Drug Distribution system & Hospital formulary

Drug Distribution System In Hospital
&Hospital formulary
By:- Dr. Manish Pal Singh,
Associate Professor
1AGRA PUBLIC PHARMACY COLLEGE, ARTONI, AGRA, UP, INDIA

Introduction (Drug Distribution System)-
❑ Drug Distribution System is a process of supply of drugs in the hospitals
and other clinics for the treatment of indoor and outdoor patients by indent
system.
❑ It includes the period of time from when the drug is “dispensed” until it is
“administered”.
❑ Drug distribution system divided into 3- types:-
➢ Ward-controlled system
➢ Pharmacy-controlled imprest based- system
➢ Pharmacy- controlled patient issue system (Unit dose system)
❑ Some of the newer concepts and ideas in connection with hospital drug
distribution systems are:
➢ Centralized or decentralized
➢ Automated
AGRA PUBLIC PHARMACY COLLEGE,
ARTONI, AGRA, UP, INDIA
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Drug Distribution to In-patient:-
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4- Types
of drug
distributio
n system
I-Individual
Prescription
Order
System
II-Complete
Floor Stock
System
III- Non-Floor
Stock System
IV- Unit Dose
System

I- Individual Prescription Order System:
➢ This system is generally used by small and private hospitals because of the
reduced manpower requirement and the desirability for individualized service.
➢ It includes the distribution of medicines according to need of individual
patients and his/her prescriptions by paying own charges.
➢ Patient specific containers with 2-5 day supply of drug stored on unit. Drug
order transcribed by nurse and reviewed by pharmacist.
➢ Refilling prescriptions for individual patients may be reordered by submitting a
completed LHS-181 prescription order form.
➢ It should contain Prescriber’s signature, the initials of person sending form and
date(with the form attached).
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➢ When prescriptions are dispensed by the central pharmacy, the copy of LHS-
181 is returned to the health department with patient’s medication.
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Advantages-
- Its review by pharmacist-
So, it reduces the medication
error.
- Facilitate patient’s billing.
- Provides closer control of
inventory.
- It turns to be a patient complied system
as individually the drug distribution
takes place- patient satisfaction.
Disadvantages-
- Applicable only in small
hospitals.
- Storage problems in patient
care systems
- Cost of the medicine to patient increases.
- Delay in obtaining the required medication
or time of delivery is not clear sometimes.

II- COMPLETE FLOOR STOCK SYSTEM
➢ This system deals with drug-order interpretation, drug inventory and drug preparation
on the patient care units to the nurse.
➢ Under to this system the nursing station carries both “charge” & ‘non-charge’ patient
medications.
➢ Drugs stored in nursing station depending upon specialty of care is term as floor stock
drugs. It should be minimum in quantity.
➢ This system is used most often in governmental and other hospitals in which charges
are not made to the patient or when the all inclusive rate is used for charging.
➢ The pharmacist dispenses multiple doses, bulk supply of drugs which are not labelled
for a specific patient.
➢ The system of drug distribution has an effect upon the incidence of adverse drug
reactions.
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➢ Drugs on the nursing station may be divided into “charge floor stock drugs” and
“non-charge floor stock drugs”.
➢ Non-charge floor stock drugs: Medicaments that are placed at nursing station for the use
of all patients .There shall be no direct charge from patients account.
➢ Charge-floor stock drugs: Medicaments that are charged from patients after
administration.
“Non-charge floor system” divided:-
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Drug Basket Method Mobile Dispensary Unit

Advantages-
▪ It may be useful in emergency
patient care conditions .
▪ Elimination of drug returns.
▪ Reduction in the number of drug
order indents for the pharmacy
▪ Reduction in the number of
pharmacy personnel required.
▪ Ready availability of the required
drugs.
Disadvantages-
▪ Increased danger of unnoticed drugs
which are deteriorated.
▪ Medication errors may increase
because the review of medication
order is eliminated.
▪ Incidence of adverse drug reactions
increases.
▪ The proper storage facilities are not
upto mark and may require capital
layout.
▪ The opportunity of pilferage(steal
small items of little value) arises
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III- NON-FLOOR STOCK SYSTEM
➢ All medicaments are available inside the pharmacy and the hospitals use the
individual prescription order system as their primary means of dispensing but
have several drugs in the floor stock.
➢ They have following features that differentiate them from floor system:
➢ A mini-pharmacy
➢ They include a stock of drugs left over by a departed patient to be used for other
patients;
➢ The stock of drugs can be used without a drug order and;
➢ The stock of the drugs can be used without the record keepings.
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Advantages:-
▪ This system is not a complex system
as compared to other systems.
▪ Only pharmacist is involved as the
major personnel.
▪ It is not time consuming.
▪ It plays an important role in the
emergency conditions as no
compulsory medicament indent
required.
▪ Leftover stocks can be used. So,
wastage of medicaments is minimized.
Disadvantages:-
▪ Medication errors increase.
▪ No record is maintained so, it is
not a preferred system used by
hospitals.
▪ The opportunity of pilferage is
maximum in this system.
▪ Not well organized storage
facility.
▪ Not much attention is paid to
prescription monitoring.
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IV- UNIT DOSE SYSTEM
➢ Unit Dose system includes distribution of medications which are contained in,
and administered from, single unit or unit-dose packages and dispensed in
ready-to administer form, to the extent possible.
➢ A patient medication profile is concurrently maintained in the pharmacy for
each patient.
➢ It defined as: “Those medications which are ordered, packaged, handled,
administered and charged in multiples of single dose units containing a
predetermined amount of drugs or supply sufficient for one regular dose
application or use.”
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UNIT DOSE COMPLETE FLOOR STOCK

2-methods of Dispensing Unit Doses:-
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CUDD
(Centralized unit-dose drug
distribution system)
DUDD
(Decentralized unit-dose drug
distribution system)
✓The characteristic features of centralized
unit-dose dispensing are that all in-patient
drugs are dispensed in unit-doses and all the
drugs are stored in a central area pharmacy
and dispensed at the time the dose is due to be
given to the patient.
✓To operate the system effectively, electronic
data processing equipment is not required,
however delivery systems such as medication
carts and dumbwaiters are needed to get the
unit-doses to the patients
✓This operates through small
satellite pharmacists located on
each floor of the hospital.
✓The main pharmacy serves to all
satellite pharmacists.
✓This type of system is used in a
hospital with several buildings.

Procedure for unit dose system:-
➢ Patient profile card containing full date , allergy, diagnostic is prepared.
➢ Direct copies of medication orders are sent to the pharmacist.
➢ The medications ordered are entered on to the Patient Profile card.
➢ Pharmacist checks medication order for:
- Allergies
- Drug –interactions
- Drug-laboratory test effects and
- Rationale of therapy.
➢ Dosage scheduled is coordinated with the nursing station.
➢ Pharmacy technician picks medication orders. Placing drugs in bins of transfer cart per
dosage schedule.
➢ Upon returns to the pharmacy, the cart is rechecked.
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Advantages:-
▪ Patients receive improved
pharmacy service 24 hours day
and are charged for only doses,
administered to them.
▪ All doses of medication required
at the nursing station are prepared
by the pharmacy thus allowing the
nurse more time for direct patient
care.
▪ Very low medication errors.
▪ Eliminates excessive duplication
of orders and paperwork at the
nursing station and pharmacy.
▪ Transfers intravenous preparation
and drug reconstitution
procedures to the pharmacy.
Disadvantages:-
▪ Conserves space in nursing units
by eliminating bulky floor stock.
▪ Eliminates pilferage and drug
waste.
▪ Extends pharmacy coverage and
control throughout the hospital
from the time the physician writes
the order to the time the patient
receives the unit-dose.
▪ Communication of medication
orders and delivery systems are
improved.
▪ The pharmacists can get out of the
pharmacy and onto the wards
where they can perform their
intended function for better
patient care.
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Charging Policy:
➢ A method of charging for pharmaceutical services is described which includes
the cost of drug products , an equitable price for drugs should be charged to
all categories of patient.
➢ These policies can be categorized under several system like-
1. A per diem drug charge or all inclusive or no special rate- A comparison of the
actual charge and the projected per diem rate would produce the same revenue as the
itemized charging method.
2. A Part –inclusive rate- Charge are made for drug not on the ‘free’ or ‘supplied’ list.
3. The professional fee concept- is that fee charged for services from doctors; but not
the actual cost of drug & container.
4. Break-even point pricing- is an accounting pricing methodology in which the price
point at which a product will earn zero profit is calculated. In other words, it is the
point at which cost is equal to revenue.
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5. A cost-plus rate system- is also known as markup pricing. It's a pricing method where a
fixed percentage is added on top of the cost to produce one unit of a product (unit cost)
the resulting number is the selling price of the product.
6. The Profit Aspect- Price o the patient calculated by- a fixed fee per prescription &
addition of predetermined % of the break-even point figure.
7. Computerized Pricing- This system is quite fair and provides computerized on-line
pharmacy pricing. The charges are calculated by adding the product of total cost of
medication and make up factor, to the product of the dose fee and total number of doses
received .
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Distribution of Drugs to OUT-PATIENT/AMBULATORY- Patient:
❑ 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:- Primary care is the day-to-day healthcare given by a health care provider.
▪ 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.
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19
Types of Out patient drug distribution area- 2- ways
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 .
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.

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Hospital Formulary
❑ The hospital formulary is a continuously revised compilation of
pharmaceutical dosage agent and their forms etc. which reflects the current
clinical judgment of the medical staff.
❑ The hospital formulary system is a method whereby the medical staff of a
hospital evaluates & selects from among numerous available medicinal
agents & dosage forms that are considered most useful in the patient care in
the particular hospital.
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Source*-https://www.google.com/url

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Hospital Formulary give the information of-

❑ The main responsibility of making a formulary is of ‘Pharmacy and
Therapeutic Committee’, but pharmacist is an important member of this
committee.
❑ The first hospital formulary in India was published in 1968 by the Department
of Pharmacy ,CMC, Vellore.
❑ The first hospital formulary for the development of government hospital
teachings was published in 1997 at Government Medical College, Trivendrem,
Kerala
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24
Source*-https://www.google.com/url/thiruvananthapuram-medical-college-

Types of Formulary
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OPEN FORMULARY
CLOSED OR
RESTRICTED
FORMULARY
INCENTIVE BASED
FORMULARY

Contents of Hospital Formulary:
❑ The main objective of a formulary in not only to control the use of drug but also
to supply useful information to the prescribers.
❑ The primary objectives of the formulary is to provided the hospital staff with-
❑ Information of drug products approved by PTC
❑ Information of hospital policies & procedures governing the use of drug.
❑ Special information regarding drug.
26

In this view there are three main section of formulary-
1. Information on hospital policies & procedures concerning drugs.
2. Drug products listing
3. Special information
1. Information on hospital policies & procedures concerning drugs-
❑ Information on hospital regulations governing the prescribing, dispensing,
administration of drugs.
❑ Description of PTC
❑ Pharmacy operating procedures
❑ Information on using formulary
❑ How the formulary and the entries are arranged in the system.
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2. Information Drug Products -
❑ This section is the heart of formulary and consist of descriptive entries for each item.
- Formulary item entries:
✓ Alphabetically by generic name
✓ Alphabetically within therapeutic class
-Type of information:
✓ Dosage form, strength, packaging
✓ Active ingredients
✓ Adult/pediatric dose
✓ Route of administration
✓ Cost
-Indexes to the drug products listing:
✓ Generic name/brand name
✓ Therapeutic /pharmacological index
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3. Special information:
✓ Equivalent dosages of similar drugs
✓ Hospital approved abbreviations
✓ Rules for calculating pediatric dosages
✓ List of sugar free drugs
✓ List of dialyzable poisons
✓ Metric conversion tables
✓ Poison control information
✓ Table of drug interactions
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PREPARATION OF FORMULARY
❑ Essential point of formulary for improving drug therapy in hospitals.
❑ Effectiveness of formulary system depends on the abilities of the pharmacists
involved with it.
❑ It is decided by PTC.
❑ Visually pleasing, easily readable and professional in appearance.
❑ A drug that has specific advantages in a small number of patients will be
included in the formulary.
❑ The initial step in the preparation of a formulary for any hospital is its size.
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A typical formulary must have the following composition;
1. Title page
2. Names & titles of the members of the PTC
3. Table of contents
4. Information on hospital policies & procedures concerning drugs
5. Products accepted for use at hospital
6.Appendix
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CONTENTS
❑ Introduction
polices and procedures
list of abbreviations
❑ List of drugs
monographs
❑ Additional information of drugs
storage guidelines
patient counseling information
prescribing and dispensing guidelines
dose adjustments
poison information and antidotes
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❑ Basic information on each drug-
Efficacy for the treatment of specific conditions
Safety profile of the item
Interaction profile
Adverse effects
Pharmacokinetic profile
Availability of the item
Available dosage form
Cost
Acceptability to patients
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❑ Supplementary information on each drug-
Storage guidelines
Patient counseling information
Labelling information
Brand names and prices
❑ Prescribing and dispensing guidelines-
Principles of prescription writing
Reporting of ADR
Prevention of ADR
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❑ General drug use and advice-
Use of IV drugs
Special situations like pregnancy, breast feeding, liver/kidney diseases
Poisoning information and antidotes
Treatment of snakebites and insect bites
❑ Miscellaneous section-
Children’s dose
Renal adjustments
Metric units
Diagnostic aids
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Differences Between Formulary vs Drug list
Hospital Formulary
❖ Listing of drugs by their generic names
followed by information on strength, form,
posology, toxicology, use & recommended
quantity to be dispensed.
❖ Prepared locally by its own clinical staff.
❖ Information provided is subject to local
needs and desires.
Drug List
❖ Generic names followed by data on
strength & form.
❖ Prepared by country’s outstanding
clinicians, pharmacologists and
pharmacists.
❖ According to their pharmacological
properties
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Managing of formulary
❑ Formulary may become a collection of older, less effective drugs.
❑ The entire formulary should be reviewed every 2–3 years.
❑ Requests for the addition of new medicines and deletion of old medicines.
❑ For a new medicine to be added into the hospital formulary, the committee should
consider the therapeutically equivalency to existing drugs in terms of efficacy, safety, or
convenience of dosing/administration.
❑ For the addition and deletion of drugs the total cost for a course of treatment with new
medicine should be compared with the already listed medicines
❑ If a new medicine is added to the list for reasons of improved efficacy, safety or lower
price, serious consideration should be given to delete the medicine which was
previously on the formulary list for the same indication.
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Drug Distribution system & Hospital formulary

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