Artigo Científico - Quality of pharmaceutical care In hospitals

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Am J Hosp Pharm 32: 567-574 (Jun) 1975 
Quality of pharmaceutical care In hospitals 
Roiiert L. Mikeal, Thomas R. Brown, Herman L. Lazarus and Michael C. Vinson 
The objective of this study was to measure the quality of phannaceutical services provided 
to hospital inpatients. Using Donahedian's inodel, normative standards from the Joint Com­
mission on Accreditation of Hospitals and the American Society of Hospital Pharmacists 
were used to develop a personal interview schedule to access the structure and process com­
ponents of pharmaceutical services. To determine the effect of bed size, rural vs. luban, and 
presence of a full-or part-time pharmacist on the quality of pharmaceutical services, three 
nnmplwi of short-term hospitals were drawn: a random sample of Mississippi hospitals with 
less than 100 beds; all Mississippi hospitals of 100 or more beds; and a sample of hospitals in 
Philadelphia, Pennsylvania. In each of the 112 hospitals a personal interview was conducted 
with either the chief pharmacist or the administrator responsible for tbe pbarmaceutical ser­
vice. The responses to the items were then tabulated and a structure and a process score were 
• obtained for eacb hospital. 
The following conclusions can be made: (1) The quality of the "structural" components is 
positively related to the bed size and not to wbetber the hospital is located in a rural or urban 
setting; (2) the quality of the "process" components is related to both the bed size and the 
location of the hospital—hospit^ having 100 or more beds or located in an urban area have a 
higher process quality than those having less than 100 beds or located in a rural area; and (3) 
hospitals employing a full-time pharmacist have a higher quality of care than those who do 
not 
Key words: Control, quality; Patients; Pharmacy; Pharmacy, institutional, hospital 
The pturamount position occupied by the modern hos­
pital in the current medical care system is evidenced by 
the fact that hospital care accounted for $32.5 billion or 
45% of the total health care expenditures in 1972.^ Its eco­
nomic importance becomes even clearer when compared 
to the $16.2 biUion or 23% of total health care expendi­
tures which was paid for physician services.^- The $32.5 
billion represents payments made by or for approximately 
15% of the United States' population for a myriad of ser­
vices: laboratory, nursing care, room and board, surgery, 
drugs, etc. The present day hospital is the physician's lab­
oratory, the place where most lives begin and many end, 
the repository for the most acutely ill, and the major loca­
tion where surgery is performed. Given these factors, and 
with hospitals and hospital-based services receiving such 
a predominant share of health care expenditures, it is not 
surprising that a majority of the efforts to quantify and 
study the quality of medical care would be dealing with 
hospital-based services. While most of the studies have 
primarily focused on the services provided by physicians, 
the services of all hospital health professionals are in­
creasingly being examined. 
Robert L. Mikeal, Ph.D., is Associate Professor of Pharmacy Care Ad,, 
ministration. School of Pharmacy, University of Georgia, Athens 30602. 
Herman L. Lazams, MA, is Director of Pharmacy Services, University 
of Alabalna Hospitals and Clinics, Birmingham. Michael C. Vinson, 
MA, is Instructor in Clinical Pharmacy, and Thomas R. Brown, M.S., is 
Assistant Professor of Pharmacy and Hospital Pharmacy, School of Phar­
macy, University of Mississippi, University. 
Presented at the 31st ASHP Annual Meeting, August 6,1974, Chicago, 
Illinois. 
Copyright© 1975, American Society of Hospital Pharmacists, Inc. All 
rights reserved. 
Theoretical Considerations 
Evaluation. Evaluation is not a newly conceived pro­
cess or procedure that is under the purview of any single 
discipline, internal or external to the health care system. 
Traditionally, evaluation has been considered a subjective 
process with results highly dependent upon the investiga­
tor's biases. According to Knutson, evaluation has been 
undertaken for reasons ranging from justification of past 
or projected expenditures to it being "the thing to do."^ 
Even though evaluation has existed for several decades 
under different titles—organizational analysis, operations 
research, PERT, systems analysis—the American Public 
Health Association and most health care researchers ad­
here to the goal-attainment model.® Suchman's landmark 
text, Evaluative Research, which deals exclusively with 
the goal-attainment model, has been the evaluation prim­
er for most researchers in health care since it was pub­
lished in 1967 
Etzioni, Parsons and others have emphasized that the 
realities of institutional activity force realization that 
many of the activities undertaken by any program are 
only tangentially related to goal-attainment and for this 
reason they advocate using the system model for evalua­
tive studies.®'® The primary difference between the two 
models is that the goal-attainment model has as its refer­
ence point the system's stated or implied goal(s), whereas 
the system model's reference point is a working model of 
a social unit which is capable of achieving the system's 
stated or implied goal(s). The system model also assumes 
that one or more of the system's activities will be nongoal 
activities. While this model more closely mirrors reality, it 
requires a more thorough understanding of component in­
terrelationships, prior success probabilities for various or­
ganizational formats and resource allocations. 
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Evaluative research, regardless of which model is used, 
does not differ in methodology or design from any other 
type of research. Both evaluative and nonevaluative re­
search use symbolization, description, explanation or 
theorizing as their methods. Both evaluative and nonev­
aluative research use cross-sectional or longitudinal, ex 
post facto or experimental, and retrospective or prospec­
tive types of designs. The dual problems of reliability and 
Validity plague the researcher whether he is conducting 
evaluative or nonevaluative research. Succinctly stated, 
evaluative research is still research with its usual princi­
ples, tenets and admonishments. 
Pharmaceutical Patient Care. According to the Ameri­
can Public Health Association, the term medical care can 
be defined as: 
The provision of all types of personal health services, in­
cluding the range of services from prevention, diagnosis and 
treatment, to rehabilitation provided by physicians, den­
tists, nurses and other health personnel. Medical care in­
cludes the complex of personal relationships and organized 
arrangements through which health services of a personal 
nature are made available to the population.' 
Using an analogous definitional format, pharmaceutical 
care can be defined as: 
The provision of any personal health service involving the 
decision whether to use, the use and the evaluation of the 
use of drugs, including the range of services from preven­
tion, diagnosis and treatment, to rehabilitation provided by 
physicians, dentists, nurses, pharmacists and other health 
personnel. Pharmaceutical care includes the complex of per­
sonal relationships and organized arrangements through 
which these health services of a personal nature are made 
available to the population. 
' Using this definition, pharmaceutical care is a subset of 
medical care; is not provided by any one hesdth practi­
tioner exclusively; is not delineated by environment, the 
writing of a prescription, or even a patient consuming a 
- drug. 
Conceptual Model. The most widely used conceptual 
model in the area of medical care is the one proposed by 
Donabedian.® This model dimensionalizes health care 
into three components: structure, process and outcome. 
The structure componentrefers to the settings and the 
instrumentalities available and used for the provision of 
medical care. While including the physical aspects of fa­
cilities and equipment, structure also encompasses the 
characteristics of the administrative organization and the 
qualifications of the involved health professionals. Ac­
cording to Donabedian, "... structure also signifies the 
properties of the resources used to provide care and the 
manner in which they are organized." ® The process com­
ponent consists of the activities of health professionals in 
the managernent of patients. It is here that the structure 
instrumentalities are brought to bear on the patient con­
dition. The outcome component consists of the resultant 
phjraical structure, physiological, psychological and social 
fimctioning of the patient. 
Donabedian stresses that the components of this con­
ceptual rhodel cannot always he clearly delineated and 
that there is no clear-cut, universally agreed upon transi­
tion point between process and outcome. Nevertheless, 
the components of the model, once operationalized, are 
assumed to be sequentially dependent or at least interre­
lated. 
Evaluative and Operationalized Conceptual Model. 
For. this series of studies of pharmaceutical care, a goal-
attainment evaluative model was used. The goals or stan­
dards were derived from the" standards set forth by the 
Joint Commission on Accreditation of Hospitals (JCAH)® 
and the American Society of Hospital Pharmaciste 
(ASHP).i° The components of Donahedian's conceptual 
model of medical care were operationalized as follows: 
1. Structure—the provision of a pharmacist, a physical 
drug room or pharmacy, pharmacy equipment and other 
tangible elements which serve as prerequisites for the 
functioning of a pharmacy. 
2. Process—administrative procedures, the technical com­
petence of the providers of pharmaceutical care, and the 
types and kinds of pharmaceutical care provided. 
3. Outcome—the provision of the proper drug, in the prop­
er strength, by the proper route, to the proper patient, at-
the proper time. 
Previous Studies 
The most comprehensive study of pharmaceutical care 
in the hospital was conducted by Barker and associates at 
the University of Arkansas Medical Center in the early 
and middle 1960's.'^ Although they did not formally state 
the model of pharmaceutical care used, they did in fact 
examirie the phenomenon using a structure, process and 
outcome approach. The main emphasis of this unobtrus­
ive observational study was an examination of the process 
of administering medications to the patient. They also ex­
amined the outcome and consequences of the errors 
which occurred during this process. Barker et al found 
that in 9,789 opportunities for error, 1,461 errors actually 
occurred. The summarized data showed the percentage of 
errors per error category as follows: 13% of the errors were 
oinission of a drug or a dose, 17% were wrong dose, 8% 
were extra dose, 6% were unordered drugs, 1% were wrong 
dosage form, and 55% were wrong tiine. Even though this 
study was conducted a decade ago, any study dealing with 
the quality of pharmaceutical care has its genesis in the 
results, implications and recommendations of this land­
mark investigation. 
All of the studies conducted subsequent to Barker's 
have been much narrower in scope. Parker conducted a 
study implementing a drug distribution system similar to 
the one developed by Barker et al comparing medication 
errors under a unit dose medication distribution system 
and a "traditional" system.^^ He found the unit dose sys­
tem hospital had fewer medication distribution and ad­
ministration errors, but his Hndings should be tempered 
with caution. The problem Parker encountered was that 
the foim hospitals he chose with the traditional system 
had differing medication error rates. 
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PHARMACEUTICAL CARE 
Several authors have suggested audits or a usage review 
of pharmaceutical care as a means of improving quality 
without collecting data to substantiate these conten­
tions.^®-" TuUis examined the composition and actual ac­
tivity of the pharmacy and therapeutics (P & T) commit-. 
tee and found it to be primarily Hnancial control-oriented 
although the stated function was to improve pharmaceu­
tical care.^® Brumhack and Howell reported, "Effective 
stajff pharmacists can be characterized by their efficiency 
in communicating drug information to others and in con­
trolling the quality and quantity of drugs." 
A large number of studies can be characterized as "this 
is the way we do it now" or "look what we have done." 
Most of these studies have only limited data and suffer 
from the use of improper designs or unwarranted analysis. 
While these studies do discriminate valuable ideas, they 
are not usually the basis to draw conclusions from and 
will not be mentioned. 
Ob|ectives 
A holistic approach to the evaluation of the quality of 
pharmaceutical care provided to hospitalized patients, 
while desirable, would be infeasihle at this time. There­
fore, it was decided to limit this series of studies to the as­
pects of pharmaceutical care that have been reported to 
be the responsibility of the hospital phfirmacist. This lim­
itation specifically excluded for the most part any evalua­
tion of the outcome of pharmaceutical care as well as di­
rect evaluation of the administration of medication to pa­
tients. 
Specifically this study addresses itself to the determi­
nation of the relationship between aspects of the struc­
ture and process components of pharmaceutical care as 
well as the influence of bed size, urban versus rural loca­
tion, and the presence of a full-time or part-time pharma­
cist on some aspects of the quajity of pharmaceutical care. 
Procedure. It was decided to use a combination of ob­
servation and a personally administered interview sched­
ule for the 112 hospitals. The director of pharmaceutical 
services was interviewed at each of the hospitals, and 
where the situation warranted it, direct observations were 
made either to verify or obtain the necessary data. 
Interview Schedule Generation. Using the work of 
Gibson, and the publications of the JCAH and the ASHP, 
an interview schedule was developed®-^®-®® (Appendix A). 
All interviews were conducted by the authors. In each 
case an attempt was made to establish a rapport with the 
person being interviewed. Each question was read as writ­
ten; if the question was not understood, it was reread in 
the same manner. If explanation was required it was 
made in as few words as possible. In some c£ises, the an­
swer to a question indicated that the question had ob­
viously been misunderstood. When this occurred, an ex­
planation was made without rereading the question. 
Scoring of Interview Data. The scoring procedure and 
the component of quality determination for each question 
of the questionnaire is presented in detail in Appendix B 
as well as the operational definitions for P & T committee 
activity and duplicate drug products. 
The questionnaires were scored by allowing one point 
for each response which indicated compliance with ac­
cepted standards of the agencies previously mentioned. 
No point was allowed for the alternate answer. Each ques­
tion concerning the control of drugs was scored as one 
point if control was the responsibility of a designated per­
son such as a pharmacist, physician or nurse. No point 
was allowed if control appeared to be lacking. 
The questions concerning duplication of drugs were 
scored as one point if a single drug item was stocked; no 
points were awarded if a drug item was duplicated by one 
or more drugs of the same chemical composition, dosage 
strength and dosage form. 
The total possible points for structure, process and 
drug duplication were: 
Methodology 
Sample Selection. Three samples of short-term generalacute hospitals were drawn. Sample I was selected from 
all Mississippi hospitals having less than 100 beds in 
1970. The sample from this population was composed of: 
1. All 11 hospitals with a full-time pharmacist, 
2. Eleven randomly selected hospitals having no pharma­
cist, arid 
3. Twenty-three randomly selected hospitals with a consul­
tant or part-time pharmacist. 
Sample II consisted of all 31 Mississippi hospitals having 
100 or more beds in 1970. Sample III consisted of 36 of 
the 43 hospitals within the city limits of Philadelphia, 
Pennsylvania, as of 1970. (Seven hospitals refused to par­
ticipate in the study for various reasons.) The hospitals in 
samples I and II were operationally defined as rural and 
those in sample III as urban in location. 
1. Thirty-three points for structure, 
2. Sixty-seven points for process, and 
3. Eight points for duplication. 
Analysis of the Data 
Because of the voluminous data generated, the raw 
data will not be presented in the paper but can he ob­
tained from the primary author. The detailed analysis of 
the data appears in Appendix C because of its length and 
technical nature. 
Conclusions 
From the analyses of the data several general conclu­
sions can be made with regard to the hospitals studied if 
the study's operational definitions are accepted: 
1. The relationship between the structure and process com-
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ponente for the total medical care complex stated in Dp-
nabedian's model also exists in the pharmaceutical care 
subsystem. 
2. The quality of pharmaceutical care is significantly af­
fected by both the bed size of the hospital and whether 
the hospital is located in a rural or urban area. 
3. The quality of pharmaceutical care is significantly relat­
ed to the employment of a full-time pharmacist. 
The statistically? significant correlations between the 
structure and process components of pharmaceutical care 
across the samples of hospitals shows that while there are 
magnitude differences in quality between samples there 
exists no significant pattern difference. While this allows 
the prediction of the process quality of pharmaceutical 
care from a knowledge of the structure quality, it must al­
ways be kept in mind that this relationship is not causal. 
It is important to. know that the two components are re­
lated; but construing this relationship to imply, "If a hos­
pital develops a" high quality structure component in 
pharmaceutical care, then a high quality process compo­
nent will ensue," would he an erroneous extension of 
these findings. , 
The results with regard to magnitude of differences will 
be interpreted, using a conclusion paradigm based on a 
classification of the possible statistical differences which 
• can exist among any three measures of magnitude. If any 
three measures of magnitude are represented by the let­
ters A, B, and C, then the only three-element relations 
possible are the eight shown in Table 1. Those measures 
of magnitudes represented by letters underlined by a 
common line are statistically equal, and those letters not 
underlined by a common line are not statistically equal. 
Applying this conclusion paradigm to the analysis of 
the structure and process components of pharmaceutical 
care, the following conclusions can he made: 
1. Bed size dpes have an effect on the quality of the struc­
ture component of pharmaceutical care, but the hospi­
tal's location does not, since the Newman-Keuls proce­
dure ori the hospital's structure scores produced the pat­
tern shown in Table 1 as relation 4. Mississippi hospitals 
with less than 100 beds had a lower structure quality 
than , Mississippi hospitals with 100 or more beds or the 
Philadelphia hospitals (Appendix C, Table 3). 
• 2. Both bed size and location have an effect on the quality 
of the process component of pharmaceutical care, since 
.the Newman-Keuls procedure on the hospital's process 
scores produced the pattern shown in Table 1 as relation 
8. Mississippi hospitals with less than 100 beds had the 
lowest process component quality; the Philadelphia hos­
pitals had the highest; and the Mississippi hospitals hav­
ing 100 or more beds were in between (Appendix C, 
Table 4). 
With regard to the P & T committee, this study could 
find only one component of pharmaceutical care to which 
either the number of meetings held or the drug product 
duplication score was related. The number of meetings 
held annually was related to the quality of the structure 
component of phaririaceutical care. The number of meet­
ings held annually was not related to the hospital's drug 
product duplication score, except for those hospitals in 
sampleT. This was somewhat surprising, since supposedly 
Table 1. The Eight Three-Element Relations and 
Conclusion Paradigm for Determining the Effect of Bed 
Size and Location 
EFFECT ~~ 
RELATION BED SIZE LOCATION 
1. ABC No No 
2. ABC No NO 
3. A B C No , Yes 
4. A B C Yes No 
5.AC B No No 
6. A C B No No 
7. CAB No No 
8. A B C Yes . Yes 
A = Magnitude measure from sample i hospitals (less than 100 
beds, Mississippi). 
B = Magnitude measure from sample II hospitals (100 beds or 
more, Mississippi). 
C = Magnitude measure from sample III hospitals (100 beds or 
more, Philadelphia). 
this is one of the committee's raisons d'etre. 
The study did find tfeat the drug product duplication 
score was affected by the location of the hospital but not 
by the hospital's bed size, since the Newman-Keuls proce­
dure on the hospital's drug product duplication score pro­
duced the pattern sliown in Table 1 as relation 3. The 
rural hospitals (those located in Mississippi), had more 
drug product duplications than the urban hospitals. 
Those hospitals which employed a full-time pharmacist 
had a higher quality of structure and a higher quality of 
process component of pharmaceutical care than those 
hospitals which did not employ a full-time pharmacist. 
The employment of,a full-time pharmacist, though, had 
no effect on the hospital's drug duplication score. 
Implications for Future Research 
Needless to say, this study of the quality of pharmaceu­
tical care in hospitals should he replicated. With regard to 
the absolute level of quality found to exist in the 112 hos­
pitals studied, one of two conclusions must he accepted: 
the normative standards for quality are poor. Or the quali­
ty of the pharmaceutical care provided by the hospitals is 
poor. It must be kept in mind that this study did not in­
clude any quality of outcome measure determination. 
Therefore, given the embryonic state of hospital pharma­
ceutical care quality determination, a rational choice as to 
which conclusion is valid cannot he made at this time. 
But, if one is willing to accept the validity of the stan­
dards established by the JCAH and the ASHP, then it 
must be concluded that the hospitals studied performed 
at a much less than desirable level of quality. 
With only about 60% of' all United States hospitals 
employing a full-time pharmacist, and with very few ex­
amining the quality of the pharmaceutical care they are 
providing, the task will he monumental, but it must be ac­
complished. 
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PHARMACEUTICAL CARE 
References 
1. United States Department of Health, Education and Wel-
fwe: The size.and shape of the medical care dollar, U.S. Govern­
ment Printing Office, Washington, D.C. 1973, p 22-25. 
2. Knutson AL: Evaluation for what?. In Schulberg HC et al: 
Program evaluation in the health fields. Behavioral Publications, 
New York, New York 1970, p 42-44. 
3. American Public Health Association: Glossary of adminis­
trative terms in public health. Am J Pub Health 50:225—226,. 
1960. 
4. Suchman EA: Evaluativeresearch, Russell Sage Founda­
tion, New York, New York 1967. 
5. Etzioni A: Two approaches to organizational analysis: a 
critique and a suggestion. In Schulberg HC et al: Program evalu­
ation in the health fields. Behavioral Publications, New York, 
New York 1969, p 103-112. 
6. Parsons T: A sociological approach to the theory of organi­
zations, Adm Sci Q, 7:3-85,1956. 
7. Myers BA (ed): A guide to medical care administration, 
volume 1: concepts and principles, American Public Health Asso­
ciation, Washington, D.C. 1969, p 81. 
8. Donabedian A: Evaluating the quality of medical care. In 
Mamland: Health Serv Res, Mdbank Memorial Fund, New York, 
New York 1967, p 167-170. 
9. Joint Commission on Accreditation of Hospitals: Stan­
dards for hospital accreditation (Jan 2) 1964. 
10. Guidelines relative to the safe use of medications in hospi­
tals, Am J Hasp Pharm 19:577,1962. 
11. Barker KN et al: A study of medication errors in a hospi­
tal, Research Institute of Pharmaceutical Sciences, University of 
Mississippi, University, Mississippi, 1968. 
12. Parker PF: A Comparison of medication errors under the 
University of Kentucky unit dose system and traditional drug 
distribution systems in four hospitals. Am J Hasp Pharm 27: 
302-814,1970. 
13. Hassan WE Jr: Pharmacist vital to utilization review. 
Hasp Progr 50:90,1969. 
14. Derewicz HJ: An audit of pharmaceutical services—a new 
committee begins. Drug Intell 2:261-265 (Oct) 1968. 
15. Archambault, GF: Evaluation of a pharmaceutical service 
in hospitals. Am J Hasp Pharm 16:390-398,1959. 
16. Brodie DC and Graber JB: Institutional pharmacy prac­
tice in the 1970's, Am J Hasp Pharm 28:240-246,1971. 
17. Brodie DC: Drug utilization review/planning. Hospitals 
46:103-110,1972. . 
18. Tullis NE: The role of the pharmacist in the pharmacy 
and therapeutics committee: a study of small group dynamics, 
master's thesis. University of Mississippi, 1969. 
19. Brumback GB and Howell MA: Evaluating the profession­
al performance of staff pharmacists: a methodological study. Am 
J Hasp Pharm 28:336-342,1971. 
20. Gibson JT: Pharmaceutical services within the units of the 
university system of Georgia, master's thesis. University of Geor­
gia, 1969. „ . 
21. American Hospital Formulary Service: American Society 
of Hospital Pharmacists, Washington, D.C. 1970. 
Appendix A 
Questionnaire Used In Interviews 
Directions: Ask each question in the same manner. Read the question as it 
is stated on the questionnaire. Do not elaborate; if clarification is neces­
sary, do so but in as few words as possible. 
• 1. Name of hospital 
Number of beds 
Arrangement of pharmacist: full-time; part-time; consultant 
How many hours does the pharmacist spend in your facility each 
week? 
How many times each week does the pharmacist visit your hospital? 
2. Are separate locked storage areas provided for disinfectants and drugs 
intended for external use? 
3. Are drugs within the pharmacy and throughout the hospital inspected 
at least once a month by the person in charge of drugs? 
4. Are there locked drug storage areas on the nursing units? 
5. Is double-locked storage provided for narcotics on each nursing sta­
tion where drugs are kept? 
6. Are nursing stations provided with a separate medication preparation 
area? 
7. Are periodic inspections of nursing station medication centers per­
formed to ensure: 
a. That medications for external use are kept apart from internal and 
injectable medications? 
h. That special storage is provided for biologicals and other relatively 
unstable products? 
c. That there are no outdated or deteriorated medications? 
d. That there is an adequate supply of emergency drugs (e.g., for ana­
phylaxis, heart failure, etc.)? 
e. That there is posted on the nursing units a conversion chart for 
each change from the metric to the apothecary systems? 
8. Card#l 
9. Ask the person being interviewed to: 
Name'the poison control center in his area. 
Show you where the telephone number for the center is posted. 
10. Does your facility have a defined procedure for returning drugs re­
called by their supplier or manufacturer? 
11. Please give the title of the. person responsible for handling the recall of 
drugs. 
12. Has your facility ever returned drugs that have been recalled by their 
supplier? 
13. Is there a policy that drugs he administered only on the written order 
of a physician? 
14. Are investigational drugs used at this facility? If yes, is there written 
provision for the handling of investigational drugs? 
15. Does your facility have a written policy for reporting adverse drug 
reactions? 
16. Does your facility have a written policy for recording medication er­
rors? 
17. Do you report medication errors to the administrator? 
18. Labels for nursing station medication containers indicate the fol­
lowing: 
Name of hospital. 
Name of medication. 
Strength of drug. 
Lot or control number. 
Date of issue. 
Directions for use. 
Other information. 
19. Are labels on nursing station medication containers machine typed? 
20. Do detail men regularly visit your "facility? If so, do they visit the 
pharmacy or drug room? 
21. Has the person in charge of the pharmacy or drug room ever arranged 
an exhibit relating to drugs in this facility? 
22. Are inservice training programs sponsored by pharmacy personnel? If 
yes, give the subject(s) covered by the program. 
23. On the outpatient prescription order itself, is the source and lot num­
ber of the drug recorded? 
24. Is a standard list of abbreviations and symbols used for the writing of 
medication orders? 
25. Are medication cards used for the prescription and administration of 
most medications? 
26. Is the person responsible for pbarmaceutical services a member of the 
following: 
American Pharmaceutical Association. 
American Society of Hospital Pharmacists. 
State pharmaceutical association. 
Any drug information service. 
27. The pharmaceutical or drug service within your facility is under the 
direct supervision of (give title of person): (M.D., R.Ph., R.N., Admin., 
etc.) 
28. Are vaccines refrigerated? 
29. Are thermometer(s) kept in refrigerators so that the temperature in­
side the refrigerator can be readily determined? 
30. Which of the following are your medication refrigerators equipped 
with? 
Biological drawer inserts. 
Deep freeze or ice cu^ unit. 
; Automatic defrosting equipment. 
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Circulation fan. 
31. Do you dispense medications to outpatients? If yes, do you feel that 
• your record of drugs and medications dispensed to outpatients are 
readily available and sufficient? 
32. Card #2.' , 
33. When a person fiils a narcotic prescription or order, does he write his 
full signature across the face of the prescription? 
34. What equipment is available within the pharmacy or drug room for 
the compounding and dispensing of pharmaceutical and parenteral 
preparations? 
35. Cards #3-7. 
36. Give the title of the person(s) responsible for adding substances to in­
travenous solutions: 
37. If drugs are added to i.v. solutions, is a supplementary label attached 
to the parenteral solution container? 
38. Does the i.v. label contain the indicated information: 
Name of drug added. 
Amount of drug added. 
Date drug was added. 
Time drug was added. 
, Name or initials of jperson who added the drug(s). 
39. Are written specifications established for the procurement of all or 
any approved drugs, chemicals antibiotics, biologicals and pharmaceu­
tical preparations?" 
40. Does the person filling the drug order review the prescriber's original 
order (or direct copy)? (Explain if necessary.) 
41. Are provisions provided for the return of containers with marred la­
bels, unlabeled medications or discontinued medications to the phar­
macy or drug room?42. What is the disposition of discontinued or unused medications? 
43. Which of the following person(s) may remove drugs from the drug 
room or pharmacy after closing time? 
• Physician. ' ' 
A designated nurse. 
. Any nurse. 
All these. 
None of these. 
Some other person. 
44. When the pharmacy or drug room is closed, is the quantity of drug or 
medication that may, be removed from the pharmacy or drug room re­
stricted? 
45. Do you have a written policy on automatic stop orders? If yes, do you 
have an automatic stoj) order for: 
- Narcotics. 
Hypnotics and sedatives. 
Tranquilizers. 
Antibiotics. 
Steroids: 
Mood elevators. 
. ̂ Anticoagulants. 
46. Is there written provision for recording on the patient's record each 
dose of medication administered? 
47. Do you have a policy for handling medications brought into your facil­
ity by admitted patients? If yes, is this policy oral or written? 
48. Are bedside medications allowed in your facility? 
49. Are radioactive medications used in this facility? 
50. Are empty medication containers from the nursing stations returned 
to'the pharmacy or drug room? 
51. Do drugs that are reconstituted on the nursing stations carry an auxil­
iary label prepared by the nurse? 
52. Are medication cards used for the preparation and administration of 
most medications? 
53. Cards #8-10. 
54. Are medications to be administered by the nurses ever prepared sever­
al hours in advance? 
55. Are large-volume (e.g. 1000 ml i.v.) parenteral solutions used in your 
facility? " •» 
56. Cards #11 and 1& , 
57. Are drugs and medications issued to nursing stations on a period 
basis? If yes, which of the following apply? The period of issue to 
nursing stations is: 
Daily. * 
Twice weekly. 
Once weekly. 
Monthly. 
Other (specify). 
58. Is a manual of policies and procedures provided to cdntrol the admin­
istration of toxic or dangerous drugs (anticoagulants, narcotics, antibi­
otics)? If yes, ask to see it and record the name of the publicatiqn as 
shown on its cover. - • 
59; Cards #13 and 14. 
60. What is the number of patient days per year at your hospital? 
61. What is the approximate dollar volume of all drugs purchased during 
fiscal year? 
You have novr finished the questionnaire. At this time, request: 
1. An i.v. label, preferably obtain a used i.v. bottle with a label attached. 
• 2. A medication floor stock label. 
3. Any commentbr observations that the interviewer has to offer. 
Card#1 
Which of the following are readily avateble to the person In cliarge of drugs? 
American Journal of Hospital Fharmacy p 
^umal of American Ptrarmaceutlcal Association 
Remington's Practice of Ptrarmacy (13th edition) 
U.S. Dispensatory (25th or later edition) ^ 
Modem Drug Encyclopedia (10th edition) 
A handbook on poisons 
A medical dictionary 
U.S.P.XVI1I 
Physician's Desk Reference, 1969 or 1970 ed. 
Facts and Comparisons (with current additions) 
American Hospital Formulary Service . -
Other (please specify) - ' 
Card#2 , • 
Please place a check by any of. the following registration classes In which 
your facffity Is registered with the Bureau of Narcotics and Dangerous Drugs. 
Class 1 • ' . 
Class 2 
Class 3 -
Class 4 - , 
• Class 5 • , . 
None of the above 
Card#3 
Which of these Items are available In your hospital? " 
PolycWn capsules 
- Amcll capsules 
Penbritin capsules 
. Princlpen capsules 
Omnlpen capsules 
generic amplclllln • 
.Card#4" ' 
Which of these Items are available in your hospital? 
• Eskfrex tablets 
HydroDluril tablets 
Oretia tablets 
Card#5 , 
Wtilch of these Items are available In your hospital (any brand, any dosage 
•form)? 
amplclllln 
mettiacHlln 
. nafclllln . 
oxacillin 
cloxacHlln 
dicloxaclllln . 
Card #6 
Which of these Kerns are available In your hospital? 
DllaucBd hypodermic tablets 
Codeine hypodermic tablets 
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PHARMACEUTICAL CARE 
Card #7 
Which of these items are avallabia in your hospHal? 
Tenuate tabiets 
TepanBtabiets-
Card#8 
Which of ttiese items are avaBable in your hospitai? 
Tofranii ' 
Pertofrane 
Morpramin 
Card#9 
Which of tfiese items are avaiiabie in your hospitai? 
EiavB 
Aventyl 
Card #10 
Which of these items are avaBabie in your hospitai? 
Triavii 
Etrafon 
Card#11 
Which of these jtems are avaiiabie in your hospitai? 
iiotycin 
Erythrocin 
Pediamycin 
llosone 
generic erythromycin 
Card #12 
Which of the foilowing persons attaches the suppiementary iabel to i.v. Pot­
ties? 
RN 
LPN • . -
nurses aide 
pharmacist 
physician 
other (specify) 
Card #13 
Do you have a P & T committee? 
This committee met—times iast year. 
Card #14 
Which of the foliowing persons attaches the supplementary iabei to i.v. bot­
tles (check as many as apply); 
R.N. 
L.P.N. 
Nurse's aide . . 
Pharmacist 
Physician 
Other 
Appendix B 
Scoring of Interview Data 
The questions numbered 2, 4,5,6,9,19, 26, 27, 30, 31, 34, 36, 39,55, and 
58 and card number 1 were designed to measure structure. Questions 
numbered 3, 7, 9b, 10-18, 20-25, 28, 29, 31b, 33, 37, 38, 40-52, 54, and 57 
and the cards numbered 6 and 12 were designed to measure process. Card 
number 13 was used to determine if a^pbarmacy and therapeutics commit­
tee was organized in the hospital and if so, ite activity as reflected by the 
number of meetings held annually. If the P & T committee met four or 
more times per year, it was classified as "active." If it met three or less 
times per year, it was classified as "inactive." 
The remaining cards were used to assess the functional activity of the P 
& T committee as reflected by the extent of duplication of drugs in the 
hospital. The functional activity of the P & T committee was operationally 
defined as the extent to which the hospital stocked duplicate drug prod­
ucts. One drug product was considered to duplicate another if it was iden­
tical in chemical composition and dosage form to another drug product or 
if it represented a repeat of the pharmacological action of another drug 
product as listed in the American Hospital Formulary Service.^^ Using 
these operational definitions, the eight lists of drug products which appear 
on cards numbered 3-5 and 7-11 were generated. 
Appendix C 
Analysis olthe Data 
The relationship between the structure and process scores for each sam­
ple was quantified using the Pearson r correlation coefficient. The Pear­
son r for the sample I data was equal to 0.77; for the sample II data, 0.76; 
and for the sample HI data, 0.48. The Pearson r for the combined data 
from samples I and II was equal to 0.79; and for the combined data from 
samples I, II, and III, it was 0.63. All of the Pearson r's were statistically 
signiflcant at the 0.05 level and none of the correlation coefficients dif­
fered statistically at the 0.05 level. 
Given the significant linear correlation between the structure and pro­
cess scores, a linear regression equation for predicting a hospital's process 
score from its structure score was developed. The calculated linear regres­
sion equation was found to be: 
Y'= 12.50-I-1.84X 
where: 
Y' = hospital's predicted process score 
•X = hospital's actual structure score 
The standard error of estimate was equal to 8.71 for the linear regression 
equation. 
The mean and standard deviation for the structure, process, and drug 
product duplication scores of each sample are shown in Table 2. The data 
summarized in this table were' further analyzed using a single factor un­
weighted means analysis of variance procedure and a Newman-Keuls pro­
cedure for each sample. These three analyses are shown in Tables 3-5. 
The ANOV in Tables 3-5 shows the three samples of hospitals differed 
significantly in their structure, process and drug product duplication 
scores. The Newman-Keuls procedure shows hospitals in samples II and 
III did not differ in their structure scores but did differ from sample I hos­
pitals,whereas the Newman-Keuls procedure on the process scores 
showed all three samples differed. The drug product duplications' New­
man-Keuls procedure showed sample I and sample II hospitals did not dif­
fer from each other but did differ from sample III hospitals. 
The relationship between the number of meetings held annually by the 
hospital's P & T committee and the hospital's drug product duplication, 
structure and process score was quantified using a point-hiserial correla­
tion coefficient. The hospitals in each of the three samples were divided 
into groups of "has active P & T committee" or "does not have active P & 
T, committee" using the above definitions. Using this classification proce­
dure as the dichotomous variable and the drug product duplication, struc­
ture and process score as the continuous variable, the point-hiserial corre-
Table 2. Means and Standard Deviations for the Structure, 
Process and Drug Product Duplication Scores of the Three 
Samples of Hospitals 
SCORES 
DRUG 
STA- PRODUCT 
SAM^ TIS-. STRUC- PROC­ DUPLICA­
PLEa TIC'' , TURE ESS TION 
1 X 14.29 34.84 2.82 
s 3.96 9.57 2.22 
II X 17.10 45.94 2.55 
s 4.83 7.64 1.91 
III X 17.28 53.30 5.17 
s 2.50 5.35 2.02 
^Sample notation: 
I—Sample of 45 Mississippi hospitals with less than 100 beds. 
II—Sample of 31 Mississippi hospitals with more than 100 beds. 
III—Sample of 36 Philadelphia hospitals all having more than 
100 beds. 
bStatistic notation: 
. X—Sample mean, 
s—^Sample standard deviation. 
American Journal of Hospital Pharmacy Vol. 32 JUNE 1975 573 
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Table 3. Analysis of Variance and Newman-Keuls 
Procedure for the Structure Scores of the Three Samples 
of Hospitals 
SOURCE SS df MS F 
Samples 
Error 
^227.74 2 
109 
113.87 
15.20 
7.49a 
Total 1884.92 111 
ap.,, (2,120) =4.79. 
SAMPLE . 1 II III 
X 14.29 17.10 17.28 
I 
II 
III 
14.29 
17.10 
17.28 
— 2.81b 2.99b 
0.18 
q.„(r,120) . 
''{MS error/n)''^ q.ssif. 120) 
r = 2 
3.70 
2.39 
r = 3 
4.20 
2.70 
Table 4. Analysis of Variance and Newman-Keuls 
Procedure for the Process Scores of the Three Samples 
of Hospitals 
SOURCE SS . df MS F 
Samples 
Error 
Total 
7003.00 
6961.42 
13964.42 4 3501.50 63.87 54.82a 
aP.gg (2,120) = 4.79 
SAMPLE 1 II III 
X 34.84 45.94 53.30 
I 
II 
III 
34.84 
45.94 
53.30 
11.10b 18.46b 
7.36b 
q.gg(r, 120) 
^(MS error in V "'q.gg(r,120) 
r = 2 
3.70 
4.92 
r = 3 
4.20 
5.59 
Table 5, Analysis of Variance and Newman-Keuls 
Procedure for the Drug Product Duplication Scores 
of the Three Samples of Hospitals 
SOURCE SS df MS F 
Samples 
Error 
Total . 
148.74 
483.26 
532.00 m 74.37 4.43 16.97a 
aF.g9(2,120) = 4.79. 
SAMPLE II 1 III 
X 2.55 2.82 5.17 
II 
1 
III 
2.55 
2.82 
5.17 " 
0.27 2.62b 
2.35b 
Q,gg(r,120) 
•' (MS error In) "^ q.gg (r.120) 
r = 2 
3.70 
1.29 
r = 3 
4.20 
1.46 
lation coefficients were calcukted. The values are presented in Table 6. A 
point-biserial correlation coefficient was calculated on the combined data 
from samples I, II, and III for the activity dichotomy and the drug product 
duplication scores as well as the process scores. The calculate values were 
0.12 and 0.16 resp^tively and both were nonsignificant at the 0.05 level. 
The relationship between the hospital's drug product duplication score 
and its structure and process score was also quantified using a point-biser-
ial correlation coefficient. For this procedure the hospitals in each of the 
three samples were divided into two groups according to then: structure or 
process score. Those scoring above the mean comprised one group and 
those hospitals scoring below the mean comprised the other. Therefore, 
the dichotomous variable was the structure or process score and the con­
tinuous variable was the hospital's drug product duplication score. The 
calculated point-hiserial correlation coefficients are presented in Table 7. 
None of the six calculated correlation coefficients was statistically signifi­
cant. 
The relationship of the presence of a full-time or part-time pharmacist 
to the structure, process and drug product duplication score for the hospi­
tals in samples I and II was quantified using a point-biserial correlation 
coefficient. The poipt-biserial technique was applied by dividing those 
hospitals employing a full-time pharmacist from those hospitals with a 
part-time pharmacist (deleting the-four hoepitals reporting no pharmacist 
contact) and comparing this dichotomy to the hospital's4tructure, process 
and drug product duplication score. The calculated correlation coefficient 
for the structure scores was 0,59 for the combined samples, and was 0.62 
for the process scores. Both of the point-biserial correlation coefficients 
were significant at the 0.05 level. The calculated point-biserial for the drug 
product duplication scores was equal to 0.05 for the combined samples and 
was not significant. These three analyses did not include the hospitals in 
sample III because they all reported having a full-time pharmacist and 
this would have unduly biased the results. 
Table 6. Point-Biserial Correlation Coefficients 
for Pharmacy ai\d Therapeutics Committee Activity 
Classification Versus Drug Product Duplication, 
Structure and Process Scores 
DRUG 
PRODUCT STRUC­
SAMPLE DUPLICATION TURE PROCESS 
1 0.32a 0.40a 0.46a 
II 0.26 0.46a 0.24 
III = 0.08 0.4la • 0.15 
3Statistically significant ht the 0.05 level. 
Table 7. Point-Biserial Correlation Coefficients for Drug 
Product Duplication Score Versus Structure 
and Process Scores 
SAMPLE , STRUCTURE PROCESS 
I 
II 
III 
0.24 
-0.09 
0.31 
0.16 
0.31 
0.30 
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