgical operation, the hospital pharmacist must
have necessary information regarding the surgical supplies.
 The selection of correct type of ancillary items would be a critical factor for the welfare of patient
undergoing surgery, the pharmacy practice in Pakistan yet devoid of such services

39. RELATIONSHIP BETWEEN PURCHASING AND DISTRIBUTION
 Our basic concern is with planning , organizing and controlling the flow of materials from their initial
purchase through internal operations to the service point through distribution.
 Purchasing and distribution is a main function of hospital pharmacy.

41. A BRIEF REVIEW ON PURCHASE:
 Purchase : It means to obtain an item by paying money per its equivalent or to buy for a price.
 Drugs and allied items can be purchased by following methods:
 Direct purchase from manufacturer or wholesaler
 Bid from either manufacturer or wholesale
 Purchase from local retail pharmacy or contract purchase.

42. PURCHASING AUTHORITY
(1) Centralized Purchase
(2) Purchase by hospital pharmacist
Centralized Purchase:
An institutional material purchase department or its purchasing agent is responsible for purchase of
drugs and related supplies.
The pharmacist requests the items to be purchased on a special form , guides and assists the
purchasing agent in purchasing function.

43. Purchase by hospital pharmacist :
The other system is purchase of drugs and related items by the pharmacist .
The pharmaceuticals and related items constitute specialties that require the technical skills of a
trained pharmacist for their proper selection and purchase.

44. DRUG DISTRIBUTION
 At the health centre level , drug distribution concerns mainly dispensing drugs to patients.
 This requires an understanding of the patients ( who may not speak or understand the language of
the dispenser ) and practical skills in dispensing and record keeping.
 The other aspect of distribution of drugs at health centre is the return of overstocked and nearly
expired drugs to the medical store.

46. FLOW CHART

47. DISTRIBUTION NETWORK
 As you can see in the flowchart:
 The drug travels from the manufacturer to the purchaser and then to the distributor.
 From the distributor to the pharmacies and health centers.

48. PURCHASING AND CLINICAL PHARMACY SERVICES
 Purchasing
 Purchasing refers to a business or organization attempting to acquire goods or services to
accomplish its goals. Although there are several organizations that attempt to set standards in the
purchasing process, processes can vary greatly between organizations. Typically the word
“purchasing” is not used interchangeably with the word “procurement”, since procurement typically
includes expediting, supplier quality, and transportation and logistics (T&L) in addition to purchasing
 An inventory control pharmacist or technician may develop specific purchasing criteria based on
budget planning
 Suppliers and manufacturers then compete for the business through a confidential sealed bid
process

49. PURCHASING MANAGEMENT
 Budget planning and accurate inventory tracking are extremely important and are often responsibility of
the clinical pharmacist
 This person assumes the role of buyer and is responsible for contracts , ordering and receiving
 Automation assists the pharmacy in meeting and adjusting budgeting control
 Space is limited so it is important to have sufficient inventory without shortages
 Physical inventories are performed annually
 This management is the cornerstone of purchasing inventory control
 Maintained by P&T committee
 The products on formulary dictate what the pharmacy should dictate and keep in inventory

50. PURCHASING RELATED TO CLINICAL PHARMACY SERVICES
 It includes :
 Maintain drug inventory control
 Purchase all drugs
 Receive, store and distribute drugs
 Interview medical service representatives

51. PURCHASING SYSTEMS IN CLINICAL PHARMACY
 It might be independent purchasing and group purchasing
INDEPENDENT:
A single entity establishes a contractual agreement with a pharmaceutical manufacturer or whole seller
GROUP:
Agreement between a manufacturer and a group of entities

52. OBJECTIVES
 It outlines the progression of automation
 Describes the strategic planning process for incorporating automation into current and future clinical
pharmacy practice
 Define the selection process for automation that incorporates the clinical, dispensing and purchasing
functions of pharmacy department
 Discuss the impact of automation on purchasing in clinical pharmacy

53. BENEFIT OF PROPER MANAGEMENT IN PURCHASING IN CLINICAL
PHARMACY
 Efficient dispensing
 Improved accuracy
 Lower inventory costs
 Scalable fulfillment capacity
 Support for clinical programs
 Frees up time for the patients
 Increases business opportunities

54. PURCHASING SUPPORT FOR CLINICAL PHARMACIST
 The clinical specialist should work very closely with the purchasing agent
 Tell them what they do not know
 Think outside the package
 Know the formulary and empower yourself

55. CLINICAL PHARMACY
Clinical pharmacy is the branch of pharmacy in which doctor of pharmacy provide patient care that
optimizes the use of medication and promotes health, wellness, and disease prevention
 Clinical pharmacy is a health science discipline in which pharmacists provide patient care that optimizes
medication therapy and promotes health, and disease prevention. The practice of clinical pharmacy
embraces the philosophy of pharmaceutical care, blending a caring orientation with specialized
therapeutic knowledge, experience, and judgment to ensure optimal patient outcomes. As a discipline,
clinical pharmacy also has an obligation to contribute to the generation of new knowledge that
advances health and quality of life.

56. PROCUREMENT CYCLE IN CLINICAL PHARMACY
 Review selection
 Determine needed quantities
 Reconcile needs and funds
 Choose the method
 Select suppliers
 Specify contract terms
 Monitor order status
 Inspection

57. DRUG PROCUREMENT IN CLINICAL PHARMACY
 It is based on selected drugs and dosage forms and available financial resources
Procedures adopted in this process are
1. Estimating quantity of each drug product required for a given period
2. Finding out prices of different drugs
3. Allocating funds for each dosage forms
Requisition for drugs and dosage form is made after due consultation with prescribers

58. ROLE OF CLINICAL
PHARMACIST
 While regular pharmacists normally work in
a pharmacy, a clinical pharmacist works
directly with medical professionals and
patients, usually in a medical center,
hospital or health care unit. The job of
the clinical pharmacist is to determine the
best medications for a given symptom for a
patient at a given time

59. CLINICAL PHARMACY
SERVICES
 Clinical Services Provided
by Pharmacists. Clinical
Pharmacy .These pharmacists work with
other members of the health care team to
promote optimal patient outcomes
 Maintenance of Regulations. Various rules
and regulations are in place in regards to
procurement of drugs in a pharmacy. It is
the duty of pharmacy procurement to
ensure that the procedures regarding
purchasing, storage and distribution of
drugs from the pharmacy follow the
prescribed legal polices.

61. MEDICATION USE EVALUATION
 Despite rigorous expert review, medications often fall into routine use with unrecognized and unwanted
complications. Use of some medications remains controversial because information to support efficacy is
conflicting, scant, or nonexistent. Medication use evaluation (MUE) is a performance improvement tool
that can be used when there is uncertainty regarding whether a medication will be beneficial. It is
particularly useful when limited evidence is available on how best to choose between two or more
medications. MUEs can analyze the process of medication prescribing, preparation, dispensing,
administration, and monitoring. MUEs can be part of a structured or mandated multidisciplinary quality
management program that focuses on evaluating medication effectiveness and improving patient safety.

62. THERAPEUTIC DRUG MONITORING
 Therapeutic drug monitoring is a branch of clinical chemistry and clinical pharmacology that specializes
in the measurement of medication concentrations in blood. Its main focus is on drugs with a narrow
therapeutic window.

63. ADVERSE DRUG
REACTION REPORTING
 Established in 1968, The
WHO Program for Internati
onal Drug
Monitoring(PIDM) provides
a forum for WHO Member
States to collaborate in
the monitoring
of drug safety, and notably,
the identification and
analysis of new adverse
reaction signals from data
submitted to the
WHO global individual case
safety report (ICSR) ..

64. PAIN MANAGEMENT
 Pain management, pain medicine, pain
control is a branch of medicine employing
an interdisciplinary approach for easing the
suffering and improving the quality of life of
those living in misery

65. PHARMACEUTICAL
CARE
 Pharmaceutical care is the
responsible provision of
drug therapy for the
purpose of achieving
definite outcomes that
improve a patient's quality
of life . These outcomes are
 cure of a disease;
 elimination or reduction of
a patient's symptomatology;
 arresting or slowing of a
disease process; or
 preventing a disease or
symptomatology

66. NUTRITIONAL SUPPORT
 The provision of enteral or parenteral nutrients to treat or prevent malnutrition. Nutrition
Support Therapy is part of Nutrition Therapy which is a component of medical treatment that can
include oral, enteral, and parenteral nutrition to maintain or restore optimal nutrition status and health.

67. CHEMOTHERAPEUTIC DRUG MONITORING
 Therapeutic drug monitoring is not routinely used for chemotherapy agents. There are Several reasons,
but one major drawback is the lack of established therapeutic Concentration ranges. Combination
chemotherapy makes the establishment of Therapeutic ranges for individual drugs difficult, the
concentration-effect relationship for a single drug may not be the same as when that drug is used in a
drug combination. Pharmacokinetic optimization protocols for many classes of cytotoxic compounds
exist in specialized centers, and some of these protocols are now part of large multi center trials.

68. INVESTIGATIONAL DRUG SERVICES
Some of these services includes
 Integrity of blinding
 Regulatory compliance
 Prevention of errors involving study drugs
 Dispensing of investigational products in a timely manner
 Contribution to study design and data integrity
 Randomization and study drug accountability
 Sterile preparation and distribution
 Drug and supply procurement as needed
 Preparation of Drug Data Sheets for study medications
 In-services and education for inpatient studies

70. REFERENCES:
 https://www.slideshare.net/rajusanghvi1/drug-distribution-in-hospital-pharmacy
 https://www.ncbi.nlm.nih.gov/pubmed/12422558
 http://apps.who.int/medicinedocs/documents/s19622en/s19622en.pdf
 Book; Hospital Pharmacy, Nadeem Irfan