International Reprorts

Scope of International Hospital Pharmacy Practice

Jaclyn M LeBlanc and Joseph F Dasta

OBJECTIVE: To review the published English literature regarding international hospital pharmacy practice.
DATA SOURCES:

A computer search of all English-language articles in MEDLINE (1966June 2004) and other Internet sources and
International Pharmaceutical Abstracts (1971June 2004).
STUDY SELECTION AND DATA EXTRACTION: All studies that discussed hospital pharmacy or clinical hospital pharmacy activities
outside of the US were considered for inclusion.
DATA SYNTHESIS: The scope of international hospital pharmacy practice is quite varied, both inter- and intra-country, and varying
degrees of specialization exist. Although clinical pharmacy is well developed in some countries, it is still in infancy stages in others.
In addition, there is disparity in the actual definition of clinical pharmacy throughout the world.
CONCLUSIONS: Since very few data have been published regarding hospital pharmacy practice on an international scale, we
suggest a survey be conducted to objectively capture this information and increase awareness of clinical pharmacy in this setting.
KEY WORDS: clinical pharmacy services, hospital pharmacy services, internationality.

Ann Pharmacother 2005;39:183-91.

Published Online, 14 Dec 2004, www.theannals.com, DOI 10.1345/aph.1E317

n many countries, the definition and responsibilities of a

Irecent
hospital pharmacist have evolved dramatically, with the
focus of practice changing from medication oriented
to patient outcomes oriented. The profession has dealt with
obstacles such as gaining the recognition of pharmacists
capabilities and activities by other health professionals, as
well as the escalating economic strain as hospitals budgets
decrease and drug costs increase. In developing countries,
pharmacists often face unique challenges due in part to the
economic hardships endured. However, global hospital
pharmacy practice appears to have begun changing as
well, expanding its practice beyond the confines of the
pharmacy. The purpose of this review is to examine the English-language literature regarding international hospital
pharmacy practice and compare the scope of the pharma-

Author information provided at the end of the text.

www.theannals.com

cists practice in various countries outside of the US. A computer search of all English-language articles in MEDLINE
(1966June 2004), other Internet sources and International
Pharmaceutical Abstracts (1971June 2004) was conducted.
One of the difficulties in assessing international literature is the variation in the definitions of clinical pharmacy
and pharmaceutical care. For example, in the early 1990s,
clinical pharmacy practice in Poland was confined to the
analysis of samples of urine, blood, microbiology, and
drug concentrations for hospitalized patients.1 In the Western world, clinical pharmacy was defined many years ago,
and the American College of Clinical Pharmacy (ACCP)
is currently updating that definition. For the purposes of
this review, we define clinical pharmacy very broadly as
the provision of a patient-oriented service provided in
pharmacists daily activities. In 2000, the European Society of Clinical Pharmacy defined clinical pharmacy as a
health specialty, which describes the activities and services

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JM LeBlanc and JF Dasta

of the clinical pharmacist to develop and promote the rational and appropriate use of medicinal products and devices by the individual and society.2 It proceeded to state
that the focus of this discipline is the patient or population
receiving the medications. In addition, there are many
published definitions of pharmaceutical care. Hepler and
Strand3 in 1990 defined pharmaceutical care as the responsible provision of drug therapy for the purpose of achieving definite outcomes which improve a patients quality of
life. van Mil et al.4 later published an article detailing the
reasons for various definitions of pharmaceutical care including language and cultural differences, influence of the
respective healthcare systems, and professional differences
between countries. Although many countries have adopted
the Hepler and Strand definition of pharmaceutical care, a
number of countries have developed their own definitions.
One must be aware of the interpretations and lack of definitions found in the literature.
Organizations
Hospital pharmacy societies have been formed in many
countries, including Estonia, South Africa, and Peru, in response to the evolution of hospital pharmacy practice.
These organizations serve to support the pharmacists
practice in the hospital setting. However, there is not one
society that represents hospital pharmacy on an international basis. The International Pharmaceutical Federation
(FIP) has a hospital pharmacy section that attempts to solidify a global relationship between pharmacists through
discussion and exchange of experiences; however, only recently has this organization begun to welcome individual
members. In the past, only organizations could join the FIP.
Many hospital pharmacy societies have endorsed standards for practice including Canada, the Netherlands, and
Ireland.5-7 The constant theme throughout these standards
is pharmacists responsibility to the patient for pharmacotherapeutic outcomes. The Good Pharmacy Practice
Guidelines developed by the FIP, and subsequently adopted by the World Health Organization, state that a pharmacists first concern should be the welfare of the patient.8
These guidelines were first adopted in 1997 to help national councils develop national standards; however, there has
been no update since that time.
Clinical Activities
There is a wide range of clinical pharmacy activities
performed throughout the world, which include, but are
not limited to, patient medication review, ward rounds,
therapeutic drug monitoring, drug information, inservice
education, medication counseling, medication histories,
drug utilization evaluations, adverse drug reaction (ADR)
management, clinical research, and participation in specialty teams.9 In many countries, clinical pharmacy services are still in their infancy, with pharmacists spending a
predominant amount of time on distributive and manufacturing activities. However, the development of clinical ser184

The Annals of Pharmacotherapy

vices is increasing. For example, pharmacists in Japan previously spent a great deal of time in manufacturing of
products,10 but recently, approximately 50% of inpatients
received clinical services on the wards in this country.11 A
questionnaire circulated in 2001 to hospital pharmacies in
Australia showed that 41% of the pharmacists time was
spent in clinical activities dedicated to the patient, drug information services, training, and education; 39% of the
time was dedicated to acquisition, manufacture, and dispensing of medications; and 16% of the time was allocated
to managing drug and personnel resources.12 Clinical pharmacy services in Korea are not well established, as evidenced by a study on ADR reporting, in which no reports
were made by a pharmacist.13 Reports of clinical and distributive functions for selected countries are summarized
in Table 1.10,11,14-65
As well as considerable inter-country variability in the
practice of hospital pharmacy, there is much intra-country
variability. This is true for Africa, where many of the countries in the past undertook the style of pharmacy practice
of its many colonists.66 For example, certain countries in
West Africa took on the standards of either British or
French colonists, whereas North Africa was subject to
Arabic influence. In the past, practice between the northern
and southern parts of Nigeria were very different due to
different educational standards.66 In a survey of hospital
pharmacy services in Australia in 1998, wide variations
were reported between the states in many different areas,
including ADR monitoring (50100%) and manufacturing
of non-sterile products (35.5100%).14
The European Association of Hospital Pharmacy
(EAHP) conducted surveys in 1995 and 2000, comprising
16 European countries67,68; however, only a portion of the
surveys concentrated on clinical duties. Regardless, striking differences were seen between many of the countries.
In the most recent survey, for example, pharmacokinetic
consults were provided in <1% of hospital pharmacies in
Austria, but >6% in the Netherlands and the UK. Although
it appears that these numbers are low compared with those
from the American survey in 2003,69 the questions may
have been worded differently and the data may not have
been collected in the same way. This limits the ability to
compare this information. To our knowledge, the only other international survey published was a combination of 2
surveys conducted by the FIP in 52 countries in the mid1970s, focusing mainly on community pharmacy.70
In Pakistan, there are opportunities for pharmacists to
become more involved with patient care; however, there
are difficulties with identifying their role and responsibilities and having those recognized by hospital administrators, government, and patients.49 A study was conducted in
a 220-bed Nigerian teaching hospital examining communication between pharmacists and elderly patients during
medication history interviews to identify the communication gaps between pharmacists and patients.71 Only a small
number of pharmacists were willing to participate in the
study due to time commitment or refusal to be videotaped.
The results illustrated miscommunication during verbal in-

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International Hospital Pharmacy Practice

Table 1. Scope of Hospital Pharmacist Activities in Selected Countries

Country

Ref.

Year

Distribution System

Distribution Activities

Clinical Activities

Formulary

Australia

1416 2000,
2003

ward stock replenished

by the pharmacy department

inpatient dispensing, drug review of charts, monitoring

formulary systems in place
purchasing, some cytotox- drug therapy, counseling,
in public hospitals, but not
ic manufacturing
ADR monitoring, some clinical necessarily private ones
trial support and research activities, basic drug information

Belgium

17,18 2002,
2004

unit dose

main duties preparation

and distribution of drugs

limited time spent on clinical

tasks, collaboration with nursing staff about the use of
medicines

ND

Bermuda

19

1996

ND

manufacture and supply

patient-controlled analgesic packs for the ward

each pharmacist assigned a

ward

limited formulary

Canada

20

1999

traditional drug distribu- chemotherapy and TPN

tion and unit-dose sys- preparation, increased
tems, decreasing ward iv admixture
stock systems

increasing participation in ward ND

rounds, admission histories,
pt. group teaching, clinical
drug trial services, pharmacokinetic dosing

China

22

1994

ND

TDM not individualized for the

pt., ADR monitoring for identified drug classes

Denmark

21, 23, 1993, ND

24
2000,
2004

drug distribution and inven- drug information, increasing

tory control management, ward rounds and interaction
cytotoxic and TPN reconwith ward personnel
stitution

local government committee

reviews and compiles formulary

France

25, 26 1996,
1997

dispensing of medications, counsel pts., serum assay

heavy compounding role
of medications (but often no
assessment provided)

ND

Germany

2730 1995, ND
1999,
2003

cytotoxic and TPN services pharmacokinetics, drug information, some ward rounds,
,
some pt. counseling, increasing involvement in clinical trials

most hospitals have formulary and committee; in large

hospitals (>500 beds), pharmacists are chairpersons of
the committee in 5278%
of hospitals

Grenada

31

1999

ward stock, requisitions filling prescriptions, some

ward-based pharmacist to
sent to pharmacy to fill extemporaneous dispens- cover ward; however, due to
ing, some cytotoxic recon- short-staffing, this practice
stitution
was not consistent

ND

Iceland

32

1994

ward stock with all

parenterals except
TPN

India

unit-dose system

ND

ND

maintain floor stock and

dispense some outpatient
prescriptions, 2 hospitals
report parenteral admixture programs

updating daily medication,

dispensing 7-day supply of
medication

ND

3335 1998, ND
2002,
2003

ND

increasing clinical activities

including ward rounds, drug
information services, and
ADR monitoring/reporting

initiation of DTC in some

hospitals

Indonesia

36

2000

ND

procurement, supply, and

ND
distribution of medications
main focus

ND

Republic of
Ireland

37

1999

ward stock system in

~50% hospitals

ND

moderate numbers of hospitals (~30%) offered clinical

pharmacy services, pt. counseling, drug information,
attendance at ward rounds

ND

Israel

38

1996

ND

manufacturing cytotoxics,
iv additives, TPN

some clinical trial involvement,

increasing clinical pharmacy
services

ND

Japan

10,
11,
39

1995,
2000,
2002

ND

compounding and dispens- pharmacokinetic and drug

ing, focus on preparing
therapy consults, drug inforand delivering, dispense
mation services, some DUE/
parenteral drugs
DUR

ND

ADR = adverse drug reaction; DTC = drug and therapeutics committee; DUE/DUR = drug use evaluation/drug use review; ND = not described;
TDM = therapeutic drug monitoring; TPN = total parenteral nutrition.
(continued on page 186)

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Table 1. Scope of Hospital Pharmacist Activities in Selected Countries (continued)

Ref.

Year

Distribution System

Kuwait

Country

40

2003

ND

pharmacists: drug ordering,

stock control, personnel
management
technicians: dispensing
duties

clinical services limited

ND

Lebanon

41

2004

ND

distribution of medications,
compounding

provide pharmaceutical
care, especially in large
centers

involvement in formulary review and cost management

Lithuania

42

2003

no unit dose

heavy emphasis on manufacturing, no TPN or cytotoxic manufacturing

none (do not go to wards

or counsel pts. on medications)

ND

Nepal

43

1996

ND

some cytotoxics and manufacturing

ND

ND

Netherlands 4446 2003

most hospitals have

unit-dose system

dispensing done by technianalyze drug prescriptions,

cians supervised by a phar- check for contraindications,
macist
TDM, pharmacokinetic
modeling, some clinical trial
involvement, participate in
ward rounds

pharmacists involved in decisions of the DTC

New
Zealand

47

2001

ND

for inpatient and clinical trials daily visits to the ward

only; limited manufacturing,
most cytotoxic and TPN outsourced

ND

Norway

48

2002

ND

ND

ND

pharmacists involved in the

drug committee making
decisions

Pakistan

49, 50 1993,
2002

ND

main focus dispensing and

storage, distribution, administration of medications
and TPN

increased awareness in last

ND
few years with development
of ADR monitoring programs,
drug information services;
medication review in larger
hospitals

Russia

51, 52 1996,
2002

mainly parenteral
heavy in-house sterile and
products dispensed; non-sterile manufacturing
ward stock system
due to lack of medications;
no individual prescriptions

ND

Slovenia

5355 2004

ND

Radiopharmaceuticals and
cytotoxic preparation at
larger hospitals, TPN
preparation at 1 large
hospital (with aid of
computer system)

some research activity and

ND
counseling at larger hospitals

South
Africa

56

majority ward stock

for inpatient drug
distribution

TPN and cytotoxic preparation in bigger hospitals

attend clinical ward rounds,

TDM, pt.-oriented services
in some hospitals

ND

Spain

57, 58 1993,
1999

ND

ND

increasing clinical activities

ND

Sweden

59

unit dose to pt. on

daily basis

ND

some involvement in research pharmacists involved with

(although mainly distributive) the DTC

Switzerland

60, 61 2003

ND

ND

increasing ward rounds

ND

Ukraine

62

1995

ND

mainly dispensing and

quality control at the manufacturing level, most medications made from scratch

no pt. contact, no ADR

monitoring

ND

United
Kingdom

63

1994

ND

ND

ward-based activities stanpharmacists usually particidard practice, many pharma- pated as part of the DTC
cists attend ward rounds,
some research activity

Zimbabwe

64, 65 1996,
2002

general ward stock

system

manufacture many items

including syrups, antacids,
eye drops

ward rounds in 2 central hos- ND

pitals, some pharmacokinetic
consults

1994

2003

Distribution Activities

Clinical Activities

Formulary

mostly parenteral products

ADR = adverse drug reaction; DTC = drug and therapeutics committee; ND = not described; TDM = therapeutic drug monitoring; TPN = total parenteral nutrition.

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International Hospital Pharmacy Practice

teractions with elderly patients. In many developing countries, clinical pharmacy has not yet begun to be realized.
The role of the hospital pharmacist in Armenia is classic,
with the traditional responsibility of storage, production,
and distribution of drugs.72 In Uganda, clinical pharmacy
is very much in its infancy.73 Matowe and Katerere74 suggest that increased interaction between international pharmacists may aid in transferring skills and further the profession to those in developing countries.
Personnel Shortages
Even though there is an impetus toward clinically competent graduates, the majority of students graduating from
a pharmacy college will not choose the hospital sector as
their preferred area of practice. The actual number of pharmacy graduates entering hospital pharmacy is very low in
countries like Slovakia (5%),75 Indonesia (10%),36 Pakistan
(<10%),50 and Grenada (8%).31 In 1994, approximately
12% of the pharmacy workforce in South Africa was involved in hospital practice.56 In the early 1990s, Zimbabwe
reported that, although clinical opportunities existed, there
was a severe shortage of staff, and these opportunities
could not be realized.76 A recent paper revealed that only
30 pharmacists are trained each year in Zimbabwe due to
the high cost of education undertaken by the government.74
Insufficient staffing has curtailed the opportunities to work
with medical staff and increase the influence of pharmacists within hospitals in Slovenia.77 A recent workload
questionnaire circulated to all hospital pharmacies in Australia highlighted a 14% vacancy rate for pharmacists.12 As
well, 60 additional pharmacists would be needed to cover
the overtime currently being expended at the surveyed
hospitals.
Stemming from the pharmacist shortage comes the frustration of having the desire to offer clinical and specialized
pharmacy services, but not having the staff to perform
those functions. In addition, many hospitals have had to
decrease clinical services just to maintain adequate distribution function. A study in Japan showed that a higher dispensing load was associated with fewer inpatients being
provided clinical pharmacy services.11 The Society of Hospital Pharmacists of Australia (SHPA) recently published a
position statement on the shortage of hospital pharmacists
in which it warned of compromised patient care as a direct
result of pharmacists leaving the profession.78 The Victorian
Branch of the SHPA completed a Public Hospital Pharmacy Workforce Analysis, which revealed that 74 pharmacists
resigned in that state in 2001, of which only 16% remained
in hospital pharmacy: 25% transitioned to community
pharmacy and 20% cited overseas/travel as the reason for
resignation.79 Fifty percent of pharmacy resignations were
due to increased workload and stress associated with overtime and inability to take vacation. In British Columbia
during 2003, there was an estimated vacancy rate of 10%
in hospital pharmacist positions, with the majority of pharmacists leaving the hospitals for the community sector.80
Many pharmacy schools in the US and Canada have tried
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to respond to the shortage problem by increasing enrollment in pharmacy schools; however, in developing countries, this is usually not feasible due to costs of education
and facilities. One recent article highlighted the frustration
of pharmacists in Armenia.72 With drug supply shortages,
worn-out facilities, and delays in salary payouts, many
pharmacists were turning toward the private sector. Developing countries may face an even greater challenge, with
few pharmacists trained per year and better conditions in
more developed countries. Regarding globalization and
pharmacy, Matowe and Katerere74 highlighted the free
movement of personnel from one country to another as an
issue in the developing world since many competent graduates leave to pursue their careers elsewhere.
Impact of a Pharmacist
Another statement from the SHPA declares that all patients should receive clinical pharmacy services as part of
routine care since clinical pharmacists have been shown to
decrease the incidence of adverse drug events (ADEs).81
This is based on a study of the impact of pharmacists in 8
Australian teaching hospitals that documented the clinical
impact of pharmacist-initiated drug therapy.82 Twenty-five
percent of the interventions were determined to be of major significance (preventing or addressing very serious drugrelated problems). Thirty-eight percent of the interventions
were of moderate significance (prevented major temporary
injury, enhanced the effectiveness of drug therapy, or produced minor decreases in patient morbidity or a <20%
chance of noticed effect), and 30.4% were of minor significance (small adjustments and optimizations of therapy).
One percent of the interventions documented were life-saving. The Gillie report described a high rate of drug administration errors in British hospitals in the late 1960s, and
ward-based practice of pharmacy was a direct consequence
and solution to this.83 A more recent article from Israel documented 160 medication errors over a 6-month period (11.2
errors/1000 prescriptions) and showed that pharmacists identified and rectified these errors.84 Of the documented errors, subsequent pharmacy interventions were accepted in
87.5% of cases. The introduction of a clinical pharmacist
to an intensive care unit (ICU) team in Pakistan demonstrated a high acceptance rate of interventions (91.6%) and
has led to the creation of other clinical positions in varying
practices in the hospital.50
Hospital pharmacy interventions have also been demonstrated to have a cost-savings in many countries. Dooley et
al.82 reported that the annualized cost-savings associated
with economically measured resources due to pharmacists
interventions was $4 447 947 (AUS) in the 8 institutions;
$23 were saved for every $1 spent on a pharmacist to initiate an intervention. A hospital in Spain reported pharmacist
interventions regarding antibiotic prophylaxis, pharmacokinetics, thromboembolism prophylaxis, non-formulary prescription requests, inappropriate duration, and others were
associated with a cost-savings of 129 059 over a 6-month
period.85 In Canada, the addition of a clinical pharmacist to

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JM LeBlanc and JF Dasta

an ICU resulted in pharmacist-initiated consultations leading

to an annualized cost-savings of approximately $67 665
(CAN) in 1994.86 The introduction of a part-time pharmacist into the ICU in Malaysia resulted in savings of $4014
(US) over one month.87
Specialization
As pharmacists become more integrated into the patient
care stratum, more choose to specialize in a particular
medical discipline. For example, in Australia, Canada, and
the UK, pharmacists specialize in critical care. Divergent
values from the EAHP survey68 occurred in the number of
hospital pharmacies that had dedicated drug information
positions, ranging from <10% in Finland and Slovenia to
>70% in Denmark and the UK. Pharmacy in the Netherlands is also developing specialization in clinical areas
such as pulmonology, neurology, and cardiology.45 The initiation of a pediatric clinical pharmacy service in Zimbabwe was described in 2002.64 Two years after the service
was instituted, a questionnaire was distributed to the nursing staff working with the pharmacist, which showed 90%
felt the service was good or excellent, and 91% thought
the relationship between pharmacy/medical and nursing
staff was improved due to better communication.
The practice of radiopharmacy has been evolving in
Slovenia, with recent introduction of a postgraduate training program by the Faculty of Pharmacy in Ljubljana in
2003.55 Similar to the ACCP in the US, the European Society of Clinical Pharmacy had developed special interest
groups in disciplines such as cancer, nutritional support,
and pediatrics where pharmacists can exchange information. In the UK and the Netherlands, there are subgroups of
hospital pharmacists who specialize in psychiatric pharmacotherapy. An interesting specialty in many countries is the
practice of herbal and traditional medicine. For example, at
the School of Pharmacy at Kumasi in Ghana, there is a degree course offered in herbal medicine.88 In Nepal, an entirely separate area of ayurvedic pharmacy exists, which
uses plant derivatives available as raw products or in pharmaceutical products.43
As clinical practices increase, the numbers of pharmacists who participate in research also increases. A questionnaire sent to drug information centers in Italy revealed
that 22.5% were involved in self-initiated research projects
and 57.5% conducted research both independently and in
partnership with other institutions.89 In the Canadian pharmacy services survey, participation in clinical drug trials
increased from 50% of hospitals in 19911992 to 80% in
19971998.20 Fifty-seven percent of Australian hospitals
reported provision of pharmacy services for clinical trial
support, and 34.3% indicated there were research activities
or opportunities.14
Formularies and Economics
Due to increasing costs, formularies were being implemented in Slovakia in 1998.75 In hospitals in Denmark,
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there is a formulary committee, and cost was the predominating factor in the selection of drugs.24 A study examining
the function of hospital formularies in the Netherlands
found wide variationsfrom being solely drug lists to almost complete therapeutic manuals.90 Hospital pharmacists
in Guernsey, one of the Channel Islands, exclusively make
changes to the drug formulary due to the absence of junior
physicians.91 In the 1992 survey of clinical services of the
UK, 96% of pharmacies had involvement on the drug and
therapeutic committee, 91% provided financial information on drug use, and 73% provided information used in
making formulary decisions.63 In the 2000 version of the
EAHP survey, most countries reported >60% of hospitals
had formularies in place.68 In the early 1990s, both Australia and Canada were compiling formularies for drug use,
with pharmaceutical companies required to submit an economic analysis as one of the criteria for evaluation of the
medication.92
In many hospital pharmacies around the world, purchasing of medications is an important role. An article regarding the state of pharmacy in Zimbabwe in 1991 reported
that drug supply was a major issue.76 Pharmacists in
French hospitals are the primary personnel responsible for
the purchase of pharmaceutical products,93 and in the past,
many hospitals in Indonesia employed only one pharmacist focused primarily on procurement, supply, and distribution of medications.36 Developing countries often face
hardships at this stage as well due to financial shortages
within the hospital and country and lack of in-country production of medications.
Cost-effectiveness data are often used in assessing new
drugs proposed for addition to the reimbursable drugs
list in the country.93 As additional cost analysis data are
published, pharmacists and formulary committees are under increased pressure to consider cost in formulary decisions. A survey on the use of economic data in formulary
decisions in France revealed that, although price information was frequently examined, pharmacoeconomic evaluations were rarely used.94 Barriers identified in the use of
this information included lack of time, limiting collection
and analysis of the information, insufficient health economics training, and closed budgets within hospitals. Pharmacoeconomics is becoming increasingly used in hospitals
in the Netherlands.45
Summary
The Good Pharmacy Practice Guidelines8 attempt to
provide a set of guidelines that can be applied internationally to all hospital pharmacists and pharmacies, although
they have not been updated recently. There are arguments
against a universal set of standards given the differences in
training of graduates and the wide breadth of activities and
responsibilities both inter-and intra-country. As well, the
different philosophies and infrastructures of the many
healthcare systems worldwide make it very difficult to try
to define the professions roles and responsibilities within
one set of standards. However, from our review, it is appar-

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ent that all hospital pharmacists are trying to advance the

profession, often with the same goal of increasing involvement in direct patient care. Some countries are further
ahead of others, but this is where a global partnership of
pharmacists would be of great benefit. In sharing information about the successes and failures of promoting and advancing pharmacy activities, the profession could facilitate
its own expansion. Perhaps as a profession we should encourage our respective leading professional organizations
to work together to accomplish this goal.
There is increasing evidence that pharmacists improve
patient care and decrease health-related costs and, as such,
have begun to economically justify their place within the
clinical care of the patient. As well, the improvement in
patient safety through reduction of ADRs has given pharmacists an important justification for involvement in direct
patient care. Despite this impetus, clinical pharmacy has
been slow to develop in many countries. The reasons for
this are very similar to those that American and Canadian
pharmacists faced 1520 years ago: the obstacles of being
recognized as clinical practitioners by the government;
other health professionals, who are sometimes threatened
by the proposed expansion of pharmacy practice; and patients, who invariably only associate pharmacists with dispensing of medications. Personnel shortages have curtailed
the development of clinical services in many hospitals, as
pharmacists are drawn to alternate sectors of the profession
for a variety of reasons. The remaining pharmacists are often then only able to provide basic services, usually comprised of a dispensing-only role. This promotes frustration
and stress associated with being overworked with subsequent resignations leading to a cycle of chronic shortstaffing. The curriculum at pharmacy schools is beginning
to change with the introduction of clinical pharmacy as the
focus; however, there are still many universities that focus
upon the classical laboratory-based chemistry curriculum.
This leaves graduates unprepared to enter into or develop
clinical pharmacy positions and consequently fosters the
belief that the profession is only capable of the classical responsibilities of purchasing, manufacturing, storing, and
dispensing of medications. Developing countries face even
greater difficulty due to lack of funds and resources, where
obtaining medications alone is often a difficult process in
those hospitals.
From the review of the literature, it is apparent that there
is a wealth of information about pharmacists activities
from a global perspective; however, the distribution of
clinical versus technical activities of pharmacists in other
countries is sparsely described. A limitation of this review
is the inclusion of only English-language articles. Many of
the reports reviewed convey an increasing awareness of
clinical activities, and clinical positions have been initiated
in selected countries; however, many of those reports are at
least 5 years old. As well, there are selected references that
discuss specialization of clinical pharmacy services, but
the degree of specialization has not been quantified. There
are few data regarding research involvement of pharmacists, except in a select group of countries. As clinical
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activities increase, it would be appealing to determine

whether pharmacist involvement in research is also increasing. The drug approval process and the existence of formularies in the hospitals have also not been fully elucidated.
The practice of hospital pharmacy around the world is
diverse. Hospital pharmacists should be encouraged to publish their experiences and research in international journals.
We advocate that a survey of hospital pharmacy practice in
international countries be conducted to objectively document their varying practices.
Jaclyn M LeBlanc PharmD, Critical Care Pharmacy Research Fellow, College of Pharmacy, The Ohio State University, Columbus, OH
Joseph F Dasta MSc, Professor of Pharmacy, College of Pharmacy, The Ohio State University
Reprints: Professor Dasta, College of Pharmacy, The Ohio State
University, 500 W. 12th Ave., Columbus, OH 43210-1291, fax
614/292-1335, dasta.1@osu.edu
We thank Trudy Arbo BSc Pharm for her time in reviewing this manuscript.

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EXTRACTO

Revisar la literatura cientfica publicada sobre la prctica

internacional de farmacia hospitalaria.
FUENTE DE DATOS: Bsqueda de todos los artculos en ingls en
MEDLINE (de 1966 hasta la actualidad), IPA (de 1971 hasta la
actualidad), y en Internet.
SELECCIN DE ESTUDIOS Y OBTENCIN DE DATOS: Se incluyeron todos los
estudios en los que se discutan actividades de farmacia hospitalaria o
farmacia clnica hospitalaria.
SNTESIS DE DATOS: El alcance de la prctica internacional de farmacia
hospitalaria presenta bastante variabilidad, tanto dentro de un pas como
entre pases, incluyendo el grado de especializacin que existe en la
OBJETIVO:

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farmacia clnica. A pesar de que la farmacia clnica est bien

desarrollada en algunos pases, en otros todava se encuentra en etapas
iniciales de desarrollo. Adems, existe variabilidad en la definicin de
farmacia clnica por todo el mundo.
CONCLUSIONES: Se sugiere efectuar una encuesta para documentar
objetivamente la informacin relacionada con la prctica internacional
de la farmacia hospitalaria.
Luz M Gutirrez
RSUM
OBJECTIF: Rviser la littrature publie concernant la pratique de la
pharmacie hospitalire au niveau international.
REVUE DE LITTRATURE: Recherche informatise darticles en langue
anglaise sur MEDLINE (1966 maintenant), IPA (1971 maintenant),
et lInternet.
SLECTION DES TUDES ET DE LINFORMATION: Les tudes relatives aux
activits de pharmacie hospitalire ou de pharmacie clinique hospitalire
ont t incluses.
RSUM: Le champ de la pratique internationale de la pharmacie
hospitalire est assez vari, la fois au sein dun mme pays et dun
pays lautre et divers degrs de spcialisation existent. Bien que la
pharmacie clinique soit bien dveloppe dans certains pays, elle est
encore au berceau dans dautres nations; de mme, il y a des disparits
dans les dfinitions de la pharmacie clinique de par le monde.
CONCLUSIONS: Dans la mesure o il y a trs peu de donnes publies en
anglais en ce qui concerne la pratique de la pharmacie hospitalire au
niveau international, les auteurs suggrent quune enqute soit conduite
pour rassembler objectivement cette information.

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