International Reprorts

Scope of International Hospital Pharmacy Practice

Jaclyn M LeBlanc and Joseph F Dasta

OBJECTIVE: To review the published English literature regarding international hospital pharmacy practice.

DATA SOURCES: A computer search of all English-language articles in MEDLINE (1966–June 2004) and other Internet sources and
International Pharmaceutical Abstracts (1971–June 2004).
STUDY SELECTION AND DATA EXTRACTION: All studies that discussed hospital pharmacy or clinical hospital pharmacy activities
outside of the US were considered for inclusion.
DATA SYNTHESIS: The scope of international hospital pharmacy practice is quite varied, both inter- and intra-country, and varying
degrees of specialization exist. Although clinical pharmacy is well developed in some countries, it is still in infancy stages in others.
In addition, there is disparity in the actual definition of clinical pharmacy throughout the world.
CONCLUSIONS: Since very few data have been published regarding hospital pharmacy practice on an international scale, we
suggest a survey be conducted to objectively capture this information and increase awareness of clinical pharmacy in this setting.
KEY WORDS: clinical pharmacy services, hospital pharmacy services, internationality.

Ann Pharmacother 2005;39:183-91.

Published Online, 14 Dec 2004, www.theannals.com, DOI 10.1345/aph.1E317

n many countries, the definition and responsibilities of a
Irecent
hospital pharmacist have evolved dramatically, with the
focus of practice changing from medication oriented
to patient outcomes oriented. The profession has dealt with
obstacles such as gaining the recognition of pharmacists’
capabilities and activities by other health professionals, as
well as the escalating economic strain as hospitals’ budgets
decrease and drug costs increase. In developing countries,
pharmacists often face unique challenges due in part to the
economic hardships endured. However, global hospital
pharmacy practice appears to have begun changing as
well, expanding its practice beyond the confines of the
pharmacy. The purpose of this review is to examine the En-
glish-language literature regarding international hospital
pharmacy practice and compare the scope of the pharma-
Author information provided at the end of the text.
cist’s practice in various countries outside of the US. A com-
puter search of all English-language articles in MEDLINE
(1966–June 2004), other Internet sources and International
Pharmaceutical Abstracts (1971–June 2004) was conducted.
One of the difficulties in assessing international litera-
ture is the variation in the definitions of clinical pharmacy
and pharmaceutical care. For example, in the early 1990s,
clinical pharmacy practice in Poland was confined to the
analysis of samples of urine, blood, microbiology, and
drug concentrations for hospitalized patients.1 In the West-
ern world, clinical pharmacy was defined many years ago,
and the American College of Clinical Pharmacy (ACCP)
is currently updating that definition. For the purposes of
this review, we define clinical pharmacy very broadly as
the provision of a patient-oriented service provided in
pharmacists’ daily activities. In 2000, the European Soci-
ety of Clinical Pharmacy defined clinical pharmacy as “a
health specialty, which describes the activities and services

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JM LeBlanc and JF Dasta
of the clinical pharmacist to develop and promote the ra-
tional and appropriate use of medicinal products and de-
vices by the individual and society.”2 It proceeded to state
that the focus of this discipline is the patient or population
receiving the medications. In addition, there are many
published definitions of pharmaceutical care. Hepler and
Strand3 in 1990 defined pharmaceutical care as “the respon-
sible provision of drug therapy for the purpose of achiev-
ing definite outcomes which improve a patient’s quality of
life.” van Mil et al.4 later published an article detailing the
reasons for various definitions of pharmaceutical care in-
cluding language and cultural differences, influence of the
respective healthcare systems, and professional differences
between countries. Although many countries have adopted
the Hepler and Strand definition of pharmaceutical care, a
number of countries have developed their own definitions.
One must be aware of the interpretations and lack of defi-
nitions found in the literature.
Organizations
Hospital pharmacy societies have been formed in many
countries, including Estonia, South Africa, and Peru, in re-
sponse to the evolution of hospital pharmacy practice.
These organizations serve to support the pharmacists’
practice in the hospital setting. However, there is not one
society that represents hospital pharmacy on an interna-
tional basis. The International Pharmaceutical Federation
(FIP) has a hospital pharmacy section that attempts to so-
lidify a global relationship between pharmacists through
discussion and exchange of experiences; however, only re-
cently has this organization begun to welcome individual
members. In the past, only organizations could join the FIP.
Many hospital pharmacy societies have endorsed stan-
dards for practice including Canada, the Netherlands, and
Ireland.5-7 The constant theme throughout these standards
is pharmacists’ responsibility to the patient for pharma-
cotherapeutic outcomes. The Good Pharmacy Practice
Guidelines developed by the FIP, and subsequently adopt-
ed by the World Health Organization, state that a pharma-
cist’s first concern should be the welfare of the patient.8
These guidelines were first adopted in 1997 to help nation-
al councils develop national standards; however, there has
been no update since that time.
Clinical Activities
There is a wide range of clinical pharmacy activities
performed throughout the world, which include, but are
not limited to, patient medication review, ward rounds,
therapeutic drug monitoring, drug information, inservice
education, medication counseling, medication histories,
drug utilization evaluations, adverse drug reaction (ADR)
management, clinical research, and participation in spe-
cialty teams.9 In many countries, clinical pharmacy ser-
vices are still in their infancy, with pharmacists spending a
predominant amount of time on distributive and manufac-
turing activities. However, the development of clinical ser-
184 ■ The Annals of Pharmacotherapy ■ 2005 January, Volume 39
vices is increasing. For example, pharmacists in Japan pre-
viously spent a great deal of time in manufacturing of
products,10 but recently, approximately 50% of inpatients
received clinical services on the wards in this country.11 A
questionnaire circulated in 2001 to hospital pharmacies in
Australia showed that 41% of the pharmacists’ time was
spent in clinical activities dedicated to the patient, drug in-
formation services, training, and education; 39% of the
time was dedicated to acquisition, manufacture, and dis-
pensing of medications; and 16% of the time was allocated
to managing drug and personnel resources.12 Clinical phar-
macy services in Korea are not well established, as evi-
denced by a study on ADR reporting, in which no reports
were made by a pharmacist.13 Reports of clinical and dis-
tributive functions for selected countries are summarized
in Table 1.10,11,14-65
As well as considerable inter-country variability in the
practice of hospital pharmacy, there is much intra-country
variability. This is true for Africa, where many of the coun-
tries in the past undertook the style of pharmacy practice
of its many colonists.66 For example, certain countries in
West Africa took on the standards of either British or
French colonists, whereas North Africa was subject to
Arabic influence. In the past, practice between the northern
and southern parts of Nigeria were very different due to
different educational standards.66 In a survey of hospital
pharmacy services in Australia in 1998, wide variations
were reported between the states in many different areas,
including ADR monitoring (50–100%) and manufacturing
of non-sterile products (35.5–100%).14
The European Association of Hospital Pharmacy
(EAHP) conducted surveys in 1995 and 2000, comprising
16 European countries67,68; however, only a portion of the
surveys concentrated on clinical duties. Regardless, strik-
ing differences were seen between many of the countries.
In the most recent survey, for example, pharmacokinetic
consults were provided in <1% of hospital pharmacies in
Austria, but >6% in the Netherlands and the UK. Although
it appears that these numbers are low compared with those
from the American survey in 2003,69 the questions may
have been worded differently and the data may not have
been collected in the same way. This limits the ability to
compare this information. To our knowledge, the only oth-
er international survey published was a combination of 2
surveys conducted by the FIP in 52 countries in the mid-
1970s, focusing mainly on community pharmacy.70
In Pakistan, there are opportunities for pharmacists to
become more involved with patient care; however, there
are difficulties with identifying their role and responsibili-
ties and having those recognized by hospital administra-
tors, government, and patients.49 A study was conducted in
a 220-bed Nigerian teaching hospital examining commu-
nication between pharmacists and elderly patients during
medication history interviews to identify the communica-
tion gaps between pharmacists and patients.71 Only a small
number of pharmacists were willing to participate in the
study due to time commitment or refusal to be videotaped.
The results illustrated miscommunication during verbal in-
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 International Hospital Pharmacy Practice

Table 1. Scope of Hospital Pharmacist Activities in Selected Countries

Country Ref. Year Distribution System Distribution Activities Clinical Activities Formulary
Australia 14–16 2000, ward stock replenished inpatient dispensing, drug review of charts, monitoring formulary systems in place
2003 by the pharmacy de- purchasing, some cytotox- drug therapy, counseling, in public hospitals, but not
partment ic manufacturing ADR monitoring, some clinical necessarily private ones
trial support and research ac-
tivities, basic drug information
Belgium 17,18 2002, unit dose main duties preparation limited time spent on clinical ND
2004 and distribution of drugs tasks, collaboration with nurs-
ing staff about the use of
medicines
Bermuda 19 1996 ND manufacture and supply each pharmacist assigned a limited formulary
patient-controlled anal- ward
gesic packs for the ward
Canada 20 1999 traditional drug distribu- chemotherapy and TPN increasing participation in ward ND
tion and unit-dose sys- preparation, increased rounds, admission histories,
tems, decreasing ward iv admixture pt. group teaching, clinical
stock systems drug trial services, pharmaco-
kinetic dosing
China 22 1994 ND ND TDM not individualized for the ND
pt., ADR monitoring for iden-
tified drug classes
Denmark 21, 23, 1993, ND drug distribution and inven- drug information, increasing local government committee
24 2000, tory control management, ward rounds and interaction reviews and compiles for-
2004 cytotoxic and TPN recon- with ward personnel mulary
stitution
France 25, 26 1996, unit-dose system dispensing of medications, counsel pts., serum assay ND
1997 heavy compounding role of medications (but often no
assessment provided)
Germany 27–30 1995, ND cytotoxic and TPN services pharmacokinetics, drug infor- most hospitals have formula-
1999, mation, some ward rounds, ry and committee; in large
2003 , some pt. counseling, in- hospitals (>500 beds), phar-
creasing involvement in clin- macists are chairpersons of
ical trials the committee in 52–78%
of hospitals
Grenada 31 1999 ward stock, requisitions filling prescriptions, some ward-based pharmacist to ND
sent to pharmacy to fill extemporaneous dispens- cover ward; however, due to
ing, some cytotoxic recon- short-staffing, this practice
stitution was not consistent
Iceland 32 1994 ward stock with all maintain floor stock and updating daily medication, ND
parenterals except dispense some outpatient dispensing 7-day supply of
TPN prescriptions, 2 hospitals medication
report parenteral admix-
ture programs
India 33–35 1998, ND ND increasing clinical activities initiation of DTC in some
2002, including ward rounds, drug hospitals
2003 information services, and
ADR monitoring/reporting
Indonesia 36 2000 ND procurement, supply, and ND ND
distribution of medications
main focus
Republic of 37 1999 ward stock system in ND moderate numbers of hos- ND
Ireland ~50% hospitals pitals (~30%) offered clinical
pharmacy services, pt. coun-
seling, drug information,
attendance at ward rounds
Israel 38 1996 ND manufacturing cytotoxics, some clinical trial involvement, ND
iv additives, TPN increasing clinical pharmacy
services
Japan 10, 1995, ND compounding and dispens- pharmacokinetic and drug ND
11, 2000, ing, focus on preparing therapy consults, drug infor-
39 2002 and delivering, dispense mation services, some DUE/
parenteral drugs DUR

ADR = adverse drug reaction; DTC = drug and therapeutics committee; DUE/DUR = drug use evaluation/drug use review; ND = not described;
TDM = therapeutic drug monitoring; TPN = total parenteral nutrition.
(continued on page 186)

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JM LeBlanc and JF Dasta

Table 1. Scope of Hospital Pharmacist Activities in Selected Countries (continued)

Country Ref. Year Distribution System Distribution Activities Clinical Activities Formulary
Kuwait 40 2003 ND pharmacists: drug ordering, clinical services limited ND
stock control, personnel
management
technicians: dispensing
duties
Lebanon 41 2004 ND distribution of medications, provide pharmaceutical involvement in formulary re-
compounding care, especially in large view and cost management
centers
Lithuania 42 2003 no unit dose heavy emphasis on manu- none (do not go to wards ND
facturing, no TPN or cyto- or counsel pts. on medi-
toxic manufacturing cations)
Nepal 43 1996 ND some cytotoxics and manu- ND ND
facturing
Netherlands 44–46 2003 most hospitals have dispensing done by techni- analyze drug prescriptions, pharmacists involved in deci-
unit-dose system cians supervised by a phar- check for contraindications, sions of the DTC
macist TDM, pharmacokinetic
modeling, some clinical trial
involvement, participate in
ward rounds
New 47 2001 ND for inpatient and clinical trials daily visits to the ward ND
Zealand only; limited manufacturing,
most cytotoxic and TPN out-
sourced
Norway 48 2002 ND ND ND pharmacists involved in the
drug committee making
decisions
Pakistan 49, 50 1993, ND main focus dispensing and increased awareness in last ND
2002 storage, distribution, ad- few years with development
ministration of medications of ADR monitoring programs,
and TPN drug information services;
medication review in larger
hospitals
Russia 51, 52 1996, mainly parenteral heavy in-house sterile and ND mostly parenteral products
2002 products dispensed; non-sterile manufacturing
ward stock system due to lack of medications;
no individual prescriptions
Slovenia 53–55 2004 ND Radiopharmaceuticals and some research activity and ND
cytotoxic preparation at counseling at larger hospitals
larger hospitals, TPN
preparation at 1 large
hospital (with aid of
computer system)
South 56 1994 majority ward stock TPN and cytotoxic prep- attend clinical ward rounds, ND
Africa for inpatient drug aration in bigger hospitals TDM, pt.-oriented services
distribution in some hospitals
Spain 57, 58 1993, ND ND increasing clinical activities ND
1999
Sweden 59 2003 unit dose to pt. on ND some involvement in research pharmacists involved with
daily basis (although mainly distributive) the DTC
Switzerland 60, 61 2003 ND ND increasing ward rounds ND
Ukraine 62 1995 ND mainly dispensing and no pt. contact, no ADR ND
quality control at the manu- monitoring
facturing level, most med-
ications made from scratch
United 63 1994 ND ND ward-based activities stan- pharmacists usually partici-
Kingdom dard practice, many pharma- pated as part of the DTC
cists attend ward rounds,
some research activity
Zimbabwe 64, 65 1996, general ward stock manufacture many items ward rounds in 2 central hos- ND
2002 system including syrups, antacids, pitals, some pharmacokinetic
eye drops consults

ADR = adverse drug reaction; DTC = drug and therapeutics committee; ND = not described; TDM = therapeutic drug monitoring; TPN = total par-
enteral nutrition.

186 ■ The Annals of Pharmacotherapy ■ 2005 January, Volume 39 www.theannals.com


teractions with elderly patients. In many developing coun-
tries, clinical pharmacy has not yet begun to be realized.
The role of the hospital pharmacist in Armenia is classic,
with the traditional responsibility of storage, production,
and distribution of drugs.72 In Uganda, “clinical pharmacy
is very much in its infancy.”73 Matowe and Katerere74 sug-
gest that increased interaction between international phar-
macists may aid in transferring skills and further the pro-
fession to those in developing countries.
Personnel Shortages
Even though there is an impetus toward clinically com-
petent graduates, the majority of students graduating from
a pharmacy college will not choose the hospital sector as
their preferred area of practice. The actual number of phar-
macy graduates entering hospital pharmacy is very low in
countries like Slovakia (5%),75 Indonesia (10%),36 Pakistan
(<10%),50 and Grenada (8%).31 In 1994, approximately
12% of the pharmacy workforce in South Africa was in-
volved in hospital practice.56 In the early 1990s, Zimbabwe
reported that, although clinical opportunities existed, there
was a severe shortage of staff, and these opportunities
could not be realized.76 A recent paper revealed that only
30 pharmacists are trained each year in Zimbabwe due to
the high cost of education undertaken by the government.74
Insufficient staffing has curtailed the opportunities to work
with medical staff and increase the influence of pharma-
cists within hospitals in Slovenia.77 A recent workload
questionnaire circulated to all hospital pharmacies in Aus-
tralia highlighted a 14% vacancy rate for pharmacists.12 As
well, 60 additional pharmacists would be needed to cover
the overtime currently being expended at the surveyed
hospitals.
Stemming from the pharmacist shortage comes the frus-
tration of having the desire to offer clinical and specialized
pharmacy services, but not having the staff to perform
those functions. In addition, many hospitals have had to
decrease clinical services just to maintain adequate distri-
bution function. A study in Japan showed that a higher dis-
pensing load was associated with fewer inpatients being
provided clinical pharmacy services.11 The Society of Hos-
pital Pharmacists of Australia (SHPA) recently published a
position statement on the shortage of hospital pharmacists
in which it warned of compromised patient care as a direct
result of pharmacists leaving the profession.78 The Victorian
Branch of the SHPA completed a Public Hospital Pharma-
cy Workforce Analysis, which revealed that 74 pharmacists
resigned in that state in 2001, of which only 16% remained
in hospital pharmacy: 25% transitioned to community
pharmacy and 20% cited overseas/travel as the reason for
resignation.79 Fifty percent of pharmacy resignations were
due to increased workload and stress associated with over-
time and inability to take vacation. In British Columbia
during 2003, there was an estimated vacancy rate of 10%
in hospital pharmacist positions, with the majority of phar-
macists leaving the hospitals for the community sector.80
Many pharmacy schools in the US and Canada have tried
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International Hospital Pharmacy Practice
to respond to the shortage problem by increasing enroll-
ment in pharmacy schools; however, in developing coun-
tries, this is usually not feasible due to costs of education
and facilities. One recent article highlighted the frustration
of pharmacists in Armenia.72 With drug supply shortages,
worn-out facilities, and delays in salary payouts, many
pharmacists were turning toward the private sector. Devel-
oping countries may face an even greater challenge, with
few pharmacists trained per year and better conditions in
more developed countries. Regarding globalization and
pharmacy, Matowe and Katerere74 highlighted the free
movement of personnel from one country to another as an
issue in the developing world since many competent grad-
uates leave to pursue their careers elsewhere.
Impact of a Pharmacist
Another statement from the SHPA declares that all pa-
tients should receive clinical pharmacy services as part of
routine care since clinical pharmacists have been shown to
decrease the incidence of adverse drug events (ADEs).81
This is based on a study of the impact of pharmacists in 8
Australian teaching hospitals that documented the clinical
impact of pharmacist-initiated drug therapy.82 Twenty-five
percent of the interventions were determined to be of ma-
jor significance (preventing or addressing very serious drug-
related problems). Thirty-eight percent of the interventions
were of moderate significance (prevented major temporary
injury, enhanced the effectiveness of drug therapy, or pro-
duced minor decreases in patient morbidity or a <20%
chance of noticed effect), and 30.4% were of minor signifi-
cance (small adjustments and optimizations of therapy).
One percent of the interventions documented were life-sav-
ing. The Gillie report described a high rate of drug adminis-
tration errors in British hospitals in the late 1960s, and
ward-based practice of pharmacy was a direct consequence
and solution to this.83 A more recent article from Israel docu-
mented 160 medication errors over a 6-month period (11.2
errors/1000 prescriptions) and showed that pharmacists iden-
tified and rectified these errors.84 Of the documented er-
rors, subsequent pharmacy interventions were accepted in
87.5% of cases. The introduction of a clinical pharmacist
to an intensive care unit (ICU) team in Pakistan demon-
strated a high acceptance rate of interventions (91.6%) and
has led to the creation of other clinical positions in varying
practices in the hospital.50
Hospital pharmacy interventions have also been demon-
strated to have a cost-savings in many countries. Dooley et
al.82 reported that the annualized cost-savings associated
with economically measured resources due to pharmacists’
interventions was $4 447 947 (AUS) in the 8 institutions;
$23 were saved for every $1 spent on a pharmacist to initi-
ate an intervention. A hospital in Spain reported pharmacist
interventions regarding antibiotic prophylaxis, pharmacoki-
netics, thromboembolism prophylaxis, non-formulary pre-
scription requests, inappropriate duration, and others were
associated with a cost-savings of 129 059 over a 6-month
period.85 In Canada, the addition of a clinical pharmacist to
■ 2005 January, Volume 39 ■ 187
JM LeBlanc and JF Dasta
an ICU resulted in pharmacist-initiated consultations leading
to an annualized cost-savings of approximately $67 665
(CAN) in 1994.86 The introduction of a part-time pharma-
cist into the ICU in Malaysia resulted in savings of $4014
(US) over one month.87
Specialization
As pharmacists become more integrated into the patient
care stratum, more choose to specialize in a particular
medical discipline. For example, in Australia, Canada, and
the UK, pharmacists specialize in critical care. Divergent
values from the EAHP survey68 occurred in the number of
hospital pharmacies that had dedicated drug information
positions, ranging from <10% in Finland and Slovenia to
>70% in Denmark and the UK. Pharmacy in the Nether-
lands is also developing specialization in clinical areas
such as pulmonology, neurology, and cardiology.45 The ini-
tiation of a pediatric clinical pharmacy service in Zimbab-
we was described in 2002.64 Two years after the service
was instituted, a questionnaire was distributed to the nurs-
ing staff working with the pharmacist, which showed 90%
felt the service was good or excellent, and 91% thought
“the relationship between pharmacy/medical and nursing
staff was improved due to better communication.”
The practice of radiopharmacy has been evolving in
Slovenia, with recent introduction of a postgraduate train-
ing program by the Faculty of Pharmacy in Ljubljana in
2003.55 Similar to the ACCP in the US, the European Soci-
ety of Clinical Pharmacy had developed special interest
groups in disciplines such as cancer, nutritional support,
and pediatrics where pharmacists can exchange informa-
tion. In the UK and the Netherlands, there are subgroups of
hospital pharmacists who specialize in psychiatric pharma-
cotherapy. An interesting specialty in many countries is the
practice of herbal and traditional medicine. For example, at
the School of Pharmacy at Kumasi in Ghana, there is a de-
gree course offered in herbal medicine.88 In Nepal, an en-
tirely separate area of “ayurvedic pharmacy” exists, which
uses plant derivatives available as raw products or in phar-
maceutical products.43
As clinical practices increase, the numbers of pharma-
cists who participate in research also increases. A ques-
tionnaire sent to drug information centers in Italy revealed
that 22.5% were involved in self-initiated research projects
and 57.5% conducted research both independently and in
partnership with other institutions.89 In the Canadian phar-
macy services survey, participation in clinical drug trials
increased from 50% of hospitals in 1991–1992 to 80% in
1997–1998.20 Fifty-seven percent of Australian hospitals
reported provision of pharmacy services for clinical trial
support, and 34.3% indicated there were research activities
or opportunities.14
Formularies and Economics
Due to increasing costs, formularies were being imple-
mented in Slovakia in 1998.75 In hospitals in Denmark,
188 ■ The Annals of Pharmacotherapy ■ 2005 January, Volume 39
there is a formulary committee, and cost was the predomi-
nating factor in the selection of drugs.24 A study examining
the function of hospital formularies in the Netherlands
found wide variations—from being solely drug lists to al-
most complete therapeutic manuals.90 Hospital pharmacists
in Guernsey, one of the Channel Islands, exclusively make
changes to the drug formulary due to the absence of junior
physicians.91 In the 1992 survey of clinical services of the
UK, 96% of pharmacies had involvement on the drug and
therapeutic committee, 91% provided financial informa-
tion on drug use, and 73% provided information used in
making formulary decisions.63 In the 2000 version of the
EAHP survey, most countries reported >60% of hospitals
had formularies in place.68 In the early 1990s, both Aus-
tralia and Canada were compiling formularies for drug use,
with pharmaceutical companies required to submit an eco-
nomic analysis as one of the criteria for evaluation of the
medication.92
In many hospital pharmacies around the world, purchas-
ing of medications is an important role. An article regard-
ing the state of pharmacy in Zimbabwe in 1991 reported
that drug supply was a major issue.76 Pharmacists in
French hospitals are the primary personnel responsible for
the purchase of pharmaceutical products,93 and in the past,
many hospitals in Indonesia employed only one pharma-
cist focused primarily on procurement, supply, and distri-
bution of medications.36 Developing countries often face
hardships at this stage as well due to financial shortages
within the hospital and country and lack of in-country pro-
duction of medications.
Cost-effectiveness data are often used in assessing new
drugs proposed for addition to the “reimbursable” drugs
list in the country.93 As additional cost analysis data are
published, pharmacists and formulary committees are un-
der increased pressure to consider cost in formulary deci-
sions. A survey on the use of economic data in formulary
decisions in France revealed that, although price informa-
tion was frequently examined, pharmacoeconomic evalua-
tions were rarely used.94 Barriers identified in the use of
this information included lack of time, limiting collection
and analysis of the information, insufficient health eco-
nomics training, and closed budgets within hospitals. Phar-
macoeconomics is becoming increasingly used in hospitals
in the Netherlands.45
Summary
The Good Pharmacy Practice Guidelines8 attempt to
provide a set of guidelines that can be applied internation-
ally to all hospital pharmacists and pharmacies, although
they have not been updated recently. There are arguments
against a universal set of standards given the differences in
training of graduates and the wide breadth of activities and
responsibilities both inter-and intra-country. As well, the
different philosophies and infrastructures of the many
healthcare systems worldwide make it very difficult to try
to define the profession’s roles and responsibilities within
one set of standards. However, from our review, it is appar-
www.theannals.com

ent that all hospital pharmacists are trying to advance the
profession, often with the same goal of increasing involve-
ment in direct patient care. Some countries are further
ahead of others, but this is where a global partnership of
pharmacists would be of great benefit. In sharing informa-
tion about the successes and failures of promoting and ad-
vancing pharmacy activities, the profession could facilitate
its own expansion. Perhaps as a profession we should en-
courage our respective leading professional organizations
to work together to accomplish this goal.
There is increasing evidence that pharmacists improve
patient care and decrease health-related costs and, as such,
have begun to economically justify their place within the
clinical care of the patient. As well, the improvement in
patient safety through reduction of ADRs has given phar-
macists an important justification for involvement in direct
patient care. Despite this impetus, clinical pharmacy has
been slow to develop in many countries. The reasons for
this are very similar to those that American and Canadian
pharmacists faced 15–20 years ago: the obstacles of being
recognized as clinical practitioners by the government;
other health professionals, who are sometimes threatened
by the proposed expansion of pharmacy practice; and pa-
tients, who invariably only associate pharmacists with dis-
pensing of medications. Personnel shortages have curtailed
the development of clinical services in many hospitals, as
pharmacists are drawn to alternate sectors of the profession
for a variety of reasons. The remaining pharmacists are of-
ten then only able to provide basic services, usually com-
prised of a dispensing-only role. This promotes frustration
and stress associated with being overworked with subse-
quent resignations leading to a cycle of chronic short-
staffing. The curriculum at pharmacy schools is beginning
to change with the introduction of clinical pharmacy as the
focus; however, there are still many universities that focus
upon the classical laboratory-based chemistry curriculum.
This leaves graduates unprepared to enter into or develop
clinical pharmacy positions and consequently fosters the
belief that the profession is only capable of the classical re-
sponsibilities of purchasing, manufacturing, storing, and
dispensing of medications. Developing countries face even
greater difficulty due to lack of funds and resources, where
obtaining medications alone is often a difficult process in
those hospitals.
From the review of the literature, it is apparent that there
is a wealth of information about pharmacists’ activities
from a global perspective; however, the distribution of
clinical versus technical activities of pharmacists in other
countries is sparsely described. A limitation of this review
is the inclusion of only English-language articles. Many of
the reports reviewed convey an increasing awareness of
clinical activities, and clinical positions have been initiated
in selected countries; however, many of those reports are at
least 5 years old. As well, there are selected references that
discuss specialization of clinical pharmacy services, but
the degree of specialization has not been quantified. There
are few data regarding research involvement of pharma-
cists, except in a select group of countries. As clinical
www.theannals.com The Annals of Pharmacotherapy
International Hospital Pharmacy Practice
activities increase, it would be appealing to determine
whether pharmacist involvement in research is also increas-
ing. The drug approval process and the existence of formula-
ries in the hospitals have also not been fully elucidated.
The practice of hospital pharmacy around the world is
diverse. Hospital pharmacists should be encouraged to pub-
lish their experiences and research in international journals.
We advocate that a survey of hospital pharmacy practice in
international countries be conducted to objectively docu-
ment their varying practices.
Jaclyn M LeBlanc PharmD, Critical Care Pharmacy Research Fel-
low, College of Pharmacy, The Ohio State University, Columbus, OH
Joseph F Dasta MSc, Professor of Pharmacy, College of Phar-
macy, The Ohio State University
Reprints: Professor Dasta, College of Pharmacy, The Ohio State
University, 500 W. 12th Ave., Columbus, OH 43210-1291, fax
614/292-1335, dasta.1@osu.edu
We thank Trudy Arbo BSc Pharm for her time in reviewing this manuscript.
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EXTRACTO
OBJETIVO: Revisar la literatura científica publicada sobre la práctica
internacional de farmacia hospitalaria.
FUENTE DE DATOS: Búsqueda de todos los artículos en inglés en
MEDLINE (de 1966 hasta la actualidad), IPA (de 1971 hasta la
actualidad), y en Internet.
SELECCIÓN DE ESTUDIOS Y OBTENCIÓN DE DATOS: Se incluyeron todos los
estudios en los que se discutían actividades de farmacia hospitalaria o
farmacia clínica hospitalaria.
SÍNTESIS DE DATOS: El alcance de la práctica internacional de farmacia
hospitalaria presenta bastante variabilidad, tanto dentro de un país como
entre países, incluyendo el grado de especialización que existe en la
www.theannals.com The Annals of Pharmacotherapy
International Hospital Pharmacy Practice
farmacia clínica. A pesar de que la farmacia clínica está bien
desarrollada en algunos países, en otros todavía se encuentra en etapas
iniciales de desarrollo. Además, existe variabilidad en la definición de
farmacia clínica por todo el mundo.
CONCLUSIONES: Se sugiere efectuar una encuesta para documentar
objetivamente la información relacionada con la práctica internacional
de la farmacia hospitalaria.
Luz M Gutiérrez
RÉSUMÉ
OBJECTIF: Réviser la littérature publiée concernant la pratique de la
pharmacie hospitalière au niveau international.
REVUE DE LITTÉRATURE: Recherche informatisée d’articles en langue
anglaise sur MEDLINE (1966 à maintenant), IPA (1971 à maintenant),
et l’Internet.
SÉLECTION DES ÉTUDES ET DE L’INFORMATION: Les études relatives aux
activités de pharmacie hospitalière ou de pharmacie clinique hospitalière
ont été incluses.
RÉSUMÉ: Le champ de la pratique internationale de la pharmacie
hospitalière est assez varié, à la fois au sein d’un même pays et d’un
pays à l’autre et divers degrés de spécialisation existent. Bien que la
pharmacie clinique soit bien développée dans certains pays, elle est
encore au berceau dans d’autres nations; de même, il y a des disparités
dans les définitions de la pharmacie clinique de par le monde.
CONCLUSIONS: Dans la mesure où il y a très peu de données publiées en
anglais en ce qui concerne la pratique de la pharmacie hospitalière au
niveau international, les auteurs suggèrent qu’une enquête soit conduite
pour rassembler objectivement cette information.
Bruno Edouard
■ 2005 January, Volume 39 ■ 191