Practice Settings–Guidelines 617 ASHP Guidelines: Minimum Standard for Pharmacies in Hospitals Purpose services throughout the hospital, which every member of the pharmacy team should cultivate at every opportunity. The following minimum standard guidelines are intended to serve as a basic guide for the provision of pharmacy services A. Pharmacy and Pharmacist Services in hospitals. These guidelines outline a minimum level of Pharmacy Mission, Goals, and Scope of Services. The services that most hospital pharmacy departments should pharmacy shall have a written mission statement that reflects consistently provide. The reader is strongly encouraged to both patient care and operational responsibilities. Other as- review the American Society of Health-System Pharmacy pects of the pharmacy’s mission may require definition as (ASHP) guidance documents referenced throughout these well (e.g., educational and research responsibilities). The guidelines for more detailed descriptions. Certain elements mission statement shall be consistent with the mission of the of these guidelines may be applicable to other health care hospital and, if applicable, aligned with the health system of settings or may be useful in evaluating the scope and quality which the hospital is a component. The development, priori- of pharmacy services. tization, and implementation of the pharmacy’s goals should be consistent with the mission statement. Determination of Elements of Care short- and long-term goals and the undertaking of imple- mentation activities should be performed in collaboration with institutional leadership and other hospital staff (e.g., The mission of pharmacists is to help people make the pharmacy, nursing, and medical staff), and these should be best use of medications.1 Therefore, pharmacists shall be integrated with the goals of the hospital. The mission state- concerned with not only the provision but the outcomes of ment may also incorporate consensus-based national goals, pharmacy services. The elements of pharmacy services that such as those expressed in the recommendations from the are critical to safe, effective, and cost-conscious medica- 2 ASHP Pharmacy Practice Model Initiative. tion use in a hospital include (1) practice management, (2) The pharmacy shall also maintain a written document medication-use policy development, (3) optimizing medica- describing the scope of pharmacy services. These services tion therapy, (4) drug product procurement and inventory should be consistent with the hospital’s scope of services and management, (5) preparing, packaging, and labeling medi- should be applied throughout the hospital in all practice sites. cations, (6) medication delivery, (7) monitoring medication The mission, goals, and scope of services shall be use, (8) evaluating the effectiveness of the medication-use clearly communicated to everyone involved in the provision system, and (9) research. Although the scope of pharmacy of pharmacy services, including pharmacists, residents, stu- services will vary from site to site, depending upon the needs dents, technicians, and support staff. of patients and the hospital as well as the resources avail- able, these core elements are inextricably linked to success- 24-Hour Pharmacy Services. Adequate hours of opera- ful outcomes. Failure to provide any of these services may tion for the provision of needed pharmacy services shall be compromise the quality of patient care. maintained; 24-hour pharmacy services should be provided when possible. Twenty-four hour pharmacy services should Terminology be employed in all hospitals with clinical programs that require intensive medication therapy (e.g., transplant pro- In these guidelines, the term “shall” is used to indicate a grams, open-heart surgery programs, neonatal intensive care minimum standard of practice set forth in this document, in units, and trauma centers). When 24-hour pharmacy ser- other ASHP policies, or in requirements established by laws, vices are not feasible, a pharmacist shall be available on an regulations, accrediting bodies, or other binding authorities. on-call basis. Remote medication order processing may be The term “should” is used to indicate a best practice that is employed (to the extent permitted by law and regulation) to strongly encouraged by ASHP but which may not be appli- help provide pharmacy services but is not a substitute for an cable to all institutions or in all circumstances. on-call pharmacist.3 Automated drug dispensing equipment and computer databases are also not a substitute for the skills Standard I. Practice Management and knowledge of a pharmacist and should not be considered alternatives to 24-hour pharmacy services.4 Effective leadership and practice management skills are necessary for the delivery of pharmacy services in a manner After-Hours Pharmacy Access. In the absence of 24-hour consistent with the hospital’s and patients’ needs. Such lead- pharmacy services, access to a limited supply of medica- ership should foster continuous improvement in patient care tions shall only be available to authorized, licensed health outcomes. The management of pharmacy services should care professionals for use in carrying out urgent medica- focus on the pharmacist’s responsibilities as a patient care tion orders. Access to such medications shall be carefully provider and leader of the pharmacy enterprise through the monitored and documented, and after-hours access shall development of organizational structures that support that be reviewed regularly to ensure appropriate use. The list of mission. Development of such structures will require com- medications to be accessible and the policies and procedures munication and collaboration with other departments and to be used (including subsequent review of all activity by a 618 Practice Settings–Guidelines pharmacist) shall be developed by a multidisciplinary com- response (including evacuation), and the facility’s business mittee of physicians, pharmacists, and nurses (e.g., by the continuity plan shall include procedures for providing safe pharmacy and therapeutics [P&T] committee or its equiva- and efficient pharmacy services in case of emergencies. lent).5 Access to medications should be limited to cases in Appropriately trained pharmacists should be members of which the P&T committee (or its equivalent) determines emergency preparedness teams and participate in applicable that the urgent clinical need for the medication outweighs preparations and drills.7 The pharmacy shall establish, in the potential risks of making the medication accessible. The conjunction with the hospitalwide emergency plan, policies potential safety risks of medications should be considered and procedures for the safe and orderly evacuation of phar- in the decision to make them accessible, and medications, macy personnel in the event of an emergency in the hospital. quantities, dosage forms, and container sizes that might en- danger patients should be limited whenever possible. Medical Emergencies. The pharmacy shall participate in Routine after-hours access to the pharmacy by non- hospital decisions about the contents of code carts, emer- pharmacists for access to medications shall not be permit- gency medication kits and trays, and the role of pharma- ted. The use of well-designed night cabinets, after-hours cists in medical emergencies. Pharmacists should serve on medication carts, automated dispensing devices,6 and other cardiopulmonary resuscitation teams, and such pharma- methods precludes the need for nonpharmacists to enter the cists should receive appropriate training and maintain ap- pharmacy.4 propriate certifications (e.g., Basic Life Support, Advanced Cardiopulmonary Life Support, Pediatric Acute Life Practice Standards and Guidelines. The standards and Support). regulations of all relevant government bodies (e.g., state boards of pharmacy, departments of health) shall be met. Immunization Programs. The pharmacy shall participate The practice standards and guidelines of ASHP, appropri- in the development of hospital policies and procedures ate accrediting bodies (e.g., Joint Commission, American concerning preventive and postexposure immunization pro- Osteopathic Association Healthcare Facilities Accreditation grams for patients and hospital employees.8 When practi- Program, Det Norske Veritas), and the Centers for Medicare cal, pharmacists should participate as active immunizers for and Medicaid Services shall be viewed as applicable, and the hospital and health-system-based preventive immunization hospital should strive to meet all applicable standards. programs (e.g., influenza). B. Laws and Regulations Substance Abuse Programs. The pharmacy shall assist in Applicable local, state, and federal laws and regulations the development of and participate in hospital substance shall be met, and relevant documentation of compliance abuse education, prevention, identification, treatment, and shall be maintained. employee assistance programs.9 C. Policies and Procedures D. Human Resources Policy and Procedures Manual. There shall be a policy and Position Descriptions. Areas of responsibility within the procedures manual governing pharmacy functions (e.g., ad- scope of pharmacy services shall be clearly defined. The ministrative, operational, and clinical), and all pharmacy responsibilities and related competencies of professional personnel shall follow those policies and procedures. The and supportive personnel shall be clearly defined in written manual may include a statement