SCHOOL OF PHARMACY

PHARMACY PRACTICE 3
SPH 3024

NAME: NUR SHAZANA BINTI NAZERI

I.D NO: 012013110197
TITLE: HOSPITAL ATTACHMENT IN HKL
DUE DATE: 21/08/2015
LECTURER: MR MOHAMAD NIZAM BIN ABDUL GHANI

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TABLE OF CONTENT
Content

Page

Introduction
Outpatient
Overview
SMS & take medication
UMP1 Malaysia
SPUB
MTAC

3-4
5-14

Inpatient
Overview
Unit of dose
Unit of use
Psychotropic drug & Dangerous drug indent
Floor stock system
Drug Information Services (DIS)
Role of DIS pharmacist
Adverse drug reaction report
Drug product complaint
Drug formulary and drug source

15-17

18-20

Total Parenteral Nutrition (TPN)

Overview
Role of TPN pharmacist
TPN regimen

21-25

Cytotoxic Drug Reconstitution (CDR)

Overview
Role of CDR pharmacist

26-28

Therapeutic drug Monitoring (TDM)

Overview
Role of TDM pharmacist
Protocol of TDM service

29-30

Storage
Overview
Objective
Drug purchase
Flow of storage management

31-38

Conclusion
39
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Knowledge gain during hospital attachment

Problem face during hospital attachment
Advice to student

Reference

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INTRODUCTION

The Kuala Lumpur Hospital or commonly known as HKL (Hospital Kuala Lumpur)
has 53 different departments and units. These include the administration & finance
department, the pharmaceutical department, training and research, 28 clinical departments and
12 clinical support services.
Kuala Lumpur Hospital is now the largest hospital under the Ministry of Health of
Malaysia and is considered to be one of the biggest in Asia. It is a government tertiary referral
hospital, located on 150 acres of prime land with 83 wards and 2300 beds.
View of the 5 storey hospital's main block as you approach from the Maternity
Hospital. The building on the right foreground is part of the Radiotherapy Outpatient Clinic.
HKL has a huge staff of 7 000 workers with almost 100 professions in various fields and
disciplines. Out of the total number of staff, there are about 200 consultants and specialists,
500 medical officers and registrars, 32 matrons, 221 sisters (ward managers), 3,101 registered
nurses, 253 community nurse, 6 trained assistant nurses and 1 trained mid-wives. The
remaining staff are pharmacists, tutors, assistant pharmacists, medical assistants,
administrative personnel and hospital attendants.
The Pharmacy Department of Kuala Lumpur Hospital (HKL) was established to
provide optimal pharmaceutical care to cater for the needs of all patients as well as to support
the objectives and mission of HKL. With more than 350 members stationed in 19 units
distributed throughout the hospital, the department aims to deliver a wide scope of quality
services while simultaneously dealing with over 5000 prescriptions daily from inpatient and
outpatient settings. Services offered include clinical pharmacy services such as Parenteral
Nutrition, Therapeutic Drug Monitoring, Cytotoxic Drug Reconstitution, Patient Counseling
to inpatient pharmacy and outpatient pharmacy, Adverse Drug Reaction monitoring, as well as
Drug Information centre services.
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In regards to management, the Pharmacy Department plays a major role in the

procurement, storage and distribution of drugs and non-drugs (e.g. medical equipment and
consumable items) in the hospital.
4th semester pharmacy students are required to complete their hospital attachment at
respective hospital. 10 students are allocated at hospital pharmacy. The scopes of the hospital
pharmacy include:
1.
2.
3.
4.
5.

Outpatient pharmacy
Inpatient pharmacy
Manufacturing section
Clinical support section (DIS, TDM, TPN, CDR)
Store management section

Pharmacy department in HKL can divided into sub-department which each department
is manage under its own clinical services. Pharmacy department at HKL can be divided into
13 sub-departments. These include Accident and Emergency (A&E) Pharmacy, Satellite I and
II Pharmacy, Radiotherapy and Oncology Pharmacy, Main Outpatient Pharmacy, Nuclear
Pharmacy, Obstetrics and Gynaecology Pharmacy, Nuclear Pharmacy, Ophthamology
Pharmacy, Specialist Clinic Pharmacy, Paediatric Pharmacy, National Pharmacy Call Centre
(NPCC), Pharmacy Resources and Information Centre (PRIC), and Methadone Pharmacy.

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OUTPATIENT PHARMACY
We had visited the outpatient pharmacy on the first day of the 7 days attachment for 4 th
semester students. We are exposed with the role, workflow of the outpatient pharmacy and
setup of outpatient pharmacy in dispensing system.
Outpatient pharmacy at Kuala Lumpur Hospital (HKL) plays an important role in the
dispensing system depending on the types of clinical services. There are 20 Specialise Care
Clinic in HKL which means there are more than 350 members stationed in 20 units of
pharmacy distributed throughout the hospital including 2 satellite pharmacy. However, main
outpatient pharmacy is under Outpatient department that is located on the Ground floor of
Kuala Lumpur Hospitals main block. Main role is to dispense medications, educate patient on
the proper way to take the medication and provided counseling services in such way that it
will help patients to have more information to clear their doubt in any if the medication. In
Kuala Lumpur Hospital, it also has value added services such as Appointment-based
Medicines Dispensing System (SMART), Medicine through Postal Services 1 Malaysia (UMP
1Malaysia), and Drive-Thru Pharmacy.
For Specialist Clinic Pharmacy, the person in charge to exposed us regarding to
Outpatient Pharmacy is a senior registerd pharmacist, Encik Zulsairi Mohd. Fauzi. He
explains the role, setup, and the flow of outpatient pharmacy at HKL including visit the
outpatient pharmacy.
In outpatient service, they have four major roles. They are responsible in management
of outpatient pharmacy. In managing the outpatient pharmacy, they have to handle any drug
information request. Besides that, they also have to manage in term of patient waiting time,
peak hour management, staff training and stock movement and control. The second major
service is dispensing of medication or prescription. Pharmacists must aware about the
importance of patients medication record. If there is any error or ambiguous prescriptions,
pharmacist have to contact the prescribers and discuss with them about the prescriptions. In
dispensing the medication, pharmacist should be knowledgeable enough in prepacking
process, packaging and labelling the medication. In order to supply the prescribed medication
in the effective way, pharmacist should be able to implement prescription ordering and supply
system which including Integrated Medication Supply System. After received and screen the
prescription, pharmacists have to dispense the medications. In addition, pharmacists in
outpatient department have to counsel patients about the medication and how to use the
therapeutic devices. In group counselling session, pharmacists have the role in assisting that
session.
Drug arrangement in outpatient pharmacy is followed by pharmacological group and
tall-man lettering.

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Work flow of Outpatient Department:

1) Receive
prescritption
(electronic
prescription)

6) Dispense
medicine to
patient and
counsel if needed

2) Screen and
label the
prescription

5) Checked by
pharmacist
before dispense
to patient

3) Filling the
prescription

4) Counterchecked by
registered
pharmacist

Value added services:

These services are done in this Kuala Lumpur Hospital which are SMS & take
medication, UMP 1 Malaysia service, SPUB. SMS & take medication is a new intervention
that increases patient compliances in obtaining their medicines. Objective is to decrease
patients waiting time to get their medicine in outpatient pharmacy and reduce the
overcrowded scene. Besides, this service provided for patients who want to take follow-up
medication in easier way as they do not need to queue for a longer time.
UMP 1 Malaysia (Ubat melalui Pos 1 Malaysia) service is by sending the
medication as parcel to the patient houses. The first supply of medications needs to be given
at the pharmacy counter in hospital. Then, patients need to apply for the medication to be send
through postage service. Pharmacist will prepare the next supply of medicine and send to the
patient a week before the next appointment date scheduled for medication supply. The parcels
will be sent hand-to-hand to the patient via this postage (POSLAJU) service.
Besides that, SPUB (Sistem Pembekalan Ubat Bersepadu) or Integrated Drug
Dispensing System is also done in this outpatient department. This system gives convenience
to patients who live far from the hospital. Patients can get their refill of medicines in hospital
or Klinik Kesihatan nearby their houses. This service enables the patient who prescribed with
long term therapy to access to their medication supply easily. By doing this, patient
compliance will be improved.

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Flow of SPUB:

Patient receive prescription after

regular doctor visit

Patient will be referred to

nearest medicalinstitution to
get their medication supply

Pharmacy staff will

stamp 'SPUB'
referralstamp and signed
the prescription

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Get the first medication

supply from the pharmacy

Consult the pharmacy staff

on appropriate
hospital/health care center
to get their next supply

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MTAC (medication therapy adherence clinic)

There are a lot of MTAC in Kuala Lumpur Hospital. However, due to time constraints,
we do not have any chance to visit any MTAC in HKL. We only had a briefing session
regarding to MTAC and services which they provided.
The following Medication Therapy Adherence Clinics (MTAC) were set up by HKL to
help enhance patients adherence towards medications in a long term basis:
1.Respiratory
Medication
Therapy
Adherence
Clinic
2.Peadiatric
Asthma
Medication
Therapy
Adherence
Clinic
(PAMTAC)
3.Cardiac Rehabilitation Medication Therapy Adherence Clinic (CRMTAC)
4.Diabetes
Medication
Therapy
Adherence
Clinic
(DMTAC)
5.Peritoneal Dialysis (PD) Medication Therapy Adherence Clinic (PDMTAC)
6.NephroTransplant
Medication
Therapy
Adherence
Clinic
7.Paediatric Retroviral Disease Medication Therapy Adherence Clinic (PRVD MTAC)
8.Geriatric
Medication
Therapy
Adherence
Clinic
(GMTAC)
9.Warfarin
Medication
Therapy
Adherence
Clinic
(WMTAC)
1.

Respiratory

Medication

Therapy

Adherence

Clinic (RMTAC)

Respiratory Medication Therapy Adherence Clinic, formerly known as Asthma Medication

Therapy Adherence Clinic (AMTAC) is a pharmacist-managed clinic aimed at improving
patient asthma control by enhancing compliance and improving inhaler technique. Thus, it
indirectly improves patients Quality of Life (QoL). Started in the year of 2009 in HKL,
AMTAC is a clinical pharmacy service under the directive and supervision of Pharmaceutical
Services Division which sees the expansion of clinical role of pharmacists in the out-patient
setting.

A situation in RMTAC
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The clinic is conducted by dedicated pharmacists who help asthma patients to gain better
knowledge and understanding of their medications, and therefore, improving patients
adherence to the medication regimen. The pharmacist does pharmacotherapy review of the
patient, identifies pharmaceutical care issues, provides solution to drug-related problems,
educates patient, and monitors the therapeutic outcome to ensure therapeutic goal is achieved.

2.

Peadiatric

Asthma

Medication

Therapy

Adherence

Clinic

(PAMTAC)

PAMTAC was introduced in Jun 2009 as part of the services provided by Pediatric Pharmacy.
Its policy is to provide service for all patients currently managed in the PAMTAC; and other
patients whom are referred to this clinic by other healthcare professionals.
The pharmacist running the PAMTAC has multitasking duties throughout the clinic for
example assessing patients and addressing their needs, documenting actions and plans, giving
appropriate
education
to
patients/caregivers,
and
completing
follow-ups.
Objectives:
To educate patients/caregivers about asthma and its complications, the use of medications
and self-care devices to increase patients adherence towards medication.
To provide continuous individualized patient counseling.
To reduce the emergency room visits of patients and decrease the total healthcare cost of
paediatric asthma treatment.

A situation in PAMTAC

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3. Cardiac Rehabilitation Medication Therapy Adherence Clinic (CRMTAC)

CRMTAC is the first of its kind and has been set up in Hospital Kuala Lumpur since 2009. An
approximate of 15-20 patients visits the Cardiac Rehabilitation Clinic every Thursday and
they are followed up for duration of two years after in-patient discharge. These patients are
automatically recruited into the pharmacist-managed CRMTAC for optimization of postmyocardial infarction pharmacotherapy. The clinic is staffed by ward pharmacists who
undergo intensive one-month training on cardiac rehabilitation. Among the activities involved
are assessing medication adherence, providing drug information, identifying and solving
pharmaceutical care issues (including recommending dose adjustment, alternatives and
monitoring parameters), educating on cardiac rehabilitation (including smoking cessation and
other non-pharmacological measures), screening prescriptions, dispensing one-month supply
of medications in the clinic and counseling on medication regimes.

A situation in CRMTAC
4.

Diabetes

Medication

Therapy

Adherence

Clinic

(DMTAC)

DMTAC is a pharmacist-managed clinic aimed at improving medication adherence and

glycaemic control in order to prevent diabetes related complication in diabetes patients.
This clinic which is in collaboration with the Physicians Diabetes Clinic (Medical
Department) and Out-Patient Clinic (Out-Patient Department) is conducted by dedicated
pharmacists who help diabetes patients have better knowledge and understanding of their
medications thus improving their adherence to the medication regimen.
The pharmacist does pharmacotherapy review of the patient, identifies pharmaceutical care
issues, provides solution to drug related problems, educates the patient and monitors the
therapeutic outcome until the therapeutic goal is achieved. The patient for DMTAC program
is recruited at the Physician Clinic (first visit) and followed up on a monthly or two monthly
intervals at the Out-Patient Pharmacy (second and subsequent visits).
Since its commencement in 2008, the DMTAC pharmacists have helped many Type 2
Diabetes patients achieve optimal adherence to medication therapy as well as improvement in
glycaemic
control.

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A situation in DMTAC
5. Peritoneal Dialysis (PD) Medication Therapy Adherence Clinic (PDMTAC)
PDMTAC was introduced by the Pharmacists in the Urology and Nephrology department in
April 2010. This service is extended to adult patients on Continuous Ambulatory Peritoneal
Dialysis (CAPD) and Automated Peritoneal Dialysis (APD). The clinic is located on the third
floor of Specialist Complex & Ambulatory Care Centre (SCACC), and is scheduled on every
Thursday from 9.00am-12.00pm. Our main objective is to provide continuous pharmaceutical
care to patients on dialysis in addition to preventing drug related problems. During each clinic
visit, patients adherence towards medication will be assessed, followed by medication
counselling. This clinic acts as a platform for the pharmacist to increase patients drug and
disease knowledge and understanding, hence enabling them to fully optimize the benefit from
the
treatment
offered.

A situation in PDMTAC

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6.

NephroTransplant

Medication

Therapy

Adherence

Clinic

NephroTransplant MTAC formerly known as renal transplant MTAC was introduced by

Urology and Nephrology Pharmacy in April 2008. New adult patients who underwent renal
transplant will be recruited. The MTAC service is scheduled from 9.00am-12.00pm every
Wednesday at the Nephrology Clinic, located at the third floor of SCACC. Patients will be
advised on their immunosuppressive drugs and other related agents, together with their
possible side effects, while focusing on the importance of medication compliance. With the
right advice on both therapy and medication, the outcome of this MTAC is not only to help
patients understand their condition, medications, related side effects, importance of
compliance,
but
also
to
prolong
graft
survival.

A situation in NephroTransplant MTAC

7. Paediatric Retroviral Disease Medication Therapy Adherence Clinic (PRVD MTAC)

PRVD MTAC was set up in March 2008 by Paediatric Pharmacy, Paediatric Institute, Hospital
Kuala Lumpur. Its policy is to provide service for all patients currently managed in the PRVD
MTAC
and
other
new
cases
referred
by
Infectious
Disease
team.
The objectives of PRVD MTAC are to optimise the benefits of Highly Active Antiretroviral
Therapy (HAART) and other therapy related to HIV patient, to help patient /caregiver to
recognize and manage adverse effects due to HAART, to serve as an information resource for
patients, their caregivers and healthcare providers (i.e. doctors and allied health personnel)
and to collaborate with paediatricians and other healthcare professionals in pharmacotherapy
management
of
paediatric
HIV
patients.

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8.

Geriatric

Medication

Therapy

Adherence

Clinic

(GMTAC)

GMTAC is a pharmacist-managed clinic aimed at geriatric patients in order to improve

therapeutic care and patients quality of life. The objectives of this clinic is to improve
patients compliance with medications, to provide pharmaceutical care for geriatrics patients
so that the effectiveness of the medication can be optimized and the adverse reactions can be
minimized, to educate patients and their care taker on the management of their medications, to
foster co-operation between medical professionals and other healthcare professionals in
optimizing
patient
care
and
to
improve
patients
lifestyle
quality.
Among the services provided in GMTAC include counseling and education on the
management of medications to patients and their care taker, monitoring of patients
medications and identification any pharmaceutical care issues, monitoring effectiveness of
patients
treatment
and
dispensing
of
medications
to
patients.

A situation in GMTAC

9.

Warfarin

Medication

Therapy

Adherence

Clinic

(WMTAC)

WMTAC was established in April 2008. Anticoagulation with blood thinners is recommended
for the management of several disorders and conditions including: deep vein thrombosis,
pulmonary embolism, atrial fibrillation and prosthetic heart valves. Warfarin, an oral blood
thinner, has a very narrow therapeutic index meaning that too much or too little can lead to
serious consequences. As a result, this medication requires precise management, including
periodic blood testing. If therapeutic intensity if not well maintained, there is a high
possibility of an adverse outcome, such as major bleeding or blood vessel blockage caused by
a particle breaking away from the site of a blood clot. Careful management of anticoagulation
clinic has been shown to improve patient safety by reducing serious complications.
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A situation in WMTAC

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INPATIENT PHARMACY
The Inpatient Pharmacy provides comprehensive pharmaceutical services to all
categories of patients from newborn to geriatric admitted to the wards of the hospital. These
include stocking and dispensing of medication, medication history investigation, evaluation of
medication and dosing on an individual patients basis, collaborating with the doctors and
nurses on the appropriate plan of care regarding drug use, discharge planning, implementing
and evaluating cost containment, drug therapy evaluation for the Drug and Therapeutic
Committee, educating and disseminating drug information to patients, family members and
other healthcare professionals.
For Inpatient Pharmacy, the person in charge to exposed us regarding to Inpatient
Pharmacy is a senior registerd pharmacist, Encik Hassryn Annuar. He explains the role, setup,
and the flow of inpatient pharmacy at HKL including visit the inpatient pharmacy.
Inpatient pharmacy flow:

Screen prescription
Medicationt filling
Medication trolley method
Counter-checked by registered Pharmacist
Bedside dispensing to patient

The medication supply service is provided through Floor stock which supply bulk
quantity of medication to the ward. Unit of Use which is supply drugs based on the individual
prescription usually for a specific drug and short duration. Unit Dose Drug Distribution
system, which can be developed to an automated dispensing system for provision of routine
medication in unit dose packaging. This includes those which need sterile preparation in the
Production Pharmacy namely intravenous admixtures, parenteral nutrition preparations and
cytotoxic drug reconstitution. Scheduled checks shall be carried out on medication storage
and expiration, as well as in ensuring right administration of right medications to the right
patients.

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For Ward Supply Pharmacy, there is Trolley Parking Bay and Waiting Area. Trolley
parking bay is located in front or adjacent to the ward supply counter. The space shall be
adequate for trolley parking and movement and shall be based on the number of wards and
units served.

Issuing Area is the area that is easily accessible to wards and units. An open counter
for supply and receiving drugs and prescriptions. The counter can accommodate at least two
persons at the same time. Adequate storage cabinets or shelves or pigeon holes made available
for holding issued items prior to ward/unit collection.
Basically, issuing area is for pharmacist to supply drugs including issuing
psychotropics and dangerous drug. Documentation is very important to know the quatity of
drugs available and have been used. As these drugs are kept in double lock cabinet containing
locked and also closed-circuit television (CCTV). It is pharmacists responsible to kept it
safely without mis-used of it and need to report it to authorirties if having any problems such
as damage or lost of dangerous drugs.
As the documentation of dangerous drugs are important, Kuala lumpur Hospital are
using Yellow Book for ward use documentation, Blue Book for record supplying dangerous
drug to the ward, and Green Book for pharmacist to check the current stock available in the
inpatient department (IPD).

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Flow chart of supplying psychotropic and dangerous drug to the ward.

Picture was taken during our visit to IPD

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DRUG INFORMATION SERVICES (DIS)

Basically, the purpose of the Drug Information Services (DIS) is to serve health care
professionals throughout Kuala Lumpur Hospital staff, patients, and also people outside from
the hospital area. It usually done by answering critical questions on drug use and its possible
side effects. The DIS routinely responds to inquiries regarding appropriate therapy for specific
patients; adverse reactions to drugs; efficacy of drugs; drug interactions; intravenous additive
incompatibilities; biopharmaceutic and pharmacokinetic parameters of drugs; dosing in renal
failure; appropriate therapy for a disease state; identification of foreign drugs; information on
investigational agents; and information on new drugs. The purpose of the service is to provide
accurate, current and unbiased drug information in the promotion of rational drug therapy. We
had a briefing session with Mr. Abdul Qayyum Zainal which also one of the registered
pharmacist in Kuala Lumpur Hospital which is being responsible to handle the Drug
Infromation Services (DIS) department.
In 2008, the first drug information center was relocation at Wisma Rekod in Kuala
Lumpur Hospital area and was intended to be utilized as a source of selected, comprehensive
drug information for staff physicians, dentists, medical officers, and specialist to allow them
to evaluate and compare drugs besides catering to the information needs of nursing staff. The
staffs of the drug information center were expected to take an active role in the providing
information to health professionals within the hospital.
Drug Information Services (DIS) was reviewed retrospectively. Journals were the most
frequently used literature source. Commonly used medical and clinical pharmacology
journals, together with standard textbooks, provided the necessary information to solve more
than 50% of drug information requests. Most questions could be answered by including the
complementary use of the question/answer database Drug line. Drug information access is
important for the improvement of rational use of drugs. According to the present study, this
activity is possible with a fairly limited number of sources.

Setup and equipment

The center is equipped with computer terminals, printed materials (current,
periodicals, bound journal volumes, reference texts) and has access to Medline, the Internet
and various other online drug and medical references. The center maintains subscriptions to
nationally recognized journals and texts of Pharmacy and Medicine. Direct access to
computerized on-line data searching, CD ROM databases and the World Wide Web are also
available.

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Table 1: The working model of drug information service

Staff, Student and Time
One full-time Director, and six pharmacist form the staff at the drug information
center. This center also serves as a training site for undergraduate and postgraduate study in
Pharmacy. Drug information requests may be initiated in person, by phone, fax, e-mail or by
mail. The center is accessible by telephone 24 hours a day.
Service activities
The staff answers questions on drug related matters, particularly to those related to
safety of drug. The doctors, Pharmacists and patients could visit the center in person to get
information. The literature searches are provided free of charge to all hospital faculty,
clinicians, and pharmacy staff for patient specific issues and for research as well as teaching
activities. The center is accessible to undergraduate or graduate students working on special
projects or patient care activities. Since one of its aims is to promote physician-pharmacistpatient relationships it does not advertise to the lay public.
General information is provided to patients for immediate information needed but they
are strongly urged to consult with their treating physician. The center also provides written
information in the form of articles, news-letters and journal columns to encourage and inform
health professionals on rational drug therapy.
An adverse drug reaction (ADR) monitoring and reporting program is in place which
provides guidance for the monitoring, detection, reporting and evaluations of ADRs in the
hospital. It also promotes ADR awareness and information dissemination to the medical,
nursing and pharmacy staff. The data generated is used by the Pharmacy and Therapeutics
Committee to ensure drug safety. The center also participates in the ADR reporting program
of Food & Drugs. Administration (FDA) and has The Product Problem Reporting' system to
ensure drug safety by providing guidance in the event of a defect in the quality of drugs (for
example: color change in tablet or particulate matter in infusion fluid).

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Quality of information
Drug information centers have been criticized for providing information that is mostly
passive or nonjudgmental and perhaps lacking in accuracy. It is also highlighted that,
information is not knowledge, and knowledge comes from the interpretation of information' .
The DIC has provide itself to be an impressive resource, which is used regularly as an
information source by all levels of people involved in the health system from patient to
provider and also contribution through providing access to up-to-date. It has been a steady
increase in the number of enquiries indicating an increase in awareness of the center, as a
source of unbiased drug information among the doctors.

Pictures taken during our visit to DIS department

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TOTAL PARENTERAL NUTRITION

Preparation of sterile pharmaceutical products in hospital includes the aseptic
preparation of products and the preparation of terminally sterilized products. Sterile
preparations are considered to be high risk category products due to the increased risk and
higher level of microbiological contamination for products and need to be prepared in
controlled environments. Preparation should take place in well controlled environment using
well established quality assurance-driven procedures. This operation is applicable to all
products prepared aseptically for administration to patients, which includes Cytotoxic Drug
Reconstitution (CDR), Parenteral Nutrition (PN), Intravenous Admixture and Eye
Preparation.
Total Parenteral Nutrition (TPN) is defined as the process of supplying the daily
calorie requirement and other nutrition such as carbohydrates, protein, fats, vitamins,
electrolytes and water via parenteral route. Parenteral route can be divided into 2 either
peripheral or central lines.
The main objective of this TPN is to maintain the equilibrium between the nutritional
requirement and the metabolic needed by the patient who cannot take the food orally for a
long period of time. TPN is generally indicated by chronic vomiting, anorexia, coma,
gastrointestinal disease surgical complications and pre-operatively malnourished patients.
The pharmacist in TPN unit will receive and screen the TPN form from the doctor
start preparing the worksheet and calculating the requirement needed by the patients
accordingly. The parenteral nutrition is prepared according to the procedure written in the
worksheet. Next, after labeling and rechecking the TPN bag, the bag is dispensed to patients
in wards. Each patient is monitored by looking at clinical examination, vial sign, fluid
balance, blood sugar profile, body temperature, and body weight.
General workflow of TPN:

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Most of the time the patients in Kuala Lumpur Hospital will use ready-made TPN bag either 2
chambers or 3 chambers.

3 chambers TPN bag

2 chambers TPN bag

In certain special case, the TPN is being made in controlled environment with a
complete PPE. The pressure is maintained at positive pressure inside the clean room and the
room temperature should be maintained at 20C 2. Cleanroom maintains the particulate-free
air through the use of either HEPA or ULPA filters employing laminar or turbulent air flow
principles. Laminar or unidirectional air flow systems direct filtered air downward in a
constant stream. Laminar air flow systems are typically employed across 100% of the ceiling
to maintain constant, unidirectional flow.

Location of Clean room of TPN and Sterile Preparation

TPN compounding is made inside the clean room with positive pressure. Air
classification or quality must meet ISO class 8 standards. In terms of physical characteristics
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of construction, the walls, floors, fixtures and ceilings should be smooth, impervious and free
of cracks, crevices and non-shedding. Surfaces should be resistant to damage from sanitizing
agents. Junctures of ceilings to walls should be coved and caulked.
If ceilings consist of inlaid panels, the panels should be impregnated with a polymer to
render them impervious and hydrophobic and they should be caulked around each perimeter
to seal them to the support frame. Walls may be panels locked together and sealed or epoxy
coated gypsum board. Floors should be overlaid with side sheet vinyl flooring with heatsealed seams and coving at the sidewall. The buffer or ante area should contain no sinks or
floor drains.
Before entering the ante or buffer area, personnel should remove outer lab coats,
make-up, and jewelry, and thoroughly scrub hands and arms to the elbows. After drying hands
and arms they should don clean non-shedding uniforms consisting of: Hair covers, Shoe
covers, Coveralls or knee length coats. The coats must fit snuggly at the wrists and be zipped
or snapped in the front, appropriate gloves, and facemasks should be put on after entering the
cleanroom. Upon leaving the clean room the coveralls or coats should be carefully removed
and hung outside the entry in the buffer area. Coveralls and coats can be used for one shift.
All other coverings are to be discarded and new ones donned prior to reentry.

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Clean room of TPN and Sterile Preparation

Parenteral nutrition components made from macronutrient such as carbohydrate,
protein (amino acid) and fat. Other components that might present in TPN compounding are
water soluble vitamin, fat soluble vitamin, traces element and electrolyte. These are the
example of TPN components in ready-made TPN bag available in Kuala Lumpur Hospital:

Components list of Emulsion

for infusion via peripheral vein

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Components list of Emulsion

for infusion via central vein

TPN bag containing

micronutrients
components: glucose,
amino acid and lipid (3
chambers TPN bag)

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Carbohydrate is the main source of energy that is important for body metabolism. The
recommended intake for glucose is minimum 2g/kg/day and maximum 5-7g/kg/day. 1g of
glucose is equal to 4kcal energy. This source of carbohydrate can be found in dextrose
solution which can be varied 5%, 10% or 50%. 1g of protein is equal to 4kcal. This protein is
available in the market such as Glamin which contain dipeptide solution and Dipeptiven
which contain L-alanyl-L-glutamin solution. 1g of fat is equal to 9kcal. Examples of fat
available in market are SMOFlipid 20%, Intralipid 20% and Lipidem.

Example of single macronutrient component to be mixed in TPN compounding bag

available

Vitamin and traces element are added to maintain the body metabolism and fluid
balance in body. It can also act as antioxidants. The commercially available products are
Soluvit N, Vitalipid N, Cernevit, Vaminolact, Glycophos and Sodium Acetate. Glycophos is
the mineralization of organic phosphate solution.

Vitamin and traces element

CYTOTOXIC DRUG RECONSTITUTION (CDR)
In 1960, the Radiotherapy centre was a single storey building located adjacent to the
present Maternity Hospital. There was only a handful of staff running the department. It
consisted of a consultant radiotherapist, two radiographers, a staff nurse, a receptionist and a
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female attendant. Dato Dr S.K Dharmalingam, the consultant radiotherapist at that time,
mooted the idea of setting up a new radiotherapy department. With the support of the Prime
Minister and the Finance Minister at that time, the project was approved. A sum of RM3
million was allocated for the Institute.
The physical construction that was started in August 1967 and completed in November
1968 was then called the Institute of Radiotherapy, Oncology and Nuclear Medicine. The
centre treated about 1000 patients a year and had an inpatient capacity for 100 patients. It was
an exciting year as the department moved from the kilovoltage era to the megavoltage era.
This meant we could treat deep-seated tumours with less fields and spare normal superficial
tissues from side effects.
In the mid 80s new equipments were bought to replace the old. In 1986 a Treatment
Simulator was bought to simulate and verify treatment fields to ensure that we were treating
the tumour sites accurately whilst at the same time sparing critical structures. A dual energy
Linear Accelerator (Linac) with electron beam facility was installed. Electrons were
particularly useful in treating superficial tumours, sparing deep-seated normal tissues.
Today the centre boasts of treating about 4000 new cases of cancer annually and has
an in-patient capacity of about 200 patients. There are 5 consultants, 4 physicists, 41 Therapy
Radiographers, 94 nurses of all categories and 59 attendants.
The Department of Radiotherapy and Oncology, Hospital Kuala Lumpur is the
national referral centre in the field of oncology. Besides providing radiotherapy,
chemotherapy, hormonal therapy and palliative care services, the Department of Radiotherapy
and Oncology, Hospital Kuala Lumpur acts as the impetus for the development of
Radiotherapy and Oncology in Malaysia. The present Department of Radiotherapy and
Oncology is situated opposite the Institute Kaji Saraf Tunku Abdul Rahman (IKTAR),
Hospital Kuala Lumpur.
Miss Siti Fatimah Azura Mat Zin explains to us about the basic, role of pharmacist in
CDR department, and setup of the CDR room. Basically, they provide high quality cancer
care, such as cancer patient so that they will have the ooportunity to receive the best possible
management. Oncology services usually at all times be delivered with emphasis on precision,
accuracy, quality, innovation and commitment by a multidisciplinary team which is dedicated,
caring, responsible, efficient and high-skilled.
Their aims is to deliver optimal treatment to cancer patients with radiotherapy,
chemotherapy and other non-surgical modalities in order to achieve cure whenever possible.
In all patients, including those in whom cure is not possible, the objective is to optimize care
and comfort. Ensure the delivery of timely cancer treatment that is accurate, appropriate,
affordable and patient-centred. Promote the principles and the practice of quality
improvement in all areas of cancer management including curative, palliative and
rehabilitative aspects. Promote professional ethics relating to practice of quality cancer care.
Promote a working environment that is safe for staff, patients and their families and be a

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reputable centre for training of oncologists and allied health professionals involved in cancer
care.
In general, oncology pharmacist plays significant roles in cancer treatment patient. They
not just dispense the drugs but also valuable information throughout the therapy; including
counseling of side-effect and management of proper handling technique. There are several
roles of oncology pharmacist such as:

The pharmacist at Cytotoxic Drug Reconstitution (CDR) unit must provide the best
pharmaceutical care to the patient which include the through screening on the
prescription and check for any errors/discrepancies/doubtful. Thus, here screening
process is still a part of the functions that pharmacist working at CDR unit.

To ascertain certain information and to clarify the values written, the prescription will
be needed to be prepared by another pharmacist.

Pharmacist have to make sure that error is at minimal level while deliver the most
effective drugs to the patient at safe recommended drug level since this issue has
involved pharmacokinetic formulas.

Teaching, mostly the undergraduate nurses or pharmacy students from the college and
university.

Provide information to the ward

Monitor stock level

Provide safety talk to the personnel

In Clinical part, most of the oncology pharmacist involved in monitoring, mainly sign
and symptom of the patient, ward round, counseling, providing information, advice
and assistance to help patient for better adherence towards their treatment and also
give suggestion to the doctor

REGIMEN OF CHEMOTHERAPY
What is Chemotherapy regime/protocol?
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The chemotherapy protocol describes in detail the aim, the modalities, the complications and
the expected results of the medical treatment which is going to be prescribed. It is used as a
reference throughout the prescription.
What it is used for?
It is used for calculation of the dose need to be given to cancer patient. The amount of needed
drugs times with the body surface area (BSA) gives the recommended dose for the patient.

REGIMEN FOR BREAST CANCER

There are various selections of chemotherapy protocol used for treatment of breast
cancer. This chemotherapy protocol is decided to start on a patient based on the particular
patients type of breast cancer she have. Breast cancer can be classified into several types such
as adjuvant, high risk adjuvant, neoadjuvant, and metastatic breast cancer. For every type of
these breast cancers, there are different chemotherapy regimens or protocol for the treatment
of each type of breast cancer.

Picture was taken during out visit to CDR department

THERAPEUTIC DRUG MONITORING

Therapeutic drug monitoring (TDM) is a branch of clinical chemistry and clinical
pharmacology that specializes in the measurement of medication concentrations in blood. Its
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main focus is on drugs with a narrow therapeutic range, for example, drugs that can easily be
under- or overdosed. However, since TDM department in Kuala Lumpur Hospital has been
too busy, we could not get so much information about the basic, workflow and setup of the
Therapeutic Drug Monitoring department. Basically, Miss Charlene Tay Szu Lyn has been
described a little bit about the roles of pharmacist in TDM department.
Therapeutic drug monitoring (TDM) refers to the measurement and interpretation of
principally blood plasma drug concentration measurements with the purpose of optimising a
patient drug therapy and clinical outcome while minimising the risk of drug-induced toxicity.
For Kuala Lumpur Hospital, TDM is done for drugs like Vancomycin, Thephylline, Digoxin,
Carbamazepine, Phenobarbitone, Phenytoin, Amikacin, Valproic Acid, Gentamycin and
Aspirin. TDM involves tailoring a dose regimen to an individual patient by maintaining the
plasma or blood concentration within a particular range. To achieve optimal drug therapy
three objectives should be met, which are to attain desired pharmacological effect of the drug,
to reach the maximal effect in shortest possible time and to decrease the risk of toxicity. The
goals of TDM are to optimise the patients drug therapy and to prevent or minimise drug
related problems/medication errors.
TDM is useful in drugs with a narrow therapeutic index, which are highly protein
bound which is drugs that are liable to interact and the metabolite might be toxic. For roles of
pharmacists, a reliable and responsive TDM service depends on team work between nurses,
doctors, pharmacists, scientist and technical staff. The clinical pharmacist should provide
advice to medical staff on the appropriate use and timing of TDM and assist with the
interpretation of results and even for the initial suggestion for drug regimen. This may involve
decisions about drug choice, dose, dosing interval, route of administration and dosage form of
the drug, taking into account factors such as sex, age, body weight, race, metabolism status,
renal function, plasma albumin concentration, use of other drugs and laboratory results.
Adjustment of the dosage regimen based on TDM results and the patient clinical response.
Assessment of possible causes for unexpected results, such as non- compliance,
bioavailability problems, medication errors, or drug interactions. Dose adjustment for patients
on haemodialysis or peritoneal dialysis and provision of poisons information.
Pharmacists need to check complete drug profile for medication duplication,
interactions or incompatibilities, ensuring that administration times are appropriate with
respect to food, other drugs and procedures. Checking the medication administration record to
ensure that all ordered have been administered, ensuring that the drug administration order
clearly indicates the time at which drug administration is to commence, special considerations
should be given especially in short course therapy as in antibiotics and analgesics, ensuring
that the order is cancelled in all sections of medication administration record when the drug
therapy is intended to cease are also need to be done. If appropriate follow up of any nonformulary drug orders, recommending a formulary equivalent if required. Ensuring
appropriate therapy monitoring is implemented and all necessary medication is ordered which
are premedication and prophylaxis.

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Identification of drug related problems like for examples untreated indication,

inappropriate drug selection, sub therapeutic dose, adverse drug reaction, failure to receive
drug, drug interactions, drug use without indication and over dosage. Another important goal
is to minimise the risk of medication errors that might occur at the level of prescribing or drug
administration. A medication error is any preventable error that may lead to inappropriate
medication use or harmful to patients. To prevent potential morbidity and mortality associated
with these errors, pharmacists should systematically review the medication chart and write
annotations on the chart where the medication orders are unclear.
Clinical review is one of the integral components of medication review and should
preferably be performed on a daily basis. It is the review of the patients progress for the
purpose of assessing the therapeutic outcome. The therapeutic goal for the specific disease
should be clearly identified before the review. The primary aims of the clinical review are to
assess the response to drug treatment, evaluate the safety of the treatment regimen, the
progress of the disease and the need for any change in therapy. It is also to assess the need for
monitoring and the convenience of therapy which is to improve compliance.

Picture was taken during our visit to TDM department

STORAGE

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In Hospital Kuala Lumpur, a separate department manages all hospital purchasing

including pharmaceuticals, medical supplies, and equipment. This department is called Setor
Farmasi. In this department, Miss Flora Ling explains to us about basic, workflow and setup
of the store department. In this hospital pharmacy store is the key facility in Ministry of
Health (MOH) supply chain and distribution for pharmaceutical medical and surgical
inventories. Store pharmacy department function as a distribution warehouse for all
inventories required for patient care services. Its design, structure, construction, flow, location
and built shall meet the Tatacara Pengurusan Stor (TPS), Good Storage Practice (GSP),
other relevant guidelines from MOH and other authorities requirements. A strategic planning
for logistic, storage capacity and workspace is required to ensure this store is capable to
provide safe, efficient and effective services. The planning of the store shall take into
consideration the broad general functions (Impression, Utility and Amenity) served by any
other health facilities.
Basically, in this department their aims is to ensure an edequate storage space and
continuous supply of pharmaceutical, medical, and surgical inventories to improve customer
service. Location of the store is outside but near to the main block of Hospital Kuala Lumpur.
Main purpose it is located outside of any blocks but away from public area is due to allow
efficient delivery activities to be carried out.

General flow in store pharmacy department :

Routine checking is necessary during items receiving and
supplying.
inspect/check for any signs of damage or tempering.
The spillage of product can be determined from physical
apperance of box.
Stock control is important to minimise the cost of holding these
stocks whilst ensuring that there are enough supply to meet
patient demand.
Poor stock control can lead to problems associated with
overstocking or stock-outs.
Efcient stock control allows us to have the right amount of
stock in the right place at the right time.
Expiry date is the date given on the individual container of a
drug product designating the date up to which the product is
expected to remain within specifications, if stored correctly.
It is important to avoid any evitable wastage of items and
directly avoid the wastage of money.

INVENTO
RY
CONTROL
ROUTINE
CHECKIN
G
EXPIRY
DATE

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 Obtain supplies, equipment and services at the lowest

possible cost consistent with quality, delivery requirements
and sustainability,and in accordance with sound business
practice.
Supply is the provision of stock necessary for
maintenance and operation. Drugs and non-standard
items will be supplied and distributed to diferent
departments in the hospital, including aseptic dispensing
unit, out-patient department, satellite pharmacy,
pharmaceutical preparation unit.
There are two types of drug supply. They are
scheduled/schematic supply and supply based on
patients needs.
The stock can be arranged according to several strategies,
which include first in, first out (FIFO), last in, first out
(LIFO) and first expired, first out (FEFO).

PROCUREMENT
SUPPLY
AND
DISTRIBUTI
ON
STORAGE

The Chief Pharmacist is the system administrator for the Pharmacy Information
System (PhIS). The highest level of security are provided to all stores. There will be one
database for monitoring the procurement and supply of pharmaceutical products in the
hospital. All procedures and regulations follow the Treasury Instructions and Government
Procedures and MOH guidelines for procurement. The Pharmacy Store is responsible for
procurement and supply of all pharmaceutical products to the hospitals and health centres.

Procurement and Inventory

Drug Inventory System and Card-based System
Miss Flory Ling has given brief introduction about the hospital inventory system (HIS) and
stock-controlled card.
The purpose of recording the transactions and the received stocks are;

To locate the stored items

To check the quantity and the price of the received stocks

To control the stock level

To ensure the maximum and minimum quantity of the stocks

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HIS software is developed by Pharmaniaga Sdn Bhd and the objective of HIS implementation
is to reduce the cost of administrative and clinical transactions. HIS automates the process of
collecting, and retrieving patient information. Apart from using HIS, Hospital Kuala Lumpur
also use square card which known as Bin Card. Bin Card need to be placed next to the stocks
and must be numbered. For chemicals, flammable or cold storage stocks, the Bin Card need to
be kept separately.
Pink Card is used for stocks that have expiry date and the expiry date is printed on the
stocks. Green Card is for stocks that has no expiry dates.
Red-inked Pen is used to take note on received stocks, Black or Blue inked Pen for issued
stocks and Green inked pen for audit.

Drug Purchasing and Procurement Activities

If drug supplies to wards reached the minimum amount, the units will submit request to the
store personnel to make new orders of drug stocks. Then, the store personnel will evaluate the
requested items. After evaluation, store personnel need to get quotations and calculate the
costs in order to purchase new stocks.
Store personnel will inform the calculated costs to the store department. The store department
will decide whether to make new purchases and if the purchases are important then they need
to check the allocations. If the (money) allocations for drug purchasing are not enough,
department will send request to hospital admin asking for additional allocation.
Next, hospital admin need to get additional allocation from state or from Ministry of Health.
If the allocations are now enough, the purchasing activities can be done. Department will put
indent to the store through HIS.
The drug procurement can be processed via ePerolehan and also eSPKB. There are 3 ways
used in purchasing activities:
1) Concession (already in standard Ministry of Health list)
2) Contract, with MOH or between Hospital
3) Local Purchase
In procurement processes, it is very important to choose the company that sells quality drugs
and goods at reasonable prices, and usually one out of three companies (3 are minimum, by
the way) are chosen based on their business proposal with the hospital. When the procurement
processes are finished, and later the ordered stocks are received, the store personnel will
supply through department and department will redistribute the supplies to the wards. Thats
how drug procurements activities are done.

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Drug Supply and Distribution to Other Units within the Hospital and Other Institutions
Hospital Kuala Lumpur plays important role in providing diagnostic and curative services to
patients, increase the effective use of drugs and make it necessary for hospital to maximize
drug use rational. Drug Integration Store in HKL responsible in procurement, receiving,
storing and distribute the drugs, IV drip, gaseous and consumables tools for pharmacy unit in
HKL. Drug Integration Store under direction of pharmacist is responsible for controlling
distribution of drugs within the hospital and other institution thus promoting their appropriate
and safe use of drugs. This department also responsible in distribute the drugs and nonmedication within the hospital to other pharmacy unit in hospital which is:
1. Outpatient pharmacy
2. Satellite pharmacy
3. Oncology pharmacy
4. Pharmacy ward (Pediatric, Cardiothoracic, Nephrology, Respiratory, Cardiology,
Neurology, Endocrinology and Infectious Disease)
5. Clinical Pharmacokinetic Services
6. Therapeutic Drug Monitoring (TDM)
7. Total Parenteral Nutrition (TPN) and IV Admixture
8. Pharmaceutical galenical and extemporaneous
9. Medication Therapy Adherence Clinic, MTAC (HIV, Diabetes, Warfarin, Methadone,
Rheumatology and Renal Transplant)
10. Nuclear Pharmacy

Distribution activities are based on Nota Keluaran Barang (NKB) that has been approved by
pharmacy officer according to regulations state on the Tatacara Pengurusan Stor, TPS (Store
Management Regulation). The earliest drugs or inventory item purchase are the first inventory
items distribute to match the cost of the inventory value on the balance sheet with actual flow.
This inventory method called first-in, first-out (FIFO) which has been used in managing the
procurement and distribution of the drugs.[1]This system may minimize the drugs from expired
date before distribute to pharmacy unit in the hospital or other institution.

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Entertaining Requests from Other Pharmacists and Doctors Regarding Drug Supply
Pharmaceutical services in the general hospital should have great inter-professional
perspective in terms of medicine management and relevant information to guide in
prescribing and use of drugs. Integration Store activities must match these needs in order to
satisfy others members of healthcare team and patients. For doctors and pharmacists who
want to order medication and non-medication tools from Integration Store, they need to fill
Distribution Order form. Medications can be ordered monthly and the orders should be sent a
week before queue order. For non-medications tools such as surgical scissors, catheters and
others, orders can be made by filling the Procurement Application Tools form that can be
getting from each pharmacy unit in the hospital. Only qualified officer can make order from
Integration Store.
Some doctors prefer a pharmacist to assist them while prescribing drugs because they believe
they have insufficient feedback on their drug prescribing practices and they also believe with
great interaction with pharmacist. Some doctor also felt that pharmacists interventions
challenged their authority because they believe they need no further information on medicine
prescribing. When doctors order older drugs, pharmacist will recommend the replacement of
other drugs that have same mechanism of action with fewer adverse drugs reactions and more
efficacies. A new drugs list that will replace with older drugs will be distribute to all pharmacy
unit in the hospital to improve the quality of patient care with involvement of pharmacist in
medication review and feedback of prescribing patterns to doctors.

Drug Storage System

The integration store of pharmacy department uses ordinary conventional system for storing
drugs and consumable products and some rooms are equipped with special conditions to meet
the requirement of certain types of drugs. The main objective is to preserve drug condition to
its normal value while receiving and to maintain drug stability (to prevent deterioration of
susceptible drug products). Different items are stored in different areas/room based on their
common features and specific characteristics. A proper strategy is needed and a systematic
handling of drugs to ensure effective drug storage system.
The ground floor has a loading bay which is use for the purpose of loading and unloading
products.
Storage room in Integration store can be divided into:
i)

Common Room

The drugs that come in large quantity are mostly fast moving products and will be placed first
in common room before any movement is carried out. The condition in this room is
maintained at room temperature (~25C). Most of new arrival drug and non-drug items
(mainly those not heat-labile) will be stored in common room including the cytotoxic and
dangerous drugs. The storage space for cytotoxic and dangerous drugs are separated from
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others and labeled differently. Most of the products stored in this room are those products
from Pharmaniaga.
ii)

Cold Room

This room is designed for heat-labile items or items that need to be kept at low temperature
due to stability concern will be placed in cold room. Temperature in this room ranging from
2C-8C, which is controlled automatically by computer system. Example of drugs/items that
is stored in this room is vaccine, insulin products and Sandimmun. Assigned staff needs to
make sure that the temperature in this room is within the range. And if any changes to the
condition of rooms or items are notified, immediate correction actions need to be taken to
solve the problem. The cool room is located at the ground floor.
iii)

Strong Room

This room is designed for most of the Dangerous and psychotropic drugs. As compared to
common room, this room is locked most of the time except required to be opened for
storage/distribution/inspection activities and only pharmacist/provisional pharmacist are
allowed to hold the key for this room. Thus for any activities need to be done in this room, it
must gone thru the assigned pharmacist. The drugs stored in this room include tablet, liquid
for injection and capsule and the temperature is maintained at 25 degree Celsius. There are
also separated rooms for storage of non-drug items such as surgical equipment (cotton wood,
soap, syringes).

Cold room (bilik sejuk)

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a storage room on the ground floor

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Inside strong room

Store A/P

Disposable of Expired Drugs

Expiry date is the date given on the individual container of a drug product designating the
date up to which the product is expected to remain within specifications, if stored correctly.
Expiry date is established by the manufacturer for each batch by adding the shelf-life period
to the date of manufacture.
Normally when the Integration store of HKL want to purchase any items especially
drugs, they will make sure that the expiry date of the item is around 18 months. So when the
expiry date is about 2 month, the in-charge pharmacist will take an action by informing the
supplier to change the item. However for items with expiry date less than 18 month from the
day of receiving, guarantee letter must be obtained from the supplier. The guarantee letter may
include the return/exchange system for expired items. The expired items may be exchanged
with same items, different items with same price or exchanged with money. For example
today is 2 Sept 2010 and our Pharmaniaga Bethamethasone N 15g stock item will expire on 1
Nov 2010. So the responsible person in charge will inform the manufacturer to replace if the
items cant be finished.

Inventory Management and Distribution

The objective is to minimize the cost of holding these stocks whilst ensuring that there is
enough supply to meet patient demand. Poor stock control can lead to problems associated
with overstocking or stock-outs. If a pharmacy store holds too much buffer stock (stock held
in reserve) or overestimates the level of demand for its drugs, then it will overstock. Excess of
stock increases costs for the pharmacy department as holding stocks is considered as an
expense for the hospital pharmacy for several reasons:
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Increases space of the store needed

Higher insurance and security costs needed

Stocks may be damaged or become expired

Money tied up in the stocks could have been better spent elsewhere

Besides that, the items should be arranged according to the several factors such as:

Stock rotation

Type of items (i.e.: drugs and non-drugs).

Storage condition

Controlled substances.

Attractive items

Flammable and corrosives.

Those stated factors are important to ensure the quality of the item before distribute to the
desired customer.

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CONCLUSION
The Pharmacy Practice Programme attachment is made up for student attachments
who are practising pharmacists after our second year final examinations. The programme is
for a week in Kuala Lumpur Hospital. The programme provides an opportunity for
experiential learning in work environments of different pharmacy practice sector.
10 pharmacy students participated in this attachment and for the first time we were
experienced this programme. Each one of us were having a log book and required to prepare a
report after the programme which the preceptors incharged will be evaluate us on the logbook.
The attachment carried out in the right time where we had finished our fnal exams and had
learned about core subjects such as Pharmacy Practice, and Pharmacology. I am able to apply
knowledge I have learnt and to correlate experience with examples cited in class. I gained an
understanding of the practice of pharmacy and to learn more about career opportunities
available to pharmacy practitioners. I also able to acquire and apply some knowledge,
experience, and skills to achieve professional competency in pharmacy. In a good way, I
believed that I had begun to develop high standards of ethical, legal, and professional conduct.
The problems face during these one week of hospital attachment is limitation of time.
Since we only have one week to explore and learn about 7 departments, it is very difficult for
us to discover and understood in a short period. Thus, my suggestion is we should extend the
attachment programme at least for a month.
Second, as we are in second year program, we do not have much knowledge regarding
to human body system and also about drugs. Therefore, as a student, we need to prepare notes
regarding to the departments that we visit, and also prepare reference books or ebooks.
Lastly, punctuality is an important aspect for pharmacist. Punctuality is the
fundamental of discipline. However, throughout the programme, none of us having problems
as being late or did not come to the attachment.
The hospital attachment consists of four main sections. These are outpatient, inpatient,
manufacturing section, clinical support section and storage management section.Generally, we
had learnt the workflow, basic setup, role of pharmacist in each department. However, we
could not had a chance to visit Galenicals department and MTAC department. Hopefully, in
next attachment with enough time, we can visit and discover other departments too.

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REFERENCES:
1.
2.
3.
4.

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http://www.hkl.gov.my
www.slideshare.com/outpatient-overview
www.scribd.com/hospital-setup
Ebooks.clinicalguidelines

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