Statement 2.7

“Hospital pharmacists should be involved in the development of policies regarding the use of medicines brought into the hospital by patients.“

What does it mean for patients? For patients’ safety, all medication, herbal and dietary supplements brought into the hospital should be registered in the patient ́s medical record, used, and stored according to the policies established in the hospital. Patients’ specific medication policies should assist in increasing patient ́s knowledge of their medication and increase adherence.

What does it mean for healthcare professionals? Doctors and nurses can rely on the support of hospital pharmacist to establish policies regarding the use and storage of medicines, herbal and dietary supplements brought to hospital by the patients in order to ensure patient safety if the use of such medication and other products is required . Doctors, nurses and hospital pharmacists should collaboratively complete the patient ́s record concerning all the medicines brought into the hospital by the patient, including the herbal and dietary products and should follow the policies established.

What does it mean for Hospital Pharmacists? Hospital pharmacists should support the development of policies regarding the use of medicines brought into the hospital by patients, including the evaluation of appropriateness of herbal and dietary supplements. Hospital pharmacists have a duty of care to assist patients in managing their medications. Policies including patient’s own medication should address adherence and medication issues across the primary secondary care interface.

Statement 2.6

“Hospital pharmacies should have responsibility for all medicines logistics in hospitals. This includes proper storage, preparation, dispensing, distribution and disposal conditions for all medicines, including investigational medicines.”

What does it mean for patients? Patients can rely on the conditions of storage, preparation, dispensing, distribution and administration of medicines in the hospital. The pharmacist, who is the expert in the management of medicines within the hospital, is responsible for ensuring that the medicines required are available in the best conditions when patients need them, including investigational medicines. That means that medicines are stored in appropriate conditions and that other healthcare professionals have sufficient information available on how to prepare and administer them to patients.

What does it mean for healthcare professionals? Doctors and nurses should be aware that all logistics procedures for medicines, including investigational medicines, and pharmaceutical products are under the control of hospital pharmacists. Their specialised training provides the assurance that the recommendations made on the storage, preparation, dispensing and distribution of medicines will aim to ensure the integrity of the medicine in the hospital. They are also available to provide information required to prepare and administer the medicine safely.

What does it mean for Hospital Pharmacists? Hospital pharmacists should have the responsibility for all medicines logistics in hospitals, including the proper storage, preparation, dispensing, and distribution conditions for all medicines, including investigational medicines and pharmaceutical products used in the hospital. Hospital pharmacists should establish standard operational procedures on the appropriate storage, preparation and distribution of medicines. Hospital pharmacists should clearly set out the distribution processes having regard to the nature of the product and the correct ordering, dispensing, storage and handling requirements. Hospital pharmacists should address the needs of the healthcare professionals to have user friendly access procedures in place that address the professional responsibilities. Hospital pharmacists should have a complaints/comments system in place to identify issues with the distribution systems.

The Tyne and Wear NHS Foundations Trust Hospital is SILCC Host providing training on this Statement. Please learn more about the SILCC programme here.

The Fatebenefratelli e Oftalmico Hospital is SILCC Host providing training on this Statement. Please learn more about the SILCC programme here.

Statement 2.5

“Each hospital pharmacy should have contingency plans for shortages of medicines that it procures”

What does it mean for patients? Patients can be assured that contingency plans for shortages are well established by hospital pharmacists to obtain all medication needed or alternative supplies. This includes whenever there is a shortage it or an emergency, ensuring a continuous supply of medicines is a high priority for the pharmacy service.

What does it mean for healthcare professionals? Doctors will face fewer barriers in prescribing habits and nurses will face fewer problems, while there are contingency plans for medicines shortages and purchases in emergencies established by hospital pharmacists. Ensuring the appropriate medicines are available for the patients is a high priority for the pharmacy department. Hospital pharmacists ́ goal is to minimise any interruption to the treatment of the patients. If a medication required for prescribing is not obtainable the pharmacist will discuss with doctors the possible alternative treatments. Hospital pharmacists will advise on contingency supplies for emergencies and for supply shortages and will enable ease of access to government schemes for medication access, as appropriate.

What does it mean for Hospital Pharmacists? Hospital pharmacists should establish contingency plans for shortages and purchases in emergencies for medicines and all products under their responsibility. They should organise a formal mechanism for pharmacists to request designated funds, if this possibility exists to procure medicines for the patients. Hospital pharmacists should have clear and transparent policies for procurement during shortages and during emergencies. Hospital pharmacists should remain knowledgeable about all government schemes to assist with the supply of medication and should engage with all procedures to aid with the supply of medications to patients in line with available resources.

Learn more about medicines shortages here.

Statement 2.4

“Procurement should be according to the medicine formulary and informed by the formulary selection process. A robust process should also be in place to appropriately procure medicines not included in the formulary where their use is indicated for the safe and effective care of individual patients.”

What does it mean for patients? Patients can rely on the medicines available in hospital because they are all assessed by experts for patient safety, appropriateness and cost effectiveness in accordance to the best national and international practice. All members of the care team are well informed about the medicines used in the hospital.

What does it mean for healthcare professionals? Doctors and nurses must be aware that there is an agreed list of medicines (formulary) within the hospital which have been approved for use. Medicines that are not on the formulary, but considered necessary for the patient ́s treatment, can be submitted for consideration, assessment and addition to it. The assessment process will be undertaken in an ethical and professional manner. The pharmacist will procure medicines in accordance with the evidence-based decisions of the Drug and Therapeutics Committee (DTC)

What does it mean for Hospital Pharmacists? Hospital pharmacists should establish procedures for procurement based on the hospital formulary. There should be appropriate procedures in place to assess medicines for addition to the formulary. The assessment process should be undertaken ethically and fairly.Hospital pharmacists as part of the Drug and Therapeutics Committee (DTC)must provide all the relevant information to the committee and manage the practice changes that arise from the committee decisions. This will be measured by the change management process and clinical audits.

The Tyne and Wear NHS Foundations Trust Hospital is SILCC Host providing training on this Statement. Please learn more about the SILCC programme here.

Statement 2.3

“Hospital pharmacists should coordinate the development, maintenance and use of a medicines formulary system, which may be local, regional and/or national. The medicine formulary system should be linked to guidelines, protocols and treatment pathways based on the best available evidence including patient outcomes and pharmacoeconomic evaluations where these are available.”

What does it mean for patients? Patients can be assured that the medicines used in the hospital undergo a robust assessment process underlying the formulary system. Standardisation of concentrations of medicines should be used in order to avoid medication errors, increasing patient safety. Paediatric, neonatal and critical care patients are especially at risk of medication error and thus standardisation of medication use is very important in those groups.

What does it mean for healthcare professionals? Healthcare professionals must be aware that in the hospital all medicines prescribed and administered are selected based on an evidence based formulary system. This selection is linked to standard treatment guidelines, protocols and treatment pathways based on the best available evidence, supported by a reliable information system and also considering the risks associated with medicine use. Medicines will be provided in the formulation and concentrations appropriate for the patient groups in line with available resources.

What does it mean for Hospital Pharmacists? Hospital pharmacists should establish formulary system procedures linked to guidelines and evidence based pathways. A reliable information system should provide accurate, timely, and accessible information and should help to promote the use of standard concentrations of medicines.

In the selection of medicines for the formulary international, national and local treatment guidelines and protocols and manufacturer information should all be considered.
The formulary should be accompanied by a comprehensive internal information system to guarantee the proper use of the listed medicines. Accurate, timely, and accessible information should be available promoting the use of standard concentrations especially for high risk patient groups

Statement 2.2

“Hospital pharmacists should take the lead in developing, monitoring, reviewing and improving medicine use processes and the use of medicine related technologies. Responsibility for using these processes may rest with other health care professionals and may vary according to the medicine, the medicine related technology, the health care setting and the multidisciplinary team delivering care.”

Hospital pharmacists have a key role, working with others, in ensuring continuous quality improvement for medicines use processes, including where information technology is utilised.

What does it mean for patients? Patients can be assured that the selection and all process use of medication and other health technologies (e.g. medicine-related devices) in the hospital are under the authority of hospital pharmacists whose expertise is available to all. Having a clear chain of responsibility with the professionals well trained in medications ensures the medication supply for the patient in a cost effective manner

What does it mean for healthcare professionals? Hospital pharmacists have a responsibility to ensure that the medicines prescribed by doctors and the medication related devices to be used by nurses for the patients’ needs are of appropriate quality. Doctors and nurses should have sufficient information available to use medicines safely and correctly and that this should be accessible in a timely manner to healthcare professionals and to patients. Having a clear line for consultation on all medicine related devices means that the concerns of prescribers are taken into consideration when selecting the devices for use in the hospital.

What does it mean for Hospital Pharmacists? Hospital pharmacists should collaborate with doctors and nurses on the wards in order to have detailed procedures for the medicine use process, the selection and use of medicine-related devices such as administration devices, giving sets, infusion pumps and computer- controlled dispensing cabinets, as well as the selection of drugs and pharmaceutical products to be included in the ward stock.

Statement 2.1

“Hospital pharmacists should be involved in the complex process of procurement of medicines. They should ensure transparent procurement processes are in place in line with best practice and national legislation, and based on the principles of safety, quality and efficacy of medicines.”

What does it mean for patients? Patients can be assured that the processes of selection and purchase of all medicines used in hospitals for inpatients and outpatients are undertaken / supervised by pharmacists, to ensure the appropriate safety and quality.
The medication for patient ́s treatments is selected with all the ethical, professional, legal and transparent procedures guaranteeing the quality of patient ́s medication and the equity of access. A good procurement process will have an impact on patient outcomes by having high quality medicines available in the right place and at the right time.

What does it mean for healthcare professionals? Doctors and nurses need to be aware that procurement is a complex process and when managed by pharmacists and competent staff ensures that appropriate quality control and safety measures are in place to provide the medicines required to patients. To avoid medication errors pharmacists, minimize look- and sound alike (LASA) medicines on the formulary. The procurement process will address all legal and professional standards and provide the right medicines to be prescribed in the appropriate formulation for administration. 

What does it mean for Hospital Pharmacists? Standard operating procedures must be in place to guide the procurement process. These operating procedures must be in compliance with legal requirements, professional and ethical. They should be audited and regularly reviewed to ensure the process is transparent.

The procurement process must be:

–  Ethical, transparent and 
professional;

–  Under pharmacy control and 
technically competent staff;

–  Guided by the principle of 
procuring for safety and efficacy

–  Guided by principles of equity of

access and ensuring accountability to relevant

governing and legal entities;

–  Supported by strong quality 
assurance principles;

–  Regularly reviewed and updated 
on its operational principles to fit different settings and emerging needs;

–  Guided by best utilisation of finance resources 


The Uppsalla University Hospital is SILCC Host providing training on this Statement. Please learn more about the SILCC programme here.

The Fatebenefratelli e Oftalmico Hospital is SILCC Host providing training on this Statement. Please learn more about the SILCC programme here.