Hospital Inpatient Pharmacy

For about a week and a half I had the opportunity to work in the inpatient pharmacy at Tema General Hospital. In contrast to the outpatient pharmacy, which was big and open, the inpatient pharmacy was tiny and cramped. It was smaller than the studio apartment I used to live in in Corvallis. The entire pharmacy consisted of two large desks with chairs crammed around them and a few cabinets stocked with medications. At any one time there were 10-12 people trying to work in the pharmacy,so it could get very crowded and hot in there.

The process of filling a prescription was different here than in the outpatient pharmacy. One major difference is that instead of getting written prescriptions, we were given patient charts. This hospital still uses paper charts, so the nurses or patients would bring the charts by when they needed medications. Things generally didn't pick up in the pharmacy until after 10, when the doctors finished their rounds. Then we would start getting stacks of charts from nurses for patients either needing medications or needing their medication bills calculated before being discharged.

If a patient needed medications, the chart would be evaluated by a pharmacist who would key the medications into the computer system. The pharmacist or intern must go to the plan section in the chart to determine which and how many medications are necessary. They are starting to transfer to a computer system, so they enter the patient's medications and directions into the computer system before filling the prescription. Once the drugs are keyed into the computer system, the drug names are written into the back of the chart along with the number of tablets or units to be given. This is later used in discharging which I will explain later. Then the charts are given to another worker who pulls the drugs off of the shelf and gives them to a nurse or a family member of a patient to take to the patient's room.

Now I will explain the discharging process, which is the area that I primarily worked in, so I can explain it in more detail. Before patients are discharged from the hospital, their hospital bill must be calculated. This billing process usually includes services billed to the national health insurance and services that are paid in cash. The inpatient pharmacy here is responsible for writing in all of the charges for medications that patients get at the hospital. When a nurse brought in charts for discharge, I would take the chart, and turn to the back section, which consisted of essentially a cost sheet. This is where all of the medications and quantities that the  patient had while at the hospital are listed. I would then do a quick skim of the rest of the chart to make sure all of the medications given were written down on the cost sheet. At this point I would also assess if there were any discharge medications to be given and calculate the number of tablets that would need to be provided to the patient. I would add those medications to the list in the back of the chart. Then I would go through the process of calculating the drug bill. If the patient had the National Health Insurance, there would usually be a separate insurance sheet that would have the patient's information and diagnoses in it. If the patient's diagnoses were not on the form already, I would look through the chart to find them and write them down. I would then fill out the medications section of the claims form where I would write down the name, quantity, price, and date that the medication was administered to the patient. I had to look up all of the prices in a pricing book, which usually listed prices on a per tablet or per vial basis. The pricing book would also say if the particular drug was covered by the national health insurance or if it needed to be paid for with cash. The prices for the cash prescriptions were written in on the cost sheet in the chart. Once I had prices all of the drugs figured out, I would add the totals for both cash and insurance. Then I would tell another student keeping the record book the insurance and cash charges along with the folder number and ward. This book is their handwritten record of all pharmacy charges since they do not have a complete electronic system available at this time. Finally I would hand the chart to another student or pharmacist to fill the prescriptions if there were discharge medications, or back to the nurse if there weren't any prescriptions to fill. Then patients would take their folder to the billing and claims office after discharge so that the medication bills could be paid.

This process proved to be difficult at first because they gave me about a three minute introduction to the entire process. However, I was able to adapt pretty quickly  and a pharmacist in another section of the hospital was even surprised that I had figured out their system so quickly, so I was pretty proud of myself. Luckily certain medications were repeated a lot so I had quite a few of the prices memorized by the end of the week. It was a lot quicker if I didn't have to look up all of the prices for every single patient.

Though at times I felt like a worker at an insurance claims office or an accountant during this process, doing these discharges was a great pharmacy experience for me. I spent quite a bit of time reading through and assessing patient charts. When discharge medications were required, I was really able to flex my pharmacy muscles since I needed to assess these prescriptions before they were filled. I got to see profiles of patients from many different wards with many disease states. I became familiar with treatment regimens for different conditions, which I think will be beneficial once I start my hospital rotations back in Oregon. I learned a little bit about how billing works in a hospital, which is great even though I know it is different in the United States. I also learned how to quickly work and adapt to a busy and pressured work environment because speed was definitely emphasized and the work was nonstop.

I also realized from this experience how grateful I am for all of the technological advances we have back home. Doing almost everything without a computer made me realize how much I rely on them. Doing things by hand takes a lot of time and concentration. When you read a handwritten chart, there is a greater potential for error if the handwriting is not very legible. I have a new appreciation for the difficulties that hospitals must go through in providing patient care while having to do nearly everything by hand. The people are extremely hardworking and I respect them immensely for being able to do this everyday.

The inpatient pharmacy was a tough week, but the people who I worked with definitely made the experience so much better, even in a sometimes stressful environment. I especially want to thank my pharmacists, Auntie Sylvia and Auntie Janice, who pushed me to really be involved in the process and were always supportive. The experienced female pharmacists and technicians are all called "Auntie" as a term of respect. Additionally I want to thank all of my new student friends who worked with me. Harris and George always managed to make me laugh with their questions and jokes. Lillian was always supportive and the first to say good morning to me and ask me how I was doing. Priscilla was my partner in crime for the week, always sticking by my side, and Samantha, the non-newbie of the group showed me the ropes so that I could really participate in the pharmacy.

The inpatient pharmacy is where I began to really feel like a part of the pharmacy team. Everyone played an integral role in providing patient care, and if all of the pieces hadn't fit together, we would have fallen apart under the pressure. With new students constantly rotating through the pharmacy, it would be easy for the pharmacy to get overwhelmed and fall behind. However, this was not the case when I was there and I was able to have one of my most rewarding experiences yet in Ghana!