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1. Defination of hospital pharmacy:-

Hospital pharmacies can usually be found within the premises of a hospital. Hospital pharmacies usually stock a larger range of medications, including more specialized and investigational medications (medicines that are being studied, but have not yet been approved), than would be feasible in the community setting. Hospital pharmacies typically provide medications for the hospitalized patients only, and are not retail establishments.

They typically do not provide prescription service to the public. Some hospitals do have retail pharmacies within them (see illustration), which sell over-the-counter as well as prescription medications to the public, but these are not the actual hospital pharmacy.

The classifications of pharmacy are given below:- 1. Indoor pharmacy in the hospital. 2. Outdoor pharmacy in the hospital. 3. Retail pharmacy. 4. Whole shale pharmacy. 5. Industrial pharmacy.Indoor pharmacy:- Indoor pharmacy is very important department of the hospital. The physician prescribes to the patient. The nursing personal copies it & write it on requisition form or books & send it to the pharmacy. The pharmacist compounds & dispenses according with usual

VISION COLLEGE OF PHARMACEUTICAL SCIENCES & RESEARCH

http://en.wikipedia.org/wiki/Over-the-counter_drug

http://en.wikipedia.org/wiki/Hospital

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labeling as unite dose or multiple dose system as desired by hospital authority.

Outdoor Pharmacy:- Outdoor pharmacy is very important of the hospital. Here medicines are prepared in bulk form. According the hospital formulary for the extensively used selected medicines & dispenses them to the outdoor patient according to the prescription of the medical officers.

Retail Pharmacy:- Retail Pharmacy is an industry-leading publication that has firmly established itself as the most informative magazine for Pharmacy-specific business and retail-related topics.

Distributed to pharmacies nationally, the monthly business to business publication reaches pharmacists not only as influential health professionals but also as business operators, helping them make informed and responsible decisions about their pharmacy within a retail environment.

Whole shale pharmacy:- Our pharmaceutical wholesale businesses, together with our associates and joint ventures, supply medicines, other healthcare products and related services to more than 180,000 pharmacies, doctors, health centres and hospitals from more than 370 distribution centres in 20 countries.

Industrial pharmacy:- The mission of the Industrial Pharmacy Lab is to focus on research in process technology and dosage form design. This research is very close to the today’s needs of the pharmaceutical industry looking for robust formulations


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and process technologies, which should enable to shorten the development time and to increase the product quality. A close cooperation with the pharmaceutical industry is a prerequisite to be able to do studies in the area of scale-up. Thus a win-win situation is created as there is no time for basic studies in scale-up in the industry and there is no large scale equipment for such studies at the university.

Special reference to neonatal death:- causes of neonatal death or newly bron death:-

Definitions:-

Stillbirth:- the death of a baby before or during birth after 24 weeks of gestation in the UK. (The World Health Organization (WHO) definition is after 28 weeks.)

Neonatal death:- the death of a baby within the first 28 days of life.

Perinatal mortality:-stillbirths plus early neonatal deaths (under 7 days). (This is a universal definition.)

Stillbirth rate:- the number of stillbirths per thousand total births.

Low birth weight:- weight at birth under 2500 g. (The universally accepted definition.)

Incidence:-

According to the Office for National Statistics (ONS) in England and Wales, there were 3,558 stillbirths in 2012 - a


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stillbirth rate of 4.9 per 1,000 live births. This had dropped from 5.3 in 2011. There were 2,042 neonatal deaths - a rate of 2.8 per 1,000 live births - of which 2.2 were early neonatal deaths. Both rates have continued to fall over a period of two decades, and perinatal mortality rates have fallen by a third since 1982. It is felt that improvements in general healthcare, midwifery and neonatal intensive care are bringing about the gradual decline in deaths. Worldwide figures are higher. A recent WHO survey gives the stillbirth rate (although note the variable definition affects numbers) as 17.7 across 29 countries, and the early neonatal death rate as 8.4

Risk factors:-

Fetal growth restriction:

The biggest risk factor for stillbirth. A 2012 study of stillbirths in England showed the risk to be significantly higher where the growth restriction was not detected antenatally, suggesting this as an important avenue for reducing stillbirth rates in the future.[3] It concluded strategy should focus on improving antenatal detection of growth restriction, and subsequent management of pregnancy and delivery.

Preterm birth:-

This is the biggest risk factor for neonatal death. Obstetric and neonatal care can have a major impact on death rates of preterm babies. (For example, antenatal steroids for women in preterm labour, and advanced neonatal intensive care which may not be available in some parts of the world.)


http://www.patient.co.uk/doctor/stillbirth-and-neonatal-death#ref-3

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Age of mother:- The rate of neonatal death is higher in babies born to women under the age of 25, and women over the age of 40. In the UK, women aged 40 or over are 1.3 times more likely to have a neonatal death compared to women aged 25-29. Stillbirth rates increase with advancing maternal age. The rate increases from 4.6 in the 25- to 29-year age group to 7.6 for mothers aged 40 or over.

Systematic reviews have confirmed advancing maternal age as a risk factor. However, the most recent UK-based study of risk factors did not bear this out.This may have been because babies with congenital abnormalities, known to occur more often in pregnancies of older women, were excluded from the study. Cochrane reviews have demonstrated that induction of labour in women going past term reduces the risk of perinatal death. National Institute for Health and Care Excellence (NICE) guidelines therefore recommend that women going past their term dates be induced at 41 weeks.There is discussion ongoing about whether older women should be offered induction earlier, at 39-40 weeks of gestation, in order to reduce the risk of perinatal deaths.

Obesity:- a mother's BMI ≥30 increases risk of stillbirth and neonatal death, and possibly as much as doubles it. Smoking:- smoking causes increased risk of stillbirth where it leads to growth restriction but not as an independent factor. It increases the risk of neonatal death in a number of ways, including adding to the risk of preterm birth.


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Chronic diseases :- eg, diabetes, renal failure, hypertension, haemoglobinopathy, rhesus disease, thrombophilias, antiphospholipid syndrome. Pre-existing diabetes increases risk of stillbirth significantly, whereas gestational diabetes does not appear to increase risk.

Infection - eg, erythema infectiosum, varicella, measles.

Substance abuse, especially cocaine.

A history of mental health problems increases risk.

Obstetric complications:- Pre-eclampsia and antenatal haemorrhage increase the risk of stillbirth. Intrapartum complications, such as malpresentation or obstructed labour, confer high risk of perinatal mortality. Multiplicity of pregnancy:-

The risk of perinatal death is 2-5 times higher for multiple pregnancies compared to singleton pregnancies.

Stillbirth and neonatal death rates are significantly higher in monochorionic twins than in dichorionic twins (44.2 vs 12.2 per 1,000 births in the North England study of twin and multiple pregnancy).

Parity:- Nulliparous women have a higher risk of stillbirth than multiparous women across all ages. Third and subsequent pregnancies have a higher risk than second pregnancies.

Congenital abnormality:-


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Increases risk of stillbirth and neonatal death. In the main not a potentially avoidable risk factor so it is often left out of analyses. Fewer than 10% of stillbirths are caused by congenital abnormalities.

Low birth weight:- Strongly linked with neonatal death and infant mortality. Inter-related with other factors, such as prematurity, multiple pregnancy, smoking.

In 2012, there were 173 deaths per 1,000 live births for very low birth weight babies (<1500 g), 35.2 per 1,000 for low birthweight babies (<2500 g), compared to 1.3 per 1,000 for normal birth weight babies. These ONS figures are for infant mortality as a whole, ie deaths up to the first year of life, but neonatal deaths show a similar trend.

Region of maternal residence:- Most regions in the UK show fluctuations in stillbirth rates. In 2012, rates of both stillbirths and neonatal deaths were highest in the West Midlands and lowest in the South of England.[1]

Social factors:- Lack of employment and high deprivation index increase risk of stillbirth. Later antenatal booking appointments past 13 weeks was associated with increased risk of stillbirth.

Ethnicity:-



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African and African-Caribbean women have significantly higher risk of stillbirth. Risk is also increased in Indian mothers and first-generation migrants from Pakistan.[3]

Sex:- Trends show that stillbirth rates are slightly higher among males compared to females.

Causes of neonatal death:- Prematurity (causing particularly respiratory and neurological conditions)

Congenital abnormality

Obstetric complications

Infection

Causes of stillbirth:-

Congenital abnormality Haemorrhage, during pregnancy or labour

Placental insufficiency

Placental abruption

Pre-eclampsia

Obstetric complications

o Spontaneous premature labour

o Premature rupture of membranes

o Polyhydramnios

o Oligohydramnios

o Intrapartum asphyxia



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o Birth trauma

Cord prolapse

Intra-uterine growth restriction

Liver disease - obstetric cholestasis, intrahepatic cholestasis of pregnancy

Diabetes

Infections during pregnancy

In England the latest report into causes of perinatal death was the Centre for Maternal and Child Enquiries (CMACE) report of 2009, published in 2011.This long-term audit has been now passed on to 'Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries in the UK' (MBRRACE UK), and there are currently no more recent reports. The classification system for causes of death changed in 2008, in an attempt to reduce the number of previously "unclassifiable" deaths.

In the 2011 UK report, 28% of stillbirths remained unexplained. Placental conditions caused 12% of stillbirths, antepartum/intrapartum haemorrhage 11%, and major congenital abnormality 9%. 8% of stillbirth deaths occurred during labour or delivery.

For neonatal deaths, 27% were from obstetric factors, of these spontaneous premature labour being the most common. 25% were due to congenital abnormality, and 10% due to infection. A further neonatal classification system uses the specific cause of death in premature babies, the most common causes being respiratory disorders (of which the most


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common was severe pulmonary immaturity), followed by neurological disorders (particularly hypoxic-ischaemic encephalopathy and intraventricular/periventricular haemorrhage).

Reports for Scotland, Wales and Northern Ireland have continued. Differing classification systems are used. In Scotland, the 2011 report showed for stillbirths the most common cause was fetal growth restriction (38%), followed by APH (15%) and congenital abnormality (12%). Conditions associated with prematurity were the most common cause of neonatal death (41%) followed by congenital abnormality. In the 2012 report for Wales, 42% of stillbirths are classified as unexplained, with APH the most common classifiable cause (13.3%), and congenital abnormality next (6.6%). For neonatal deaths, preterm birth caused 37%, congenital abnormality 22% and infection 14.5%.The 2012 report for Northern Ireland gives placental conditions and congenital abnormalities as the most common cause for stillbirths.

Diagnosis:- The mother may be aware of a decrease in fetal movements in many cases of stillbirth. Other stillbirths may be discovered at the routine antenatal check.

An ultrasound examination is used to confirm that the fetus has died; this is seen as lack of a visible heartbeat.

Management:-

"The quality of care that bereaved families receive when their baby dies has long-lasting effects. Good care cannot


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remove parents' pain and grief, but poor care can and does make things much worse.”

Where the death of the baby is diagnosed antenatally, labour is induced using prostaglandins administered vaginally. This does nThe mother will need to have:

Blood pressure checked. Urine tested for protein.

Temperature taken.

Cervical and vaginal swabs for MC&S.

Blood taken for FBC, clotting screen (including antiphospholipid antibody and thrombophilias), Kleihauer test, HbA1c, cultures (Listeria spp.) and serology (parvovirus B19, toxoplasmosis and cytomegalovirus) and cytogenetics.

out need to be immediate, but should happen within 2-3Bereavement care:

Hospital counsellors and chaplains may provide comfort to families of stillborn infants. All maternity units should have specially trained bereavement midwives. Discuss the need, and arrange consent, for post-mortem examination.

Inform GP practice, so that GP and practice staff are aware of the death, and so GP can provide support where appropriate. Registering a stillbirth

Stillbirth registration began on 1 July 1927, to help protect infant life.


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As well as being an important source of historical and statistical information, it also gives parents the opportunity to have their child officially acknowledged and to give him or her names if they wish to, which can help with grief.

Stillbirths in England and Wales must normally be registered at the hospital or local register office within 42 days of the stillbirth, but cannot be registered more than 3 months after its occurrence.

To register the stillbirth, the medical certificate of stillbirth issued by the doctor or midwife present at the time is required.

The registrar will issue a certificate for burial or cremation of the stillborn infant. This certificate is usually passed to the funeral director who will make the arrangements.

Following a stillbirth or neonatal death, parents are entitled to maternity leave, paternity leave, statutory maternity pay/allowance or statutory paternity pay as relevant.

ROLE OF HOSPITAL PHARMACISTS IN TRANSITIONS OF CARE:-

Transition of Care:-

“care transitions" refers to the movement patients make between health care practitioners Transitional care is defined as a set of actions designed to ensure the coordination and continuity of health care as patients transfer between different locations or different levels of care within the same location.


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Representative locations include (but are not limited to) hospitals, sub-acute and post-acute nursing facilities, the patient's home, primary and specialty care offices, and long-term care facilities.

Medication Errors in Transitions of Care:-

Study Design: Prospective

Results:

After screening 523 admissions, 151 patients were enrolled based on the inclusion criteria

81patients (53.6%; 95% confidence interval, 45.7%-61.6%) had at least 1 unintended discrepancy.

Most common error (46.4%) was omission of a regularly used medication.

61.4% of the discrepancies were judged to have no potential to cause serious harm.

38.6% of the discrepancies had the potential to cause moderate to severe discomfort or clinical deterioration.

Study Design:

Population-based cohort study using admin records from 2007 to 2009 of hospitalizations and outpatient prescriptions


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Results:

Patients admitted to the hospital (n = 187,912) were more likely to experience potentially unintentional discontinuation of medications than controls (n = 208,468) across all medication groups examined.

Admission to an ICU was associated with an additional risk of medication discontinuation in 4 of 5 medication groups vs hospitalizations without an ICU admission.

One-year follow-up of patients who discontinued medications showed an elevated AOR for the secondary composite outcome of death, emergency department visit, or emergent hospitalization of 1.07 (95% CI, 1.03-1.11) in the statins group and of 1.10 (95% CI, 1.03-1.16) in the antiplatelet/anticoagulant agents group.

Patients prescribed chronic medications were at higher risk for unintentional discontinuation following hospital discharge, and ICU stay during hospitalization increased the risk of medication discontinuation even further.


Method:

60 randomly selected patients at a Canadian Community hospital


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At admission, compared patients’ medication ordesr with pre-admission medication use based on med vials and interviews with patients, caregivers and/or outpatient healthcare providers

At discharge, pre-admission and in-patient medications were compared with discharge orders and written instruction

Variances were discussed with prescriber and classified either as intended or unintended.

Results:

Overall, 60% (95% CI 48 to 72) of patients had at least one unintended variance and 18% (95% CI 9 to 28) had at least one clinically important unintended variance.

None of the variances had been detected by usual clinical practice before reconciliation was conducted.

Of the 20 clinically important variances, 75% (95% CI 56 to 94) were intercepted by medication reconciliation before patients were harmed.


Method: studied patients who were consecutively discharged home or to a seniors' residence from the general internal medicine service during a 14-week


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interval in 2002; phone interview and chart review to identify outcomes; 2 physicians conducted an independent review the outcomes to determine occurrence of AE

Results:

outcomes were determined for 328 of the 361 eligible patients, who averaged 71 years of age

After discharge, 76 of the 328 patients experienced at least 1 AE (overall incidence 23%, 95% confidence interval [CI] 19%–28%).

AE severity ranged from symptoms only (68% of the AEs) or symptoms associated with a nonpermanent disability (25%) to permanent disability (3%) or death (3%).

Most common AEs were adverse drug events (72%), therapeutic errors (16%) and nosocomial infections (11%). Of the 76 patients, 38 had an AE that was either preventable or ameliorable (overall incidence 12%, 95% CI 9%–16%).

Case in point:

MEDICATION ERRORS HAPPEN During patient hand-offs

Medication Reconciliation:-


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“the process of creating the most accurate list possible of all medications a patient is taking — including drug name, dosage, frequency, and route — and comparing that list against the physician’s admission, transfer, and/or discharge orders, with the goal of providing correct medication to the patient at all transition points within the hospital.”

Impact of Medication Reconciliation during Admission:-

Study Method: Study pharmacist and hospital-physician medication histories were compared with medication orders to identify unexplained history and order discrepancies in 651


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adult medicine service inpatients with 5,701 prescription medications

Results:

35.9% experienced 309 order errors85% of patients had errors originate in medication histories, and almost half were omissions.

Cardiovascular agents were commonly in error (29.1%). If undetected, 52.4% of order errors were rated as potentially requiring increased monitoring or intervention to preclude harm; 11.7% were rated as potentially harmful.

In logistic regression analysis, patient's age > or = 65 [odds ratio (OR), 2.17; 95% confidence interval (CI), 1.09-4.30] and number of prescription medications (OR, 1.21; 95% CI, 1.14-1.29) were significantly associated with errors potentially requiring monitoring or causing harm.

Presenting a medication list (OR, 0.35; 95% CI, 0.19-0.63) or bottles (OR, 0.55; 95% CI, 0.27-1.10) at admission was beneficial.

Pharmacist Facilitated Discharge:-

Study Design: Descriptive Report

Methods:


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Clinical pharmacist participated in multidisciplinary discharge rounds in selected medicine services

Patient selection: (1) discharge to home, (2) with >5 medications with at least 1 high risk medicine; (3) English speaking; (4) active telephone service

CP activities: (1) reconciled with clinicians discharge medication discrepancies; (2) counseled patients and families; (3) provided reconciled medication list to subsequent providers; (4) contacted patients within 72 hours after discharge and at 30 days to identify and address post-discharge medication problems.

Results (10-month period):

958 out 1122 patients (85%) were screened (75%) patients met the inclusion criteria

477 (66.2%) patients were interviewed to assess current medication use 248 (34%) patients were counseled at discharge 486 discrepancies identified and resolved in 63% of patients counseled with an average of 3 discrepancies per patient

Missing Meds (41.2%)

Failure to Discontinue unnecessary or inactive meds (23.7%)

Wrong dose/frequency (16.3%)


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Discrepancy occurred most frequently in the following therapeutic classes: CV, analgesic, endocrine, antimicrobial and gastric acid suppression

Follow-up phone call within 72 hrs. and at 30 days are completed in 24% (59) and 8.5%(21), respectively.

123 post-discharge problems were identified and resolved.

ONE SOURCE OF TRUTH:-

Develop a single medication list, shared by all disciplines for documenting the patient's current medications

A SEMINAR TOPIC on hospital pharmacy.

BACHLOR OF PHARMACY

DEPT: PHARMACEUTICS

By

ARTHAM.RAJASHEKAR(11HA1R0043)

UNDER GUIDENCE OF


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Mrs.JHARANA MALLICK

Assistant professor

GUIDENCE SIGNITURE PRINCIPAL SIGNITURE


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