Despite the rise of pharmacies in grocery stores and warehouses (e.g., Costco), the hospital pharmacist remains the second most common job setting for PharmD graduates, behind only the retail pharmacist. A hospital pharmacist is quite a generalized term. Hospital pharmacists can range from new graduates to highly experienced pharmacists specializing in a niche area.
At its most basic level, the role of a pharmacist in a hospital can be seen as similar to that of a pharmacist in a retail or community setting: review a medication order written by a prescriber to assess its appropriateness given the patient’s current clinical picture and get it to the patient safely and efficiently.
Similarly, a pharmacist at a hospital pharmacy is expected to manage and lead a pharmacy tech. However, once you pull back the curtain, you’ll quickly discover many factors, clinical analyses, and conversations that take this process from A to B.
Responsibilities of a Hospital Pharmacist
Verify a Medication Order
Most hospitals today operate through an electronic health record (EHR) or electronic medical record (EMR) backbone. This means all medication orders are ordered electronically, and each action, from ordering by prescribers to verifying and dispensing by pharmacists to administering by nurses, is tracked using identifiable tokens such as fingerprints or passwords. Once a prescriber places a medication order, it becomes available for the pharmacist to review.
A prescriber can consist of a physician, such as a medical doctor (MD) or a doctor of osteopathic medicine (DO), or a mid-level provider, such as a nurse practitioner (NP) or a physician assistant (PA). Depending on your specific practice area, there are undoubtedly many other provider types, but these are the main types. Once the medication order reaches the pharmacist, the hospital pharmacist is responsible for determining the appropriateness of the medication. There is a concept of medication error reduction called the ‘Swiss Cheese Model’.
An Introduction to the Swiss Cheese Model
This has a cumulative effect, which visualizes several layers of Swiss cheese stacked on each other. Each slice of Swiss cheese has holes (opportunities for errors). Some holes are large, and some are small, but each piece of Swiss cheese is unique. If you stack a second piece of Swiss cheese on top of the first, the likelihood of both pieces having a whole in the exact location decreases. If you add a third piece, that likelihood decreases even more. The prescriber is the first slice of Swiss cheese, the pharmacist is the second slice, and the nurse is typically the third slice.
There are typically six slices of Swiss cheese or more for high-risk medication, such as chemotherapy agents (cancer treatments) (commonly two senior physicians, two pharmacists, and two nurses). Hospital pharmacists determine that the medication fulfills the ‘Five Rights’, meaning the drug is for the right patient, it is the right drug, it is the right dose, it is given in the correct route, and it is given at the right time. Determining these five rights requires a high level of clinical expertise and knowledge gained through familiarity with the medication, the patient’s disease, syndrome, or condition, and the patient’s current physiology and organ system functionality.
Dispensing the Medication
Dispensing medication in the hospital setting can be completely different than that in the retail setting. In retail, medications are usually dispensed as full bottles, as a 30- or 90-day supply, and given orally. The condition is known and established in a community setting, and the patient is generally stable. In the hospital setting, a condition or diagnosis may still be unknown. The patient’s condition (especially in the Emergency Department or Intensive Care Unit) may constantly change. Medications may be designed for as-needed use or use if the patient’s condition suddenly declines (crashes or decompensates).
Medications may be for intravenous (IV) use or subcutaneous (SQ) use, or they may need to be infused over many hours (or even continuously). Patients who typically can take medications by mouth may require temporary feeding tubes or IV administration if they are sick. If patients cannot eat for several days, they will need to receive an IV of total parenteral nutrition (TPN). Medications are typically dispensed either as one dose or 24 hours of dosing, as the patient’s status constantly changes.
Therapeutic Drug Monitoring
Certain antibiotics for serious infections and medications used to treat active blood clots require daily monitoring. Patients in intensive care units may be on long-term pain medications or in medically induced comas and may need to be frequently assessed for over-sedation or withdrawal. The pharmacist plays a critical role in these scenarios.
In many hospitals, the pharmacist determines when to assess a medication level in the patient’s blood. This level can vary drastically based on how well the patient’s kidneys and liver function. Furthermore, the pharmacist is typically relied upon for recommending dose adjustments based on these levels to ensure that the patient is appropriately treated by the medication (not over-dosed or under-dosed). Many drugs require dose increases or decreases based on renal (kidney) or hepatic (liver) function or concurrent medications (drug interactions).
Certain medications will make the liver metabolize another medication slower or faster, increasing or decreasing drug levels in the body. If drug levels get too low, the medication won’t work. If drug levels get too high, the medication may become toxic and result in side effects and organ damage. Many medications in the hospital have a narrow therapeutic window, meaning that slight increases or decreases in levels in the blood can be significant. Pharmacists in the hospital are relied upon to manage these medications.
Consulting and Counseling
In many hospitals, a pharmacist works within the healthcare team and sees the patient directly. This pharmacist is trusted to provide appropriate and effective medication. Once the patient is ready for discharge, it is expected that the patient may be going home on a new medication (or many new medications). The pharmacist often coordinates how this patient will get this medication upon discharge and educates the patient on how to take the medication, how to store the medication properly, what side effects to look out for, and when to seek care.
The Different Roles of the Hospital Pharmacist
The Staff Pharmacist
This is the pharmacist who works within the physical pharmacy within the hospital. A pharmacy may be centralized (dispenses medications for the whole hospital) or decentralized (dispenses medications to a specific area like an intensive care unit, an emergency department, or a cancer department). This pharmacist is often responsible for determining the appropriateness of medications, preparing drugs, and ensuring that the medications leaving the pharmacy arrive safely and on time. The pharmacy services a staff pharmacist provides include managing and supervising pharmacy technicians.
The staff pharmacist may also be located in an area that specializes in compounding medications or in an area that requires sterile preparation (such as an IV room).
The Clinical Pharmacist
While every pharmacist within a hospital is constantly making clinical decisions and recommendations based on his or her extensive schooling and experience, a clinical pharmacist is usually a pharmacist who is embedded within the treatment team and is making decisions and recommendations in real-time. These are the pharmacists who provide direct patient care. Many clinical pharmacists are categorized as patient care pharmacists or advanced patient care pharmacists, depending on their experience and advanced credentials.
Clinical pharmacists typically have completed one or two years of residencies and/or have achieved a specific board certification. This is not a typical position a new graduate would be qualified for, but it is certainly something you could work towards. Choosing the right pharmacy schools is critical if you are interested in pursuing a career as a clinical pharmacist at a hospital. To give an example of the type of specializations a clinical pharmacist may possess, look no further than the variety of sub-specialties for a second-year pharmacy resident (PGY2).
A pharmacist can specialize in their second year of residency in the following areas: cardiology (the heart), clinical pharmacogenomics (the relationship between medication and an individual’s genetic material), critical care (the intensive care unit), emergency care, geriatric care (care for the elderly), administration and leadership, infectious disease, internal medicine, investigational drug services (experimental medications), medication safety, neurology (headache, seizures, or stroke), oncology (cancer), palliative care (end of life or hospice care), pediatrics (babies, infants, and children), informatics (the relationship with pharmacy and technology), psychiatry (behavioral health), and solid organ transplant (heart, lungs, kidney, liver, etc.).
As you can see, there are various exciting and impactful areas for clinical pharmacists.
Hospital Pharmacist Roles are Expanding
While retail pharmacist positions are expected to decrease in future years, hospital pharmacist roles continue to expand and grow, specifically in hospital administration, medication safety, and research. Many pharmacists in the hospital setting collaborate with other healthcare professionals and develop great relationships, which lead to incredible learning and publication opportunities. Hospital pharmacists can also be assistants or associate professors in pharmacy colleges as they possess clinical real-world expertise and are best positioned to teach future pharmacists.
A hospital pharmacy position is highly rewarding, allows the pharmacist to practice at the top of his or her license, and often has less burnout than many retail pharmacy positions.
