Nour Awad, BScPharm, Amjad Abuirmeileh, BScPharm, MSc, PhD, and Saad Jaddoua, BScPharm
Jordan is one of the few destinations in the Middle East that patients target when seeking optimal medical care. The King Hussein Cancer Center (KHCC) is a comprehensive cancer center with a capacity of 160 beds. It is an established health care provider known to be a leader in the region.
The pharmacy department at KHCC experienced a lot of development during the past 10 years since its establishment under a new name and administration. It was transformed from a mere medication dispensing area to a department that provides complete pharmaceutical care to the patients, and thus has become an integral part of the center’s structure and administration.
In 2003, the pharmacy was mainly a procurement and operations department and the staff was composed of no more than 20, mostly pharmacy technicians. Basic responsibilities of pharmacists were not being practiced, and the service provided was limited to dispensing medications and maintaining inventory. Pharmaceutical care was an alien concept at that time, which made KHCC (then called the Al-Amal Center) no different from other hospitals in Jordan.
A new era began with a mission of establishing a pharmacy that would provide comprehensive and cost-effective pharmaceutical care of the highest standards for patients treated at KHCC and to serve as a model for pharmaceutical care in Jordan.
I joined KHCC in early 2004, an enthusiastic fresh graduate with the will to take on the world and start my career in the pharmacy profession. I was one of the first pharmacists to be recruited, so I had the opportunity to experience KHCC pharmacy from its beginning.
At the time, KHCC was a really inspiring place to be, where everyone was aiming to excel. The uniqueness of this health care facility was brought about by the new focus on high quality while implementing high standard protocols. At that time, this was not present in any other health care establishment in the country. Examples were clearly present in the chemotherapy pharmacy. Here, any chemotherapy order had to be written by a hematologist or oncologist. This order then had to be reviewed against established chemotherapy protocols by 2 chemotherapy-certified pharmacists. Medications were prepared inside a Class II B biological safety cabinet contained in a specially designed IV room. The preparations were properly labeled with all the needed patient and medication-specific information. In developed countries, this may not be anything exceptional, but in a country like Jordan this is unfortunately still not common practice.
Also, at that time, the inpatient pharmacy used to dispense medications against the nursing medication administration sheet, that is, the pharmacist did not verify physician medication orders and played the limited role of medication supplier.
This was one of the first things to change. The main duty of a pharmacist in the inpatient pharmacy, and all other pharmacy areas, evolved into reviewing medication orders against the patient’s active medication profile to determine the appropriateness of dose and route, assess drug-drug or drug-food interactions, and make sure that the patient did not have an allergy to the ordered medication or any contraindication.
Today, the inpatient pharmacy views physician orders on the computer system, which has played a key role in increasing efficiency, minimizing cost, and enhancing speed and accuracy. This has contributed to transforming the environment in the inpatient pharmacy into a paperless one.
The sterile preparation area is designed with the highest standards for sterile preparations. About 90% of all IV medications are prepared ready to administer in the pharmacy; this includes all parenteral antibiotics, electrolytes, and chemotherapeutic agents. Pharmacy staff is trained to prepare IV preparations using the proper techniques and their competencies are assessed periodically.
Today, the pharmacy department at KHCC consists of 50 pharmacists and 24 pharmacy technicians. It is composed of 5 sections: the pharmacy clinical operations section, clinical service section, center for drug policy and evaluation, procurement section, and inventory control and management section.
The pharmacy department at KHCC also focuses on a number of activities including:
Quality Improvement Projects
Throughout the years, the pharmacy department has worked on various quality improvement projects, using the Focus-PDCA methodology. One of the more recent projects carried out during the past year is the prescription waiting time improvement project. Here, the main aim was to improve patient satisfaction through reducing their waiting time while prescriptions are prepared in the outpatient pharmacy.
The team identified the main reasons for order preparation delays which lead to increased waiting time and classified them into 6 categories: staff-related, technology-related, processes, communication, workload distribution, and the environment. One example was how the insufficient number of computers in the outpatient pharmacy was found to contribute to prescription delay. Here, the action taken was to increase the number of computers available to allow a larger number of pharmacy staff to enter prescriptions into the computer system or to check ready prescriptions. One by one, the problems were addressed and consequently the waiting time improved from 40% meeting the expected waiting time to just under 80% meeting the expected waiting time.
Providing Medications for Non-KHCC Patients
The pharmacy at KHCC has taken on the role of providing best patient care whether for KHCC patients or patients from outside the center. One of its main impacts on society is that it provides medications that are not available elsewhere in Jordan. KHCC has imported some products that are not registered in Jordan, such as dantrolene used in malignant hyperthermia and colestin used in multidrug resistant infections. Other medications include vasopressin, fondaparinux, phenylephrine, suxamethonium, and many others. Being a cancer center, KHCC has also imported some controlled drugs such as hydromorphone, methadone, and oxycodone. These medications and other chemotherapeutic medications are supplied through a special import procedure with permission of the Jordanian Food and Drug Administration (JFDA).
Some medications which are registered in Jordan and are usually available through different health care providers become unavailable in the country for various periods; this is usually due to lack of logistic planning or international stock shortage. These periods could be as little as a few days, but could sometimes be measured in weeks or months. This usually does not happen at KHCC, especially for essential medications. Examples of these medications include norepinephrine and intravenous cyclosporine.
The Table demonstrates the large number of non-KHCC patients served and the number of prescriptions dispensed for non-KHCC patients. These numbers have been increasing significantly, which can be explained by either the lack of planning by other health care providers and their reliance on KHCC, or more recently, the rise in total number of non-Jordanian patients now in Jordan. This is due to the increase in other Arab nationals residing in Jordan because of political problems in their own countries. Another reason could be that in 2012 there was a worldwide shortage in some chemotherapy drugs and KHCC was one center that had available stocks.
Pharmacy Publications and Research
The pharmacy has had numerous publications during the past few years on various topics such as the adherence to KHCC guidelines for surgical antimicrobial prophylaxis and the clinical pharmacy interventions at KHCC. Also among the topics was the clinical pharmacy service in pediatric oncology clinics in a comprehensive cancer center. Another topic was the adverse drug reactions that resulted in intensive care unit admissions and their implications.
Total Parenteral Nutrition (TPN) Preparation
KHCC pharmacy provides TPN service for both adult and pediatric patients. Pharmacists are part of the multidisciplinary team that assesses the patients’ need for TPN. The team also consists of physicians, nurses, and nutritionists. Two-in-one TPN preparations are done in a clean room under aseptic conditions. The pharmacy prepares an average of 5 TPNs per day.
Medication Error and Clinical Intervention Documentation
The pharmacy department at KHCC has been using the Quantifi reporting software to help determine the number of interventions, medication errors, and Adverse Drug Reactions (ADRs) reported by pharmacists. This has helped the pharmacy department to take appropriate action to decrease medication errors. The Figure shows the number of clinical interventions, medication errors, and ADRs reported in the years 2010, 2011, and 2012. The ability to detect such a large number of interventions ensures better quality of service and better use of medications and also helps in strategic planning.
Recently, the pharmacy department has adopted a patient medication reconciliation policy. For just over a year, KHCC pharmacy department has started medication reconciliation on patient admission, transfer, and discharge. Aiming to decrease patient readmission, the patient’s current medications, allergies, and medication sensitivities are acquired and documented on admission. Any new prescribed or administered medications are reconciled against the patient’s documented medication.
Jordan is still a developing country, and the field of hospital pharmacy has more to grow. Concepts of good pharmaceutical care need to be understood and implemented in a lot of hospitals. Private hospitals are still too profit oriented and, on the other hand, public hospitals are overloaded and struggling to maintain higher standards of health care.
The pharmacy at KHCC has undergone a process of transformation—it now is one of the leading health care providers in the entire region. This was only achieved through hard work and the belief that achieving high standards of care is possible. In these times of high political volatility in the Middle East and continuous advances in the health care sector, KHCC has the capabilities to balance both circumstances and provide the best health care in such a challenging environment.
Nour Awad, BScPharm, is currently head of the clinical operations section in the pharmacy department at King Hussein Cancer Center in Amman, Jordan, and is working on his MBA. Amjad Abuirmeileh, BScPharm, MSc in Biopharmacy, PhD in Pharmacology, is currently the head of the clinical pharmacy department at the Al Isra University in Amman, Jordan. Saad Jaddoua, BScPharm, is currently the chairman of the pharmacy department at King Hussein Cancer Center in Amman, Jordan.