History of Hospital Pharmacy

14 Pages·2009·6.22 MB·English

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Chapter 2
Overview of the History of Hospital
Pharmacy in the United States
William A. Zellmer
dreaded impurity and exiled human wreckage,” and
Introduction
doctors had little to do with each other.8Hospitals
Hospitals today offer immense opportunities for phar- played a small role in health care, and pharmacists
macists who want to practice in an environment that played a very small role in hospitals.
draws on the full range of their professional education In the early 1800s, drug therapy consisted of strong
and training. It was not always so. cathartics, emetics, and diaphoretics. From the 1830s
This chapter tells the story of how hospital pharma- to the 1870s, clean air and good food rather than medi-
cy developed in this country, analyzes the forces that cines were the treatments emphasized in hospitals. In
shaped the hospital pharmacy movement, and draws
lessons from the changes in this area of pharmacy
Figure 2-1
practice. The historical facets discussed here are high-
ly selective, reflecting the author’s judgment about the Hospital Pharmacy Department,
most important points to cover within the limits of one Bellevue Hospital, New York City,
chapter.
Late 1800sa
Hospital Pharmacy’s Nascencea,1–4
Hospital pharmacy practice in the United States did
not begin to develop into a significant movement until
the 1920s. Although there were important milestones
before that era (including the pioneering hospital phar-
macy practices of Charles Rice [1841–1901]5—see
Figure 2-1—and Martin Wilbert [1865–1916]), many
factors kept hospital pharmacy at the fringes of the
broader development of pharmacy practice and phar-
macy education.6When the Pennsylvania Hospital
(the first hospital in Colonial America) was established
in 1752 and Jonathan Roberts was appointed as its
apothecary, medicine and pharmacy were commonly
practiced together, with drug preparation often the
aThe bulk medicine area,where medicines were packaged for use on the wards,
responsibility of a medical apprentice.7In 1800, with at Bellevue Hospital,New York City,in the late 1800s.Standing on the right is
a population of 5 million, the nation had only two hos- Charles Rice,the eminent chief pharmacist at Bellevue,who headed three revi-
sions of the United States Pharmacopeia.
pitals. Even by 1873, with a population of 43 million,
the United States had only 178 hospitals with fewer
Source:AJHP.
than 50,000 beds.2Hospitals, which were “places of
aWell-documented accounts of the development of hospital pharmacy practice in the United States were published by the
American Society of Health-System Pharmacists (ASHP) in conjunction with anniversaries of its 1942 founding.
Particularly noteworthy are the “decennial issue” of the Bulletin on the American Society of Hospital Pharmacistsand articles
that markedASHP’s 50thanniversary.1–3Readers who have an interest in more detail are encouraged to seek out those ref-
erences and others.4This section of the chapter is based closely on Reference 2.
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PHARMACY IN THE UNITED STATES
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the mid-1800s, the medical elite avoided drug use or characterized pharmacy practices in hospitals as
used newer alkaloidal drugs such as morphine, strych- “chaotic” and commented, “Few departments in hospi-
nine, and quinine. An organized pharmacy service was tal performance have been given less attention by and
not seen as necessary in hospitals, except in the largest large than the hospital pharmacy.” In the committee’s
facilities. The situation changed somewhat during the view, “…any hospital larger than one hundred beds
Civil War when hospital directors sought out pharma- warrants the employment of a registered pharmacist….
cists for their experience in extemporaneous manufac- Unregistered or incompetent service should not be
turing and in purchasing medical goods.2 countenanced, not only because of legal complications
In the 1870s and 1880s, responding to the influx of but to insure absolute safety to the patient.”9The pro-
immigrants, the number of hospitals in cities doubled. liferation of unapproved and proprietary drug products
Most immigrants in this period were Roman Catholic, in hospitals was the target of extensive criticism by the
and they built Catholic hospitals. This was significant committee.
for two reasons—Catholic hospitals chargedpatients a
small fee (which allowed services to be improved) and
A Fifty-Year Perspective
they were willing to train, or obtain training for, nuns
There is much that can be learned by comparing con-
in pharmacy. This era of hospital expansion coincided
temporary hospital pharmacy with practice of 50 years
with reforms in nursing, development of germ theories,
ago. Fifty years is a comprehensible period of time for
and the rise of scientific medicine and surgery. The
most people and, in hospital pharmacy’s case, the past
general adoption of aseptic surgery in the 1890s made
half century was a period of astonishing advancement.
the hospital the center of medical care. Advances in
The data sources for making such a comparison are
surgery led to growth of community hospitals, most of
remarkably good. A major study of hospital pharmacy
which were small and relied on community pharmacies
was conducted between 1957 and 1960—the Audit of
to supply medicines.2
Pharmaceutical Services in Hospitals—under the direc-
By the early twentieth century, hospitals had devel-
tion of Donald E. Francke and supported by a federal
oped to the point of having more division of labor, more
grant (see Figure 2-2). The results were published in a
specialization in medical practice, a greater need for
book, Mirror to Hospital Pharmacy, which remains a
professional pharmaceutical services for handling com-
reference of monumental importance.10In more recent
plex therapies, and recognition that it was more eco-
times, ASHP has conducted an annual survey of hospi-
nomical to fill inpatient orders in-house. Hospital
tal pharmacy, yielding contemporary data for compari-
pharmacists retained the traditional role of compound-
son with the figures of an earlier era.
ing, which fostered a sense of camaraderie among them
Four major themes emerge from an examination of
and an impetus to improve product quality and stan-
changes over this period:
dardization. The advent of the hospital formulary con-
cept persuaded many hospital leaders about the value 1. Hospitals have recognized universally that
of professional pharmaceutical services. An important pharmacists must be in charge of drug product
reason for hiring a hospital pharmacist in the 1920s acquisition, distribution, and control.
was Prohibition—alcohol was commonly prescribed, 2. Hospital pharmacy departments have assumed
and a pharmacist was needed for both inventory control a major role in patient safety.
and to manufacture alcohol-containing preparations,
3. Hospital pharmacy departments have assumed
which were expensive to obtain commercially.2
a major role in promoting rational drug therapy.
By the 1930s, pharmacy-related issues in hospitals
had coalesced to the point that the American Hospital 4. Hospital pharmacy departments have come to
Association (AHA) created a Committee of Pharmacy see their mission as fostering optimal patient
to analyze the problems and make recommendations. outcomes from medication use.
The 1937 report of that committee was considered so It is important to keep in mind what was happening
seminal by hospital pharmacy leaders that even a over this period in the United States as a whole. Since
decade later they saw value in republishing it.9The 1950, the U.S. population has grown 86%. Expendi-
aim of the committee was to develop minimum stan- tures for health care services have grown from about
dards for hospital pharmacy departments and to pre- 5% of gross domestic product to 14%. This growth has
pare a manual of pharmacy operations. The committee fostered an endless stream of public and private initia-
20 HANDBOOK OF INSTITUTIONAL PHARMACY PRACTICE
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tributed only 10% to the overall rating. Pharmacy was
Figure 2-2
perceived as a complementary service department, not
Authors of the Mirror to Hospital as an essential service.12
Pharmacya Fewer than half the hospital beds in the nation
(47%) in the late 1950s were located in facilities that
had the services of a full-time pharmacist.10Fewer than
four out of 10 hospitals (39%) had the services of a
pharmacist. Hospital size was an important determi-
nant of the availability of a pharmacist. All larger short-
term institutions—those with 300 beds or more—
employed a full-time pharmacist. This performance
declined sharply with decreasing hospital size:
200–299 beds 96%
100–199 beds 72%
50–99 beds 18%
under 50 beds 3.5%
Today, the vast majority of hospitals in the United
States have the services of one or more pharmacists.
Important exceptions are small rural hospitals that still
aThe authors of the Mirror to Hospital Pharmacyexamining a slide containing data
from the results of the Federal Audit of Pharmaceutical Services in Hospitalsthat rely on the services of local community pharmacists.
was conducted in 1957.From left,Clifton J.Latiolais,Donald E.Francke,Gloria About 7% of the nation’s hospitals have fewer than
Niemeyer Francke,and Norman F.H.Ho.The results were published by ASHP in
25 beds; it is not known how many of them employ a
the book,Mirror to Hospital Pharmacy,in 1964.
pharmacist.
Source:ASHP Archives. In 1957, the total number of hospital pharmacists
was 4,850 full time and about 1,000 part-time.10Today,
there are about 50,000 full-time equivalent pharma-
tives to curtail health care spending. Average daily hos-
cists providing inpatient services in nonfederal short-
pital census, on a per-population basis, has declined by
term hospitals.b,13(Hospitals employ an equal number
24% during this period as a result of public and private
of pharmacy technicians.) About one-fourth of all
initiatives to reduce hospital use. Nonfederal, short-
actively practicing pharmacists in the U.S. today are in
term general hospitals in 1950 numbered 5,031 and
hospitals.
rose to a zenith of 5,979 in 1975; in 2003 the number
Today’s hospitals employ approximately twelve full-
stood at 4,918, nearly 18% fewer than the peak of
time equivalent pharmacists per 100 occupied beds.13
three decades before. On a per-capita basis, the num-
The comparable figure for 1957 was approximately
ber of inpatient hospital beds has declined 65% since
0.4 FTE pharmacists per 100 occupied beds. In other
1950. Since 1965 (the first year AHA reported these
words, pharmacist staffing in hospitals is 30-fold more
data), hospital outpatient visits have increased more
intensive today. During the same interval, the intensity
than fourfold.11
of hospital staffing as a whole increased approximately
sevenfold.c
Drug Product Acquisition,Distribution,and Reflective of more intensified pharmacist staffing,
Control 30% of hospitals today offer 24-hour inpatient phar-
macy services. In the largest hospitals (400 beds),
Fifty to sixty years ago, pharmaceutical services were
95% of pharmacy departments are open around the
of marginal importance to hospitals. The 1949 hospital
clock.13
standards of the American College of Surgeons had
In the middle of the 20th century, nurses and com-
only three questions related to pharmacy in its point-
munity pharmacists had significant responsibility for
rating system, and responses to those questions con-
bThroughout this chapter, pharmacy data from recent ASHP surveys refer to U.S. nonfederal short-term hospitals.
cCalculated based on data in Reference 11.
CHAPTER 2: OVERVIEW OF THE HISTORY OF HOSPITAL 21
PHARMACY IN THE UNITED STATES
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hospital drug product acquisition, distribution, and
Table 2-1
control. The Mirror to Hospital Pharmacy estimated
Percentage of U.S. Hospitals
that 4,000 nurses were engaged in pharmacy work.
Here are specific data collected in 1957 showing who Providing (or Desiring to Provide)
handled drugs for the 2,200 hospitals that did not
Specific Pharmacist Services,
have a full-time pharmacist:
1957–1960a,10
Nonpharmacist personnel 45%
(generally nurses) Service Provide Would Like
Nonpharmacist personnel 45% to Provide
plus community pharmacist Supply drugs to nursing units 97 1
Supervision by local 9% Inpatient prescriptions 95 1
community pharmacist
Prescription compounding 94 1
Table 2-1 shows the services hospital pharmacists
Interdepartmental drug needs 91 1
were providing in 1957–1960. Two types of services—
Drug information 84 9
bulk compounding and sterile solution manufactur-
ing—were a major element of the hospital pharmacists’ Outpatient prescriptions 64 6
professional identity in the 1950s (Figure 2-3). Hospi- Formulary system 53 25
tal pharmacy leaders of the day cited the following
Bulk compounding program 41 12
factors in explaining the heavy involvement in manu-
facturing: Teaching program 28 23
■ The unsuitability of many commercially available Product development/research 13 23
dosage forms for hospital use Sterile solution manufacturing 11 15
■ The close relationship between physicians and
aHospitals with a chief pharmacist.
pharmacists in hospitals
■ The opportunity to serve a need of physicians
and patients anyone in the hospital field that medications need to
be controlled by a pharmacy department that is run by
■ The opportunity to offer a professional service
qualified pharmacists. Moreover, as pharmacists have
and build interprofessional relations10
become firmly established in hospitals, they have been
Today, bulk compounding or manufacturing is no
recognized for their expertise beyond drug acquisition,
longer a significant activity in U.S. hospital pharma-
distribution, and control functions, which has led to
cies. In sharp contrast to 50 years ago, hospital phar-
greatly intensified pharmacy staffing. The growing
macists now prefer to purchase commercial products
opportunities in hospitals have attracted more practi-
whenever they are available, in the interests of appro-
tioners to the field, which has made hospital practice
priate deployment of the workforce and of using prod-
a major sector of the profession.
ucts of standard commercial quality. Changes in the
laws and regulations that govern drug product manu-
facturing and distribution, the development of a well- Patient Safety
regulated generic pharmaceutical industry, and a shift The clarion call to professionalism in hospital pharma-
in the perceived mission of pharmacy practice were cy in recent times has been the patient safety impera-
among the factors that led to the relegation of manu- tive. Hospital pharmacists have made immense progress
facturing to hospital pharmacy’s past. in this arena. Initially, that progress was tied to greater
In summary, from mid-twentieth century to today, accuracy in dispensing and administration of medica-
hospital pharmacy in the United States moved from an tions, but it has evolved to also focus on improving
optional service to an essential service. It used to be prescribing and monitoring the results of therapy. But
that the administrator, the physicians, and the nurses in it all started with a desire to improve drug product dis-
many institutions, especially smaller facilities, believed tribution for inpatients.
that they could function adequately with a drug room In 1957, there were two ways in which drug prod-
controlled by nurses. Today it is beyond question by ucts were distributed to hospital inpatients: as ward
22 HANDBOOK OF INSTITUTIONAL PHARMACY PRACTICE
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often go undetected, while the patient receives
Figure 2-3
the wrong drug, the wrong dosage form, or wrong
Sterile Solution Laboratory,
amount of the drug, or is given the drug by injec-
Cardinal Glennon Memorial tion when oral administration was intended, and
vice versa.”14
Hospital for Children, St. Louis,
Concerns about medication errors and about over-
Missouri, circa 1950sa
all efficiencies and best use of hospital personnel led
to the development of improved drug distribution sys-
tems.15Two major studies were done in the early 1960s
on unit dose drug distribution. At the University of
Arkansas Medical Center, a centralized system was
developed, and at the University of Iowa, a decentral-
ized system was studied (see Figure 2-4).16,17Both
projects documented important benefits to unit dose
drug distribution, including greater nursing efficiency,
better use of the pharmacist’s talents, cost savings, and
improved patient safety.
The key elements of unit dose drug distribution, as
the system has evolved from the original studies, are as
follows:
1. The pharmacist receives the physician’s original
aProduction of distilled water and the manufacture of large-volume sterile solutions order or a direct copy of the order.
were major pharmacy activities in medium and large hospitals in the 1950s and
1960s.
Figure 2-4
Source:ASHP Archives.
Pioneers in Unit Dose Drug
Distribution—William Heller (circa
stock or as individual prescriptions. If the patient was
1965) and William Tester (circa
charged for the medication, individual prescriptions
were generally used. Otherwise, it was most common 1965)a
for stock containers of medications to be available to
the nurse for administration to the patient as needed.10
The authors of the Mirror to Hospital Pharmacy
highlighted a critical limitation of medication systems
of that era:
“From the viewpoint of patient safety, one of the
major advances in dispensing procedures would
be the interpretation by the pharmacist of the
physician’s original … order for the patient. In
many hospitals, the pharmacist never sees the
physician’s original order. In cases where the
physician does write an original prescription, he
does so only for a limited number of drugs, the
aThe pharmacy departments led by these two prominent hospital pharmacists—
other drugs being stock items on the nursing
William M.Heller (left),University of Arkansas Medical Center,and William W.
units. In many cases the pharmacist receives only Tester (right),University of Iowa Hospital—conducted important studies on unit
an order transcribed by a nurse or even more dose drug distribution in the 1960s.This method of drug distribution was devised
in response to the results of medication error studies.
commonly by a lay person such as a ward clerk.
As a result, errors made by the prescribing physi- Source:ASHP Archives.
cian and errors made in transcribing his orders
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2. A pharmacist reviews the medication order as a whole, ASHP estimates that about 80% of IV
before the first dose is dispensed. admixtures are now prepared by the pharmacy depart-
ment.19
3. Medications are contained in single-unit
ASHP’s 2002 survey showed that most hospitals
packaging.
regularly engage in a number of programs designed to
4. Medications are dispensed in as ready-to-
increase the safety of injectable medications, including
administer form as possible.
educational programs on IV administration equipment
5. Not more than a 24-hour supply of doses is (82%), administration and precautions associated with
delivered or available at the patient-care area at high-risk therapies (71%), and administration of IV
any time. push medications (62%); promulgating lists of approved
6. A patient medication profile is concurrently IV push medications (57%); and affixing supplemental
maintained for each patient.18 labels for IV push medications (53%).19
There is immense interest in U.S. hospitals in
These precepts for state-of-the-art drug distribution
applying computer technology to improve the safety of
are met widely in U.S. hospitals today. For example, in
medication prescribing, dispensing, and administration.
a 2002 survey, in 79% of hospitals, pharmacists
Computer-generated medication administration records
reviewed and approved all medication orders before
are used in 64% of all hospitals and in 75% of the
the drug was administered to patients. The figure for
the largest hospitals (≥400 beds) was 92%.19 largest hospitals.19The foregoing data notwithstanding,
the cost of such technology is having a decided moder-
There has been much debate in hospital pharmacy
ating effect on the rate of adoption. For example, in
over the years about the virtues of centralized versus
2002, only about 2% of hospitals used computer-
decentralized drug distribution. With a decentralized
readable coding technology to improve accuracy of
system, pharmacists come in contact more regularly
medication administration, and, in 2004, only about
with physicians, nurses, and patients, which is consis-
3% of hospitals used a computerized prescriber order
tent with contemporary views about how the profession
entry system that was linked to a decision support sys-
should be practiced. Among all hospitals, 20% use a
tem.13,19
decentralized system; the figure is 41% for the largest
Because of the concerns of groups such as the
hospitals.19Many hospitals indicate that they would
Institute of Medicine and various federal agencies,
like to move toward decentralized pharmacy services in
improving patient safety is now a major national priori-
the future (see Table 2-2).
ty.21When that general interest in patient safety
U.S. hospitals have shown a remarkable rate of
embraces medication-use safety, hospital pharmacists
adoption of point-of-use automated storage and distri-
have cheered and felt “it’s about time!” Further break-
bution devices, which are now used to some extent in
throughadvances in medication-use safety will depend
58% of facilities. Point-of-use dispensing is now the
on a fundamental reengineering of the entire medica-
primary method of dose delivery in about one-fourth
tion-use process, a shift toward a true team culture in
of U.S. hospitals.19
providing care, and wider application of computer
Pharmacy-based IV admixture services have been
technology.22As new technologies or new patterns of
widely adopted by U.S. hospitals. Development of such
health professional behavior evolve, history suggests
services, as a professional imperative, was a topic of
that hospital pharmacists will be at the leading edge of
intense interest in the 1960s.20For short-term hospitals
those advances.
Table 2-2
Promoting Rational Drug Use
Hospitals with Decentralized Drug
In U.S. hospitals, the concept of a pharmacy and thera-
Product Distribution19
peutics (P&T) committee, as a formal mechanism for
the pharmacy department and the medical staff to
Year 2002 Future Desire
communicate on drug-use issues, was first promulgated
All hospitals 20% 44%
in 1936 by Edward Spease (dean of the School of
Largest hospitals (≥400 beds) 41% 56%
Pharmacy at Western Reserve University) (Figure 2-5)
and Robert Porter (chief pharmacist at the University’s
24 HANDBOOK OF INSTITUTIONAL PHARMACY PRACTICE
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In 1957, 58% of hospitals had an active P&T com-
Figure 2-5
mittee, and a similar percentage of hospitals had a
Advocate of the Pharmacy and
formulary or approved drug list. However, about one
Therapeutics Committee—Edward fourth of the P&T committees were inactive.10Today,
nearly all hospitals in the U.S. have an active P&T
Spease (1883–1957), circa 1952a
committee that meets an average of seven times a
year.13
In the late 1950s, the functions of P&T committees
focused on very basic activities such as delegating to
the chief pharmacist responsibility for preparing prod-
uct specifications and selecting sources of supply
(66% of committees) and approving drugs by nonpro-
prietary name (50%).10In most hospitals today, the
P&T committee has authorized pharmacists to track
and assess adverse drug events (ADEs), conduct retro-
spective drug-use evaluations, and identify and moni-
tor patients on high-risk therapies.13
In summary, concepts first advanced in the 1930s
regarding a formal communications linkage between
the hospital pharmacy department and the medical
aEdward Spease established one of the first college courses in hospital pharmacy staff with respect to drug-use policy have taken hold
and developed the Minimum Standards for Hospital Pharmacies for the American firmly. Hospital pharmacists are heavily engaged in
College of Surgeons in 1936.At the time,Spease was dean and professor at helping the medical staff establish drug-use policies, in
Cleveland’s Western Reserve University School of Pharmacy.
implementing those policies, in monitoring compliance
Source:ASHP Archives. with those policies, and in taking corrective action. The
invention of the pharmacy and therapeutics committee
and the hospital formulary system has facilitated the
hospitals).23Subsequently, the American Hospital
deep involvement of pharmacists in promoting rational
Association and the American Society of Hospital
drug use in hospitals.
Pharmacists jointly developed guidance on the P&T
committee and on the operation of a hospital formula-
Fostering Optimal Patient Outcomes
ry system. The formulary system is a method whereby
the medical staff of a hospital, working through the U.S. hospital pharmacists have evolved markedly in
P&T committee, evaluates, appraises, and selects from their self-concept over the past 50 years. As recently as
among the drug products available those that are con- 20 years ago, the traditional pharmacist mission pre-
sidered most useful in patient care. The formulary sys- vailed, a mission that was captured in the words, right
tem is also the framework in which a hospital’s medi- drug, right patient, right time, connoting a drug-
cation-use policies are established and implemented. product-handling function. Right drug in this context
A major imperative for the advocates of the formu- meant whatever the physician ordered. Today’s philos-
lary system in the mid-1900s was to manage the proli- ophy about the mission of pharmacists focuses on
feration of drug products. The number of new market achieving optimal outcomes from medication use. The
entries for just one year, 1951, were as follows: overarching question for the hospital pharmacist is
New drug products, 332 whether the right drug is being used in the first place.
New drug entities, 35 A popular phrase used to summarize this philosophy
Duplications of drug entities, 74 is, “The mission of pharmacists is to help people make
Combination products, 22124 the best use of medicines.” These words reflect a pro-
found paradigm shift with respect to the primary pur-
In 1957, slightly more than half of all hospitals
pose of pharmacy practice.25,26
operated under the formulary system.10Today, essen-
In the 1950s, hospital pharmacy’s Spartan staffing
tially all hospitals do so.13
levels did not leave much time for work beyond the
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basics of acquiring, storing, compounding, and distri-
Figure 2-6
buting medications. Nevertheless, chief pharmacists of
Hilton Head Conference, 1985a
the time were called upon frequently by physicians and
nurses to answer drug information questions related to
dosage, dosage forms, and pharmacology. Somewhat
less frequently, pharmacists were asked for advice on
adverse drug reactions and clinical comparisons of
products. In analyzing pharmacist consultations, the
authors of the Mirror to Hospital Pharmacy suggested
that both weakness in the pharmacist’s scientific know-
ledge and lack of time contributed to limited progress
in this realm.
The transformation of the hospital pharmacy
department from a product orientation to a clinical
orientation was stimulated by active consensus-build-
ing efforts by hospital pharmacy leaders. One impor-
tant example of such efforts was the ASHP Head con-
ference.25
aA workshop session at ASHP’s Hilton Head conference in 1985.This invitational
Hilton Head refers to a consensus-seeking invita- consensus-seeking program was designed to assess the progress of hospital
tional conference conducted in 1985 in Hilton Head, pharmacy departments in implementing clinical pharmacy; as a result of the dis-
cussions,many hospital pharmacy departments began to conceptualize their
South Carolina, officially designated as an invitational
mission in terms of fostering appropriate use of medicines.Standing at the flip
conference on Directions for Clinical Practice in Phar- chart at one of the break-out sessions is Henri R.Manasse,Jr.,at the time dean
macy (see Figure 2-6). The purpose of the meeting was of the School of Pharmacy,University of Illinois at Chicago
to assess the progress of hospital pharmacy departments
Source:ASHP Archives.
in implementing clinical pharmacy. What emerged
from the event was the idea that clinical pharmacy
should not be thought of as something separate from shown in Table 2-3. There is a growing body of scien-
pharmacy practice as a whole. Rather, hospital phar- tific evidence, published in both the medical and phar-
macies should function as clinical departments with a macy literature, about the positive outcomes achieved
mission of fostering the appropriate use of medicines. through pharmacist involvement in direct patient
This was a very important idea because most hospital care.27–30
pharmacists thought in terms of adding discrete clini- In summary, U.S. hospital pharmacists today are
cal services (such as pharmacokinetic monitoring) engaged in extensive clinical activity, which is a major
rather than conceptualizing the totality of the depart- change from practice of 50 years ago. We are not yet
ment’s work as a clinical enterprise. at the point where a majority of hospital patients who
Working through its affiliated state societies, ASHP are on medication therapy receive the benefit of clini-
supported repetitions of the conference on a regional cal oversight by the pharmacist, but progress in this
basis. ASHP leaders spoke at meetings around the direction continues to be made.
country about the ideas of Hilton Head, and the Ameri-
can Journal of Hospital Pharmacy published numerous Recap of Major Themes
papers on the subject.
Thus we have a picture of the major thrust of changes
As a result, many individual pharmacy departments
in hospital pharmacy over the past 50 years. The four
began to hold retreats of their staffs to reassess the
major themes have been, first, the universal recogni-
fundamental mission of their work. It was common for
tion by hospitals that pharmacists must be in charge of
departments to adopt mission statements that, for the
drug product acquisition, distribution, and control;
first time, framed their work not in terms of drug dis-
second, hospital pharmacy departments have assumed
tribution but in terms of achieving optimal patient out-
a major role in patient safety; third, pharmacy depart-
comes from the use of medicines.
ments have assumed a major role in promoting ration-
The most important indirect indicators of hospital
al drug therapy; and, finally, pharmacy departments
pharmacist clinical activity in the current era are
26 HANDBOOK OF INSTITUTIONAL PHARMACY PRACTICE
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■ Greater complexity and cost of drug therapy
Table 2-3
accompanied by sophisticated pharmaceutical
Indicators of Contemporary
product marketing.
Hospital Pharmacist Clinical ■ Growing interest in improving the quality of
Activity health care services.
More important for this chapter’s discussion are the
All Largest
internal factors within hospital pharmacy that precipi-
Hospitals Hospitals
tated the changes discussed above. In this category,
(≥400 beds)
five points merit discussion:
Hospitals with decentralized pharmacists
29% 82% 1. Visionary leadership
(1999 data)a
2. Professional associations
Percentage of decentralized pharmacists
59% - 3. Pharmacy education
time spent on clinical activities (1999)
4. Postgraduate residency education and training
Pharmacists have authority to initiate
52% 62%
medication orders (2001) 5. Practice standards
Pharmacists attend rounds (2004) 35% 79%
Pharmacists provide drug information Visionary Leadership
90% -
consultations (2004)
One cannot read the early literature of hospital phar-
Pharmacists monitor prescriber macy in the U.S. without being impressed by the clear
compliance with medication-use 81% 92% articulation of an exciting, uplifting vision by that era’s
policies (2004) practice leaders. These views were being expressed at a
time when pharmacy was a marginal profession in the
aAll data are from ASHP national surveys of the year shown.
U.S.; when most pharmacists were engaged primarily
in retail, mercantile activities; when hospital pharmacy
have defined their mission in terms of optimal patient had little visibility and respect; and when hospital
outcomes from medication use. Taken together, these pharmacy was a refuge for pharmacists who preferred
changes signify that pharmacy practice in U.S. hospi- minimal interactions with the public. Out of this envi-
tals over the past 50 years has become more intensive ronment emerged a number of hospital pharmacists,
in its professional staffing, more directly focused on many of them at university teaching hospitals, who
patient care, and more directly influential on the quali- expressed an inspiring vision about the development of
ty and outcome of patient care. In short, hospital phar- hospital pharmacy and about the role of hospital phar-
macy has been transformed from a marginal, optional macy in elevating the status of pharmacy as a whole.
activity into a vital profession contributing immensely These were leaders such as Arthur Purdum,
to the health and well being of patients and to the sta- Edward Spease, Harvey A. K. Whitney, and Donald E.
bility of the institutions that employ them. Francke (to mention only a few) who were familiar
with the history of pharmacy and had a sense of phar-
macy’s unfulfilled potential. Many of them had seen
Explaining the Transformation
European pharmacy firsthand and decried the immense
A combination of indirect and direct factors helps gap in professional status and scope of practice
explain this transformation in hospital pharmacy. between the two continents.
Indirect factors are those forces external to hospital A sense of the deep feelings of these leaders may be
pharmacy that fostered development of the field. These gained from the following comment by Edward Spease,
factors include the following: a retired pharmacy dean speaking in 1952 about his
■ Shift of national resources into health care, initial exploration of hospital pharmacy 40 years earlier:
especially hospital care (stimulated immensely “I expected to see true professional pharmacy in
by implementation of Medicare in 1965 and hospitals and was much disappointed that it did
expansion of other health insurance coverage). not exist there. The more I observed and heard
about the growing tendency towards commercial-
■ Expanded clinical research and drug product
development.
CHAPTER 2: OVERVIEW OF THE HISTORY OF HOSPITAL 27
PHARMACY IN THE UNITED STATES
17283_019-032_CHAPTER 2 10/18/05 4:06 PM Page 28
ism in drugstores, the more I felt that if profes- actualization of the professional ideals and aspirations
sional pharmacy was to exist, let alone grow to an of hospital pharmacists. In its early years, ASHP con-
ideal state, it would have to be in the hospital ducted a series of educational institutes that were very
where the health professions were trained…. influential in enhancing knowledge and skills and in
Good pharmacy is as important in hospitals away building esprit de corps among hospital pharmacists.33
from teaching centers as it is in the teaching and Also noteworthy, especially as the organization has
research hospital. It can be developed to a high grown in size and diversity, is ASHP’s efforts to devel-
degree of perfection there, too, if the pharmacist op consensus about the direction of practice.25,26
can get the picture in his mind.” (Emphasis The second essential act of ASHP has been its cre-
added.)31 ations of resources to assist practitioners in fostering
“…if the pharmacist can get the picture in his the development of hospital pharmacy practice. One
mind.” Those are key words that reflect that early hos- example is the AHFS Drug Information reference book
pital pharmacy leaders were trying to create a new (and, in recent times, electronic versions for central
model for pharmacy practice in hospitals and not allow information systems, desktop computers, and hand-
this practice setting to become an extension of the type held devices), which is the most widely used independ-
of practice that prevailed in community pharmacies. ent source of drug information in U.S. hospitals.
These leaders were change agents with a missionary Another example is the American Journal of Health-
zeal, and they were blessed with the ability to infect
others with their passion.
Figure 2-7
It is noteworthy that the Mirror to Hospital Phar-
A Leading Force in the Creation of
macy framed the entire Audit project in the context of
professional advancement. The report laid out the ASHP—Harvey A. K. Whitney
essential characteristics of a profession and articulated
(1894–1957) circa, 1940a
goals for hospital pharmacy that would bring pharmacy
as a whole into better alignment with those character-
istics.
Professional Associations
The national organization of hospital pharmacists—
the American Society of Health-System Pharmacists
(ASHP)—has had a profound effect on the advance-
ment of the field. The visionary hospital pharmacists
of the early 1900s focused much of their energies on
the creation of an organizational structure for hospital
pharmacy. One landmark event was the creation of the
Hospital Pharmacy Association of Southern California
in 1925. On a national level, organizational efforts
were funneled through the American Pharmaceutical
Association (APhA), the oldest national pharmacist
organization in the country. For years, hospital phar-
macists participated in various committee activities of
APhA focused on their particular interest. Then, in
1936, a formal APhA subsection on hospital pharmacy
aHarvey A.K.Whitney took the lead in organizing hospital pharmacists in the
was created. This modest achievement evolved to the
United States.He was chief pharmacist at the University of Michigan Hospitals
creation of ASHP in 1942 as an independent organiza-
when he became ASHP’s first chairman (president) in 1942.Whitney was also
tion affiliated with APhA32(see Figure 2-7). a pioneer in developing postgraduate training in hospital pharmacy.
There are two essential things that ASHP has done
Source:ASHP Archives.
for the advancement of hospital pharmacy. One is to
serve as a vehicle for the nurturing, expression, and
28 HANDBOOK OF INSTITUTIONAL PHARMACY PRACTICE